Cryptococcosis medical therapy: Difference between revisions

Jump to navigation Jump to search
No edit summary
m (Bot: Removing from Primary care)
 
(13 intermediate revisions by 5 users not shown)
Line 4: Line 4:


==Overview==
==Overview==
The standard regimen of treatment in non-[[AIDS]] patients intravenous [[Amphotericin B]] combined with oral [[flucytosine]]. [[HIV AIDS|AIDS]] patients often have a reduced response to [[Amphotericin B]] and [[flucytosine]], therefore after initial treatment as above, oral [[fluconazole]] can be used.
The standard regimen of treatment in non-[[AIDS]] patients is [[Intravenous therapy|intravenous]] [[amphotericin B]] combined with [[oral]] [[flucytosine]]. [[HIV AIDS|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==
==Medical Therapy==
The standard regimen of treatment in non-[[HIV AIDS|AIDS]] patients [[intravenous]] [[Amphotericin B]] combined with [[Wiktionary:oral|oral]] [[flucytosine]].
The standard regimen of treatment in non-[[HIV AIDS|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.
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===
===Antimicrobial Regimens===
* '''1. Cryptococcus neoformans'''
* '''1. ''Cryptococcus neoformans'''''
:* '''1.1 Meningoencephalitis in HIV infected patients'''<ref name="pmid20047480">{{cite journal| author=Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ et al.| title=Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 3 | pages= 291-322 | pmid=20047480 | doi=10.1086/649858 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20047480  }} </ref>
:* '''1.1 Meningoencephalitis in HIV infected patients'''<ref name="pmid20047480">{{cite journal| author=Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ et al.| title=Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 3 | pages= 291-322 | pmid=20047480 | doi=10.1086/649858 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20047480  }} </ref>
::* '''1.1.1 Induction and consolidation'''
::* '''1.1.1 Induction and consolidation'''
:::*Preferred regimen: ([[Amphotericin B]] deoxycholate 0.7-1.0 mg/kg IV q24h for 2 weeks {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥8 weeks
:::*Preferred regimen: ([[Amphotericin B]] deoxycholate 0.7-1.0 mg/kg IV q24h for 2 weeks {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥ 8 weeks
:::*Preferred regimen (renally impaired): ([[Liposomal AmB]] 3-4 mg/kg IV q24h {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥8 weeks
:::*Preferred regimen ([[Renal impairment|renally impaired]]): ([[Liposomal AmB]] 3-4 mg/kg IV q24h {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥ 8 weeks
:::*Preferred regimen (renally impaired): ([[Amphotericin B]] lipid complex (ABLC) 5 mg/kg IV q24h {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥8 weeks
:::*Preferred regimen ([[Renal impairment|renally impaired]]): ([[Amphotericin B]] lipid complex (ABLC) 5 mg/kg IV q24h {{and}} [[Flucytosine]] 100 mg/kg/day PO/IV q6h for 2 weeks) {{then}} [[Fluconazole]] 400 mg (6 mg/kg) PO qd for ≥ 8 weeks
:::*Alternative regimen (1): [[Amphotericin B]] deoxycholate 0.7-1.0 mg/kg IV q24h {{or}} [[Liposomal AmB]] 3-4 mg/kg IV q24h {{or}} AmB lipid complex 5 mg/kg IV q24h for 4-6 weeks
:::*Alternative regimen (1): [[Amphotericin B]] deoxycholate 0.7-1.0 mg/kg IV q24h {{or}} [[Liposomal AmB]] 3-4 mg/kg IV q24h {{or}} [[Amphotericin B]] lipid complex 5 mg/kg IV q24h for 4-6 weeks
:::*Alternative regimen (2): ([[Amphotericin B]] deoxycholate 0.7 mg/kg IV q24h {{and}} [[Fluconazole]] 800 mg PO qd for 2 weeks) {{then}} [[Fluconazole]] 800mg PO qd for ≥8 weeks
:::*Alternative regimen (2): ([[Amphotericin B]] deoxycholate 0.7 mg/kg IV q24h {{and}} [[Fluconazole]] 800 mg PO qd for 2 weeks) {{then}} [[Fluconazole]] 800 mg PO qd for ≥ 8 weeks
:::*Alternative regimen (3): [[Fluconazole]] 800-1200 mg PO qd {{and}} [[Flucytosine]] 100 mg/kg/day PO qid for 6 weeks
:::*Alternative regimen (3): [[Fluconazole]] 800-1200 mg PO qd {{and}} [[Flucytosine]] 100 mg/kg/day PO qid for 6 weeks
:::*Alternative regimen (4): [[Fluconazole]] PO 800-2000 mg PO qd for 10-12 weeks
:::*Alternative regimen (4): [[Fluconazole]] PO 800-2000 mg PO qd for 10-12 weeks


