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## Complete Summary

#### GUIDELINE TITLE

Coccidioidomycosis.

#### BIBLIOGRAPHIC SOURCE(S)

Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA,
Williams PL. Coccidioidomycosis. Clin Infect Dis 2005 Nov
1;41(9):1217-23. \[47 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16206093)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Galgiani JN, Ampel NM,
Catanzaro A, Johnson RH, Stevens DA, Williams PL. Practice guidelines
for the treatment of coccidioidomycosis. Infectious Diseases Society of
America. Clin Infect Dis 2000 Apr;30(4):658-61.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Coccidioidomycosis (inhalation of *Coccidioides immitis* or *C.
posadasii* spores, \[also known as valley fever\])

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Infectious Diseases\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations about which patients with coccidioidomycosis
are likely to benefit from treatment and which therapies are most
appropriate for various forms of infection

#### TARGET POPULATION

Patients with coccidioidomycosis

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Periodic reassessment of symptoms, physical examination, sputum
    cultures, measurement of coccidioidal serum antibodies, fine needle
    aspiration of lung nodules, identification of dissemination (culture
    of suspicious skin lesions, analysis of aspirates of joint
    effusions, and lumbar puncture), laboratory studies, and
    radiographic studies (without antifungal treatment)

2.  Pharmacotherapy (antifungal therapy)

    -   Amphotericin B deoxycholate, lipid formulations of amphotericin
        B

    -   Azole antifungals

3.  Surgical management (resection, debridement, lobectomy)

4.  Shunt for hydrocephalus

5.  Prophylactic fluconazole therapy for solid-organ transplant
    recipients

6.  Management of coccidioidomycosis in patients infected with human
    immunodeficiency virus-1 (HIV-1)

#### MAJOR OUTCOMES CONSIDERED

-   Resolution of signs and symptoms of infection

-   Reduction of serum concentrations of antibodies to *Coccidioides
    immitis*

-   Return of function of involved organs

-   Prevent relapse of illness upon discontinuation of therapy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of Evidence**

I.  Evidence from at least one properly randomized, controlled trial

II. Evidence from at least one well-designed clinical trial without
    randomization, from cohort or case-controlled analytic studies
    (preferably from more than one center), from multiple time-series
    studies, or from dramatic results of uncontrolled experiments

III. Evidence from opinions of respected authorities based on clinical
     experience, descriptive studies, or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendation**:

A.  Good evidence to support a recommendation for use; should always be
    offered

B.  Moderate evidence to support a recommendation for use; should
    generally be offered

C.  Poor evidence to support a recommendation; optional

D.  Moderate evidence to support a recommendation against use; should
    generally not be offered

E.  Good evidence to support a recommendation against use; should never
    be offered

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A revision of the original Practice Guidelines for Coccidioidomycosis
was circulated among the authors. Subsequently revised drafts were
reviewed for comment by members of the Arizona Infectious Diseases
Society (6-7 March 2004) and by health care professionals who attended
the 48th Annual Coccidioidomycosis Study Group Meeting (held on 3 April
2004).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the levels of evidence (I-III) and grades of
recommendation (A-E) are provided at the end of the \"Major
Recommendations\" field.

**[Primary Respiratory Infection]{.underline}**

Primary infections due to *Coccidioides* species most frequently
manifest as community-acquired pneumonia 1 to 3 weeks after exposure.
Distinguishing coccidioidomycosis from other etiologies is usually
difficult without specific laboratory confirmation, such as detection of
anticoccidioidal antibodies in serum samples or identification of
*Coccidioides* species in sputum samples or another respiratory
specimen. Therefore, residents of and recent travelers to regions where
community-acquired pneumonia is endemic should be evaluated for
*Coccidioides* species as a possible etiologic agent. *Coccidioides*
species are listed by the Centers for Disease Control and Prevention
(CDC) as Select Agents, and their growth in culture requires handling in
a secure and contained fashion.

