Blastomycosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Vidit Bhargava, M.B.B.S [2]

Medical Therapy

Antimicrobial Regimen

• Blastomycosis

• Mild to moderate pulmonary blastomycosis

• Preferred regimen: Itraconazole 200 mg PO once or twice per day for 6–12 months
• Note: Oral Itraconazole, 200 mg 3 times per day for 3 days and then once or twice per day for 6–12 months, is recommended

• Moderately severe to severe pulmonary blastomycosis

• Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
• Preferred regimen(2): Amphotericin B deoxycholate 0.7–1 mg/kg per day for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
• Note: Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended

• Mild to moderate disseminated blastomycosis

• Preferred regimen: Itraconazole 200 mg PO once or twice per day for 6–12 months
• Note(1): Treat osteoarticular disease for 12 months
• Note(2): Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended

• Moderately severe to severe disseminated blastomycosis

• Preferred regimen(1): Lipid amphotericin B(Lipid AmB) 3–5 mg/kg per day, for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
• Preferred regimen(2): Amphotericin B deoxycholate 0.7–1 mg/kg per day, for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
• Note: oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended

• CNS disease

• Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg per day for 4–6 weeks AND an oral azole for at least 1 year
• Note(1): Step-down therapy can be with Fluconazole, 800 mg per day OR Itraconazole, 200 mg 2–3 times per day OR voriconazole, 200–400 mg twice per day.
• Note(2): Longer treatment may be required for immunosuppressed patients.

• Immunosuppressed patients

• Preferred regimen(1): Lipid amphotericin B (Lipid AmB), 3–5 mg/kg per day, for 1–2 weeks, AND Itraconazole, 200 mg PO bid for 12 months
• Preferred regimen(2): Amphotericin B deoxycholate, 0.7–1 mg/kg per day, for 1–2 weeks, AND Itraconazole, 200 mg PO bid for 12 months
• Note(1): Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 12 months, is recommended
• Note(2): Life-long suppressive treatment may be required if immunosuppression cannot be reversed.

• Pregnant women

• Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day
• Note(1): Azoles should be avoided because of possible teratogenicity
• Note(2): If the newborn shows evidence of infection, treatment is recommended with Amphotericin B deoxycholate, 1.0 mg/kg per day

• Children with mild to moderate disease

• Preferred regimen: Itraconazole 10 mg/kg PO per day for 6–12 months
• Note: Maximum dose 400 mg per day

• Children with moderately severe to severe disease

• Preferred regimen(1): Amphotericin B deoxycholate 0.7–1 mg/kg per day for 1–2 weeks AND Itraconazole 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months
• Preferred regimen(2): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks AND Itraconazole 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months
• Note: Children tolerate Amphotericin B deoxycholate better than adults do.