Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV

Epidemiology

Most HIV-associated cryptococcal infections are caused by Cryptococcus neoformans, but occasionally Cryptococcus gattii is the cause. C. neoformans is found worldwide, whereas C. gattii most often is found in Australia and similar subtropical regions and in the U.S. Pacific Northwest. Before the era of effective antiretroviral therapy (ART), approximately 5% to 8% of people with advanced HIV in some high-resourced countries had disseminated cryptococcosis.¹ In a surveillance study in the late 1990s, people with HIV who developed cryptococcosis were severely immunosuppressed and had barriers to accessing routine HIV medical care.² Estimates indicate that every year, approximately 280,000 cases of cryptococcal infection in people with AIDS occur worldwide, and the disease accounts for 15% of AIDS-related deaths.³ Overall, 90% of cryptococcal cases in people with HIV are observed in those who have CD4 T lymphocyte (CD4) cell counts <100 cells/mm³. The incidence of the disease has declined substantially among people treated effectively with ART.⁴

Clinical Manifestations

In people with HIV, cryptococcosis commonly presents as subacute meningitis or meningoencephalitis with fever, malaise, and headache slowly developing over many weeks, with a median duration of 2 weeks.¹ Classic meningeal symptoms and signs—such as neck stiffness and photophobia—occur in only one-quarter to one-third of people. Some individuals experience encephalopathic symptoms—such as lethargy, altered mentation, personality changes, and memory loss—that are usually a result of increased intracranial pressure (ICP).⁵ Among people presenting with cryptococcal meningitis shortly after initiating ART, the symptom onset can be more acute, likely related to an unmasking immune reconstitution inflammatory syndrome (IRIS).⁶

Despite manifesting principally as a central nervous system (CNS) disease, cryptococcosis may involve any bodily organ. In fact, despite widespread disseminated disease, people with HIV may manifest few symptoms. Skin lesions may show different manifestations, including umbilicated skin lesions that mimic those seen with molluscum contagiosum. Isolated pulmonary infection is also possible; symptoms and signs include cough and dyspnea in association with an abnormal chest radiograph, which typically demonstrates lobar consolidation, although nodular infiltrates have been reported. Pulmonary cryptococcosis may present as acute respiratory distress syndrome and even mimic Pneumocystis pneumonia.

Diagnosis

In people with HIV, cryptococcosis is usually disseminated at the time of diagnosis and most commonly presents as subacute meningoencephalitis. Analysis of cerebrospinal fluid (CSF) in initial cases generally demonstrates mildly elevated protein levels, low-to-normal glucose concentrations, and a variable presence of pleocytosis consisting mostly of lymphocytes. Some people with advanced HIV may have very few CSF inflammatory cells. A Gram stain or an India ink preparation, if available, may reveal numerous yeast forms. In patients with HIV and cryptococcal meningitis, the opening pressure for the CSF may be elevated, with pressures ≥25 cm CSF in 60% to 80% of patients.^7,8

Cryptococcal disease can be diagnosed by culture, CSF microscopy, cryptococcal antigen (CrAg) detection, or CSF polymerase chain reaction (PCR). In HIV-related cryptococcal meningitis, most blood cultures and CSF cultures will be positive (47% to 70% and 90% to 94%, respectively).⁵ Visible Cryptococcus colonies on a fungal Sabouraud dextrose agar plate, or even a standard aerobic bacterial culture, generally can be detected within 7 days. Cryptococcus may be identified occasionally on a routine Gram stain preparation of CSF as poorly staining Gram-positive yeasts. India ink staining of CSF demonstrates encapsulated yeasts in 60% to 80% of cases, but many laboratories in the United States no longer perform this test. India ink is relatively insensitive early in disease when <1,000 Cryptococcus colony-forming units (CFU)/mL are present.⁹ In tissue or fluids, yeasts will stain with Grocott methenamine silver stain, and the capsule will stain with mucicarmine or alcian blue stains. Positive cultures are required to prove yeast viability because strains can be stain positive with nonviable yeasts.

Cryptococcus can infect any part of the body, but brain and lungs are frequently target organs. Cultures and/or histopathology are essential for precise diagnosis. However, in many patients with advanced HIV, the presentation is more commonly a meningeal syndrome rather than a pulmonary syndrome.