**Uncomplicated Acute Coccidioidal Pneumonia**

How best to manage primary respiratory coccidioidal infections is an
unsettled issue because of the lack of prospective controlled trials.
For many (if not most) patients, management may rely on periodic
reassessment of symptoms and radiographic findings to assure resolution
without antifungal treatment. On the other hand, some authorities
propose treatment of all symptomatic patients to decrease the intensity
or duration of symptoms. Although physicians speculate that early
treatment may decrease the frequency or severity of dissemination, there
are no data to support this speculation **(C-III)**. Several special
circumstances are usually considered to warrant initiation of therapy.
Chief among these is concurrent immunosuppression, such as that which
accompanies acquired immune deficiency syndrome (AIDS), receipt of an
organ transplant, therapy with high-dose corticosteroids, or receipt of
inhibitors of tumor necrosis factor (TNF) (such as etanercept or
infliximab). Also, other patients who are likely to handle pulmonary
coccidioidal infection less well include those with diabetes mellitus or
preexisting cardiopulmonary disease **(A-II)**. The diagnosis of primary
infection during pregnancy, especially in the third trimester or
immediately postpartum frequently prompts the initiation of treatment
**(A-III)**. During pregnancy, amphotericin B is the treatment of choice
because fluconazole (and likely other azole antifungals) are teratogenic
**(A-III)**. Persons of Filipino or African descent have a higher risk
for dissemination, and this may also be taken into consideration
**(B-III)**. Finally, patients who are judged to have exceptionally
severe primary infections may be more likely to benefit from treatment
than those patients with a more mild illness. Although opinion varies as
to the most-relevant factors for judging severity of illness, commonly
used indicators include weight loss of \>10%, intense night sweats
persisting longer than 3 weeks, infiltrates involving more than one-half
of one lung or portions of both lungs, prominent or persistent hilar
adenopathy, anticoccidiodial complement-fixing antibody concentrations
in excess of 1:16 (as determined by a reference method or equivalent
titer), inability to work, symptoms that persist for \>2 months, or age
\>55 years. Commonly prescribed therapies include currently available
oral azole antifungal agents at dosages of 200 to 400 mg per day.
Courses of typically recommended treatment range from 3 to 6 months.

As the patient\'s illness improves, either with or without antifungal
therapy, continued monitoring at 1 to 3-month intervals for 1 year or
longer is advised to assess the resolution of pulmonary infiltrates and
to identify, as early as possible, those patients who develop infection
outside of the chest. Monitoring usually should include patient
interviews, physical examinations (as appropriate), serologic tests, and
radiographic examinations. Determining pulmonary lesions that evolve
into residual nodules is useful because it obviates the need for
establishing the nodule\'s etiology at a future time. Identifying
dissemination is accomplished with histologic examination and culture of
suspicious skin lesions, analysis of aspirates of joint effusions, and
lumbar puncture of patients who develop progressively severe or
persistent headaches, mental status changes, or other meningeal signs.
Although extrapulmonary dissemination is infrequent, early detection of
patients in whom dissemination does occur would afford benefit by
earlier initiation of treatment and a resulting reduction in tissue
destruction.

**Diffuse Pneumonia**

Bilateral reticulonodular or military infiltrates produced by
*Coccidioides* species suggest either an underlying immunodeficiency
state with concurrent fungemia or an exposure to a high inoculum of
fungal spores, as may occur as a result of laboratory accidents or at
archeology sites. In such patients, therapy is usually begun either with
amphotericin B or high-dose fluconazole. Amphotericin B is more
frequently used as initial therapy if significant hypoxia is present or
if deterioration is rapid **(A-III)**. Several weeks of therapy are
often required to produce clear evidence of improvement. After this
time, during convalescence, amphotericin B therapy may be discontinued
and replaced with treatment with an oral azole antifungal **(B-III)**.
In combination, the total length of therapy should be at least 1 year,
and for patients with severe immunodeficiency, oral azole therapy should
be continued as secondary prophylaxis **(A-III)**. Because diffuse
pneumonia due to *Coccidioides* species is usually a manifestation of
fungemia, patients should be evaluated for the possibility of other
extrapulmonary lesions that may also require attention.

**[Pulmonary Nodule, Asymptomatic]{.underline}**

If a stable solitary nodule is determined to be due to *Coccidioides*
species by noninvasive means or by fine-needle aspiration, specific
antifungal therapy, or resection is unnecessary **(E-II)**. Similarly,
in the absence of significant immunosuppression, antifungal therapy is
not recommended if the lesion is completely resected and the diagnosis
is determined from the excised tissue. Stability can be determined by
repeated radiographic examination of the chest for 2 years demonstrating
no change in the size of the nodule. Should enlargement of the nodule
occur, reevaluation with sputum cultures and measurement of coccidioidal
serum antibodies may help to determine whether the patient\'s infection
is active and warrants therapy. Consideration also should be given to
the possibility of cancer coexistent with the coccidioidal infection, in
which case resection of the nodule would usually be necessary.

