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## Complete Summary

#### GUIDELINE TITLE

Clinical practice guidelines for the management of sporotrichosis: 2007
update by the Infectious Diseases Society of America (IDSA).

#### BIBLIOGRAPHIC SOURCE(S)

Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases
Society of America. Clinical practice guidelines for the management of
sporotrichosis: 2007 update by the Infectious Diseases Society of
America. Clin Infect Dis 2007 Nov 15;45(10):1255-65.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17968818)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Kauffman CA, Hajjeh R,
Chapman SW. Practice guidelines for the management of patients with
sporotrichosis. For the Mycoses Study Group. Infectious Diseases Society
of America. Clin Infect Dis 2000 Apr;30(4):684-7.

### COMPLETE SUMMARY CONTENT

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

### SCOPE

#### DISEASE/CONDITION(S)

Sporotrichosis including the following types:

-   Lymphocutaneous and cutaneous

-   Osteoarticular

-   Pulmonary

-   Meningeal

-   Disseminated (systemic)

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Dermatology\
Family Practice\
Infectious Diseases\
Internal Medicine\
Obstetrics and Gynecology\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the treatment of various forms of
sporotrichosis

#### TARGET POPULATION

Patients with sporotrichosis including pregnant women, children, and
immunosuppressed patients

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment**

1.  Itraconazole and obtaining serum levels of itraconazole after 2
    weeks of treatment

2.  Terbinafine for lymphocutaneous and cutaneous sporotrichosis

3.  Fluconazole for lymphocutaneous and cutaneous sporotrichosis

4.  Amphotericin B (either lipid formulation or amphotericin B
    deoxycholate)

5.  Local hyperthermia for cutaneous sporotrichosis

6.  Saturated solution of potassium iodide (SSKI) for lymphocutaneous
    and cutaneous sporotrichosis

7.  Surgery combined with amphotericin B for localized pulmonary disease

Refer to Table 2 in the original guideline document for information on
dosages and preferred treatment.

#### MAJOR OUTCOMES CONSIDERED

Effectiveness of treatment including cure/response rate and relapse rate

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

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

For the 2007 update, the Expert Panel reviewed and analyzed the
literature on the treatment of sporotrichosis published since 2000, as
well as literature noted in the 2000 Guidelines. Computerized literature
searches of PUBMED from January, 2000 to July, 2006 from both the
English and Spanish languages were performed. Searches were limited to
human-only studies.

#### NUMBER OF SOURCE DOCUMENTS

The search yielded 93 articles: 72 case reports, 17 reviews, 1 clinical
practice guideline and 2 multicenter, randomized, controlled treatment
trials.

#### 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 ≥1 properly randomized, controlled trial

II. Evidence from ≥1 well-designed clinical trial, without
    randomization; from cohort or case-controlled analytic studies
    (preferably from \>1 center); from multiple time-series studies; or
    from dramatic results from 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

In evaluating the evidence regarding the management of sporotrichosis,
the Panel followed a process used in the development of other Infectious
Diseases Society of America (IDSA) guidelines. The process included a
systematic weighting of the quality of the evidence and the grade of
recommendation (see the \"Rating Scheme for the Strength of the
Evidence\" and the \"Rating Scheme for the Strength of the
Recommendations\" fields). Recommendations for the treatment of
sporotrichosis were derived primarily from case reports and
nonrandomized treatment trials (see Table 2 in the original guideline
document).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

A panel of experts composed of infectious diseases specialists who were
from North and South America and who were experts in sporotrichosis was
convened. The panelists had both clinical and laboratory experience with
sporotrichosis. Panel participants are listed in Appendix 1 of the
original guideline document.

**Consensus Development Based on Evidence**

The Panel met via teleconference on three occasions to complete the work
of the guideline. The purpose of the teleconferences was to discuss the
questions to be addressed, make writing assignments and discuss
recommendations. All members of the panel participated in the
preparation and review of the draft guideline. Feedback from external
peer reviews was obtained.

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

**Strength of Recommendation**

A.  Good evidence to support a recommendation for use

B.  Moderate evidence to support a recommendation for use

C.  Poor evidence to support a recommendation

#### 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

All members of the Panel participated in the preparation and review of
the draft guideline. Feedback from external peer reviews was obtained.
The guideline was reviewed and approved by the Standards and Practice
Guidelines Committee (SPGC) and the Board of Directors prior to
dissemination.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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

**What Is the Treatment for Lymphocutaneous and Cutaneous
Sporotrichosis?**

-   For cutaneous and lymphocutaneous sporotrichosis, itraconazole 200
    mg orally daily is recommended to be given for 2 to 4 weeks after
    all lesions have resolved, usually a total of 3 to 6 months
    **(AII)**.

-   Patients who do not respond should be given a higher dosage of
    itraconazole, 200 mg twice daily **(AII)**, terbinafine at a dosage
    of 500 mg orally twice daily **(AII)**, or saturated solution of
    potassium iodide (SSKI) initiated at a dosage of 5 drops (using a
    standard eye-dropper) 3 times daily, increasing as tolerated to 40
    to 50 drops 3 times daily **(AII)**.