CSF CrAg is usually positive in people with cryptococcal meningoencephalitis; however, early meningitis can present with negative CSF studies and a positive CrAg in blood only.¹⁰ Thus, serum CrAg testing always should be performed in an immunocompromised individual with an unknown CNS disorder.¹⁰ Serum CrAg is positive in both meningeal and non-meningeal cryptococcal infections and may be present weeks to months before symptom onset.¹¹ All positive CrAg tests in patients with HIV require consideration for therapy.

Three methods exist for antigen detection: latex agglutination, enzyme immunoassay (EIA), and lateral flow assay (LFA). The IMMY CrAg LFA (IMMY, Norman, Oklahoma) is the only LFA test for CrAg approved by the U.S. Food and Drug Administration (FDA). It is a useful initial screening tool for diagnosing cryptococcosis in people with HIV when applied to serum or plasma,^9,12 and it also can be used with whole blood or CSF. CrAg testing of serum or plasma may be particularly useful when a lumbar puncture is delayed or refused. In a person with HIV, when serum CrAg LFA titers are >1:160, disseminated disease becomes increasingly more likely, and when CrAg LFA titers are >1:640, or when there is high clinical suspicion, disseminated and/or CNS involvement should be assumed, regardless of CSF antigen titer results.^13,14 Antigen titers by the LFA are approximately fourfold higher than those with latex agglutination or EIA testing; thus, a titer of 1:640 by LFA is approximately equal to a titer of 1:160 by EIA or latex agglutination. A prozone effect needs to be checked when CrAg with latex agglutination and LFA testing is negative despite observing yeasts in tissues or fluids.

In 2016, the BioFire FilmArray Meningitis/Encephalitis Panel PCR assay (BioFire Diagnostics, Salt Lake City, Utah) was approved by the FDA. This multiplex PCR tests for 14 targets, including C. neoformans and C. gattii, and performs well in infections with a moderate-to-high fungal burden.^15-17 False negative results have been noted to occur when there is a low burden of yeasts; in one study, when there were <100 CFU/mL, the sensitivity of the PCR test fell to 50%.¹⁵ In one well-described case, a woman who had two negative results with this PCR assay later had a positive result on a CrAg test done by IMMY LFA.¹⁸ Thus, a negative CSF PCR does not completely exclude cryptococcal meningitis, and CrAg testing of CSF and blood should always be performed simultaneously. The PCR assay appears to have diagnostic utility when a second episode of cryptococcal meningitis is suspected; the test has been noted to differentiate a relapse (PCR positive) from IRIS (PCR negative).¹⁵

Preventing Exposure

Cryptococcus is ubiquitous in the environment, and people with HIV cannot completely avoid exposure to C. neoformans or C. gattii. Limited epidemiological evidence suggests that exposure to dried bird droppings, including those from chickens and pet birds, may increase the risk of infection and should be avoided. It is likely that many patients are infected with mixed strains of Cryptococcus over a lifetime, and clinical implications remain uncertain.^19,20

Preventing Disease

The incidence of cryptococcal disease is low among people with HIV in the United States. However, one report indicates that among study participants with HIV in the United States with peripheral blood CD4 counts ≤100 cells/mm³, the prevalence of cryptococcal antigenemia—a harbinger of disease—was 2.9%, and for those with CD4 counts ≤50 cells/mm³, the prevalence was 4.3%.²¹ Routine surveillance testing for serum CrAg in people with newly diagnosed HIV who have no overt clinical signs of meningitis is recommended for patients whose CD4 counts are ≤200 cells/mm³ and particularly in those with CD4 counts ≤50 cells/mm³ (AII).²² All positive tests generally should prompt CSF evaluation for CNS infection, particularly when the serum LFA titer is ≥1:160 (AII).²³ See section on Treatment of Asymptomatic Antigenemia.

Prospective controlled trials indicate that prophylactic fluconazole or itraconazole can reduce the frequency of primary cryptococcal disease in people with HIV who have CD4 counts <100 cells/mm.^24,25 However, in the United States, primary prophylaxis in the absence of a positive serum CrAg test is not recommended because of the relative infrequency of cryptococcal disease, lack of clear survival benefit associated with prophylaxis,²⁶ possibility of drug–drug interactions, potential development of antifungal drug resistance, and cost (BII).

