Cryptococcosis Management

Publication Date: February 1, 2010

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

...cting a Treatment Regime...

...ifungal Treatment Recommendations for Non...

...ed patients and immunocompetent pati...

...mmunosuppressed patientsa and immunoc...


...Nonmeningeal, Nonpulmonary Cryptococcosis...

...nts with cryptococcemiaSame as CNS disease fo...

Patients for whom CNS disease has been...


...ifungal Treatment Recommendations for Cryptococ...

...nduction TherapyaLiposomal AmB (3-4 mg/kg per d...

...ives for Induction Therap...

...omal AmB (6 mg/kg per day) or ABLC (5 mg/kg pe...

...mg/kg per day)for 4-6 weeks (B, III)659...

...dation therapy: Fluconazole (400-800 mg per d...

...rapy: Fluconazole (200-400 mg per d...


...able 3. Antifungal Treatment Recommend...

Induction The...

AmBda,b (0.7-1.0 mg/kg per day) plus fl...

AmBdc (0.7-1.0 mg/kg per day) for ≥ 6 week...

...omal AmB (3-4 mg/kg per day) or ABLCd (5 mg/kg...

...per day) plus flucytosine (100 mg/...

...idation therapy: Fluconazole (400-800 mg...

...nce therapy: Fluconazole (200 mg per day)b for 6-...


...e 4. Antifungal Treatment Recommendat...

...ction Therapy...

...0.7-1.0 mg/kg per day) plus flucytosine (...

...l AmB (3-4 mg/kg per day) or ABLCa (5 mg...

...(0.7-1.0 mg/kg per day) or liposomal AmB (3-4...

...lternatives for Induction Therapyb...

...plus fluconazole (B, I)6...

...plus flucytosine (B, II)659...

...uconazole (B, II)...

...aconazole (C, II)659...

Consolidation therapy: Fluconazole (400 mg per...

...rapy: Fluconazole (200 mg per day)a for...

...ives for Maintenance Therap...

...(400 mg per day)d for ≥1 year (...

AmBdd (1 mg/kg per week) for ≥1 yearc (C,...

...n highly active antiretroviral therapy (aH...


...e 1. Non-Meningeal Cryptococcosis...


...ure 2. Cryptococcal Meningoencephalit...


Complications

Complications

...mplications in Patients with Cryptococcosi...

...ersistence...

...uate measures have been taken to improve...

...stitute induction phase of primary t...

...initial dosage of induction therapy was ≤0.7...

...the patient is polyene intolerant, conside...

...ucytosine intolerant, consider AmBd (0...

...rathecal or intraventricular AmBd is generally...

...persistent and relapse isolates should be...

...zole-exposed patients, increasing the...

...ive immunological therapy with recombinant i...

Relapse

...t induction phase therapy (see Persistence)....

...ceptibility of the relapse isolate (see Persiste...

...fter induction therapy and in vitro susc...

...here are compliance issues and a susceptible isola...

...ated CSF Pressure...

Identify CSF pressure at baseline....

...ressure is ≥25 cm of CSF and ther...

...rsistent pressure elevation ≥25 c...

...t ventriculoperitoneal (VP) shunts shoul...

...ations for Intracranial Pressure...

...has no proven benefit and is not routi...

...olamide and corticosteroids to control increased...

...ider corticosteroids if signs of IRIS are...

...ence of Signs and Symptoms...

...of signs and symptoms, reinstitute drainag...

...h recurrence, measurement of openi...

...m Elevated Intracranial Pre...

...the CSF pressure remains elevated and...

...rebral Cyptococco...

...ction therapy with AmBd (0.7-1.0 mg/kg...

...on and maintenance therapy with fluconaz...

...teroids for mass effect and surrounding edema. (...

...arge (≥3 cm), accessible lesions wi...

IRIS

...ed to alter direct antifungal therapy. (B, I...

...ve specific treatment recommendation for mino...

...mplications, such as CNS inflammation wi...

...l anti-inflammatory drugs and thalidomide h...

...eatment in Special Clinical Situati...

...omen with Cryptococcosis...

...inated and CNS disease, use AmBd or LFAm...

...azole (pregnancy category C) after delivery; avoid...

...imited and stable pulmonary cryptococcosis, perfor...

...or IRIS in the postpartum period....

...dren with Cryptococ...

...d consolidation therapy for CNS and diss...

...apy is fluconazole (6 mg/kg per day or...

...ontinuation of maintenance therapy in children re...

...coccal pneumonia, use fluconazole (6-12 mg/kg pe...

...ryptococcosis in a Resource-Limited Health...

For CNS and/or disseminated disease where...

...nce therapy is fluconazole (200-400 mg pe...

...S and/or disseminated disease where poly...

...d/or disseminated disease when polyene is...