Cryptococcosis Management
Key Points
Key Points
- Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality.
- Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies.
- If the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.
Selecting a Treatment Regimen
...g a Treatment Regimen...
...1. Antifungal Treatment Recommendations for Nonmen...
...nosuppressed patients and immunocompe...
...ed patientsa and immunocompetent patients wi...
...onmeningeal, Nonpulmonary Cryptococcosis...
...nts with cryptococcemiaSame as CNS disease...
...m CNS disease has been ruled out with no fu...
...able 2. Antifungal Treatment Recommendation...
...tion TherapyaLiposomal AmB (3-4 mg/kg per day...
...ternatives for Induction Therap...
...omal AmB (6 mg/kg per day) or ABLC...
....7 mg/kg per day)for 4-6 weeks (B, III)659...
...on therapy: Fluconazole (400-800 mg per day...
...ce therapy: Fluconazole (200-400 mg...
...able 3. Antifungal Treatment Recomme...
...duction Therapy...
...Bda,b (0.7-1.0 mg/kg per day) plus flucyto...
...mBdc (0.7-1.0 mg/kg per day) for ≥ 6 weeksa...
...3-4 mg/kg per day) or ABLCd (5 mg/kg per day...
...mBde (0.7 mg/kg per day) plus flucytosin...
...erapy: Fluconazole (400-800 mg per day)f for 8 we...
...tenance therapy: Fluconazole (200...
...fungal Treatment Recommendations for Cryptococc...
...duction Therapy
...da (0.7-1.0 mg/kg per day) plus flucytosine (10...
...omal AmB (3-4 mg/kg per day) or ABLCa (5 mg/kg...
...7-1.0 mg/kg per day) or liposomal AmB (3-4 mg/kg...
Alternatives for Induction Therap...
...lus fluconazole (B, I)65...
...plus flucytosine (B, II)659
Fluconazole (B, II)...
Itraconazole (C, II)659
...tion therapy: Fluconazole (400 mg per day)...
...therapy: Fluconazole (200 mg per day)a...
...for Maintenance Therapyc
...zole (400 mg per day)d for ≥1 year (C, I...
...kg per week) for ≥1 yearc (C, I)659...
...active antiretroviral therapy (aHAART) 2-10...
...Non-Meningeal Cryptococcosis...
...tococcal Meningoencephalitis...
Complications
...lications...
...anagement of Complications in Patie...
...sistence...
...quate measures have been taken to improve im...
...institute induction phase of primary the...
...l dosage of induction therapy was ≤0....
If the patient is polyene intolerant, consider...
If patient is flucytosine intolerant,...
...intrathecal or intraventricular AmBd...
...eally, persistent and relapse isola...
...patients, increasing the dose of the azole...
...ological therapy with recombinant interf...
Relapse
...duction phase therapy (see Persistence...
...termine susceptibility of the relapse i...
...fter induction therapy and in vitro sus...
If there are compliance issues and...
...vated CSF Pressu...
...dentify CSF pressure at baseline. A prompt bas...
...CSF pressure is ≥25 cm of CSF and...
...istent pressure elevation ≥25 cm of CS...
...nent ventriculoperitoneal (VP) shunt...
...er Medications for Intracrani...
...no proven benefit and is not routinely recomm...
...e and corticosteroids to control i...
...ticosteroids if signs of IRIS are present...
...ence of Signs and Symptoms...
...urrence of signs and symptoms, reinstitute d...
...patients with recurrence, measurement o...
...ong-term Elevated Intracranial Press...
...pressure remains elevated and if sympt...
...ebral Cyptococcomas...
...herapy with AmBd (0.7-1.0 mg/kg per day IV), l...
...onsolidation and maintenance therapy with fluc...
...eroids for mass effect and surrounding e...
...for large (≥3 cm), accessible lesions...
...RIS
...o need to alter direct antifungal...
...itive specific treatment recommendation...
...r major complications, such as CNS inflammation...
...idal anti-inflammatory drugs and thalidomide have...
...Special Clinical Situations...
...regnant Women with Cryptococ...
...sseminated and CNS disease, use AmBd or LF...
...e (pregnancy category C) after delivery; avoid...
...ted and stable pulmonary cryptococco...
...atch for IRIS in the postpartum perio...
...ildren with Cryptococcosis
...consolidation therapy for CNS and dissemina...
...tenance therapy is fluconazole (6 mg/kg per day...
...ion of maintenance therapy in children receiving H...
...cryptococcal pneumonia, use fluconazole (6-1...
...occosis in a Resource-Limited Healt...
...S and/or disseminated disease where flucytosine...
...apy is fluconazole (200-400 mg per day ora...
...CNS and/or disseminated disease where polyene...
...NS and/or disseminated disease when polyene i...