Cryptococcosis medical therapy

Jump to navigation Jump to search

Cryptococcosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Cryptococcosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Chest X Ray

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Cryptococcosis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Cryptococcosis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Cryptococcosis medical therapy

CDC on Cryptococcosis medical therapy

Cryptococcosis medical therapy in the news

Blogs on Cryptococcosis medical therapy

Directions to Hospitals Treating Cryptococcosis

Risk calculators and risk factors for Cryptococcosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Serge Korjian M.D.; Yazan Daaboul, M.D.

Overview

The standard regimen of treatment in non-AIDS patients is intravenous amphotericin B combined with oral flucytosine. AIDS patients often have a reduced response to amphotericin B and flucytosine, therefore after initial treatment as above, oral fluconazole can be used.

Medical Therapy

The standard regimen of treatment in non-AIDS patients is intravenous amphotericin B combined with oral flucytosine. AIDS patients often have a reduced response to amphotericin B and flucytosine, therefore after initial treatment as above, oral fluconazole can be used.

Antimicrobial Regimens

  • 1. Cryptococcus neoformans
  • 1.1 Meningoencephalitis in HIV infected patients[1]
  • 1.1.1 Induction and consolidation
  • 1.1.2 Maintenance and prophylactic therapy
  • Preferred regimen: Fluconazole 200 mg PO qd AND HAART 2-10 weeks after initiation of antifungal therapy
  • Alternative regimen (1): Itraconazole 200 mg PO bid
  • Alternative regimen (2): Amphotericin B deoxycholate 1 mg/kg IV qw
  • Note (1): Consider discontinuing therapy if CD4 count is higher than 100 cells/uL AND undetectable OR very low HIV RNA level for > 3 months
  • Note (2): Consider reinstitution of maintenance therapy if CD4 count <100 cells/uL
  • 1.2. Cerebral cryptococcomas
  • 1.3. Cryptococcus neoformans meningitis in HIV negative patients
  • Preferred regimen: Amphotericin B deoxycholate 0.7-1.0 mg/kg IV qd PLUS Flucytosine 100mg/kg/day PO or IV qid for at least 4 weeks (which may be extended to 6 weeks if there is any neurological complication) followed by fluconazole 400mg PO qd for 8 weeks. If there's toxicity to amphotericin B deoxycholate, consider changing to liposomal AmB in the second 2 weeks
  • Note (1): After induction and consolidation therapy, start fluconazole 200mg (3mg/kg) PO qd for 6-12 months
  • Note (2): If flucytosine is not given, consider lengthening the induction therapy for at least 2 weeks
  • 1.4. Cryptococcus neoformans pulmonary disease - immunosupressed
  • Preferred regimen: Fluconazole 400 mg PO qd for 6-12 months
  • Note (1): In HIV-infected patients, treatment should be stopped after 1 year if CD4 count is > 100 and a cryptococcal antigen titer is < 1:512 and not increasing.
  • Note (2): Consider corticosteroid if ARDS is present in a context which it might be attributed to IRIS
  • 1.5 Cryptococcus neoformans pulmonary disease - non-immunosupressed
  • 1.6 Cryptococcus neoformans non-lung, non-CNS infection
  • Cryptococcemia or disseminated cryptococcic disease (involvement of at least 2 noncontiguous sites or cryptococcal antigen titer > 1:512):
  • Preferred regimen: Fluconazole 400mg PO qd for 6-12 months
  • 1.7. Cryptococcosis in children
  • Preferred regimen: Fluconazole 6-12mg/kg PO qd for 6-12 months
  • 1.8. Cryptococcosis in pregnant women
  • Preferred regimen for induction and consolidation: Amphotericin B deoxycholate 0.7-1.0 mg/kg IV qd (consider using lipid formulations for patients with renal dysfunction - liposomal AmB 3-4mg/kg IV qd OR amphotericin B lipid complex (ABLC) 5mg/kg IV qd). Consider using flucytosine in relationship to benefit risk basis, since it is a category C drug for pregnancy
  • Start fluconazole after delivery
  • Avoid use during first trimester and consider use in the last 2 trimesters with the need for continuous antifungal therapy during pregnancy
  • Note: If pulmonary cryptococcosis, perform close follow-up and administer fluconazole after delivery.
  • 2. Cryptococcus gatti
  • Pulmonary disease: Single and small cryptococcoma
  • Preferred regimen: Fluconazole 400mg per day PO for 6-18 months
  • Pulmonary disease: Very large or multiple cryptococcomas
  • Preferred regimen: Administer flucytosine AND Amphotericin B deocycholate for 4-6 weeks, followed by fluconazole for 6-18 months
  • Note: Surgery should be considered if there is compression of vital structures OR failure to reduce the size of the cryptococcoma after 4 weeks of therapy

References

  1. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ; et al. (2010). "Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america". Clin Infect Dis. 50 (3): 291–322. doi:10.1086/649858. PMID 20047480.