**[Pulmonary Cavity]{.underline}**

**Asymptomatic**

Many cavities caused by *Coccidioides* species are benign in their
course and do not require intervention. Such cavities harbor viable
fungus, and cultures of samples of sputum or other respiratory
secretions commonly yield colonies of *Coccidioides* species. Most
authorities do not consider these characteristics of asymptomatic
cavities sufficient reason to initiate treatment. Moreover, in the
absence of controlled clinical trials, evidence is lacking that
antifungal therapy has a salutary effect on the course of asymptomatic
coccidioidal cavities **(B-III)**. With the passage of time, some
cavities disappear, obviating the need for intervention. Although an
indefinite follow-up period without intervention is appropriate for many
patients, eventual resection from 1 to several years after the cavity is
identified may be recommended to avoid future complications, especially
if the cavity is still detectable after 2 years, if it demonstrates
progressive enlargement, or if it is immediately adjacent to the pleura
**(B-III)**.

**Symptomatic**

Complications of coccidioidal cavities include local discomfort,
superinfection with other fungi or possibly bacteria, or hemoptysis.
Should these complications occur, oral therapy with azole antifungals
may result in improvement, although recurrence of symptoms, (at least in
some patients), may occur on cessation of therapy. If a bacterial
superinfection is present, treatment for several weeks with an oral
antibacterial may also reduce symptoms. However, such therapies usually
do not result in the closure of the cavity. In cases in which the
surgical risks are not unusually high, resection of localized cavities
is likely to resolve the problem and may be recommended as an
alternative approach to chronic or intermittent therapy.

**Ruptured**

Rupture of a coccidioidal cavity into the pleural space, resulting in a
pyopneumothorax, is an infrequent but serious complication of a
necrotizing coccidioidal pneumonia. In young, otherwise-healthy
patients, surgical closure by lobectomy with decortication is the
preferred management **(A-II)**. Antifungal therapy is recommended for
treatment, particularly in cases with delay of diagnosis and coexistent
diseases **(C-III)**. For patients for whom the diagnosis was delayed a
week or more or for patients in whom there are coexistent diseases,
management approaches are less uniform and may include courses of
therapy with amphotericin B or oral azole antifungal drugs prior to
surgery, or chest tube drainage without surgery **(C-III)**.

**[Chronic Progressive Fibrocavitary Pneumonia]{.underline}**

Initial treatment with oral azole antifungal agents is recommended
**(A-II)**. If the patient improves sufficiently, therapy should be
continued for at least 1 year. If therapy is not satisfactory, switching
to an alternative azole antifungal, raising the dosage of the azole, or
therapy with amphotericin B are alternative strategies **(B-III)**.
Surgical resection may be a useful option for refractory lesions that
are well localized or in cases in which significant hemoptysis has
occurred.

**[Disseminated Infection (Extrapulmonary)]{.underline}**

**Nonmeningeal**

Initial therapy is usually initiated with oral azole antifungal agents,
most commonly fluconazole or itraconazole **(A-II)**. Clinical trials
have used 400 mg per day of ketoconazole, itraconazole, or fluconazole.
Some experts recommend higher dosages (up to 2000 mg per day of
fluconazole; up to 800 mg per day of itraconazole, administered in
200-mg doses) **(B-III)**. Amphotericin B is recommended for alternative
therapy, especially if lesions are appearing to worsen rapidly and are
in particularly critical locations, such as the vertebral column
**(B-III)**. Amphotericin B dosage is similar to that for diffuse
coccidioidal pneumonia, although the duration of therapy may be longer.
In patients experiencing failure of conventional deoxycholate
amphotericin B therapy or experiencing intolerable drug-related
toxicities, lipid amphotericin B formulations have been demonstrated to
be safe and to cause less nephrotoxicity and may be considered. Animal
model studies have indicated that the higher amphotericin B dosages that
can be given via lipid formulations produce results superior to those
seen with the maximally tolerated deoxycholate amphotericin B. However,
there have been no clinical trials assessing the efficacy of lipid
formulations of amphotericin B.

