However, the correlation between clinical E7080 concentration response and fluconazole MIC has been variable [31,32]. Although fungal susceptibilities should be requested initially, the decision to switch therapy should not be based on the antifungal MIC alone but requires supportive laboratory or clinical markers of an impaired response to therapy (category IV recommendation). Poor prognostic factors are blood culture positivity, low white blood cell in CSF (<20 cells/mL), high CSF cryptococcal antigen (>1:1024), a confused state and a raised intracranial pressure [33]. 2.4.4.1 Induction. • Standard induction therapy of cryptococcal

meningitis is with amphotericin B, usually combined with flucytosine 100 mg/kg/day (category Ib recommendation). Historically, the standard of care for the treatment of cryptococcal meningitis in HIV-seronegative individuals has been amphotericin B deoxycholate (0.7–1 mg/kg/day) combined with flucytosine (100 mg/kg/day) [34,35]. However, the advantages and disadvantages of the addition of flucytosine to amphotericin B deoxycholate Nutlin-3a mouse in the HIV setting should be carefully weighed for each individual patient [36–39]. The addition of flucytosine speeds the rate of sterilization of the CSF [36,39] and reduces the incidence of relapse [40] in patients not receiving HAART. However, flucytosine has been associated with enhanced toxicity in some (though not other) studies and has not been

shown to impact on early or late mortality [14,36]. In addition, most of the benefits of flucytosine have been observed in patients not receiving HAART. When flucytosine is given, it may be prescribed orally or intravenously. Flucytosine is associated with haematological toxicity and daily blood counts are required with monitoring of flucytosine levels. Standard amphotericin

B is associated with renal toxicity, and where possible should be Thymidylate synthase replaced by liposomal amphotericin B as the first choice agent (category III recommendation). In one study (including a small number of HIV-seropositive individuals) 30% of those receiving amphotericin B deoxycholate developed acute renal failure with significant associated mortality [41]. Further research has demonstrated that liposomal amphotericin B (4 mg/kg) without concomitant flucytosine therapy sterilized the CSF faster than standard amphotericin B and was associated with lower nephrotoxicity but not with any survival advantage [42]. On the basis of the lower incidence of nephrotoxicity, many pharmacy departments have stopped stocking amphotericin B deoxycholate and, on the basis of at least equivalent efficacy and lower nephrotoxicity, liposomal amphotericin B (4 mg/kg/day intravenously) is the preferred amphotericin B preparation when available for the treatment of cryptococcal meningitis. Alternative therapies to an amphotericin-based regimen are listed in Table 2.2.