Coccidioidomycosis Treatment Guidelines

First-Line Antifungal Treatment Options

The Infectious Diseases Society of America recommends fluconazole as the standard drug of choice for treating coccidioidomycosis, with dosing considerations based on pediatric antifungal guidelines suggesting weight-based dosing (8-12 mg/kg/day, maximum 400-800 mg/day depending on severity) 1, 2, 3
The American Academy of Pediatrics suggests itraconazole as an alternative first-line option, with dosing: 5 mg/kg/day in two divided doses (maximum based on adult dosing of 200 mg twice daily) 4, 5
Therapeutic drug monitoring (TDM) is recommended with target trough concentration ≥0.5 mg/L for itraconazole 1, 5

Posaconazole can be used in patients ≥13 years of age, with dosing: 200 mg three times daily (oral suspension) or 300 mg once daily (gastro-resistant tablet preferred) 4, 1, 5
TDM is recommended with target trough concentration ≥0.7 mg/L for posaconazole 1, 5
Voriconazole is approved for patients ≥2 years, with dosing: 9 mg/kg twice daily orally (maximum 350 mg twice daily) or adult dosing if >50 kg 4, 1, 2
TDM is strongly recommended with target trough concentration ≥1 mg/L for voriconazole 4, 6, 5

Azoles (itraconazole, posaconazole, voriconazole) have significant interactions with immunosuppressants, including cyclosporine, tacrolimus, and sirolimus 4, 5
Careful attention to concomitant medications is essential when selecting antifungal therapy 4