Treating Disease

Treatment of Central Nervous System and/or Disseminated Disease

Treatment of CNS and disseminated disease consists of three phases: induction, consolidation, and maintenance.

Induction Therapy

For induction treatment of cryptococcal meningitis and other forms of extrapulmonary cryptococcosis, an amphotericin B formulation given intravenously (IV), in combination with oral flucytosine, is recommended for 2 weeks in a resource-available health care system (AII), and in resource-limited health care systems, a single dose of liposomal amphotericin B (10 mg/kg) is recommended, followed by 2 weeks of flucytosine and fluconazole (AI). Historically, amphotericin B deoxycholate at a dose of 0.7 to 1.0 mg/kg daily had been the preferred formulation of the drug.²⁷ In resource-available health care systems, however, lipid formulations of amphotericin B have become the standard polyene formulations because they are effective for cryptococcosis and have lower toxicity. A study that compared amphotericin B deoxycholate (0.7 mg/kg daily) and liposomal amphotericin B (AmBisome) at two doses (3 mg/kg daily and 6 mg/kg daily) showed similar outcomes for all three regimens; however, lower nephrotoxicity was observed among those receiving the 3 mg/kg daily liposomal amphotericin B regimen.²⁸ The noncomparative CLEAR study demonstrated a 58% response rate in people with HIV and cryptococcosis who were treated with amphotericin B lipid complex (Abelcet) at a mean dose of 4.4 mg/kg daily.²⁹

Several large clinical trials that used shorter courses of amphotericin B have been reported from Africa.^30,31 A multicenter clinical trial that evaluated two different induction regimens in 721 African adults with HIV found that an initial regimen of 1 week of amphotericin B deoxycholate at 1 mg/kg/day and flucytosine 25 mg/kg four times daily, followed by 1 week of oral fluconazole 1,200 mg/day was non-inferior (95% confidence interval [CI], -12.5 to 5.35 at 10 weeks) to the standard regimen of 2 weeks of amphotericin B deoxycholate 1 mg/kg/day and flucytosine 25 mg/kg four times daily when outcomes at 10 weeks were studied.³⁰ At 1 year, follow-up of 236 participants from this treatment trial continued to show noninferiority of the 1-week amphotericin B deoxycholate regimen compared with the 2-week regimen.³²

A phase 3 open-label, randomized, controlled noninferiority trial of single-dose liposomal amphotericin B was conducted at five sites in Africa in 814 patients.³³ Results of this study showed that outcomes of people receiving a single dose of liposomal amphotericin B, 10 mg/kg, combined with 14 days of oral flucytosine, 25 mg/kg four times daily, and oral fluconazole, 1,200 mg/day, were not inferior to a control group that received therapy with amphotericin B deoxycholate, 1 mg/kg/day, and flucytosine, 25 mg/kg four times daily for 7 days, followed by oral fluconazole, 1,200 mg/day for another 7 days.³³ At 10 weeks, deaths were reported in 101 participants (24.8%; 95% CI, 20.7–‍29.3) in the liposomal amphotericin B group and 117 participants (28.7%; 95% CI, 24.4–33.4) in the control group (difference, −3.9 percentage points); the upper boundary of the one-sided 95% CI was 1.2 percentage points (within the noninferiority margin; P <0.001 for noninferiority). Grade 3 or 4 toxicity was reduced in the single-dose liposomal amphotericin B group compared with the amphotericin B deoxycholate group (50% vs. 62.3%, P <0.001).³³ It is important to note that patients in both groups were monitored closely in a hospital for a minimum of 7 days. Lumbar punctures were performed on Day 7 and Day 14 and daily if ICP was >25 cm of CSF or if the patient demonstrated symptoms and signs consistent with elevated ICP.

Currently, several different treatment regimens for induction therapy of cryptococcal meningitis are recommended:

• Irrespective of which regimen is used, patients must be followed carefully in the hospital for at least 7 days and ideally 14 days (AII). Lumbar puncture should be performed on Day 7 and Day 14 of treatment to ensure an appropriate clinical response and culture sterility. If increased ICP is documented, daily lumbar punctures should be performed until the pressure and symptoms are decreased to the normal range (AII).