-   Fluconazole at a dosage of 400 to 800 mg daily should be used only
    if the patient cannot tolerate these other agents **(BII)**.

-   Local hyperthermia can be used for treating patients, such as
    pregnant and nursing women, who have fixed cutaneous sporotrichosis
    and who cannot safely take any of the previous regimens **(BIII)**.

**What Is the Treatment for Osteoarticular Sporotrichosis?**

-   Itraconazole 200 mg orally twice daily for at least 12 months is
    recommended **(AII)**.

-   Amphotericin B, given as a lipid formulation at 3 to 5 mg/kg daily,
    or amphotericin B deoxycholate, 0.7 to 1.0 mg/kg daily, can be used
    for initial therapy **(BIII)**. After the patient has shown a
    favorable response, therapy can be changed to itraconazole, 200 mg
    orally twice daily to complete a total of at least 12 months of
    therapy **(BIII)**.

-   Serum levels of itraconazole should be obtained after the patient
    has been on this agent for at least two weeks to ensure adequate
    drug exposure **(AIII)**.

**What is the Treatment for Pulmonary Sporotrichosis?**

-   For severe or life-threatening pulmonary sporotrichosis,
    amphotericin B, given as a lipid formulation at 3 to 5 mg/kg daily,
    is recommended **(BIII)**. Amphotericin B deoxycholate, 0.7 to 1.0
    mg/kg daily, could also be used **(BIII)**.

-   After the patient has shown a favorable response to amphotericin B,
    therapy can be changed to itraconazole, 200 mg orally twice daily to
    complete a total of at least 12 months of therapy **(BIII)**.

-   For less severe disease, itraconazole 200 mg orally twice daily for
    at least 12 months is recommended **(AIII)**.

-   Serum levels of itraconazole should be obtained after the patient
    has been on this agent for at least two weeks to ensure adequate
    drug exposure **(AIII)**.

-   Surgery combined with amphotericin B is recommended for localized
    pulmonary disease **(BIII)**.

**What is the Treatment for Meningeal Sporotrichosis?**

-   Amphotericin B, given as a lipid formulation at a dosage of 5 mg/kg
    daily for 4 to 6 weeks, is recommended for initial treatment of
    meningeal sporotrichosis **(BIII)**. Amphotericin B deoxycholate,
    0.7 to 1.0 mg/kg daily, could also be used but was not preferred by
    the panel **(BIII)**.

-   Itraconazole, 200 mg twice daily, is recommended as step-down
    therapy after the patient responds to initial treatment with
    amphotericin B and should be given to complete a total of at least
    12 months of therapy **(BIII)**.

-   Serum levels of itraconazole should be obtained after the patient
    has been on this agent for at least two weeks to ensure adequate
    drug exposure **(AIII)**.

-   For patients with acquired immunodeficiency syndrome (AIDS) and
    other immunosuppressed patients, suppressive therapy with
    itraconazole, 200 mg daily, is recommended to prevent relapse
    **(BIII)**

**What is the Treatment for Disseminated (Systemic) Sporotrichosis?**

-   Amphotericin B, given as a lipid formulation at a dosage of 3 to 5
    mg/kg daily, is recommended for disseminated sporotrichosis
    **(BIII)**. Amphotericin B deoxycholate, 0.7 to 1.0 mg/kg daily,
    could also be used but was not preferred by the panel **(BIII)**.

-   Itraconazole, 200 mg twice daily, is recommended as step-down
    therapy after the patient responds to initial treatment with
    amphotericin B and should be given to complete a total of at least
    12 months of therapy **(BIII)**.

-   Serum levels of itraconazole should be obtained after the patient
    has been on this agent for at least two weeks to ensure adequate
    drug exposure **(AIII)**.

-   Lifelong suppressive therapy with itraconazole, 200 mg daily may be
    required in patients with AIDS and other immunosuppressed patients
    if immunosuppression cannot be reversed **(BIII)**.

> **What is the Treatment for Sporotrichosis in Pregnant Women and in
> Children?**

-   Amphotericin B, given as a lipid formulation at a dosage of 3 to 5
    mg/kg daily, or amphotericin B deoxycholate, given as 0.7 to 1 mg/kg
    daily, is recommended for severe sporotrichosis that must be treated
    during pregnancy **(BIII)**; azoles should be avoided.

-   Local hyperthermia can be used for cutaneous sporotrichosis in
    pregnant women **(BIII)**.

-   Itraconazole, at a dosage of 6 to 10 mg/kg to a maximum of 400 mg
    orally daily, is recommended for children with cutaneous or
    lymphocutaneous sporotrichosis **(BIII)**.

-   An alternative for children is SSKI initiated at a dosage of 1 drop
    (using a standard eye-dropper) 3 times daily, increasing as
    tolerated up to a maximum of 1 drop/kg or 40 to 50 drops 3 times
    daily, whichever is lowest **(BIII)**.

