This protocol addresses first-line antifungal management in nonpregnant adults diagnosed with coccidioidal pneumonia who present in a higher-risk clinical context — including significantly debilitating illness, extensive pulmonary involvement, concurrent diabetes, or frailty due to age or comorbidities — with no overt immunosuppressing condition.
Antifungal treatment is recommended at diagnosis for patients with significantly debilitating illness. The same applies to those with extensive pulmonary involvement, concurrent diabetes, or who are otherwise frail due to age or comorbidities. These presentations warrant prompt initiation of treatment rather than watchful waiting.
Management involves an orally absorbed azole antifungal agent. The specific agent, dosing strategy, and duration — which depends on clinical response — are set out in the full structured protocol.
Resolution of signs, symptoms, and inflammatory markers, with stabilization of serologies and chest radiographs.
DOI: 10.1093/cid/ciw360
We recommend initiating antifungal treatment for patients who, at the time of diagnosis, have significantly debilitating illness (strong, low).
For patients at the time of diagnosis with extensive pulmonary involvement, with concurrent diabetes, or who are otherwise frail because of age or comorbidities, we recommend initiating antifungal treatment.
If treatment is begun in nonpregnant adults, the treatment should be an orally absorbed azole antifungal (eg, fluconazole) at a daily dose of ≥400 mg (strong, low).
If treatment of early uncomplicated coccidioidal infection is instituted, the usual dose for adults is 400 mg daily. Some experts would recommend 800 mg daily.
The duration is not certain, although many experts would recommend a treatment duration ranging from 3 to 6 months or longer, depending on the clinical response.
Treatment can be discontinued when the patient's signs, symptoms, and inflammatory markers have resolved, and serologies and radiographs have stabilized.
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