Treatment of sporotrichosis

Manifestation	Preferred treatment	Alternative treatment	Duration	Comments
Manifestation of sporotrichosis
Cutaneous/lymphocutaneous	Itraconazole 200 mg orally once daily^*	Itraconazole 200 mg orally twice daily^* or Terbinafine 500 mg orally twice daily^¶ or SSKI initiated at a dosage of 5 drops (0.25 mL = 250 mg) orally 3 times daily and increasing to 40 drops (2 mL = 2 g) to 50 drops (2.5 mL = 2.5 g) orally 3 times daily, as tolerated; administer SSKI drops in juice or milk or Fluconazole 400 to 800 mg orally once daily (least preferred) or Local hyperthermia^Δ	Treat for 2 to 4 weeks after lesions completely resolve Duration is usually a total of 3 to 6 months
Disseminated	Lipid AmB 3 to 5 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	Deoxycholate AmB 0.7 to 1 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	Continue therapy with AmB until the patient shows objective evidence of improvement Treat for a total of at least 12 months	For immunosuppressed patients, consider long-term suppression with itraconazole 200 mg orally once daily^*
Meningitis	Lipid AmB 5 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	Deoxycholate AmB 0.7 to 1 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	Continue therapy with AmB for at least 4 to 6 weeks (although length of therapy is not well established; shorter or longer courses may be appropriate in the clinical context) Treat for a total of at least 12 months	For immunosuppressed patients, consider long-term suppression with itraconazole 200 mg orally once daily^*
Osteoarticular	Itraconazole 200 mg orally twice daily^*	Lipid AmB 3 to 5 mg/kg IV once daily^◊	If AmB was used initially, switch to itraconazole^* once symptoms improve Treat for a total of at least 12 months
Pulmonary	Mild/moderate disease: Itraconazole 200 mg orally twice daily^* Severe: Lipid AmB 3 to 5 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	Deoxycholate AmB 0.7 to 1 mg/kg IV once daily followed by itraconazole 200 mg orally twice daily^*	If AmB was used initially, switch to itraconazole^* once symptoms improve Treat for a total of at least 12 months
Special populations
Children	Cutaneous and mild disease: Itraconazole 3 to 5 mg/kg orally twice daily (400 mg/day maximum) Severe or disseminated disease: Lipid AmB 3 to 5 mg/kg IV once daily	Cutaneous disease: SSKI initiated at a dosage of 1 drop (0.05 mL = 50 mg) orally 3 times daily and increasing to 1 drop (0.05 mL) per kg orally 3 times daily, as tolerated maximum: 40 drops (2 mL = 2 g) to 50 drops (2.5 mL = 2.5 g) orally 3 times daily; administer SSKI drops in juice or milk Severe or disseminated disease: Deoxycholate AmB 0.7 mg/kg IV once daily	Cutaneous disease: Treat for 2 to 4 weeks after lesions resolve; duration is usually a total of 3 to 6 months. Severe or disseminated disease: Continue treatment with AmB until the patient shows objective evidence of improvement. Then transition to oral itraconazole^* for a total of 12 months.
Pregnant people	Cutaneous disease: Local hyperthermia Mild/moderate disease: Defer treatment until after delivery, if possible Severe or disseminated disease: Lipid AmB 3 to 5 mg/kg IV once daily	Severe or disseminated disease: Deoxycholate AmB 0.7 to 1 mg/kg IV once daily	Duration is generally similar to what is indicated for the general population	Azoles are contraindicated during pregnancy It is preferable to wait until after delivery to treat non-life-threatening forms of sporotrichosis

For approach to treatment and selection of therapy and dose intensity, refer to UpToDate content on treatment of infection due to Sporothrix schenckii (sporotrichosis). The doses listed are intended for adult patients (except as noted) with normal liver and kidney function; doses of some of these agents must be adjusted or use avoided in patients with impaired liver or kidney function. For specific dose adjustments, refer to the drug monographs included within UpToDate. Azole antifungals are subject to numerous drug interactions via CYP3A4 and/or P-glycoprotein inhibition which may require dose adjustment or avoidance of certain combinations; specific interactions can be evaluated by use of the drug interactions program.

AmB: amphotericin B; IV: intravenous; Lipid AmB: liposomal or lipid complex formulation of amphotericin B; SSKI: 1 g/mL saturated solution potassium iodide.

* Itraconazole oral solution has greater bioavailability than conventional capsules and may be preferred. If capsules are used, administer with a meal to improve absorption. Patients requiring treatment with drugs that increase gastric pH (eg, proton pump inhibitor, H2 blockers, antacids) should receive oral solution. To ensure adequate levels, serum concentrations should be checked after the patient has taken the drug for at least 2 weeks; dose should be adjusted to target a level >1 mcg/mL.

¶ Transaminase levels are typically checked at baseline and repeated at 6 weeks if treatment will continue beyond 6 weeks.

Δ Local hyperthermia can be used for treating patients, such as people who are pregnant and nursing, who have fixed cutaneous sporotrichosis and who cannot safely receive any of the other regimens.

◊ If lipid amphotericin B formulations are not available, deoxycholate amphotericin B 0.7 to 1 mg/kg IV once daily is a reasonable alternative.

Reference:

de Lima Barros MB, Schubach AO, de Vasconcellos Carvalhaes de Oliveira R, et al. Treatment of cutaneous sporotrichosis with itraconazole--Study of 645 patients. Clin Infect Dis 2011; 52:e200.

Adapted from: Kauffman CA, Bustamante B, Chapman SW, et al. Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:1255.

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Treatment of sporotrichosis