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Treating cryptococcal meningitis in people with HIV

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2203 (Published 10 April 2013) Cite this as: BMJ 2013;346:f2203

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Guidelines recommend that cryptococcal meningitis is initially treated with combined amphotericin B deoxycholate and flucytosine, although evidence is limited. Guidelines also recommend substituting fluconazole in settings such as Asia or Africa, where flucytosine is unavailable and over half of people with the disease die despite receiving treatment. In the West, up to a quarter die.

Flucytosine increased survival compared with amphotericin B alone, but the addition of fluconazole had no effect. At two weeks, 15 of the 100 people receiving combination treatment with flucytosine had died, as had 25 of the 99 people taking amphotericin B alone (hazard ratio 0.57, 95% CI 0.30 to 1.08). By day 70, the difference in deaths was 30 versus 44 (0.61, 0.39 to 0.97), confirming the importance of initial treatment on longer term prognosis. The addition of fluconazole had no effect on deaths at 14 or 70 days (0.78, 0.44 to 1.41 and 0.71, 0.45 to 1.11).

Flucytosine also increased rates of yeast clearance from cerebrospinal fluid, and fewer people receiving it had severe anaemia, compared with those taking amphotericin B alone (35% v 46%). However, serious neutropenia was seen in 9% of patients taking flucytosine versus 2% of those taking amphotericin B alone.

Notes

Cite this as: BMJ 2013;346:f2203