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Guideline

Rapid advice : diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children

Year of Publication
2011
Issuing Institution
World Health Organization
Links
WHO IRIS,WHO IRIS

Recommendations

26 included recommendations

In HIV-infected adults, adolescents and children with suspected first episode of cryptococcal meningitis (CM): In settings without immediate access to LP, or when it is clinically contraindicated. If both access to CrAg assay (either LA or LFA), and rapid results (i.e., less than 24 hours) are assured: Rapid serum or plasma CrAg. If CrAg is positive, initiate treatment for presumed cryptococcal meningitis, with immediate referral for further investigation and treatment as appropriate

Status
Updated

Recommended in favor

Strong

For the induction phase of treatment in HIV-infected adults, adolescents and children with cryptococcal disease (meningeal and disseminated non-meningeal), the following two-week antifungal regimens are recommended in order of preference: c. Amphotericin B short course (5–7 days) + high dose fluconazole (to complete 2 weeks of induction) when a minimum package of pre-emptive hydration and electrolyte replacement and toxicity monitoring and management cannot be provided for the full 2-week induction period

Status
Maintained

Recommended in favor

Conditional

For the consolidation phase treatment of HIV infected adults, adolescents and children with cryptococcal meningitis or disseminated non-meningeal disease, the following 8-week antifungal regimen is recommended: Fluconazole 400–800mg/day after a two-week induction with amphotericin B regimen (6–12 mg/kg/day up to 400–800 mg/day if below 19 years). Fluconazole 800 mg/day after induction treatment with short-course amphotericin B or fluconazole-based induction regimen (fluconazole 12 mg/kg/day up to 800 mg/day if below 19 years)

Status
Maintained

Recommended in favor

Strong

For localized non-meningeal disease, or in patients with isolated serum CrAg positivity (where active cryptococcal meningitis has been excluded). Fluconazole 800 mg/day (or 12 mg/kg/ day if below 19 years) for two weeks, then 400 mg/day (or 6 mg/kg/day up to 400–800 mg/ day if below 19 years) for 8 weeks, and continued maintenance with fluconazole 200 mg/day is recommended. The optimal antifungal regimen in this population remains to be determined

Status
Maintained

Recommended in favor

Strong

In HIV-infected adults, adolescents and children with a recent diagnosis of cryptococcal meningitis, ART initiation should be deferred until there is evidence of a sustained clinical response to antifungal therapy, and after 4 weeks of induction and consolidation treatment with amphotericin B–containing regimens combined with flucytosine or fluconazole, or after 4–6 weeks of treatment with a high-dose oral fluconazole induction and consolidation regimen

Status
Maintained

Recommended in favor

Strong

In HIV-infected adults and adolescents with successfully treated cryptococcal disease (meningeal and non-meningeal), discontinuation of antifungal maintenance treatment is recommended based on the following criteria: a. If HIV viral load monitoring is available: when patients are stable and adherent to ART and antifungal maintenance therapy for at least 1 year and have a CD4 cell count of greater than or equal to 200 cells/mm3 (two measurements 6 months apart)

Status
Maintained

Recommended in favor

Conditional

In HIV-infected adults and adolescents with successfully treated cryptococcal disease (meningeal and non-meningeal), discontinuation of antifungal maintenance treatment is recommended based on the following criteria: b. If HIV viral load monitoring is available: when patients are stable and adherent to ART and antifungal maintenance treatment for at least one year and with CD4 cell count of greater than or equal to 100 cells/mm3 (two measurements 6 months apart) and a suppressed viral load

Status
Maintained

Recommended in favor

Strong

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