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Fluconazole Prophylaxis in PLWHA

Fluconazole Prophylaxis in PLWHA. Use of fluconazole in prophylaxis of infection with C. neoformans Didier Laureillard. Fluconazole and C. albicans. No role in primary or secondary prophylaxis Effective treatment of acute disease – low mortality – resistance

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Fluconazole Prophylaxis in PLWHA

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  1. Fluconazole Prophylaxis in PLWHA Use of fluconazole in prophylaxis of infection with C. neoformans Didier Laureillard

  2. Fluconazole and C. albicans • No role in primary or secondary prophylaxis • Effective treatment of acute disease – low mortality – resistance • Secondary prophylaxis when frequent and severe recurrences interfering with quality of life • Dose: 100-200 mg daily

  3. Fluconazole and C. neoformans • Reduces the incidence of cryptococcal disease in advanced HIV infection • Lifelong suppressive treatment after initial therapy = secondary prophylaxis = chronic maintenance therapy • Dose: 200 mg daily

  4. Primary prophylaxis • Cambodia : • All patients in stage 4 or CD4 < 100/mm3 • Fluconazole 200mg daily • Thailand : • All patients with CD4 < 50/mm3 • fluconazole 200mg x 3/week • Study Havlir et al: • fluconazole 400mg weekly as effective as 200mg daily for cryptococcal disease

  5. USPHS/IDSA Guidelines 2001 • No routine primary prophylaxis because: relative infrequent disease no survival benefit drug interactions resistance cost • If applied: 100-200 mg daily in CD4<50/mm3

  6. Guidelines:Discontinuation of secondary prophylaxis • Completed course of initial therapy • Asymptomatic • Immune reconstitution due to HAART: sustained increase of CD4 to >100/mm3 • Restart if CD4 drops < 100/mm3

  7. References • USPHS/IDSA Prevention of opportunistic infections working group. 2001 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with HIV. • MSF Belgium-Luxemburg. Clinical AIDS care guidelines for resource-poor settings. 2001. • Havlir DV, Dube MP, McCutchan JA, et al. Prophylaxis with weekly versus daily fluconazole for fungal infections in patients with AIDS. Clin Infect DIS. 1998 Dec;27(6):1376-8. • Mylonakis E, Flanigan TP. Editorial response: anti-fungal prophylaxis with weekly fluconazole for patients with AIDS. Clin Infect Dis 1998;27:1376-8. • Singh N, Barnish MJ, Berman S, et al. Low-dose fluconazole as primary prophylaxis for cryptococcal infection in AIDS patients with CD4 cell counts of < or = 100/mm3: demonstration of efficacy in a positive multicenter trial. Clin Infect Dis 1996 Dec;23(6):1282-6. • Quagliarello VJ, Viscoli C, Horwitz RI. Primary prevention of cryptococcal meningitis by fluconazole in HIV-infected patients. Lancet 1995 Mar 4;345(8949):530-1. • Ammassari A, Linzalone A, Murri R, et al. Fluconazole for primary prophylaxis of AIDS-associated cryptococcosis: a case-control study. Scand J Infect Dis 1995;27(3):235-7.

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