Treatment of Cryptococcal Meningitis in Immunocompromised Patients

Induction Regimen

The Infectious Diseases Society of America recommends anfotericina B lipossomal 3-4 mg/kg/dia IV combined with flucitosina (100 mg/kg/dia) for at least 2 weeks, with evidence B-III for immunocompromised patients, including transplant recipients 1, 2
For patients with high fungal burden or treatment failure, consider anfotericina B lipossomal 6 mg/kg/dia IV for 4-6 weeks, as this higher dose has been safely administered in cryptococcal meningoencephalitis 1, 4, 5
If flucitosina is not available, anfotericina B lipossomal 3-4 mg/kg/dia should be extended to 4-6 weeks of induction therapy 2, 3

The Infectious Diseases Society of America prefers anfotericina B lipossomal over anfotericina B desoxicolato in immunocompromised patients due to the significantly lower risk of nephrotoxicity, particularly in transplant recipients with pre-existing renal dysfunction and those using nephrotoxic calcineurin inhibitors 1, 2, 6

Fluconazol 200-400 mg/dia should be used for maintenance therapy, with a duration of 6-12 months for transplant recipients and at least 1 year for HIV-positive patients 1, 4, 3

For cryptococcomas, extend induction therapy to at least 6 weeks with anfotericina B lipossomal 3-4 mg/kg/dia plus flucitosina, followed by prolonged consolidation with fluconazol 400-800 mg/dia for 6-18 months 9
Avoid starting antiretroviral therapy prematurely in HIV-positive patients, and wait 2-10 weeks after starting antifungal therapy to avoid immune reconstitution inflammatory syndrome (IRIS) 6