Preferred Regimens

In the United States and other settings where daily monitoring of electrolytes and kidney function and administration of electrolytes and intravenous fluids is possible:

• Liposomal amphotericin B (IV 3–4 mg/kg daily) plus flucytosine (25 mg/kg orally [PO] four times daily) for 2 weeks is the regimen preferred and recommended by the Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections Adults and Adolescent With HIV (the Panel) (AII).^28,34

In resource-limited health care settings:

• A single dose of liposomal amphotericin B (IV 10 mg/kg on Day 1) combined with oral flucytosine (25 mg/kg four times daily) and fluconazole (1,200 mg/day) for 2 weeks is the preferred regimen recommended by the World Health Organization (AI).³³

Alternative Regimens

• If amphotericin B lipid complex is the only available lipid amphotericin B formulation available, a dosage of 5 mg/kg IV daily combined with flucytosine 25 mg/kg PO four times daily should be administered for 2 weeks (BII). However, there is much less experience with amphotericin B lipid complex than with the liposomal amphotericin B formulation.
• If amphotericin B deoxycholate is the only available formulation of amphotericin B, this can be used at a dosage of 1 mg/kg IV daily combined with flucytosine 25 mg/kg PO four times daily for 1 week, followed by fluconazole 1,200 mg/day PO for an additional week (BI).³⁰

When using flucytosine, therapeutic drug monitoring should be performed, if available, particularly in patients who have renal impairment. Serum peak concentrations of flucytosine should be obtained 2 hours post dose after three to five doses have been administered. Peak serum concentrations should be between 25 mg/L and 100 mg/L.¹⁷ Renal function should be monitored closely and the flucytosine dose adjusted accordingly for those with renal impairment (see Table 6). For those without access to timely flucytosine concentrations, which is a common occurrence, frequent blood counts and renal functions are needed to detect bone marrow toxicity, especially when renal impairment is present. The addition of flucytosine to the amphotericin B regimen during acute treatment is associated with more rapid sterilization of CSF and survival benefit.^34-36 For instance, a randomized clinical trial of 299 patients showed that the combination of amphotericin B deoxycholate at a dose of 1 mg/kg daily plus flucytosine was associated with improved survival compared to the same dose of amphotericin B without adjunctive flucytosine.³⁷ Adjunctive fluconazole 800 to 1,200 mg per day plus amphotericin B has been used in the absence of flucytosine, but flucytosine has a survival advantage over fluconazole and is preferred (BI).³⁰ Amphotericin B deoxycholate with flucytosine (BI) or with fluconazole at a dose of 800 to 1,200 mg per day (BI) or liposomal amphotericin B with fluconazole at a dose of 800 to 1,200 mg per day (BIII) may be reasonable alternatives in some circumstances.

Fluconazole, administered at 1,200 mg daily (CIII) or with flucytosine (BII), is a potential all-oral alternative to amphotericin B regimens.^30,38 Based on studies assessing early fungicidal activity, fluconazole alone (1,200 mg/day) is inferior to amphotericin B for induction therapy.^39,40 Therefore, fluconazole is preferably used with flucytosine. Fluconazole alone is recommended only for patients who cannot tolerate other agents or who do not respond to standard treatment, or when other antifungals are not available.

Consolidation Therapy

A lumbar puncture and repeat CSF culture should be performed after 1 week and/or 2 weeks of induction therapy in all patients (AII). After 2 weeks of induction therapy, clinically stable patients may be switched to consolidation therapy while awaiting CSF culture results. Successful induction therapy is defined as substantial clinical improvement and a negative CSF culture from the end-of-induction lumbar puncture. India ink and CSF CrAg may remain positive at Week 2 of therapy and are not indicative of failure. Monitoring serum or CSF CrAg titers is of no value in determining initial response to therapy and is not recommended (AII).^41,42 If new symptoms or clinical findings occur later, a repeat lumbar puncture, with measurement of lumbar opening pressure and CSF culture, should be performed.

