B20.5
DESCRIPTION
All ART-naïve patients with CD4 <100 cells/mm3 should have cryptococcal antigen (CrAg) test done on serum, plasma or whole blood (unless they had a diagnosis of cryptococcal infection). The treatment of patients who are CrAg positive and with no signs or symptoms of meningitis and CSF crag negative is outlined below. Refer to algorithm
MEDICINE TREATMENT
Induction phase
- Fluconazole, oral 1200 mg daily for 14 days.
Consolidation phase
Follow with:
- Fluconazole, oral, 800 mg daily for 8 weeks.
Maintenance phase
- Fluconazole, oral, 200 mg daily.
- Continue for at least 1 year provided that the CD4 count increases to >200 cells/mm3 on ART. If the CD4 count does not increase continue treatment indefinitely.
- Commence ART after completion of the induction phase i.e. at 2 weeks. See : Antiretroviral therapy.
CAUTION
- Fluconazole should be avoided in the 1st trimester, but pregnant women should be counselled that the benefits of fluconazole may outweigh the risks in the management of cryptococcosis.
- All pregnant women <20 weeks gestation exposed to fluconazole should have an ultrasound scan to detect congenital abnormalities.
- For management of breastfeeding mothers, consult a specialist; as fluconazole is present at concentrations similar to maternal plasma concentrations in breast milk that will be transmitted to the breastfed infant.
Adapted from: Govender NP, Meintjes G (Chairpersons), Bicanic T, Dawood H, Harrison TS, Jarvis JN, Karstaedt AS, Maartens G, McCarthy KM, Rabie H, Variava E, Venter WDF (Expert panel members), Boulware DR, Chiller T, Meya DB, Scriven J (Reviewers). Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons: 2013 update. S Afr J HIV Med 2013;14(2):76-86. http://www.sajhivmed.org.za/index.php/hivmed/article/view/82/128