IDSA GUIDELINES Bundle (free trial)

Elevated CSF Pressure ÎIdentify CSF pressure at baseline. A prompt baseline lumbar puncture is strongly encouraged, but in the presence of focal neurologic signs or impaired mentation it should be delayed pending the results of a computed tomography (CT) or magnetic resonance imaging (MRI) scan (B-II). ÎIf the CSF pressure is ≥ 25 cm of CSF and there are symptoms of increased intracranial pressure during induction therapy, relieve by CSF drainage (by lumbar puncture, reduce the opening pressure by 50% if it is extremely high or to a normal pressure of ≤ 20 cm of CSF) (B-II). ÎIf there is persistent pressure elevation ≥ 25 cm of CSF and symptoms, repeat lumbar puncture daily until the CSF pressure and symptoms have been stabilized for > 2 days and consider temporary percutaneous lumbar drains or ventriculostomy for persons who require repeated daily lumbar punctures (B-III). ÎPermanent ventriculoperitoneal (VP) shunts should be placed only if the patient is receiving or has received appropriate antifungal therapy and if more conservative measures to control increased intracranial pressure have failed. If the patient is receiving an appropriate antifungal regimen, VP shunts can be placed during active infection and without complete sterilization of CNS, if clinically necessary (B-III). Other Medications for Intracranial Pressure ÎMannitol has no proven benefit and is not routinely recommended (A-III). ÎAcetazolamide and corticosteroids to control increased intracranial pressure should be avoided unless part of immune reconstitution inflammatory syndrome (IRIS) treatment (A-II). ÎConsider corticosteroids if signs of IRIS are present (See IRIS). Recurrence of Signs and Symptoms ÎFor recurrence of signs and symptoms, reinstitute drainage procedures (B-II). ÎFor patients with recurrence, measurement of opening pressure with lumbar puncture after a 2-week course of treatment may be useful in evaluation of persistent or new CNS symptoms (B-III). Long-term Elevated Intracranial Pressure ÎIf the CSF pressure remains elevated and if symptoms persist for an extended period of time in spite of frequent lumbar drainage, consider insertion of a VP shunt (A-II). Cerebral Cyptococcomas ÎInduction therapy with AmBd (0.7-1.0 mg/kg per day IV), liposomal AmB (3-4 mg/kg per day IV), or ABLC (5 mg/kg per day IV) plus flucytosine (100 mg/kg per day orally in 4 divided doses) for at least 6 weeks (B-III). ÎConsolidation and maintenance therapy with fluconazole (400-800 mg per day orally) for 6-18 months (B-III). ÎAdjunctive therapies include the following: > Corticosteroids for mass effect and surrounding edema (B-III). > Surgery: for large (≥ 3 cm), accessible lesions with mass effect, consider open or stereotactic-guided debulkment and/or removal. Also, enlarging lesions not explained by IRIS should be submitted for further tissue diagnosis (B-II). 7

• Cover
• Key Points
• Selecting A Treatment Regimen & Algorithms
• Complications
• Algorithms