::* '''1.1.2 Maintenance and prophylactic therapy'''
::* '''1.1.2 Maintenance and prophylactic therapy'''
:::*Preferred regimen: [[Fluconazole]] 200 mg PO qd {{and}} HAART 2-10 weeks after initiation of antifungal therapy
:::*Preferred regimen: [[Fluconazole]] 200 mg PO qd {{and}} [[HIV AIDS medical therapy#Anti Retroviral Therapy (ART)|HAART]] 2-10 weeks after initiation of [[Antifungal medication|antifungal therapy]]
:::*Alternative regimen (1): [[Itraconazole]] 200 mg PO bid
:::*Alternative regimen (1): [[Itraconazole]] 200 mg PO bid
:::*Alternative regimen (2): [[Amphotericin B]] deoxycholate 1 mg/kg IV qw
:::*Alternative regimen (2): [[Amphotericin B]] deoxycholate 1 mg/kg IV qw
Line 28: Line 27:
:::* Note (2): Consider reinstitution of maintenance therapy if [[CD4]] count <100 cells/uL
:::* Note (2): Consider reinstitution of maintenance therapy if [[CD4]] count <100 cells/uL


::*'''1.2. Cerebral cryptococcomas'''
:* '''1.2. Cerebral cryptococcomas'''
:::*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]]) {{or}} [[Liposomal AmB]] 3-4mg/kg IV qd {{or}} [[Amphotericin B]] lipid complex (ABLC) 5mg/kg IV qd) {{plus}} [[Flucytosine]] 100mg/kg/day PO or IV qid for at least 2 weeks followed by [[Fluconazole]] 400mg (6mg/kg) PO qd for at least 8 weeks
:::*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]]) {{or}} [[Liposomal AmB]] 3-4mg/kg IV qd {{or}} [[Amphotericin B]] lipid complex (ABLC) 5mg/kg IV qd) {{plus}} [[Flucytosine]] 100mg/kg/day PO or IV qid for at least 2 weeks followed by [[fluconazole]] 400mg (6mg/kg) PO qd for at least 8 weeks
:::*Note: Consider surgery if lesions are larger than 3cm, accessible lesions with mass effect or lesions that are enlarging and not explained by IRIS.
:::*Note: Consider surgery if [[lesions]] are larger than 3cm, accessible [[lesions]] with [[mass effect]] or [[lesions]] that are enlarging and not explained by [[Immune reconstitution inflammatory syndrome|IRIS]]


::*'''1.3. Cryptococcus neoformans meningitis in HIV negative patients'''
:* '''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 AmBd, consider changing to LFAmB in the second 2 weeks.
:::*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 (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.
:::*Note (2): If [[flucytosine]] is not given, consider lengthening the induction therapy for at least 2 weeks


::*'''1.4. Cryptococcus neoformans pulmonary disease - immunosupressed'''
:* '''1.4. ''Cryptococcus neoformans'' pulmonary disease - immunosupressed'''
:::*Mild-moderate symptoms, without severe immunosupression and absence of diffuse pulmonary infiltrates:
:::*Mild-moderate symptoms, without severe [[immunosupression]] and absence of diffuse [[pulmonary]] infiltrates:
::::*Preferred regimen: [[Fluconazole]] 400mg PO qd for 6-12 months
::::*Preferred regimen: [[Fluconazole]] 400 mg PO qd for 6-12 months
:::*Severe [[pneumonia]] or [[disseminated disease]] or [[CNS]] infection:
:::*Severe [[pneumonia]], [[disseminated disease]], or [[CNS]] infection:
::::*Preferred regimen: treat like CNS [[cryptococcosis]].
::::*Preferred regimen: treat like [[CNS]] [[cryptococcosis]]
:::*Note (1): In [[Human Immunodeficiency Virus (HIV)|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 (1): In [[Human Immunodeficiency Virus (HIV)|HIV]]-infected patients, treatment should be stopped after 1 year if [[CD4]] count is > 100 and a [[Cryptococcal infection|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.
:::*Note (2): Consider [[corticosteroid]] if [[ARDS]] is present in a context which it might be attributed to [[Immune reconstitution inflammatory syndrome|IRIS]]


::*'''1.5 Cryptococcus neoformans pulmonary disease - non-immunosupressed'''
:* '''1.5 ''Cryptococcus neoformans'' pulmonary disease - non-immunosupressed'''
:::*Mild-moderate symptoms, without severe immunosupression and absence of diffuse pulmonary infiltrates:
:::*Mild-moderate symptoms, without severe [[immunosupression]] and absence of diffuse [[pulmonary]] infiltrates:
::::*Preferred regimen: [[Fluconazole]] 400mg PO qd for 6-12 months
::::*Preferred regimen: [[Fluconazole]] 400 mg PO qd for 6-12 months
::::*Alternative regimen: if [[Fluconazole]] is unavailable or contraindicated, [[Itraconazole]] 200mg PO bid, [[Voriconazole]] 200 mg PO bid, and [[Posaconazole]] 400mg PO bid
::::*Alternative regimen: If [[fluconazole]] is unavailable or contraindicated, [[Itraconazole]] 200mg PO bid, [[voriconazole]] 200 mg PO bid, and [[posaconazole]] 400mg PO BID
:::*If there's severe [[pneumonia]], disseminated disease or CNS infection:
:::*If the patient has severe [[pneumonia]], [[disseminated disease]], or [[Central nervous system infection|CNS infection]]:
::::*Preferred regimen: treat like CNS [[cryptococcosis]] for 6-12 months.
::::*Preferred regimen: Treat like [[CNS]] [[cryptococcosis]] for 6-12 months


