Cryptococcosis in a Resource-Limited Health Care Environment
ÎFor 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).
ÎMaintenance therapy is fluconazole (200-400 mg per day orally) until immune reconstitution (A-I).
ÎWith 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).
ÎWith 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).
ÎWith 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).
ÎFor azole-resistant strains, administer AmBd (1 mg/kg per day IV) until CSF, blood, and/or other sites are sterile (B-III).
Infection ÎFor CNS and disseminated disease due to : Induction,
consolidation, and suppressive treatment are the same as for (A-II).
ÎMore diagnostic focus by radiology and follow-up examinations are needed for cryptococcomas/hydrocephalus due to to
ÎPulmonary cryptococcosis (same as than that due
, but the management principles are the same (B-II). ):
> 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 size of cryptococcoma after 4 weeks of therapy, or failure to thrive (B-III).
ÎRecombinant IFN-γ use remains uncertain (C-III).
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