From the Guidelines
For cryptococcal meningitis, the initial treatment should consist of amphotericin B deoxycholate (0.7-1.0 mg/kg/day) plus flucytosine (100 mg/kg/day divided into four doses) for at least 2 weeks, followed by a consolidation phase of fluconazole 400-800 mg daily for 8 weeks, and then fluconazole maintenance therapy at 200 mg daily for at least 6-12 months, as recommended by the Infectious Diseases Society of America 1.
Key Considerations
- The combination of amphotericin B and flucytosine during induction provides synergistic fungicidal activity against Cryptococcus, leading to more rapid sterilization of the cerebrospinal fluid and improved survival rates compared to amphotericin B alone.
- The extended fluconazole maintenance prevents relapse while the immune system recovers.
- For HIV-infected patients, maintenance fluconazole can be discontinued if the patient has completed at least 1 year of therapy, remains asymptomatic, and has a CD4 count >100 cells/μL with an undetectable viral load for at least 3 months, as supported by studies 1.
Treatment Duration
- Induction therapy with amphotericin B and flucytosine: at least 2 weeks
- Consolidation therapy with fluconazole: 8 weeks
- Maintenance therapy with fluconazole: at least 6-12 months
Important Notes
- Flucytosine is not typically used for maintenance therapy.
- The treatment regimen may vary depending on the patient's underlying condition, immunosuppression, and response to treatment.
- Close monitoring and follow-up are necessary to prevent relapse and adjust treatment as needed.
From the Research
Initial Treatment with Amphotericin B and Flucytosine
- The initial treatment for cryptococcal meningitis typically involves a combination of amphotericin B and flucytosine 2, 3, 4, 5, 6.
- The recommended duration of initial treatment with amphotericin B and flucytosine is typically 2 weeks 3, 5.
- This combination has been shown to improve survival rates and reduce mortality compared to amphotericin B alone 2, 3.
Maintenance Therapy with Flucytosine
- After the initial 2-week treatment with amphotericin B and flucytosine, maintenance therapy with flucytosine or an azole (such as fluconazole) is recommended 4, 5, 6.
- The duration of maintenance therapy is not explicitly stated in the provided studies, but it is typically continued for several weeks to months after the initial treatment 4, 5, 6.
- Flucytosine maintenance therapy has been shown to be effective in preventing relapse and improving outcomes in patients with cryptococcal meningitis 4, 5.