Complications IRIS ÎNo need to alter direct antifungal therapy (B-III).
ÎNo definitive specific treatment recommendation for minor IRIS manifestations is necessary, because they will resolve spontaneously in days to weeks (B-III).
ÎFor 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).
ÎNonsteroidal 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
ÎFor 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.
ÎStart 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).
ÎFor limited and stable pulmonary cryptococcosis, perform close follow-up and administer fluconazole after delivery (B-III).
ÎWatch for IRIS in the postpartum period (B-III). Children with Cryptococcosis
ÎInduction 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).
ÎMaintenance therapy is fluconazole (6 mg/kg per day orally) (A-II).
ÎDiscontinuation of maintenance therapy in children receiving HAART is poorly studied and must be individualized (C-III).
ÎFor cryptococcal pneumonia, use fluconazole (6-12 mg/kg per day orally) for 6-12 months (B-II).
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