Cryptococcal Meningitis (for non-HIV and non-transplant patients) : Treatment

 

Neurological Complications

• AmBd (0.7–1.0 mg/kg per day IV) plus flucytosine (100mg/kg per day orally in 4 divided doses) for at least 4 weeks for induction therapy. The 4-week induction therapy is reserved for persons with meningoencephalitis without neurological complications and cerebrospinal fluid (CSF) yeast culture results that are negative after 2 weeks of treatment. For AmBd toxicity issues, LFAmB may be substituted in the second 2 weeks.

• In patients with neurological complications, consider extending induction therapy for a total of 6 weeks, and LFAmB may be given for the last 4 weeks of the prolonged induction period.

• Then, start consolidation with fluconazole (400 mg per day) for 8 weeks.

AmB Intolerant

• If patient is AmBd intolerant, substitute liposomal AmB (3–4 mg/kg per day IV) or ABLC (5 mg/kg per day IV).

Treatment Interruption

• If flucytosine is not given or treatment is interrupted, consider lengthening AmBd or LFAmB induction therapy for at least 2 weeks.

Low Risk

• In patients at low risk for therapeutic failure (ie, they have an early diagnosis by history, no uncontrolled underlying disease or immunocompromised state, and excellent clinical response to initial 2-week antifungal combination course), consider induction therapy with combination of AmBd plus flucytosine for only 2 weeks, followed by consolidation with fluconazole (800 mg [12 mg/kg] per day orally) for 8 weeks.

• After induction and consolidation therapy, use maintenance therapy with fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months.

* Amphotericin B Deoxycholate and conventional Amphotericin B is the same

REFERENCE : 
http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/cryptorx.pdf (Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America)