Cryptococcal meningitis is one of the dreadful opportunistic infections in HIV/AIDS patients. The standard of care is giving amphotericin B and flucytosine initially then with fluconazole. However, in our set-up amphotericin B and flucytosine are hardly available. Hence fluconazole alone is used for treating it. Nevertheless, we lack data/information on how effective it is.
In cryctococcus meningits the treatment is, as you say Amphotericin B plus Flucytosin, then Fluconazole
Am somehow sceptical that Fluconazole as exclusive treatment is sufficient. No chance to get Amphotericin B and Flucytosin?
Christian G Meyer amphotericin B is seldom available, however i have never seen flucytosine in our set-up.
Hi Oumer,
Thank you for asking this pertinent question. You have to understand that treatment of cryptococcal meningitis (CM) is in three phases: induction, maintenance and consolidation. For the treatment of CM, the three medications are amphotericin B, Flucytosine and fluconazole all recommended for this long lasting treatment.
However, for the induction phase very crucial for patients survival, monotherapy is NOT recommended and you can only use combination therapy and in the ACTA trial ( Article Antifungal Combinations for Treatment of Cryptococcal Mening...
) which is the basis of the current WHO guidelines,- Preferred induction treatment is Amphotericin B plus oral flucytosine for 7 days.
- Alternative induction treatment is high dose fluconazole (1200mg/day) plus flucytosine for 14 days.
During the consolidation phase which should last 8 weeks
- If induction was with Ampho B plus flucytosine, give fluconazole monotherapy 1200 mg/day for one week then 800 mg/day till ten weeks
- if induction was with oral fluconazole plus flucytosine for two weeks, then give fluconazole monotherapy 800mg/day till ten weeks
During the maintenance phase which is to last till patient has >200 CD4 count is simply with fluconazole 200 mg/day as secondary prophylaxis.
One thing which is also crucial is antiretroviral therapy (re)initiation which has to happen 4 to 6 weeks after initiation of induction treatment to avoid IRIS, see summary of CM treament here ( Article Recent advances in managing HIV-associated cryptococcal meningitis
)Therefore in your setting where you already have fluconazole and some flucytosine but no amphotericine B, the recommended induction treatment would be oral combination of Fluconazole and flucytosine.
Fluconazole monotherapy is NOT recommended for induction treatment of CM because mortality is still high as you see evidence in Malawi using 800 mg/day ( Article A Prospective Longitudinal Study of the Clinical Outcomes fr...
) or 1200mg/day (Article A Prospective Study of Mortality from Cryptococcal Meningiti...
) there was no difference in mortality which still was unacceptably high.I hope my modest contribution helps to answer your question and provide insights on the way forward in your context.
I am available in case you need to discuss.
Cheers.
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