Consolidation therapy should be initiated with fluconazole 800 mg daily for at least 8 weeks after receiving a clinically successful 2 weeks of induction therapy (AII). The recommendation to use 800 mg rather than 400 mg fluconazole for consolidation therapy is based on several findings. Early clinical trials that used 400 mg fluconazole for consolidation noted breakthrough infection during consolidation.²⁷ Fluconazole 400 mg per day provides concentrations in the CSF that are only fungistatic, and other studies showed that the early antifungal activity of fluconazole in CSF of people with cryptococcal meningitis increases linearly with increasing doses of the drug.^37,39 A phase 2 trial of treatment with either 400 mg or 800 mg fluconazole found that relapses were more frequent in people receiving 400 mg fluconazole.⁴³ In clinically stable people, the dose of fluconazole for consolidation therapy should be 800 mg per day until CSF cultures are known to be sterile and ART is initiated, at which point the dose can be decreased to 400 mg per day (AII).⁴⁴

For people who have completed first-line recommended or other regimen(s) as 2-week induction therapy but have not improved clinically or remain clinically unstable, continuation or starting of amphotericin B plus flucytosine is recommended until the CSF fungal cultures are confirmed to be negative (BIII). For outpatients who are not ill enough to be hospitalized but still have positive CSF cultures after completing 2 weeks of induction therapy, flucytosine can continue to be administered for an additional 2 weeks with fluconazole at a dose of 1,200 mg daily or fluconazole monotherapy can be administered at 1,200 mg daily (BIII). A lumbar puncture should be performed after 4 weeks of induction therapy to confirm that the cultures have become negative; if still positive, another 2-week liposomal amphotericin B plus flucytosine induction course may be considered. For all people with CSF cultures positive at Week 2, the duration of consolidation therapy should be for 8 weeks from the time the CSF cultures are confirmed as negative.^27,35,45

Itraconazole 200 mg twice per day can be used as an alternative therapy for consolidation if fluconazole is not available or is not tolerated by an individual patient (CI), but it is clearly inferior to fluconazole.⁴⁵ Limited data are available for use of the newer triazoles—voriconazole, posaconazole, and isavuconazole—for either consolidation or maintenance therapy for patients with cryptococcosis. Most of the reported data have been on the use of these extended-spectrum triazole antifungals for treatment of refractory cases, with success rates of approximately 50%.^46-48 Currently, the role of posaconazole, voriconazole, and isavuconazole in the initial management of cryptococcosis has not been established, and these agents are not initially recommended for consolidation or maintenance therapy (AIII). Echinocandins have no clinical activity against Cryptococcus spp. and are not recommended for the clinical management of cryptococcosis (AII).

Maintenance Therapy

Fluconazole 200 mg per day is used for maintenance treatment and continued until at least 1 year from initiation of antifungal therapy and assuming there is some immune reconstitution on ART and the patient is asymptomatic at the end of 1 year (AI) (see the Preventing Recurrence section below).⁴⁹

Treatment of Non-Central Nervous System Cryptococcosis and Asymptomatic Antigenemia

Non-CNS extrapulmonary cryptococcosis and diffuse pulmonary disease should be treated the same as CNS disease (BIII). For those with mild symptoms and only focal pulmonary infiltrates with negative serum CrAg, treatment with fluconazole 400 mg per day for 6 to 12 months combined with effective ART is recommended (BIII). Duration of therapy should be guided by symptom resolution.²²

All people with non-CNS extrapulmonary symptoms and cryptococcal antigenemia should have their CSF sampled to rule out CNS disease.^13,23,50 If the CSF is normal but the serum CrAg titer is ≥1:640 by LFA (or ≥1:160 by EIA or latex agglutination), even in the absence of meningitis, the risk for mortality and/or progression to meningitis increases with fluconazole monotherapy alone, and these patients should be treated the same as patients with cryptococcal meningitis (BII).²³

Whether to sample the CSF to rule out CNS disease in people with isolated, fully asymptomatic cryptococcal antigenemia is dependent on underlying risk, such as advanced immunosuppression and absence of antiretroviral therapy, and the serum CrAg LFA titer. Those at lower risk and with serum CrAg titer <1:80 by LFA (or <1:20 by EIA or latex agglutination) can be safely treated without lumbar puncture, as empiric treatment for meningitis does not improve outcomes (AI).⁵¹ All others should undergo CSF sampling to rule out CNS disease. Those with normal CSF, fully asymptomatic cryptococcal antigenemia, and serum CrAg titers <1:640 by LFA (or <1:160 by EIA or latex agglutination) should be treated with fluconazole 800 to 1,200 mg per day for 2 weeks, followed by 400 to 800 mg per day for 10 weeks, followed by 200 mg daily, for a total of 6 months combined with effective ART (BIII).²²

