Approach to managing cryptococcosis

Before starting treatment for cryptococcosis, the investigations listed in Diagnosing and assessing cryptococcosis should be performed to exclude disseminated disease and identify risk factors contributing to diseaseChang 2021.

Treatment for cryptococcosis depends on the site and severity of infection as well as whether the patient is immunocompetent. In these guidelines, for simplicity, the 2 approaches to treatment are referred to as three-phase or single-phase antifungal regimens.

The three-phase regimen is recommended for those with:

  • cryptococcal meningitis
  • severe pulmonary cryptococcosis (eg extensive consolidation, respiratory compromise, multiple nodules)
  • pulmonary cryptococcosis plus extrapulmonary disease (eg cryptococcaemia, central nervous system involvement, skin involvement, endophthalmitis).

Patients with cryptococcal meningitis also require monitoring and treatment for raised intracranial pressure; see Managing raised intracranial pressure in cryptococcal meningitis for more information.

The single-phase regimen is reserved for patients with nonsevere pulmonary cryptococcosis (eg single pulmonary cryptococcoma, minimal symptoms). It is essential to exclude extrapulmonary disease (eg central nervous system involvement) in patients with immune compromise who have nonsevere infection. If extrapulmonary disease is excluded, the single-phase regimen can be used. However, some experts recommend the more aggressive three-phase regimen for all patients with immune compromise, even in the absence of extrapulmonary involvement.

A flare in disease activity (ie immune reconstitution inflammatory syndrome [IRIS]) may occur in patients with HIV infection after starting antiretroviral therapy and in patients without HIV infection after starting antifungal therapy.

Treatment with corticosteroids is of no benefit in patients with cryptococcosis, except in the setting of IRIS – seek expert advice.

For patients with large pulmonary cryptococcomas, surgery may be required – seek expert advice.