Cryptococcosis
Prevention of Exposure
Although HIV-infected persons cannot completely avoid exposure to
Cryptococcus neoformans, avoiding sites that are likely to be heavily
contaminated with C. neoformans (e.g., areas heavily contaminated
with pigeon droppings) may reduce the risk of infection.
Prevention of Disease
Routine testing of asymptomatic persons for serum cryptococcal antigen
is not recommended because of the low probability that the results will affect
clinical decisions.
Data from prospective controlled trials indicate that fluconazole and itraconazole can reduce the frequency of cryptococcal disease among patients who have advanced HIV disease. Therefore, providers may wish to consider prophylaxis for per-sons who have a CD4+ T-lymphocyte count of <50 cells/µL. 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 both Candida and Cryptococcus drug resistance, and cost. The need for prophylaxis or suppressive therapy for other fungal infections (e.g., candidiasis or histoplasmosis) should be considered in making decisions about prophylaxis for cryptococcosis. Doses of fluconazole ranging from 400 mg once a week to 200 mg daily are effective as prophylaxis against cryptococcosis; however, doses of <200 mg daily may be less effective in suppressing Candida infections, and fluconazole may not prevent Histoplasma infection.
Prevention of Recurrence
Patients who complete initial therapy for cryptococcosis should be
administered lifelong suppressive treatment with fluconazole.
Notes:
Pediatric Note
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.
Note Regarding Pregnancy
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 adverse effects of these drugs
during pregnancy. For patients who conceive while being administered
primary prophylaxis, prophylaxis should be discontinued. However, because
of the risk of the disease to maternal health, prophylaxis against recurrent
cryptococcal disease with fluconazole during pregnancy is indicated.
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