Complications
IRIS
ÎÎNo need to alter direct antifungal therapy (B-III).
ÎÎNo definitive specific treatment recommendation for minor IRIS
manifestations is necessary, because they will resolve spontaneously in
days to weeks (B-III).
ÎÎFor major complications, such as CNS inflammation with increased
intracranial pressure, consider corticosteroids (0.5-1.0 mg/kg per day of
prednisone equivalent) and possibly dexamethasone at higher doses for
severe CNS signs and symptoms. Length and dose of the corticosteroid
taper are empirically chosen and require careful following of the patient,
but a 2-6-week course is a reasonable starting point. The course should
be given with a concomitant antifungal regimen (B-III).
ÎÎNonsteroidal anti-inflammatory drugs and thalidomide have been used but
with too little experience to make a recommendation (C-III).
Treatment in Special Clinical Situations
Pregnant Women with Cryptococcosis
ÎÎFor disseminated and CNS disease, use AmBd or LFAmB, with or without
flucytosine (B-II).
Comment: Flucytosine is a category C drug for pregnancy, and therefore its use must be
considered in relationship to benefit versus risk.
ÎÎStart fluconazole (pregnancy category C) after delivery; avoid fluconazole
exposure during the first trimester. During the last 2 trimesters, judge the
use of fluconazole with the need for continuous antifungal drug exposure
during pregnancy (B-III).
ÎÎFor limited and stable pulmonary cryptococcosis, perform close follow-up
and administer fluconazole after delivery (B-III).
ÎÎWatch for IRIS in the postpartum period (B-III).
Children with Cryptococcosis
ÎÎInduction and consolidation therapy for CNS and disseminated disease
is AmBd (1 mg/kg per day IV) plus flucytosine (100 mg/kg per day orally
in 4 divided doses) for 2 weeks (for the non-HIV-infected, non-transplant
population, follow the treatment length schedule for adults), followed by
fluconazole (10-12 mg/kg per day orally) for 8 weeks; for AmB-intolerant
patients, either liposomal AmB (5 mg/kg per day) or ABLC (5 mg/kg per
day) (A-II).
ÎÎMaintenance therapy is fluconazole (6 mg/kg per day orally) (A-II).
ÎÎDiscontinuation of maintenance therapy in children receiving HAART is
poorly studied and must be individualized (C-III).
ÎÎFor cryptococcal pneumonia, use fluconazole (6-12 mg/kg per day orally)
for 6-12 months (B-II).
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