Combination therapy with amphotericin B and an azole has been
administered to some patients, especially when infection is widespread
or in cases in which there has been disease progression during treatment
with a single agent. Although combination therapy may improve responses,
there is no evidence that such an approach is superior to treatment with
a single agent, and for other fungal infections, there are examples of
antagonism with combination therapy, as has been demonstrated in vitro
with *Coccidioides* species.

Surgical debridement or stabilization is an occasionally important, if
not critical, adjunctive measure. Factors that favor a recommendation
for surgical intervention are large size of abscesses, progressive
enlargement of abscesses or destructive lesions, presence of bony
sequestrations, instability of the spine, or impingement on critical
organs (such as a pericardial effusion on the heart) or tissues (such as
an epidural abscess on the spinal cord).

**Meningitis**

Therapy with oral fluconazole is currently preferred by most clinicians.
The dosage used in reported clinical trials was 400 mg per day
**(A-II)**. Some physicians begin therapy with 800 or 1000 mg per day of
fluconazole **(B-III)**. Itraconazole, administered in dosages of 400 to
600 mg per day has also been reported to be comparably effective
**(B-II)**. Some physicians also initiate therapy with intrathecal
amphotericin B in addition to an azole on the basis of their belief that
responses are more prompt with this approach. The dose and duration of
intrathecal amphotericin B in this circumstance ranges between 0.1 mg
and 1.5 mg per dose **(C-III)**. Patients who respond to azole therapy
should continue this treatment indefinitely **(A-III)**. Hydrocephalus
nearly always requires a shunt for decompression **(A-III)**.
Hydrocephalus may develop regardless of the therapy being used and need
not require switching to alternative therapy **(B-III)**. Patients who
do not respond to fluconazole or itraconazole would be candidates for
intrathecal amphotericin B therapy with or without continuation of azole
treatment. The intrathecal dosage of amphotericin B normally ranges
between 0.1 and 1.5 mg per dose, administered at intervals ranging from
daily to weekly, beginning at a low dosage and increasing the size of
the dosage until the appearance of patient intolerance (indicated by
severe vomiting, prostration, or transient dose-related mental status).

The most common life-threatening complication of coccidioidal meningitis
in the modern era is central nervous system (CNS) vasculitis leading to
cerebral ischemia, infarction, and hemorrhage. Some physicians have
personal experience demonstrating the efficacy of administering
high-dose, intravenous, short-term corticosteroids for this condition,
whereas other physicians have not noted similar benefit.

**[Prophylaxis for Coccidioidomycosis in Solid-Organ Transplant
Recipients]{.underline}**

The risk of coccidioidomycosis among solid-organ transplant recipients
in an area of endemicity was 4% to 9%, with the majority of infections
occurring within 1 year after transplantation. Because infection in such
patients frequently disseminates and carries a high risk of mortality,
there is interest in reducing the number of these complications in
patients from or within the regions of endemicity by use of preemptive
prophylactic antifungal therapy. One transplantation program in the area
of endemicity has employed a strategy of targeted prophylaxis, whereby
patients with certain risk factors for coccidioidomycosis (a positive
serological test result prior to receipt of a transplant or a history of
coccidioidomycosis) receive prophylactic fluconazole at the time of
transplantation, and thus far, the results are encouraging.

**[Management of Patients Infected with HIV-1]{.underline}**

Before the introduction of highly active antiretroviral therapy (HAART),
coccidioidomycosis was a major opportunistic infection in the area of
endemicity among individuals infected with human immunodeficiency virus
(HIV)-1. The incidence of clinically apparent coccidioidal infection has
since decreased. Prevention of coccidioidomycosis among HIV-1-infected
patients living in the area of coccidioidal endemicity by prophylactic
use of an antifungal is not effective for most patients. Treatment is
recommended for all patients with HIV-1 infection and peripheral blood
CD4+ lymphocyte counts \<250 cells/microL who have clinically active
coccidioidomycosis. Therapy should be continued as long as the CD4+ cell
count is \<250 cells/microL. However, it may be reasonable to stop
therapy in those patients with higher CD4+ cell counts if there is
clinical evidence of control of the coccidioidal infection (except for
patients with meningitis, for whom therapy should be life-long).