::*'''1.6 Cryptococcus neoformans non-lung, non-CNS infection'''
:* '''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):
:::*Cryptococcemia or disseminated cryptococcic disease  (involvement of at least 2 noncontiguous sites or [[Cryptococcal infection|cryptococcal]] [[antigen]] [[titer]] > 1:512):
::::*Preferred regimen: treat like CNS infection.
::::*Preferred regimen: treat like [[Central nervous system infection|CNS infection]]
:::*If infection occurs at a single site and no immunosupressive risk factors
:::*If infection occurs at a single site and no [[Immunosuppressive drug|immunosupressive]] risk factors
::::*Preferred regimen: [[Fluconazole]] 400mg PO qd for 6-12 months
::::*Preferred regimen: [[Fluconazole]] 400mg PO qd for 6-12 months


::*'''1.7. Cryptococcosis in Children'''
:* '''1.7. Cryptococcosis in children'''
::::*Preferred regimen for induction and consolidation: [[Amphotericin B]] deoxycholate 1.0 mg/kg qd IV {{plus}} [[Flucytosine]] 100mg/kg PO or IV qid for 2 weeks followed by [[Fluconazole]] 10-12mg/kg PO qd for 8 weeks
::::*Preferred regimen for induction and consolidation: [[Amphotericin B]] deoxycholate 1.0 mg/kg qd IV {{plus}} [[Flucytosine]] 100mg/kg PO or IV qid for 2 weeks followed by [[fluconazole]] 10-12mg/kg PO qd for 8 weeks
::::*Alternative regimen: patients with renal dysfunction: change [[Amphotericin B]] deoxycholate by [[Liposomal AmB]] 5mg/kg IV qd or [[Amphotericin B]] lipid complex (ABLC) 5mg/kg IV qd
::::*Alternative regimen ([[Renal impairment|renally impaired]]): Change [[amphotericin B]] deoxycholate by [[liposomal AmB]] 5mg/kg IV qd or [[amphotericin B]] lipid complex (ABLC) 5mg/kg IV qd
::::*Preferred regimen for maintenance: [[Fluconazole]] 6mg/kg PO qd. Discontinuation of maintenance therapy is poorly studied and should be individualized.
::::*Preferred regimen for maintenance: [[Fluconazole]] 6mg/kg PO qd. Discontinuation of maintenance therapy is poorly studied and should be individualized
:::*Cryptococcal pneumonia:
:::*[[Cryptococcal infection|Cryptococcal]] [[pneumonia]]:
::::*Preferred regimen [[Fluconazole]] 6-12mg/kg PO qd for 6-12 months
::::*Preferred regimen: [[Fluconazole]] 6-12mg/kg PO qd for 6-12 months


::*'''1.8. Cryptococcosis in Pregnant Women'''
:* '''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.
:::*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  
:::*Note: If pulmonary cryptococcosis: perform close follow-up and administer [[fluconazole]] after delivery.
:::*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'''
*'''2. ''Cryptococcus gatti'''''
::*Disseminated cryptococcosis or CNS disease:
::*[[Disseminated disease|Disseminated]] [[cryptococcosis]] or [[CNS]] disease:
:::*Preferred regimen: treatment is the same as [[Cryptococcus neoformans|C. neoformans]].
:::*Preferred regimen: Treatment is the same as ''[[Cryptococcus neoformans|C. neoformans]]''
::*Pulmonary disease: single and small cryptococcoma:
::*[[Pulmonary]] disease: Single and small cryptococcoma
:::*Preferred regimen: [[Fluconazole]] 400mg per day PO for 6-18months
:::*Preferred regimen: [[Fluconazole]] 400mg per day PO for 6-18 months
::*Pulmonary disease: Very large or multiple cryptococcomas:
::*[[Pulmonary]] disease: Very large or multiple cryptococcomas
:::*Preferred regimen: administer [[Flucytosine]] {{and}} [[AmB deocycholate]] for 4-6 weeks, followed by fluconazole for 6-18 months.
:::*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
:::*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


Line 81: Line 82:
{{Reflist|2}}
{{Reflist|2}}


[[Category:Infectious disease]]
[[Category:Fungal diseases]]
[[Category:Fungal diseases]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious Disease Project]]
[[Category:Infectious Disease Project]]
[[Category:Emergency medicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Pulmonology]]
[[Category:Neurology]]
[[Category:Dermatology]]

Latest revision as of 21:10, 29 July 2020

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.