0521779407-C04 CUNY1086/Karliner 0 521 77940 7 June 14, 2007 20:37
Cryptococcus Neoformans 429■Follow patients closely, switch to oral azole for completion of therapy
■Lifelong suppression for HIV-positive patients
■Data on treating HIV-negative patients is sparse – care must be indi-
vidualizedspecific therapy
■All patients with CNS disease merit treatment
■HIV-positive patients and immunosuppressed treated with any site
of infection
■Pulmonary cryptococcosis without immunosuppression or predis-
posing factors often resolves without treatmentTreatment Options
■Amphotericin B for 2 weeks, then 8 weeks of fluconazole or itracona-
zole, then lifelong maintenance with flu/itra. This is the regimen for
HIV-positive patients; flucytosine was not shown to improve efficacy,
so its use is controversial.
■Amphotericin B+/−flucytosine for 6 weeks. This is the non-HIV-
infected patient regimen; with continued immunosuppression, the
therapy is often extended beyond 6 wks. 4-wk course only with neg-
ative cultures at <2 wks of therapy. Unclear if lifelong suppression
with azole is needed.
■Fluconazole: unclear if initial therapy with oral azole is appropriate–
logically this should work, but it is not yet standard of care
■Liposomal amphotericin B approved for cryptococcosis based on
open-label, noncomparative studies; may be substituted if nephro-
toxicity precludes standard amphotericin therapySide Effects & Complications
■Amphotericin B (conventional): infusion-related toxicities (often
ameliorated with hydrocortisone in IV bag), nephrotoxicity, hypo-
kalemia, hypomagnesemia, nephrotoxicity (can be dose-limiting)
■Flucytosine: Leukopenia, thrombocytopenia, GI disturbance/
diarrhea – adjust dose for renal function, especially when used with
amphotericin
■Fluconazole: transaminitis, many drug interactions
■Liposomal amphotericin: nephrotoxicity (but rarer than with con-
ventional ampho), mild infusion-relatedfollow-up
During Treatment
■Serial LP if elevated CSF opening pressure