Practice Guidelines for the Management of Cryptococcal Disease

Abstract

An 8-person subcommittee of the National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group evaluated available data on the treatment of cryptococcal disease. Opinion regarding optimal treatment was based on personal experience and information in the literature. The relative strength of each recommendation was graded according to the type and degree of evidence available to support the recommendation, in keeping with previously published guidelines by the Infectious Diseases Society of America (IDSA). The panel conferred in person (on 2 occasions), by conference call, and through written reviews of each draft of the manuscript. The choice of treatment for disease caused by Cryptococcus neoformans depends on both the anatomic sites of involvement and the host's immune status. For immunocompetent hosts with isolated pulmonary disease, careful observation may be warranted; in the case of symptomatic infection, indicated treatment is fluconazole, 200–400 mg/day for 3–6 months. For those individuals with non-CNS-isolated cryptococcemia, a positive serum cryptococcal antigen titer >1 : 8, or urinary tract or cutaneous disease, recommended treatment is oral azole therapy (fluconazole) for 3–6 months. In each case, careful assessment of the CNS is required to rule out occult meningitis. For those individuals who are unable to tolerate fluconazole, itraconazole (200–400 mg/day for 6–12 months) is an acceptable alternative. For patients with more severe disease, treatment with amphotericin B (0.5–1 mg/kg/d) may be necessary for 6–10 weeks. For otherwise healthy hosts with CNS disease, standard therapy consists of amphotericin B, 0.7–1 mg/kg/d, plus flucytosine, 100 mg/kg/d, for 6–10 weeks. An alternative to this regimen is amphotericin B (0.7–1 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 2 weeks, followed by fluconazole (400 mg/day) for a minimum of 10 weeks. Fluconazole “consolidation” therapy may be continued for as along as 6–12 months, depending on the clinical status of the patient. HIV-negative, immunocompromised hosts should be treated in the same fashion as those with CNS disease, regardless of the site of involvement. Cryptococcal disease that develops in patients with HIV infection always warrants therapy. For those patients with HIV who present with isolated pulmonary or urinary tract disease, fluconazole at 200–400 mg/d is indicated. Although the ultimate impact from highly active antiretroviral therapy (HAART) is currently unclear, it is recommended that all HIV-infected individuals continue maintenance therapy for life. Among those individuals who are unable to tolerate fluconazole, itraconazole (200–400 mg/d) is an acceptable alternative. For patients with more severe disease, a combination of fluconazole (400 mg/d) plus flucytosine (100–150 mg/d) may be used for 10 weeks, followed by fluconazole maintenance therapy. Among patients with HIV infection and cryptococcal meningitis, induction therapy with amphotericin B (0.7–1 mg/kg/d) plus flucytosine (100 mg/kg/d for 2 weeks) followed by fluconazole (400 mg/d) for a minimum of 10 weeks is the treatment of choice. After 10 weeks of therapy, the fluconazole dosage may be reduced to 200 mg/d, depending on the patient's clinical status. Fluconazole should be continued for life. An alternative regimen for AIDS-associated cryptococcal meningitis is amphotericin B (0.7–1 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 6–10 weeks, followed by fluconazole maintenance therapy. Induction therapy beginning with an azole alone is generally discouraged. Lipid formulations of amphotericin B can be substituted for amphotericin B for patients whose renal function is impaired. Fluconazole (400–800 mg/d) plus flucytosine (100–150 mg/kg/d) for 6 weeks is an alternative to the use of amphotericin B, although toxicity with this regimen is high. In all cases of cryptococcal meningitis, careful attention to the management of intracranial pressure is imperative to assure optimal clinical outcome. As is true for other systemic mycoses, treatment of disease due to C. neoformans have improved dramatically over the last 2 decades. Before 1950, disseminated cryptococcal disease was uniformly fatal. With the advent of polyene antifungal agents, particularly amphotericin B, successful outcomes were achieved in as much as 60%–70% of patients with cryptococcal meningitis, depending on the status of the host at the time of presentation [1]. During the early 1970s, flucytosine was established as an orally bioavailable agent with potent activity against C. neoformans; however, this activity was lost rapidly because of the development of resistance when the drug was used as monotherapy [2]. When flucytosine was added to amphotericin B as combination therapy, overall outcome of therapy was improved and the duration of treatment could be reduced from 10 weeks to 4–6 weeks, depending on the status of the host [1, 3]. Beginning in the 1980s, orally bioavailable azole antifu