Cryptococcus: Difference between revisions
From IDWiki
Cryptococcus
No edit summary |
(→: added pregnancy section) |
||
| Line 3: | Line 3: | ||
=== Patients with HIV === |
=== Patients with HIV === |
||
=== CNS disease === |
==== CNS disease ==== |
||
* Induction (first 2+ weeks): Liposomal amphotericin B (3-4 mg/kg IV daily) plus flucytosine (100 mg/kg per day orally in 4 divided doses) |
* Induction (first 2+ weeks): Liposomal amphotericin B (3-4 mg/kg IV daily) plus flucytosine (100 mg/kg per day orally in 4 divided doses) |
||
| Line 13: | Line 13: | ||
** Consider stopping antifungals once CD4 >= 100 for 3 months |
** Consider stopping antifungals once CD4 >= 100 for 3 months |
||
=== Fungemia === |
==== Fungemia ==== |
||
* First, rule out meningitis with an LP |
* First, rule out meningitis with an LP |
||
| Line 22: | Line 22: | ||
* Always consider decreasing immunosuppression if able to |
* Always consider decreasing immunosuppression if able to |
||
=== CNS, severe, or disseminated disease === |
==== CNS, severe, or disseminated disease ==== |
||
* Induction (first 2+ weeks): Liposomal AmB (3–4 mg/kg per day IV) plus flucytosine (100 mg/kg per day in 4 divided doses) |
* Induction (first 2+ weeks): Liposomal AmB (3–4 mg/kg per day IV) plus flucytosine (100 mg/kg per day in 4 divided doses) |
||
| Line 28: | Line 28: | ||
* Consolidation: fluconazole (400–800 mg [6–12 mg/kg] per day orally) for 8 weeks, then by fluconazole (200–400 mg per day orally) for 6–12 months (B-II) |
* Consolidation: fluconazole (400–800 mg [6–12 mg/kg] per day orally) for 8 weeks, then by fluconazole (200–400 mg per day orally) for 6–12 months (B-II) |
||
=== Mild-to-moderate non-CNS disease === |
==== Mild-to-moderate non-CNS disease ==== |
||
* Includes mild-to-moderate pulmonary disease |
* Includes mild-to-moderate pulmonary disease |
||
| Line 41: | Line 41: | ||
* Consolidation: fluconazole (400 mg per day) for 8 weeks |
* Consolidation: fluconazole (400 mg per day) for 8 weeks |
||
* Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months |
* Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months |
||
=== Pregnant patients === |
|||
* See review at [https://doi.org/10.1093/mmy/myz084] |
|||
* In short, amphotericin monotherapy is recommended, since fluconazole is teratogenic |
|||
== Further Reading == |
== Further Reading == |
||
Revision as of 01:26, 16 August 2019
Management
Patients with HIV
CNS disease
- Induction (first 2+ weeks): Liposomal amphotericin B (3-4 mg/kg IV daily) plus flucytosine (100 mg/kg per day orally in 4 divided doses)
- IV formulations may be used in severe cases and in those without oral intake where the preparation is available) for at least 2 weeks
- Consolidation: fluconazole (400 mg [6 mg/kg] per day orally) for a minimum of 8 weeks
- Maintenance:
- Fluconazole (200 mg per day orally) or Itraconazole (200 mg twice per day orally; drug-level monitoring strongly advised)
- Start HAART 2–10 weeks after starting antifungals
- Consider stopping antifungals once CD4 >= 100 for 3 months
Fungemia
- First, rule out meningitis with an LP
- If no meningitis, can treat with fluconazole 400 mg po daily until immune reconstitution
Organ transplant patients
- Always consider decreasing immunosuppression if able to
CNS, severe, or disseminated disease
- Induction (first 2+ weeks): Liposomal AmB (3–4 mg/kg per day IV) plus flucytosine (100 mg/kg per day in 4 divided doses)
- If not including flucytosine, then extend induction to 4-6 weeks
- Consolidation: fluconazole (400–800 mg [6–12 mg/kg] per day orally) for 8 weeks, then by fluconazole (200–400 mg per day orally) for 6–12 months (B-II)
Mild-to-moderate non-CNS disease
- Includes mild-to-moderate pulmonary disease
- Fluconazole (400 mg [6 mg/kg] per day) for 6–12 months
Patients without HIV or organ transplants
- Induction (first 4+ weeks): AmBd (0.7–1.0 mg/kg per day IV) plus flucytosine (100 mg/kg per day orally in 4 divided doses)
- If neurological complications or positive CSF cultures after 2 weeks of treatment, consider extending to 6 weeks total
- If not including flucytosine, then extend induction by 2 weeks
- For AmBd toxicity issues, LFAmB may be substituted in the second 2 weeks
- Consolidation: fluconazole (400 mg per day) for 8 weeks
- Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months
Pregnant patients
- See review at [1]
- In short, amphotericin monotherapy is recommended, since fluconazole is teratogenic
Further Reading
- IDSA Guidelines 2010
