Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Invasive Mycoses

Coccidioidomycosis

Last Updated: November 10, 2016; Last Reviewed: June 14, 2017

Recommendations for Treating Coccidiodomycosis

Treating Mild Infections (Such As Focal Pneumonia or Asymptomatic Patients with Positive Serology and CD4 count <250 cells/mm3)

Preferred Therapy:
  • Fluconazole 400 mg PO once daily (BII)*, or
  • Itraconazole 200 mg PO twice daily (BII)*
Alternative Therapy (for Patients Who Failed to Respond to Fluconazole or Itraconazole):
  • Voriconazole 200 mg PO twice daily after a loading dose of 400 mg twice on first day (BIII)*; or
  • Posaconazole (delayed release tablet) 300 mg PO daily after a loading dose of 300 mg twice daily for one day, then 300 mg once daily* (BIII)* or
  • Posaconazole (oral suspension) 400 mg PO twice daily (BII)*

Treating Bone or Joint Infections

Preferred Therapy:
  • Itraconazole 200 mg PO twice daily (AI)*
Alternative Therapy:
  • Fluconazole 400 mg PO once daily (BI)*

Treating Severe, Non-Meningeal Infection (Diffuse Pulmonary or Severely Ill Patients with Extrathoracic Disseminated Disease)—Acute Phase

Preferred Therapy:
  • Lipid formulation amphotericin B 3–5 mg/kg IV daily (AIII), or
  • Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily (AII)
  • Use until clinical improvement, then switch to triazole (BIII)
Alternative Therapy:
  • Some specialists add a triazole (either fluconazole 400 mg daily or itraconazole 200 mg twice daily, with itraconazole preferred for bone or joint disease) to amphotericin B therapy and continue the triazole once amphotericin B is stopped (BIII)

Treatment For Meningeal Infections (Consultation With A Specialist Is Advised)

Preferred Therapy:
  • Fluconazole 400–800 mg PO daily (AII); IV if patient unable to take orally.
Alternative Therapy:
  • Itraconazole 200 mg PO twice to three-times daily* (BII), or
  • Voriconazole 200–400 mg PO twice daily after loading dose* (BIII), or
  • Posaconazole (delayed release tablet) loading dose of 300 mg twice twice on first day, then 300 mg once daily* (CIII), or
  • Posaconazole (oral suspension) 400 mg PO twice daily* (CIII), or
  • Intrathecal amphotericin B (AIII) when triazole antifungals are not effective. Use in consultation with a specialist and should be administered by a clinician experienced in this technique.
Duration of Therapy

Focal Coccidioidal Pneumonia, or Asymptomatic Patients with Positive Serology and CD4 count <250 cells/mm3, Therapy Can Be Stopped If (AII):

  • Clinically responded to ≥6 months of antifungal therapy (for patients with focal pneumonia), and
  • CD4 count ≥250 cells/mm3and
  • Receiving effective ART with virologic suppression, and
  • Continued monitoring for recurrence should be performed using serial chest radiograph and coccidioidal serology every six to twelve months.
Diffuse Pulmonary Disease or Non-Meningeal Disseminated Coccidioidomycosis:
  • Relapse can occur in 25% to 33% of HIV-seronegative patients, and can occur in HIV patients with CD4 count >250 cells/mm3
  • Therapy is at least 12 months and usually much longer; discontinuation is dependent on clinical and serological response and should be made in consultation with experts (BIII).
Coccidioidal Meningitis:
  • Relapse has been reported in 80% of patients after stopping triazoles; therefore, suppressive therapy should be lifelong (AII)
Other Considerations:
  • Certain patients with meningitis may develop hydrocephalus and require CSF shunting in addition to antifungal therapy.
  • All triazole antifungals have the potential to interact with certain antiretroviral agents and other anti-infective agents. These interactions are complex and can be bidirectional. Table 5 lists these interactions and recommends dosage adjustments where feasible.


* It should be noted that all of the triazole antifungals have the potential for complex, and possibly bidirectional, interactions with drugs that are principally based on CYP 3A4 enzyme for metabolism. Therapeutic drug monitoring and dosage adjustments, may be necessary. Clinicians should refer to Table 5 for dosage guidance when triazoles are used with other drugs for treatment of OI, and to the antiretroviral treatment guidelines for interaction recommendations with ARV, especially when used with efavirenz, ritonavir- or cobicistat-containing regimens.

Key to Acronyms: CD4 = CD4 T lymphocyte cell; CSF = cerebrospinal fluid; IgG = immunogloblulin G; IgM = immunoglobulin M; IV = intravenous; PO = orally

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