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Primary prophylaxis with fluconazole for cryptococcosis in HIV infected patients

June 05 2017

A study has confirmed that primary prophylaxis for cryptococcosis with fluconazole has no survival benefit and may not be necessary in settings where Anti-Retroviral Therapy (ART) is widely available and when HIV-infected patients have CD4 counts <100 cells/μL are negative for serum cryptococcal antigen (CrAg).

Sungkanuparph et al  (Mahidol University, Thailand) recruited 302 HIV-infected patients with CD4 T-cell count <100 cells/µL and negative serum CrAg at the time of initiation of ART, into their prospective observational cohort study. 201 patients received fluconazole as primary prophylaxis for cryptococcosis and the remaining 101 patients did not receive prophylaxis. All patients were followed up for a period of 2 years after the start of ART.

Cryptoccocus gattii  (Image credit: Prof. Malcolm D Richardson, UHSM)

There were no differences in survival rates and occurrence of newly diagnosed cryptococcosis, between patients with and without fluconazole for primary prophylaxis of cryptococcosis. Five patients developed cryptococcosis on either arm (2.5% of the fluconazole group & 5% of the control group) and two patients died one in each group.

These findings are consistent with the recommendation in the IDSA guidelines for cryptococcosis but slightly conflicts with earlier studies and the WHO recommendation that azoles should be use for primary prophylaxis in settings with a high burden of cryptococcal disease.