Cryptococcosis in a Resource-Limited Health Care Environment
ÎÎFor CNS and/or disseminated disease where flucytosine is not available,
induction therapy is AmBd (1 mg/kg per day IV) for 2 weeks or AmBd
(0.7 mg/kg per day IV) plus fluconazole (800 mg per day orally) for 2
weeks, followed by consolidation therapy with fluconazole (800 mg per
day orally) for 8 weeks (A-I).
ÎÎMaintenance therapy is fluconazole (200-400 mg per day orally) until
immune reconstitution (A-I).
ÎÎWith CNS and/or disseminated disease where polyene is not available,
induction therapy is fluconazole (≥ 800 mg per day orally; 1200 mg per
day is favored) for at least 10 weeks or until CSF culture results are
negative, followed by maintenance therapy with fluconazole (200-400 mg
per day orally) (B-II).
ÎÎWith CNS and/or disseminated disease when polyene is not available
but flucytosine is available, induction therapy is fluconazole (≥ 800 mg
per day orally; 1200 mg per day is favored) plus flucytosine
(100 mg/kg per day orally) for 2-10 weeks, followed by maintenance
therapy with fluconazole (200-400 mg per day orally) (B-II).
ÎÎWith use of primary fluconazole therapy for induction, both primary or
secondary drug resistance of the isolate may be an issue, and MIC testing
is advised (B-III).
ÎÎFor azole-resistant strains, administer AmBd (1 mg/kg per day IV) until
CSF, blood, and/or other sites are sterile (B-III).
C. gattii Infection
ÎÎFor CNS and disseminated disease due to C. gattii: Induction,
consolidation, and suppressive treatment are the same as for
C. neoformans (A-II).
ÎÎMore diagnostic focus by radiology and follow-up examinations are
needed for cryptococcomas/hydrocephalus due to C. gattii than that due
to C. neoformans, but the management principles are the same (B-II).
ÎÎPulmonary cryptococcosis (same as C. neoformans):
>> Single, small cryptococcoma suggests fluconazole (400 mg per day orally).
>> For very large and multiple cryptococcomas, consider a combination of AmBd and
flucytosine therapy for 4-6 weeks, followed by fluconazole for 6-18 months, depending
on whether surgery was performed (B-III).
ÎConsider surgery if there is compression of vital structures, failure to reduce
Î
size of cryptococcoma after 4 weeks of therapy, or failure to thrive (B-III).
ÎÎRecombinant IFN-γ use remains uncertain (C-III).
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