Clinical management and monitoring during antifungal therapy of the HIV-infected patient with cryptococcal meningoencephalitis
- Gary M Cox, MD
Gary M Cox, MD
- Professor of Medicine
- Duke University Medical Center
- John R Perfect, MD
John R Perfect, MD
- Professor of Medicine
- Duke University Medical Center
Cryptococcal meningoencephalitis is a serious opportunistic infection that is seen among patients with untreated AIDS . The initial preferred approach to the patient with cryptococcal meningoencephalitis includes combination antifungal therapy with amphotericin B plus flucytosine (for the induction phase of therapy) followed by fluconazole (for the consolidation phase). During therapy, patients should be monitored for recurrence of clinical symptoms that may suggest increased intracranial pressure, relapse of infection (from lack of adherence or drug resistance), adverse events related to antifungal therapy, and immune recovery syndromes secondary to antiretroviral therapy (ART).
This topic is devoted to clinical monitoring of the HIV-infected host with cryptococcal meningitis. The epidemiology, clinical manifestations, diagnosis, and treatment of disease are found elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of Cryptococcus neoformans meningoencephalitis in HIV-infected patients" and "Microbiology and epidemiology of Cryptococcus neoformans infection" and "Immune reconstitution inflammatory syndrome" and "Treatment of Cryptococcus neoformans meningoencephalitis in HIV-infected patients".)
MONITORING FOR DRUG TOXICITY
Amphotericin B — Infusion-related reactions, particularly nausea, vomiting, chills, and rigors, are common with intravenous (IV) amphotericin B deoxycholate administration, and usually occur either during infusion (within 15 minutes to 3 hours following initiation) or immediately following administration of the dose. Patients with infusion-related reactions may be pretreated with acetaminophen, diphenhydramine, or corticosteroids administered approximately 30 minutes before infusion . (See "Pharmacology of amphotericin B", section on 'Infusion-related reactions'.)
Amphotericin B is associated with renal insufficiency, hypocalcemia, hypophosphatemia, and hypokalemia. Thus, patients treated with amphotericin B should have daily monitoring of serum creatinine and electrolytes. Many patients require significant amounts of potassium and/or magnesium supplementation during therapy and hydration with normal saline during amphotericin B infusions. (See "Pharmacology of amphotericin B", section on 'Adverse effects'.)
A lipid-based formulation of amphotericin B should be used for patients who develop renal insufficiency (eg, plasma creatinine concentration exceeds 2.5 mg/dL) while receiving amphotericin B deoxycholate, or if there are concerns about having to interrupt induction therapy due to toxicity. If this is not possible, the dose of amphotericin B deoxycholate can be reduced by 50 percent or given every other day. It is critical that there is no interruption of the combination regimen during the two-week induction period. (See "Treatment of Cryptococcus neoformans meningoencephalitis in HIV-infected patients", section on 'Approach to antifungal treatment'.)
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- MONITORING FOR DRUG TOXICITY
- Amphotericin B
- LABORATORY MONITORING FOR FUNGAL INFECTION
- Monitoring of serum cryptococcal antigen
- Sterilization of cerebrospinal fluid
- Drug resistance testing
- MONITORING OF INTRACRANIAL PRESSURE
- Clinical symptoms
- CLINICAL MONITORING DURING TREATMENT
- Clinical management of persistent or relapsing infection
- Assessment of new clinical symptoms
- IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME
- General background
- Symptoms and signs
- Management of IRIS
- TIMING OF ANTIRETROVIRAL THERAPY
- SUMMARY AND RECOMMENDATIONS