Special Considerations Regarding ART Initiation

Unlike with other opportunistic infections (OIs), ART initiation generally is deferred for 4 to 6 weeks after antifungal agents are started for treatment of CNS cryptococcosis (AI). A randomized clinical trial conducted at three sites in Africa compared patients with cryptococcal meningitis who started ART within 1 to 2 weeks (median 9 days) after the diagnosis of meningitis with patients for whom ART was delayed for 4 to 6 weeks (median 36 days) after diagnosis.⁵² This clinical trial used amphotericin B deoxycholate 0.7 to 1.0 mg/kg once daily plus fluconazole 800 mg once daily during the induction phase of antifungal treatment. A significantly greater increase in 6-month mortality occurred in the early ART group than in the delayed ART group (45% vs. 30%, P = 0.03). This increase was most pronounced during the first 8 to 30 days of the study (P = 0.007). The difference in mortality between the early ART group and the delayed ART group was even greater among individuals with CSF white cell count <5 cells/µL (P = 0.008). The excess deaths in the early ART group may have been attributable to paradoxical IRIS, although the timing and incidence of IRIS reportedly did not differ between the two groups.⁵³ In a trial conducted in China, 102 participants with cryptococcal meningitis were randomized to start ART within either 2 to 5 weeks or >5 weeks after starting antifungal therapy; the majority received amphotericin with flucytosine induction therapy. The primary analysis did not demonstrate a statistically significant difference in mortality; however, a smaller secondary analysis of 78 patients demonstrated excess risk of death in the early ART group compared with the deferred group within the window of 5 to 10 weeks after initiation of antifungal treatment.⁵⁴ It is not clear that the secondary analysis had adequate statistical power for the comparison, making the overall interpretation of this study complicated. In a recently published retrospective observational cohort study of participants enrolled from high-resourced health care systems in Europe and North America, investigators used marginal structural modeling with category censoring, inverse proportional weighting, and adjustment for bias to simulate a randomized trial of earlier versus later initiation of ART.⁵³ A total of 630 people with HIV were identified with cryptococcal meningitis from more than 30 cohorts between 1994 and 2012. Participants were eligible for the analyses if at meningitis diagnosis they were older than 16 years and had a CD4 count, a viral load measurement and follow-up laboratory test results, study visits, and outcomes data. Among these, 432 (69%) were considered ineligible due to insufficient outcome data (256; 41%) or missing baseline CD4 or HIV viral load (176; 28%). Among the 190 eligible patients, 145 started ART during treatment for cryptococcal meningitis.⁵⁵ The primary analysis for the simulated trial compared initiation of ART within 14 days of cryptococcal meningitis diagnosis versus starting ART within 14 to 56 days of diagnosis. There were 13 deaths in the early ART group and 20 deaths in the delayed ART group, with an adjusted hazard ratio (aHR) of 1.40 (0.66–2.95) for early versus later initiation of ART. The authors concluded that there was little evidence that earlier ART was associated with higher mortality. The incidence of IRIS was not reported.^55,56

The issue of when to start ART in the setting of cryptococcal meningitis remains controversial. The randomized trials, most of which are more than a decade old, were largely done in low- and middle- income countries where access to currently recommended antifungal treatment, monitoring, and support may have been less optimal, and they demonstrated overall mortality rates substantially higher than had been reported in higher resourced settings. While the observational cohort study in higher resourced settings is limited by its observational, retrospective nature and cannot fully address unrecognized biases, it is unlikely that a suitably powered prospective randomized trial can be done in high-resourced settings now, given the precipitous decline in incidence of cryptococcal meningitis in people with HIV treated with more effective antifungal therapy and more effective and better tolerated ART regimens than were available in some of the earlier trials. Therefore, most experts aim to start ART within 4 weeks of antifungal therapy; however, individual patient factors may allow for earlier or later initiation of ART. In general, ensuring that the patient’s CSF cultures are sterile before starting ART will reduce the risk of IRIS.⁵⁷ If ART must be started sooner, the patient should be monitored closely for paradoxical IRIS with a low threshold to intervene (see “Monitoring of Response to Therapy and Adverse Events,” below).⁵⁵ For non-CNS cryptococcosis, for which the risk of symptomatic IRIS appears to be lower, the optimal time to begin ART after antifungal therapy is less clear. However, in patients with non-CNS cryptococcosis, it is prudent to delay initiation of ART for 2 weeks after starting antifungal therapy (BIII).

