Blastomycosis
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Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
ambulatory immunocompetent nonpregnant adults
itraconazole maintenance
Outpatients with cutaneous, milder genitourinary, or milder pulmonary disease are treated with full-dose itraconazole for 6 to 12 months.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 200 mg orally three times daily for 3 days, followed by 200 mg orally twice daily
hospitalized immunocompetent nonpregnant adults
amphotericin-B
CNS disease is treated regardless of the immune status of the host or whether other sites are involved with infection.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Amphotericin-B should be continued for 4 to 6 weeks before switching to an oral agent for maintenance.
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
Primary options
amphotericin B lipid complex: 5 mg/kg/day intravenously
OR
amphotericin B liposomal: 3-5 mg/kg/day intravenously
azole antifungal maintenance therapy
Treatment recommended for ALL patients in selected patient group
Maintenance treatment, after 4 to 6 weeks of amphotericin-B.
Duration of treatment is at least 12 months.
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy.
Fluconazole has also been associated with cardiovascular effects, as well as serious dermatologic reactions. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 200 mg orally two to three times daily
Secondary options
fluconazole: 800 mg orally once daily
amphotericin-B
Amphotericin-B is given for 1 to 2 weeks, followed by oral itraconazole maintenance.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia. Use of liposomal preparations when indicated decreases the risk of nephrotoxicity.
Primary options
amphotericin B lipid complex: 5 mg/kg/day intravenously
OR
amphotericin B liposomal: 3-5 mg/kg/day intravenously
Secondary options
amphotericin B deoxycholate: 0.7 to 1 mg/kg/day intravenously
itraconazole maintenance therapy
Treatment recommended for ALL patients in selected patient group
Duration for pulmonary or genitourinary disease is 6 to 12 months.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
For osteoarticular disease it is no less than 12 months.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 200 mg orally three times daily for 3 days, followed by 200 mg orally twice daily
immunosuppressed nonpregnant adults with or without CNS disease
amphotericin-B
Amphotericin-B is given for 1 to 2 weeks and then oral itraconazole maintenance is given.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia. Use of liposomal preparations when indicated decreases the risk of nephrotoxicity.
Primary options
amphotericin B lipid complex: 5 mg/kg/day intravenously
OR
amphotericin B liposomal: 3-5 mg/kg/day intravenously
Secondary options
amphotericin B deoxycholate: 0.7 to 1 mg/kg/day intravenously
prolonged itraconazole maintenance therapy
Treatment recommended for ALL patients in selected patient group
Duration is 6 to 12 months, but some immunocompromised patients may require lifelong suppressive therapy.[2]Thompson GR 3rd, Le T, Chindamporn A, et al. Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology. Lancet Infect Dis. 2021 Dec;21(12):e364-e374. http://www.ncbi.nlm.nih.gov/pubmed/34364529?tool=bestpractice.com
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 200 mg orally three times daily for 3 days, followed by 200 mg orally twice daily
pregnant
amphotericin-B
Should be continued for the entire duration of treatment or the duration of pregnancy, whichever ends first.
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
If treatment is required after delivery, oral itraconazole can be used. However, there are insufficient data to support the safety of itraconazole during breastfeeding.
Primary options
amphotericin B lipid complex: 5 mg/kg/day intravenously
OR
amphotericin B liposomal: 3-5 mg/kg/day intravenously
postdelivery itraconazole maintenance therapy
Treatment recommended for ALL patients in selected patient group
Providing the patient is not breastfeeding. There is not a recommended therapy for breastfeeding women, as there are insufficient data in this population. Risks of treatment should be reviewed with an infectious disease specialist in these circumstances.
Some immunocompromised patients may require lifelong suppressive therapy with 200 mg once daily.
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 200 mg orally three times daily for 3 days, followed by 200 mg orally twice daily
neonates <30 days old
amphotericin-B deoxycholate
The duration of treatment is not well defined.
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
Primary options
amphotericin B deoxycholate: consult specialist for guidance on dose
amphotericin-B lipid formulation
CNS disease involvement requires the lipid formulation as it crosses the blood-brain barrier better and the increased safety factor allows higher doses into the brain.
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
Primary options
amphotericin B lipid complex: consult specialist for guidance on dose
OR
amphotericin B liposomal: consult specialist for guidance on dose
infants/children ≥30 days old
itraconazole
Duration is 6 to 12 months.
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 10 mg/kg/day orally, maximum 400 mg/day
amphotericin-B deoxycholate
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
Primary options
amphotericin B deoxycholate: consult specialist for guidance on dose
itraconazole maintenance therapy
Treatment recommended for ALL patients in selected patient group
Duration of treatment is 12 months.
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Primary options
itraconazole: 10 mg/kg/day orally, maximum 400 mg/day
amphotericin-B lipid formulation
CNS disease involvement requires the lipid formulation as it crosses the blood-brain barrier better and the increased safety factor allows higher doses into the brain.
Amphotericin-B is associated with nephrotoxicity, hypokalemia, and hypomagnesemia.
Primary options
amphotericin B lipid complex: consult specialist for guidance on dose
OR
amphotericin B liposomal: consult specialist for guidance on dose
itraconazole maintenance therapy
Treatment recommended for ALL patients in selected patient group
Itraconazole has been associated with hepatotoxicity, CNS depression, cardiovascular effects, transient or permanent hearing loss, pseudoaldosteronism, hypokalemia, and peripheral neuropathy. Azole antifungals undergo many significant drug-drug interactions.
Consult specialist for duration.
Primary options
itraconazole: 10 mg/kg/day orally, maximum 400 mg/day
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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