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
...Selecting a Treatmen...
...Table 1. An...
...ppressed patients and immunocompetent...
...ssed patientsa and immunocompetent patients...
...Patien...
...cryptococcemiaSame as CNS disease for 1...
...hom CNS disease has been ruled out with no fu...
...Table 2....
...TherapyaLiposomal AmB (3-4 mg/kg per d...
...ves for Induction Therapyb...
...mB (6 mg/kg per day) or ABLC (5 mg/kg per d...
...0.7 mg/kg per day)for 4-6 weeks (B, III...
...dation therapy: Fluconazole (400-800 mg per day...
...apy: Fluconazole (200-400 mg per day) fo...
...Table 3. A...
...uction Therap...
...7-1.0 mg/kg per day) plus flucytosine (100...
...mg/kg per day) for ≥ 6 weeksa,b (B, II)65...
...somal AmB (3-4 mg/kg per day) or ABLCd (5...
AmBde (0.7 mg/kg per day) plus flucytosine (100...
...herapy: Fluconazole (400-800 mg per day)f for 8 w...
...e therapy: Fluconazole (200 mg per day)b for...
...Table 4. Antifungal Tre...
...ction Therapy...
....0 mg/kg per day) plus flucytosine (100 mg/kg p...
...3-4 mg/kg per day) or ABLCa (5 mg/kg per day,...
...mg/kg per day) or liposomal AmB (3-4...
...ternatives for Induction...
...plus fluconazole (B, I)659
...e plus flucytosine (B, II)659...
...uconazole (B, II)65...
...raconazole (C, II)...
...ation therapy: Fluconazole (400 mg per day)...
...intenance therapy: Fluconazole (200 mg per day...
...atives for Maintenance Therapyc...
...400 mg per day)d for ≥1 year (C,...
.../kg per week) for ≥1 yearc (C,...
...ly active antiretroviral therapy (a...
...ure 1. Non-Meningeal Cryptococ...
...2. Cryptococcal Meningoencephalitis...
Complications
...Comp...
...Management of Compli...
...Persistence...
...that adequate measures have been taken to improve...
...duction phase of primary therapy for longer...
...dosage of induction therapy was ≤0.7 mg/...
...f the patient is polyene intolerant, consider fl...
...is flucytosine intolerant, conside...
...ntrathecal or intraventricular AmBd is generall...
...istent and relapse isolates should be checked fo...
...le-exposed patients, increasing the dose of the az...
...immunological therapy with recombinant inte...
...Relapse...
...duction phase therapy (see Persistence). (B,...
...rmine susceptibility of the relapse iso...
...on therapy and in vitro susceptibilit...
...mpliance issues and a susceptible isolate, prior...
...ressure at baseline. A prompt baseline lumbar pun...
...ressure is ≥25 cm of CSF and there are symp...
If there is persistent pressure elevati...
...ermanent ventriculoperitoneal (VP) shun...
...Other Medicatio...
...o proven benefit and is not routinely reco...
...ide and corticosteroids to control increased int...
...osteroids if signs of IRIS are present (See IRIS)...
...Recurrence...
...ecurrence of signs and symptoms, reinstitute drain...
...patients with recurrence, measurement of opening...
...Long-te...
...CSF pressure remains elevated and if s...
...Cerebral Cyp...
...apy with AmBd (0.7-1.0 mg/kg per day...
...nsolidation and maintenance therapy with flu...
...rticosteroids for mass effect and surroundi...
...rgery: for large (≥3 cm), accessible lesions wi...
...IRIS...
...o need to alter direct antifungal therapy. (B, III...
...finitive specific treatment recommendation for...
...plications, such as CNS inflammation with...
...nti-inflammatory drugs and thalidomide h...
...Treatment in...
...Pregnant Wo...
...disseminated and CNS disease, use AmBd or...
...luconazole (pregnancy category C) after...
For limited and stable pulmonary cryptococco...
...IRIS in the postpartum period.659...
...Children with...
...n and consolidation therapy for CNS...
...herapy is fluconazole (6 mg/kg per day orally)...
...inuation of maintenance therapy in children recei...
...ococcal pneumonia, use fluconazole (6-12 mg/k...
...Cryptococcosis i...
...or CNS and/or disseminated disease where flu...
...therapy is fluconazole (200-400 mg...
...and/or disseminated disease where polyene i...
.../or disseminated disease when polyene is n...