Cryptococcus: Difference between revisions

Revision as of 11:25, 21 November 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 amphotericin B (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): amphotericin B deoxycholate (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
- If there is amphotericin B deoxycholate toxicity, liposomal amphotericin B 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 B monotherapy is recommended, since fluconazole is teratogenic

@@ Line 1: / Line 1: @@
 == Management ==
 === Patients with HIV ===
 ==== CNS disease ====
+* Induction (first 2+ weeks): [[Is treated by::liposomal amphotericin B]] (3-4 mg/kg IV daily) plus [[Is treated by::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)
 ** 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
+* Consolidation: [[Is treated by::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)
+** [[Is treated by::Fluconazole]] (200 mg per day orally) or [[Is treated by::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 &gt;= 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): [[Is treated by::liposomal amphotericin B]] (3–4 mg/kg per day IV) plus [[Is treated by::flucytosine]] (100 mg/kg per day in 4 divided doses)
+** If not including [[flucytosine]], then extend induction to 4-6 weeks
-* Induction (first 2+ weeks): Liposomal AmB (3–4 mg/kg per day IV) plus flucytosine (100 mg/kg per day in 4 divided doses)
+* Consolidation: [[Is treated by::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)
-** 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
+* [[Fluconazole]] (400 mg [6 mg/kg] per day) for 6–12 months
 === Patients without HIV or organ transplants ===
+* Induction (first 4+ weeks): [[Is treated by::amphotericin B deoxycholate]] (0.7–1.0 mg/kg per day IV) plus [[Is treated by::flucytosine]] (100 mg/kg per day orally in 4 divided doses)
-* 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
+** If there is [[amphotericin B deoxycholate]] toxicity, [[Is treated by::liposomal amphotericin B]] may be substituted in the second 2 weeks
-* Consolidation: fluconazole (400 mg per day) for 8 weeks
+* Consolidation: [[Is treated by::fluconazole]] (400 mg per day) for 8 weeks
-* Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months
+* Maintenance: [[Is treated by::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
+* In short, [[Is treated by::amphotericin B]] monotherapy is recommended, since [[fluconazole]] is teratogenic
 == Further Reading ==