7
Î The IDSA recommends that surgical options be explored when the
cavities are persistently symptomatic despite antifungal treatment. The
IDSA recommends that surgical options be considered when cavities
have been present for >2 years and if symptoms recur whenever
antifungal treatment is stopped (S-VL).
Î The IDSA recommends that when surgical management of cavitary
coccidioidal pneumonia is undertaken, a video-assisted thoracoscopic
surgery (VATS) approach be attempted if the surgeon has significant
expertise in VATS (S-L).
Î For patients with ruptured coccidioidal cavity, the IDSA recommends
prompt decortication and resection of the cavity, if possible (S-VL). If
the pleural space is massively contaminated, decortications combined
with prolonged chest tube drainage may be more appropriate (W-VL).
Î For patients with ruptured coccidioidal cavities, oral azole therapy is
recommended. For patients who do not tolerate oral azole therapy or
patients whose disease requires 2 or more surgical procedures for
control, intravenous AmB is recommended (S-VL).
Extrapulmonary Soft Tissue Coccidioidomycosis, Not Associated
With Bone Infection
Î The IDSA recommends antifungal therapy in all cases of extrapulmonary
soft tissue coccidioidomycosis (S-M).
Î The IDSA recommends oral azoles, in particular fluconazole or
itraconazole, for first-line therapy of extrapulmonary soft tissue
coccidioidomycosis (S-M).
Î The IDSA recommends intravenous AmB in cases of azole failure,
particularly in coccidioidal synovitis (S-M).
Bone and/or Joint Coccidioidomycosis
Î The IDSA recommends azole therapy for bone and joint
coccidioidomycosis, unless the patient has extensive or limb-
threatening skeletal or vertebral disease causing imminent cord
compromise (S-L).
Î For severe osseous disease, the IDSA recommends AmB as initial
therapy, with eventual change to azole therapy for the long term (S-L).
Î The IDSA recommends surgical consultation for all patients with
vertebral coccidioidal infection to assist in assessing the need for
surgical intervention (S-L).
Î Surgical procedures are recommended in addition to antifungal drugs
for patients with bony lesions that produce spinal instability, spinal
cord or nerve root compression, or significant sequestered paraspinal
abscess (S-L).
