Cryptococcus species
From IDWiki
Clinical Manifestations
- Infects CNS, lung, and bloodstream
- Pulmonary infection more common with Cryptococcus gattii while CNS infection and fungemia were more common with Cryptococcus neoformans
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
Further Reading
- IDSA Guidelines 2010