**[Definitions]{.underline}**:

**Quality of Evidence**

I.  Evidence from [\>]{.underline}1 properly randomized, controlled
    trial

II. Evidence from [\>]{.underline}1 well-designed clinical trial,
    without randomization; from cohort or case-controlled analytic
    studies (preferably from \>1 center); from multiple time-series; or
    from dramatic results of uncontrolled experiments

III. Evidence from opinions of respected authorities, based on clinical
     experience, descriptive studies, or reports of expert committees

**Strength of Recommendation**

A.  Good evidence to support a recommendation for use; should always be
    offered

B.  Moderate evidence to support a recommendation for use; should
    generally be offered

C.  Poor evidence to support a recommendation; optional

D.  Moderate evidence to support a recommendation against use; should
    generally not be offered

E.  Good evidence to support a recommendation against use; should never
    be offered

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Early identification and treatment of complications will decrease the
amount of tissue destruction and resulting morbidity. Effective therapy
is potentially lifesaving.

**Subgroups Most Likely to Benefit**

Persons of African and Filipino descent have a higher risk for
dissemination.

#### POTENTIAL HARMS

-   Side effects of and drug interactions associated with antifungal
    therapy

-   Risks associated with surgery

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Published reports of intravenous amphotericin B treatment of chronic
pulmonary or extrapulmonary nonmeningeal coccidioidomycosis are limited
to small numbers of patients treated in open-label, nonrandomized
studies. Treatment of coccidioidal meningitis with intrathecal
amphotericin B has been reported as accumulated experience of individual
investigators.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Johnson RH, Stevens DA,
Williams PL. Coccidioidomycosis. Clin Infect Dis 2005 Nov
1;41(9):1217-23. \[47 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16206093)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Apr (revised 2005 Nov 1)

#### GUIDELINE DEVELOPER(S)

Infectious Diseases Society of America - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Infectious Diseases Society of America (IDSA)

#### GUIDELINE COMMITTEE

Infectious Diseases Society of America (IDSA) Practice Guidelines
Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: John N. Galgiani, Valley Fever Center for Excellence,
Southern Arizona Veterans Affairs Health Care System, University of
Arizona, Tucson; Neil M. Ampel, Valley Fever Center for Excellence,
Southern Arizona Veterans Affairs Health Care System, University of
Arizona, Tucson; Janis E. Blair, Mayo Clinic, Scottsdale, Arizona;
Antonino Catanzaro, University of California, San Diego; Royce H.
Johnson, Kern Medical Center, Bakersfield; David A. Stevens, Santa Clara
Valley Medical Center, Stanford University, San Jose; Paul L. Williams,
Kaiser Permanente Medical Center, Fresno, California

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

A.C. has received grant support from Schering and has lectured for
Pfizer. J.N.G. has received research support or has been a consultant
for Pfizer, Janssen, Merck, Schering, Enzon, and Lilly. R.H.J. has
received grant support from Pfizer; is a member of the speakers\'
bureaus for Sanofi-Aventis, Enzon, and Merck; and has been on the
speakers\' bureau of Bristol Myers-Squibb and Bayer. D.A.S. has received
research support from and has been a consultant for Janssen,
Ortho-McNeil, Pfizer, Gilead, Enzon, and Schering. All other authors: no
conflicts.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Galgiani JN, Ampel NM,
Catanzaro A, Johnson RH, Stevens DA, Williams PL. Practice guidelines
for the treatment of coccidioidomycosis. Infectious Diseases Society of
America. Clin Infect Dis 2000 Apr;30(4):658-61.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Infectious Disease Society of
America (IDSA) Web
site](http://www.journals.uchicago.edu/cgi-bin/resolve?CID37505).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Kish MA. Guide to development of practice guidelines. Clin Infect
    Dis 2001 Mar 15;32(6):851-4.

Electronic copies: Available from the [Clinical Infectious Diseases
Journal Web
site](http://www.journals.uchicago.edu/doi/full/10.1086/319366).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

A PDA version of the original guideline document is available from
[www.idsaguidelinesforhandhelds.org](http://www.idsaguidelinesforhandhelds.org/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 1, 2001. The information was
verified by the guideline developer as of June 29, 2001. This summary
was updated by ECRI on November 14, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/10/2008