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Î For women who develop initial nonmeningeal coccidioidal infection
during their first trimester of pregnancy, intravenous AmB is
recommended (S-M). Other options include no therapy with close
monitoring (W-L), or an azole antifungal after educating the mother
regarding potential teratogenicity (W-L). After the first trimester of
pregnancy, an azole antifungal, such as fluconazole or itraconazole,
can be considered (S-L). A final alternative would be to administer
intravenous AmB throughout pregnancy (W-M).
Î For women who develop CM during the first trimester of pregnancy,
intrathecal AmB is recommended (S-M).
• After the first trimester and in cases where disease is diagnosed after the first
trimester, an azole antifungal, such as fluconazole or itraconazole, can be
prescribed (S-L).
Î Among women with a history of prior uncomplicated
coccidioidomycosis who are not currently on therapy, the risk of
reactivation is low and antifungal therapy is NOT recommended (S-M).
• For such women, close follow-up, including obtaining coccidioidal serologic
testing at the initial visit and every 6–12 weeks throughout pregnancy, should be
performed (S-M).
Î For women with nonmeningeal coccidioidomycosis on antifungal
therapy who become pregnant while infection is in remission, azole
antifungal therapy may be discontinued with clinical and serological
monitoring every 4–6 weeks to assess for reactivation (W-L).
• An alternative to this, especially if the coccidioidal infection is not clearly in
remission, is to stop azole antifungal therapy and start intravenous AmB during the
first trimester, changing back to an azole antifungal after the first trimester (S-L).
Î For the pregnant woman with CM who is on azole antifungal therapy
at the time of pregnancy, azole therapy should be stopped for the first
trimester to avoid the risk of teratogenicity (S-M). During this period,
one approach is to initiate intrathecal AmB, especially if meningeal
signs and symptoms are present (S-M). Azole antifungal therapy may
then be restarted during the second trimester (W-L) or intrathecal
AmB continued throughout gestation (W-L). An alternative is to
continue azole antifungal therapy throughout gestation provided that
the mother agrees to this approach after being educated regarding
the risks and benefits of this strategy (W-L). A final alternative for the
pregnant woman with CM is to stop the azole antifungal, monitor the
patient closely during the first trimester, and restart azole antifungal
therapy during the second or third trimester (W-VL).
• Because of the risk of relapse with this approach, some experts do not recommend it.
Treatment
