Selecting a Treatment Regimen
Table 2. Antifungal Treatment Recommendations for Cryptococcal Meningoencephalitis in Transplant Recipients
Regimen 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
Liposomal AmB (6 mg/kg per day) or ABLC (5 mg/kg per day)
AmBd (0.7 mg/kg per day)b
Consolidation therapy: Fluconazole (400-800 mg per day) Maintenance therapy: Fluconazole (200-400 mg per day)
4-6 weeks 4-6 weeks
8 weeks 6-12 mos
a 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.
Table 3. Antifungal Treatment Recommendations for Cryptococcal Meningoencephalitis in Non-HIV-Infected and Nontransplant Patients
Regimen Induction Therapy
AmBd (0.7-1.0 mg/kg per day) plus flucytosine (100 mg/kg per day)
AmBd (0.7-1.0 mg/kg per day)c
Liposomal AmB (3-4 mg/kg per day) or ABLC (5 mg/kg per day) combined with flucytosine, if possibled
AmBd (0.7 mg/kg per day) plus flucytosine (100 mg/kg per day)e Consolidation therapy: Fluconazole (400-800 mg per day)f Maintenance therapy: Fluconazole (200 mg per day)b
a ≥ 4 weeksa,b
≥ 6 weeksa,b ≥ 4 weeksa,b 2 weeks
8 weeks 6-12 mos B-II B-II
B-III B-II
B-III B-III
b
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.
c For flucytosine-intolerant patients. d For AmBd-intolerant patients.
e f
Fluconazole is given at 200 mg per day to prevent relapse aſter induction therapy, and consolidation therapy is recommended.
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.
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.
1 Duration Evidence
B-III B-III
B-III B-III
2 weeks B-III Duration Evidence
