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IDSA releases updated guidelines for the management of cryptococcal disease
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The Infectious Disease Society of America has updated the treatment guidelines for the management of cryptococcal disease for the first time since 2000.
The authors of the guidelines said an update was needed because during the past decade, “a series of new clinical issues and host risk groups have arisen and it is timely that these guidelines be revised to assist practicing clinicians in management of cryptococcosis.”
Among some of the most notable changes, the updated guidelines include additional information on the management of cryptococcal meningoencephalitis in three risk groups: patients with HIV/AIDS, patients who have received an organ transplant, and patients who may be a host of the disease but are HIV-negative and have not been a recipient of an organ transplant.
There are also new recommendations for other patients who are not defined as a high-risk group, but who still may be at risk. These groups include children, pregnant women, people in resource-limited environments and those with Cryptococcus gattii infection.
Key management principles
The new guidelines highlight three key management principles. These are identified as:
- induction therapy for meningoencephalitis using fungicidal regimens such as a polyene and flucytosine, followed by suppressive regimens using fluconazole;
- the importance of early recognition and treatment of increased intracranial pressure and/or immune reconstitution inflammatory syndrome;
- the use of lipid formulations of amphotericin B regimens in patients with renal impairment.
In addition to these key management principals, the new guidelines include recommendations for the management of various specific sites of infection, including strategies for pulmonary cryptococcosis. The new guidelines also include more specific information on potential complications that may arise during the management of cryptococcal infection. These potential complications include increased intracranial pressure, immune reconstitution inflammatory syndrome, drug resistance, and cryptococcomas.
Other changes
Several other updates have been made to the new guidelines. Unlike the previous version, the new guidelines include separate information on Cryptococcus neoformans and Cryptococcus gattii. The authors of the guidelines said that although most clinical laboratories do not identify cryptococcus to the species level, it is beneficial to note the differences, especially since they have been associated with different outbreaks. According to the authors, C. gattii has been associated with “an ongoing outbreak of cryptococcosis in apparently immunocompetent humans and animals on Vancouver Island and surrounding areas within Canada and the northwest United States.” Because of this, the authors said that “the management of C. gattii infection in immunocompetent hosts needs to be specifically addressed.”
The new guidelines also address the effect of HAART on the rates of cryptococcosis. The authors note that because of HAART, there is now a wide disparity in the rates of cryptococcal disease between developed and developing countries.
“Although the widespread use of HAART has lowered the incidence of cryptococcosis in medically developed countries, the incidence and mortality of this infection are still extremely high in areas where uncontrolled HIV disease persists and limited access to HAART and/or health care occurs,” the authors wrote. They added that there are currently an estimated 1 million cases of HIV-associated cryptococcosis in the world; the majority of these cases are in developing countries.
The authors said that management of cryptococcal disease remains a medical challenge. The lack of new drug development and new clinical studies focusing on this disease contribute to the challenge.
“However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients,” the authors wrote.
Perfect J. Clin Infect Dis. 2010;50:291-322.