Cryptococcosis

Prevention of Exposure
(1) HIV-infected persons cannot completely avoid exposure to Cryptococcus neoformans. There is no evidence that exposure to pigeon droppings is associated with an increased risk of acquiring cryptococcosis.

Prevention of Disease
(2) Routine testing of asymptomatic persons for serum cryptococcal antigen is not recommended because of the low probability that the results will affect clinical decisions (DIII).

(3) Prospective controlled trials indicate that fluconazole and itraconazole can reduce the frequency of cryptococcal disease among patients who have advanced HIV disease. However, most experts recommend that antifungal prophylaxis not be used routinely to prevent cryptococcosis because of the relative infrequency of cryptococcal disease, the lack of survival benefit associated with prophylaxis, the possibility of drug interactions, the potential for development of antifungal drug resistance, and cost. The need for prophylaxis or suppressive therapy for other fungal infections (e.g., candidiasis, histoplasmosis or coccidioidomycosis) should be considered in making decisions about prophylaxis for cryptococcosis. If used, fluconazole at doses of 100-200 mg daily is reasonable for patients whose CD4+ T-lymphocyte counts are < 50 cells/uL (CI) (48-50).

Prevention of Recurrence
(4) Patients who complete initial therapy for cryptococcosis should be administered lifelong suppressive treatment (i.e., secondary prophylaxis or chronic maintenance therapy). Fluconazole is superior to itraconazole in preventing relapse of cryptococcal disease and is the preferred drug (AI).

Discontinuation of Secondary Prophylaxis (chronic maintenance therapy)
(5) Although patients receiving secondary prophylaxis (chronic maintenance therapy) may be at low risk for recurrence of systemic mycosis when their CD4+ T-lymphocyte counts increase to > 100 cells/uL on HAART, the numbers of patients who have been evaluated are insufficient to warrant a recommendation to discontinue prophylaxis in such patients.

Notes

Pediatric Note
(6) There are no data on which to base specific recommendations for children, but lifelong suppressive therapy with fluconazole after an episode of cryptococcosis is appropriate (AII).

Note Regarding Pregnancy
(7) Prophylaxis with fluconazole or itraconazole should not be initiated during pregnancy because of the low incidence of cryptococcal disease, the lack of a recommendation for primary prophylaxis against cryptococcosis in nonpregnant adults, and the potential for teratogenic effects of these drugs during pregnancy (DIII) (51-53). For patients who conceive while being administered primary prophylaxis and who elect to continue their pregnancy, prophylaxis should be discontinued. The occurrence of craniofacial and skeletal abnormalities in infants following prolonged in-utero exposure to fluconazole should be considered when assessing the therapeutic options for HIV-infected women who become pregnant and are receiving secondary prophylaxis (maintenance therapy) for cryptococcosis (51). In such patients, therapy with amphotericin B may be preferred, especially during the first trimester. Effective birth control should be recommended to all HIV-infected women on azole therapy for cryptococcosis (AIII).

previous page | next page

return to table of contents