Question 11 - Opportunistic Infections: Treatment Question Bank

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Opportunistic Infections: TreatmentQuestion 11/20

A 37-year-old cisgender man with no known medical problems is admitted to the hospital with a 2-week history of headache, photophobia, nausea, vomiting, poor appetite, and night sweats. Computed tomographic (CT) brain scan showed no mass lesions and no midline shift. Lumbar puncture demonstrates an opening pressure of 17 cm H₂O, and cerebrospinal fluid (CSF) examination shows 16 cells/mm³ (85% lymphocytes), a glucose of 26 mg/dL, and a protein of 90.5 mg/dL. The CSF cryptococcal antigen is positive (titer of 1:512). The serum cryptococcal antigen is positive (titer of 1:512). An HIV-1/2 antigen-antibody test is performed and is positive.

Which one of the following would be recommended as preferred initial antifungal therapy for this man?

Micafungin plus voriconazole

Caspofungin plus fluconazole

Fluconazole

Liposomal amphotericin B plus flucytosine

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Question Last Updated
September 29th, 2023

Table 1. **Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV**

Treating Cryptococcal Meningitis: Induction Therapy

Treatment consists of 3 phases: Induction, Consolidation, and Maintenance therapy
Induction Therapy (Duration of Therapy: 2 Weeks, Followed by Consolidation Therapy)
Preferred Regimens Liposomal amphotericin B 3–4 mg/kg IV once daily plus flucytosine 25 mg/kg PO four times a day (AI), or Amphotericin B deoxycholate 0.7–1.0 mg/kg IV once daily plus flucytosine 25 mg/kg PO four times a day (AI)—if cost is an issue and the risk of renal dysfunction is low Note: Flucytosine dose should be adjusted in renal impairment
Alternative Regimens Amphotericin B lipid complex 5 mg/kg IV once daily plus flucytosine 25 mg/kg PO four times a day (BII), or Liposomal amphotericin B 3–4 mg/kg IV once daily plus fluconazole 800-1,200 mg PO or IV once daily (BIII), or Fluconazole 1,200 mg PO or IV once daily plus flucytosine 25 mg/kg PO four times a day (BII), or Fluconazole 800 mg PO or IV once daily plus flucytosine 25 mg/kg PO four times a day (BIII), or Amphotericin B deoxycholate 0.7-1.0 mg/kg IV once daily plus fluconazole 800-1,200 mg PO or IV once daily (BI), or Liposomal amphotericin B 3–4 mg/kg IV once daily alone (BI), or Amphotericin B deoxycholate 0.7–1.0 mg/kg IV daily alone (BI), or Liposomal amphotericin B 3–4 mg/kg IV once daily plus flucytosine 25 mg/kg PO four times a day for 1 week, followed by fluconazole 1,200 mg PO once daily (BIII), or Fluconazole 1,200 mg PO or IV once daily alone (CI)
If the person treated does not improve clinically or remains clinically unstable, continue induction therapy until the CSF culture is confirmed to be negative (BIII).
Abbreviations: PO = orally; IV = intravenously Rating System for Prevention and Treatment Recommendations Strength of Recommendation: A = Strong; B = Moderate; C = Weak Quality of Evidence for the Recommendation: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Source:

Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Cryptococcosis. Updated: July 1, 2021. [HIV.gov]

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Opportunistic Infections: TreatmentQuestion 11/20

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Which one of the following would be recommended as preferred initial antifungal therapy for this man?

Treating Cryptococcal Meningitis: Induction Therapy

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