Selecting a Treatment Regimen
Table 2. Antifungal Treatment Recommendations for
Cryptococcal Meningoencephalitis in Transplant
Recipients
Regimen
Duration
Evidence
2 weeks
B-III
Liposomal AmB (6 mg/kg per day) or ABLC
(5 mg/kg per day)
4-6 weeks
B-III
AmBd (0.7 mg/kg per day)b
4-6 weeks
B-III
Consolidation therapy: Fluconazole (400-800 mg per day)
8 weeks
B-III
Maintenance therapy: Fluconazole (200-400 mg per day)
6-12 mos
B-III
Induction Therapya
Liposomal AmB (3-4 mg/kg per day) or AmB lipid complex (ABLC)
(5 mg/kg per day) plus flucytosine (100 mg/kg per day)
Alternatives for Induction Therapyb
Immunosuppressive management may require sequential or step-wise reductions.
b
Many transplant recipients have been successfully treated with AmBd. However, issues of renal
dysfunction with calcineurin inhibitors are important, and the effective dose is imprecise.
a
Table 3. Antifungal Treatment Recommendations for
Cryptococcal Meningoencephalitis in Non-HIV-Infected
and Nontransplant Patients
Regimen
Duration
Evidence
AmBd (0.7-1.0 mg/kg per day) plus flucytosine
(100 mg/kg per day)
≥ 4 weeksa,b
B-II
AmBd (0.7-1.0 mg/kg per day)c
≥ 6 weeksa,b
B-II
Liposomal AmB (3-4 mg/kg per day) or ABLC
(5 mg/kg per day) combined with flucytosine, if possibled
≥ 4 weeksa,b
B-III
2 weeks
B-II
Consolidation therapy: Fluconazole (400-800 mg per day)
8 weeks
B-III
Maintenance therapy: Fluconazole (200 mg per day)b
6-12 mos
B-III
Induction Therapy
AmBd (0.7 mg/kg per day) plus flucytosine (100 mg/kg per day)e
f
Four weeks are reserved for patients with meningitis who have no neurological complications, who have
no significant underlying diseases or immunosuppression, and for whom the cerebrospinal fluid culture
performed at the end of 2 weeks of treatment does not yield viable yeasts. During the second 2 weeks,
lipid formulations of AmB (LFAmB) may be substituted for AmBd.
b
Fluconazole is given at 200 mg per day to prevent relapse after induction therapy, and consolidation
therapy is recommended.
c
For flucytosine-intolerant patients.
d
For AmBd-intolerant patients.
e
For patients who have a low risk of therapeutic failure. Low risk is defined as an early diagnosis by history,
no uncontrolled underlying condition or severe immunocompromised state, and an excellent clinical
response to initial 2-week antifungal combination course.
f
A higher dosage of fluconazole (800 mg per day) is recommended if the 2-week induction regimen was
used and if there is normal renal function.
a
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