Cryptococcosis In Solid Organ Transplantation

Publication Date: April 1, 2019

DIAGNOSTIC STRATEGIES

Patients with suspected or proven cryptococcosis should have a thorough evaluation of extrapulmonary disease, including lumbar puncture, blood, and other relevant tissue cultures. (Moderate, Strong)
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Cryptococcal antigen testing from blood and CSF should be performed preferably using the lateral flow assay over latex agglutination assay. (Moderate, Strong)
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All sources should be cultured for and identified at the species level (C. neoformans vs C. gattii). (Moderate, Weak)
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Susceptibility testing is recommended for patients who fail primary therapy, who have relapse of disease, who develop cryptococcosis with prior antifungal exposure (ie, fluconazole prophylaxis), or in patients with C. gattii genotypes that have been associated with elevated fluconazole MICs. (High, Strong)
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Imaging of lungs and CNS should be performed in patients with suspected or proven cryptococcosis. (High, Strong)
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TREATMENT

A lumbar puncture should be performed for diagnosis of CNS disease and evaluation and management of intracranial pressure, (High, Strong)
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A lipid formulation of amphotericin B plus 5‐flucytosine is preferred as induction therapy for CNS disease, disseminated disease, or moderate‐to‐severe pulmonary disease. (High, Strong)
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Fluconazole is preferred for consolidation and maintenance therapy for CNS disease. (Moderate, Strong)
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Fluconazole is the preferred therapy for asymptomatic or mild‐to-moderate pulmonary disease. (Moderate, Strong)
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Newer triazoles should be reserved as alternative agents when fluconazole cannot be used or for patients with isolates that may be resistant to fluconazole. (Low, Weak)
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Reduction of immunosuppression should be performed at time of diagnosis of cryptococcosis. (Low, Weak)
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IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME

Serial lumbar punctures should be performed for the manage ment of elevated ICP. (Moderate, Strong)
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Temporary or permanent CSF drainage should be considered for in patients where serial lumbar punctures fail to normalize ICP. (Low, Strong)
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Immune reconstitution syndrome can occur within weeks of start of antifungal therapy and reduced immunosuppression. Exclusion of clinical failure with repeat cultures is warranted before initiating corticosteroid treatment. (Low, Weak)
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Recommendation Grading

Disclaimer

Overview

Title

Cryptococcosis In Solid Organ Transplantation

Authoring Organization

Publication Month/Year

April 1, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of cryptococcosis in the pre‐ and post‐transplant period.

Target Patient Population

Solid organ transplant patients

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D019072 - Antibiotic Prophylaxis, D014180 - Transplantation, D000898 - Antibiosis, D000935 - Antifungal Agents, D016377 - Organ Transplantation, D003453 - Cryptococcosis

Keywords

antifungal, antibiotic, solid organ transplant, infections

Source Citation

Baddley, JW, Forrest, GN; on behalf of the AST Infectious Diseases Community of Practice. Cryptococcosis in solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13543.