Background: Coccidioidomycosis is a fungal infection of the desert southwestern US. While many afflicted suffer a self-limited disease, others require antifungal therapy. Currently used triazoles such as fluconazole and itraconazole have largely supplanted the use of amphotericin B which was fraught with adverse effects. Voriconazole and posaconazole have shown benefit for patients with coccidioidomycosis refractory to the first line agents in limited case reports and small open label trials.
Methods: We conducted a retrospective review of all patients who were prescribed voriconazole or posaconazole for coccidioidomycosis at our institution between 1/1/2006 and 8/1/2010. We used both a retrospectively-applied Mycosis Study Group score (which includes a composite score for symptoms, serology and radiographic findings) and the documented impression of the treating medical practitioner to assess outcomes.
Results: Twenty one patients received voriconazole and 16 received posaconazole and met criteria for study inclusion. After a median duration of 6 treatment months, 14 of the 21 (67%) voriconazole recipients were improved in overall status, 5 were unchanged, and 2 patients were deemed voriconazole failures. After a median treatment duration of 17 months, 12 of 16 (75%) posaconazole recipients were improved, 1 was unchanged, and 3 patients failed treatment due to medication intolerance or relapsed infection. The cost of the medication (voriconazole or posaconazole) was a limiting factor for 4 patients who ultimately discontinued the medication.
Conclusion: Voriconazole and posaconazole are reasonable but not infallible options for salvage treatment of refractory coccidioidal infections. The high cost of these medications may limit a patient’s ability to utilize such therapy. Prospective comparative trials are required to provide further insight into the efficacy and utility of one agent over the other.