Cryptococcus: Difference between revisions
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Cryptococcus
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=== Patients with HIV === |
=== Patients with HIV === |
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| − | === 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) |
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** Consider stopping antifungals once CD4 >= 100 for 3 months |
** Consider stopping antifungals once CD4 >= 100 for 3 months |
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| − | === Fungemia === |
+ | ==== Fungemia ==== |
* First, rule out meningitis with an LP |
* First, rule out meningitis with an LP |
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* Always consider decreasing immunosuppression if able to |
* Always consider decreasing immunosuppression if able to |
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| − | === 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) |
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* 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) |
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| − | === Mild-to-moderate non-CNS disease === |
+ | ==== Mild-to-moderate non-CNS disease ==== |
* Includes mild-to-moderate pulmonary disease |
* Includes mild-to-moderate pulmonary disease |
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* Consolidation: fluconazole (400 mg per day) for 8 weeks |
* Consolidation: fluconazole (400 mg per day) for 8 weeks |
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* 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 |
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| + | |||
| + | === Pregnant patients === |
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| + | |||
| + | * See review at [https://doi.org/10.1093/mmy/myz084] |
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| + | * In short, amphotericin monotherapy is recommended, since fluconazole is teratogenic |
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== Further Reading == |
== Further Reading == |
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Revision as of 21:26, 15 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
