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

...lecting a Treatment Regimen...

...fungal Treatment Recommendations for Non...

...uppressed patients and immunocompetent patients...

...ppressed patientsa and immunocompetent patien...


...h Nonmeningeal, Nonpulmonary Cryptococcosi...

...yptococcemiaSame as CNS disease for...

...nts for whom CNS disease has been ruled out...


...ngal Treatment Recommendations for Cryptococcal M...

...apyaLiposomal AmB (3-4 mg/kg per day) o...

...s for Induction Therapyb...

...6 mg/kg per day) or ABLC (5 mg/kg per day) fo...

...mBdb (0.7 mg/kg per day)for 4-6 weeks (B, II...

...nsolidation therapy: Fluconazole (...

...nance therapy: Fluconazole (200-400 mg per d...


...le 3. Antifungal Treatment Recommendations for Cr...

Induction Therapy

...b (0.7-1.0 mg/kg per day) plus flucytosine (100...

...1.0 mg/kg per day) for ≥ 6 weeksa,b (B, II)659...

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

AmBde (0.7 mg/kg per day) plus flucytosine (100...

...erapy: Fluconazole (400-800 mg per day)...

...herapy: Fluconazole (200 mg per day)b for...


...fungal Treatment Recommendations for Cry...

...tion Therapy

...mBda (0.7-1.0 mg/kg per day) plus flucytosine (10...

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

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

...ives for Induction Therapyb...

...fluconazole (B, I)659...

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

...zole (B, II)659...

...azole (C, II)659...

...tion therapy: Fluconazole (400 mg per day) fo...

...ce therapy: Fluconazole (200 mg per da...

...ives for Maintenance Thera...

...0 mg per day)d for ≥1 year (C, I)659...

...er week) for ≥1 yearc (C, I)659...

...ghly active antiretroviral therapy (aHAART) 2-10 w...


...1. Non-Meningeal Cryptococc...


...tococcal Meningoencephalitis...


Complications

Complicat...

...of Complications in Patients with Cryptococcosis...

...ersisten...

...that adequate measures have been...

...ction phase of primary therapy for longer cours...

...tial dosage of induction therapy wa...

...e patient is polyene intolerant, cons...

...s flucytosine intolerant, consider...

...e of intrathecal or intraventricular AmBd i...

...ersistent and relapse isolates should be che...

...n azole-exposed patients, increasing the d...

...e immunological therapy with recom...

...lapse...

...estart induction phase therapy (see...

...ne susceptibility of the relapse is...

...ction therapy and in vitro susceptibil...

...ere are compliance issues and a suscept...

...ated CSF Pressure

...tify CSF pressure at baseline. A pr...

...f the CSF pressure is ≥25 cm of CSF and t...

...s persistent pressure elevation ≥25 cm of CSF...

Permanent ventriculoperitoneal (VP) shunt...

...Medications for Intracranial Pressure...

...has no proven benefit and is not routinely re...

...nd corticosteroids to control increased intr...

...der corticosteroids if signs of IRI...

Recurrence of Signs and S...

...recurrence of signs and symptoms, rein...

...th recurrence, measurement of opening pre...

...g-term Elevated Intracranial Pre...

If the CSF pressure remains elevated and if symp...

...l Cyptococcomas...

...therapy with AmBd (0.7-1.0 mg/kg per day IV), l...

...and maintenance therapy with fluconazole (400-800...

...roids for mass effect and surroundi...

...rgery: for large (≥3 cm), accessible les...

IRI...

...o alter direct antifungal therapy. (B, III)659...

...ecific treatment recommendation for mino...

...complications, such as CNS inflammation with...

...roidal anti-inflammatory drugs and thalidomide hav...

...in Special Clinical Situations...

...gnant Women with Cryptococcosis...

...nated and CNS disease, use AmBd or LFAmB, wi...

...fluconazole (pregnancy category C) after deliver...

...limited and stable pulmonary cryptococcosis,...

...r IRIS in the postpartum period.659...

...hildren with Cryptococcosis...

...on and consolidation therapy for CNS and dissemi...

...enance therapy is fluconazole (6 m...

...ation of maintenance therapy in children...

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

...osis in a Resource-Limited Health Care Environme...

...or CNS and/or disseminated disease where flucy...

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

.../or disseminated disease where polyene is not a...

.../or disseminated disease when polyene i...