-   For children with disseminated sporotrichosis, amphotericin B, 0.7
    mg/kg daily should be the initial therapy followed by itraconazole,
    6 to 10 mg/kg up to 400 mg daily maximum as step-down therapy
    **(BIII)**.

> **Performance Measures**

1.  Lymphocutaneous sporotrichosis should be treated with itraconazole
    or SSKI in countries in which the latter is the standard of care.
    When other azole agents are used, the medical record should document
    the specific reasons that they were chosen over itraconazole or
    SSKI.

2.  Patients with disseminated or severe pulmonary sporotrichosis should
    be treated with an amphotericin B formulation initially. When
    amphotericin B is used, the patient\'s electrolytes, renal function,
    and blood counts should be monitored several times a week and
    documented in the medical record.

> **[Definitions]{.underline}**:
>
> **Quality of Evidence**

I.  Evidence from ≥1 properly randomized, controlled trial.

II. Evidence from ≥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 from 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.

B.  Moderate evidence to support a recommendation for use.

C.  Poor evidence to support a recommendation

#### CLINICAL ALGORITHM(S)

> None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

> The recommendations for the treatment of sporotrichosis were derived
> primarily from case reports and nonrandomized treatment trials.
>
> The type of supporting evidence is identified and graded for each
> recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

> Appropriate treatment of various forms of sporotrichosis

#### POTENTIAL HARMS

-   *Itraconazole oral solution* is associated with gastrointestinal
    side effects. Absorption of the capsule formulation is erratic.
    Drug-drug interactions are frequent with itraconazole

-   *Terbinafine* is associated with gastrointestinal side effects and
    can cause liver toxicity.

-   *Saturated solution of potassium iodide* is inconvenient to take and
    its common side effects include metallic taste, nausea, abdominal
    pain, salivary gland enlargement, and rash.

-   Lipid formulations of *amphotericin B* are associated with decreased
    toxicity as compared with amphotericin B deoxycholate, but still
    cause nephrotoxicity and can cause infusion reactions.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

> Azoles should be avoided in pregnancy because of the teratogenic
> potential of this class of drugs.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

> It is important to realize that guidelines cannot always account for
> individual variation among patients. They are not intended to supplant
> physician judgment with respect to particular patients or special
> clinical situations. Infectious Diseases Society of America (IDSA)
> considers adherence to these guidelines to be voluntary, with the
> ultimate determination regarding their application to be made by the
> physician in the light of each patient\'s individual circumstances.

### 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

#### IOM DOMAIN

> Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

> Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases
> Society of America. Clinical practice guidelines for the management of
> sporotrichosis: 2007 update by the Infectious Diseases Society of
> America. Clin Infect Dis 2007 Nov 15;45(10):1255-65.
> [PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17968818)

#### ADAPTATION

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

#### DATE RELEASED

> 2000 Apr (revised 2007)

#### 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) Standards and Practice
> Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

> *Authors*: Carol A. Kauffman, University of Michigan, VA Medical
> Center, Ann Arbor, MI; Beatriz Bustamante, Universidad Peruana
> Cayetano Heredia, Lima - Perú; Stanley W. Chapman, University of
> Mississippi Medical Center, Jackson, MS; Peter G. Pappas, University
> of Alabama at Birmingham, Birmingham, AL

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

> C.A.K. Has research grants with Merck, Astellas and Schering-Plough
> and is on the Speaker\'s Bureau for Merck, Pfizer, Astellas and
> Schering-Plough
>
> B.B. has a research grant from Schering-Plough
>
> P.G.P. has research grants from Merck, Astellas, Pfizer and
> Schering-Plough and is on the speaker\'s bureau of Merck, Pfizer,
> Astellas and Schering-Plough
>
> S.W.C. No conflicts

#### GUIDELINE STATUS

> This is the current release of the guideline.
>
> This guideline updates a previous version: Kauffman CA, Hajjeh R,
> Chapman SW. Practice guidelines for the management of patients with
> sporotrichosis. For the Mycoses Study Group. Infectious Diseases
> Society of America. Clin Infect Dis 2000 Apr;30(4):684-7.

#### GUIDELINE AVAILABILITY

> Electronic copies: Available from the [Infectious Diseases Society
> (IDSA) Web
> site](http://www.journals.uchicago.edu/doi/full/10.1086/522765).
>
> Print copies: Available from Dr. Carol A. Kauffman, Infectious
> Diseases Section, VA Medical Center (111-I), 2215 Fuller Rd.,
> University of Michigan Medical School, Ann Arbor, MI 48105; E-mail:
> <ckauff@umich.edu>.

#### AVAILABILITY OF COMPANION DOCUMENTS

> 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 NGC
> summary was updated by ECRI Institute on October 24, 2007. The updated
> information was verified by the guideline developer on November 8,
> 2007.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

#### NGC DISCLAIMER

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> Date Modified: 11/3/2008
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