All of the triazole antifungals have the potential for complex and possibly bidirectional interactions with certain antiretroviral agents. These interactions and recommendations for dosage adjustments, where feasible, are listed in the Drug–Drug Interaction tables in the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV.

Monitoring and Management of Response to Therapy and Adverse Events

Elevation of ICP can cause clinical deterioration despite a microbiologic response; complications are more likely to occur if the CSF lumbar opening pressure is ≥25 cm CSF in the lateral decubitus position.^7,27 In a large clinical trial in people with AIDS and cryptococcal meningitis, increased ICP was associated with 92% of deaths during the first 2 weeks of antifungal therapy and 71% of deaths during Weeks 3 to 10.⁷ In another clinical trial, people with HIV who received at least one therapeutic lumbar puncture within 7 days after diagnosis (median time of 3 days) had a 69% relative reduction in the risk of death through 11 days, regardless of initial opening pressure.⁵⁸ Although it is uncertain which patients with high lumbar opening pressures will experience clinical deterioration, those with symptoms and signs of increased ICP require immediate clinical intervention to reduce ICP.

Control of elevated ICP is critical to reducing acute mortality. Lumbar opening pressure should be measured in all people with cryptococcal meningitis at the time of diagnosis. However, in routine practice, CSF opening pressure frequently is not measured. Among people in whom CSF opening pressure was not measured initially, a repeat lumbar puncture should be performed with measurement of opening pressure. For people with ongoing headaches, a repeat lumbar puncture should be performed with urgency, and among those without headaches, a repeat lumber puncture should be considered strongly within 48 hours of the initial procedure.⁵⁸ Measures to decrease ICP should be used for all people with cryptococcal meningitis who have confusion, blurred vision, papilledema, lower extremity clonus, or other neurologic signs indicative of increased ICP. Drainage of CSF via lumbar puncture is recommended for initial management (AII). One approach is to remove a volume of CSF that reduces the opening pressure by at least 50% or normalizes the pressure to <20 cm CSF.^58,59 In the absence of a manometer, removal of 20 to 25 mL of CSF is recommended (AIII). Among patients with ongoing symptoms, therapeutic lumbar punctures should be repeated at least daily until symptoms and signs consistently improve and opening pressure normalizes to <20 cm CSF (AII). Because a survival benefit is associated with therapeutic lumbar puncture regardless of baseline CSF opening pressure, strong consideration should be given to repeating a therapeutic lumbar puncture within 72 hours of the initial procedure in those who are relatively asymptomatic or who had a baseline CSF opening pressure of <25 cm CSF, because ICP can be a dynamic process that changes over time (BII).⁵⁸ If the initial opening pressure was not measured, a second lumbar puncture is recommended (AII).

CSF shunting through a lumbar drain or ventriculostomy should be considered for people who cannot tolerate repeated lumbar punctures or for those in whom signs and symptoms of increased ICP persist after multiple lumbar punctures (BIII). Corticosteroids and mannitol have been shown to be ineffective in managing ICP and are not recommended (AIII). Acetazolamide should not be used as therapy for increased ICP management because it may exacerbate hyperchloremic acidosis from amphotericin B and does not result in a meaningful decrease in ICP (AI).⁶⁰ A randomized study that compared a 6-week course of a tapering dose of dexamethasone with placebo among 451 Asian and African patients with cryptococcal meningitis found that dexamethasone did not improve survival through 10 weeks, was noted to not be as effective at killing of Cryptococcus, and was associated with more adverse events.⁶¹ These data support the recommendation that corticosteroids should not be used during induction therapy for ICP control for HIV-associated cryptococcal meningitis unless they are being used for treatment of IRIS (AI).

