Diagnosis and Management of Cryptococcosis

Publication Date: February 8, 2024
Last Updated: February 15, 2024

Key Points

  • Accurate delineation of the cryptococcosis clinical syndrome is important as it guides antifungal treatment choice and duration; cryptococcosis syndromes are divided into CNS, disseminated disease, isolated pulmonary disease, or direct skin inoculation.
  • Liposomal amphotericin B 3–4 mg/kg daily and flucytosine 25 mg/kg four times a day is the most optimal induction therapy option for cryptococcal meningitis, disseminated cryptococcosis, and severe isolated pulmonary cryptococcosis in high-income settings.
  • In low-income settings, patients with HIV-associated cryptococcal meningitis are best treated with liposomal amphotericin B 10 mg/kg as a single-dose, with 14 days of flucytosine 25 mg/kg four times a day and fluconazole 1200 mg daily as induction therapy; this induction therapy has not been trialled in non-HIV-associated cryptococcal meningitis or other non-CNS cryptococcosis syndromes.
  • Optimise outcomes by providing the most effective antifungal therapy while preventing, monitoring, and managing potential toxicity; do not stop or switch to an inferior regimen too early or unnecessarily.
  • Expect and monitor for clinical relapse and investigate thoroughly for causality; review adherence to antifungal therapy and consider drug–drug interactions; during treatment follow-up, do not escalate antifungal therapy for persistent blood antigenemia (blood cryptococcal antigen), persistently positive CSF cryptococcal antigen, visible cryptococci in CSF (without culture positivity), or abnormal CSF microscopy or biochemistry, as they are not necessarily indicators of microbiological failure.
  • Adapt and adopt these ECMM global guidelines to suit local practices, while constantly advocating for better antifungal access, scrutinising new trial data, and reviewing local data to improve patient outcomes.

Overview

Title

Diagnosis and Management of Cryptococcosis

Authoring Organizations

International Society for Human & Animal Mycology

European Confederation of Medical Mycology