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January 2010
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IDSA Updates Guideline for Management of Cryptococcal Disease

An updated IDSA guideline on cryptococcal disease will appear in the Feb. 1 issue of Clinical Infectious Diseases and is now available online.

The update addresses cryptococcal meningoencephalitis in HIV and organ transplant patients, as well as patients who do not have these risk factors. Specific recommendations are made for other unique risk populations, such as children, pregnant women, persons in resource‐limited environments, and those with Cryptococcus gattii infection.

The guideline addresses three key management principles:

  • induction therapy for meningoencephalitis using fungicidal regimens
  • the importance of early recognition and treatment of increased intracranial pressure and/or immune reconstitution inflammatory syndrome (IRIS)
  • the use of lipid formulations of amphotericin B regimens in patients with renal impairment

“Risk groups are categorized, complications are examined, and special risk groups are addressed,” said John R. Perfect, MD, FIDSA, lead author.  “We hope that these guidelines will provide the informational infrastructure for the care of patients with this deadly and increasing mycosis,” he added, noting that “guidelines are great starting points but cannot always accommodate for the nuances of clinical practice.”

The guideline addresses the role that highly active antiretroviral therapy (HAART) has played in the management of cryptococcal disease.  Although HAART has helped in reducing the incidence of cryptococcosis in well-developed countries, it has not been as effective in areas where HIV rates are much higher due to reduced availability and monitoring of HAART or need for earlier diagnosis of HIV infection. 

Tables and figures provide detailed regimens for treatment of cryptococcosis, such as appropriate dosage and duration.

Several performance measures for internal performance improvement are also suggested within the guideline.  Most notably, patients should receive a polyene at the onset of treatment for cryptococcal meningoencephalitis. When a relapse occurs, the patient should be carefully monitored to determine if it is a result of fungal growth or represents IRIS (negative consequences from therapeutic advances).  Also, patients with cryptococcosis or meningoencephalitis should be tested for HIV infection.

The guideline is available online. Other IDSA guidelines also are available on the Standards, Practice Guidelines, and Statements page of our website.
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