Reprinted from www.antimicrobe.org Table 2. Recommendations for Antimicrobial Therapy of Infections Caused by Black Fungi Clinical entity First-line therapy Second-line therapy Options for refractory infections Chromoblastomycosis Itraconazole (oral 200-400 Partial surgical resection and/or Repeated surgical resection; mg daily) for 2 - 3 cryotherapy combined with itraconazole and flucytosine; months or longer itraconazole (200 - 600 mg amphotericin B and daily) or voriconazole (400- flucytosine; ketoconazole; 600mg daily) until 2 - 3 months ketoconazole and flucytosine; after apparent mycologic cure itraconazole and terbinafine Mycetoma Itraconazole (200- Partial surgical resection Repeated surgical resection; 400 mg daily) for 2 - 3 combined itraconazole (200 - amphotericin B; ketoconazole months or longer 600 mg daily) or voriconazole and flucytosine; itraconazole (400-600mg daily); until 2 - 3 and flucytosine; amphotericin months after apparent mycologic B and flucytosine; cure itraconazole and terbinafine Subcutaneous Itraconazole (200- Partial surgical resection Repeated surgical resection; phaeohyphomycosis 400 mg daily) for 2 - 3 combined with itraconazole (200 amphotericin B; ketoconazole; months; if organisms are - 600 mg daily) or voriconazole addition of flucytosine or Immunocompetent hosts contained within a cyst, (400-600mg daily) until 2 - 3 terbinafine to medical adjunctive antifungal months after apparent mycologic regimen therapy is not needed cure Immunocompromised Itraconazole (200 - Partial surgical resection Repeated surgical resection; hosts 400mg daily), or combined with itraconazole (200 addition of flucytosine or amphotericin B (1 - 600 mg daily), voriconazole terbinafine to medical mg/kg/day) until 2 - 3 (400-600mg daily), amphotericin regimen months after apparent B (1 mg/kg/day), or mycologic cure ketoconazole (300 - 400 mg daily) until 2 - 3 months after apparent mycologic cure Cutaneous Itraconazole (200 mg Voriconazole (400mg daily) Terbinafine; Ketoconazole phaeohyphomycosis daily) until 2- 3 months Dermatomycosis, after apparent mycologic cure onychomycosis Keratomycosis Natamycin (5% Topical natamycin or Prior therapy with penetrating solution) topically amphotericin B (0.15%) keratoplasty combined with flucytosine (1% aqueous solution); topical itraconazole, ketoconazole, or miconazole; oral itraconazole (400 mg daily); oral voriconazole (400mg daily); oral ketoconazole (400 mg daily) Sinusitis Surgical drainage and Itraconazole (200-400mg daily); Allergen immunotherapy to debridement, combined voriconazole (400mg daily) decrease IgE production Allergic fungal sinusitis with postoperative corticosteroids; postoperative nasal saline irrigations and regular surveillance endoscopy Fungus ball Resection of fungus ball, In cases of local invasion of Voriconazole with aeration of sinuses bone, itraconazole or amphotericin B are indicated as adjunctive therapy Reprinted from www.antimicrobe.org Allergic bronchopulmonary Corticosteroids Corticosteroids with itraconazole mycosis (200-400mg daily) or voriconazole (400mg daily) Pneumonia Itraconazole (400mg Voriconazole (400-600mg daily) Amphotericin B with daily) or amphotericin B flucytosine (1mg/kg daily) for severe disease Central nervous system Surgical resection (brain Repeated surgical resection with infection abscess) with high dose high dose azole + echinocandin itraconazole (400-600mg +/- flucytosine daily) or voriconazole (400-600mg daily) + lipid amphotericin B +/- flucytosine Disseminated infection High dose lipid High dose lipid amphotericin B amphotericin B with azole +/- echinocandin +/- (>5mg/kg daily) with flucytosine; colony stimulating intravenous itraconazole factors if neutropenic (400-600mg daily) or voriconazole (400- 600mg daily) +/- echinocandin; colony stimulating factors if neutropenic .