People treated with amphotericin B formulations should be monitored for nephrotoxicity and electrolyte disturbances. Pre-infusion administration of 500 to 1,000 mL of normal saline reduces the risk of nephrotoxicity during amphotericin B treatment. For people with severe infusion-related adverse reactions, acetaminophen (650 mg) and diphenhydramine (25–50 mg) or hydrocortisone (50–100 mg) typically are administered 30 minutes before the infusion to reduce the severity of amphotericin B infusion reactions (CIII); meperidine (25–50 mg titrated during infusion) is effective for treating amphotericin B–associated rigors and should be given before each dose daily and after the first incidence of rigors to prevent future rigors (BII). Routine use of potassium chloride (40 mEq per day) and magnesium (8 mEq per day) supplementation should be considered because the risk of hypokalemia and hypomagnesemia becomes near universal after 1 week of therapy, regardless of the amphotericin B formulation used (AII).⁶²

Flucytosine is associated with concentration-dependent bone marrow toxicity. Patients treated with flucytosine also should be monitored for hepatotoxicity and gastrointestinal toxicities. In people receiving flucytosine, dosage should be adjusted based on changes in creatinine clearance and can be guided by flucytosine concentrations. Peak serum flucytosine concentrations should be obtained 2 hours after an oral dose; the therapeutic range is between 25 and 100 mg/L. If therapeutic drug monitoring is not possible or kidney dysfunction is not present, frequent complete blood counts with differential (i.e., at least biweekly) can be used to detect cytopenias (BII).³⁰

Common side effects of higher dose fluconazole therapy can include dry skin (17% of patients) and alopecia (16% of patients).⁶³ Increased liver transaminases or alkaline phosphatase are relatively rare in fluconazole dosages of 400 to 800 mg, with only 1 to 2% of patients having values >5 times the upper limit of normal.⁵² For people who have difficulty tolerating higher fluconazole doses, the consolidation therapy fluconazole dose can be reduced to 400 mg per day after ART initiation. (BII).⁴⁴

Immune Reconstitution Inflammatory Syndrome

An estimated 10 to 30% of people with HIV who have cryptococcal meningitis experience IRIS after initiation or reinitiation of effective ART and both unmasking (before start of antifungal therapy) or paradoxical (after start of antifungal therapy) IRIS may occur.^64,65 People with HIV who have cryptococcal IRIS are more likely to be ART naive and those whose CSF has less inflammation on presentation seem to be at higher risk of cryptococcal IRIS.⁶⁶ The risk of IRIS can be minimized by achieving CSF culture sterility before starting ART, using fluconazole 800 mg per day as consolidation therapy, and deferring ART initiation for 4 to 6 weeks from the start of antifungal therapy (AII).^52,67 Distinguishing paradoxical IRIS from treatment failure with culture-positive relapse is difficult. In general, cryptococcal IRIS presents with worsening clinical disease despite microbiological evidence of effective antifungal therapy with sterile CSF cultures,^66,68 whereas treatment failure is associated with continued positive cultures. The primary microbiological criterion for treatment failure is a CSF culture that yields Cryptococcus, not the visual appearance of yeasts during treatment; the culture may take days to weeks to become positive. A negative PCR test (e.g., BioFire FilmArray Meningitis/Encephalitis Panel) has a high predictive value for sterile CSF cultures and can be diagnostically useful for distinguishing paradoxical IRIS with a negative CSF PCR from culture-positive relapse with a positive CSF PCR.¹⁵

The appropriate management strategy for IRIS is to continue both ART and antifungal therapy and reduce elevated ICP if present (AII). While diagnostic tests are pending, escalating antifungal therapy (i.e., restarting amphotericin B therapy or increasing the fluconazole dose to 1,200 mg per day) is recommended (BIII). In people with severe symptoms of IRIS, some experts recommend a brief course of tapering doses of corticosteroids. Dosages have varied but commonly start at 1.0 mg/kg per day of prednisone; precise data-driven management strategies have not been developed. Serum C–reactive protein (CRP) is generally elevated at the time IRIS develops;⁶⁹ CRP will decrease with corticosteroid therapy if IRIS is present and can be used to empirically monitor IRIS resolution. Once clinical improvement is evident, it is recommended that fluconazole at consolidation therapy doses should be continued or restarted upon hospital discharge (BIII).

The risk of IRIS appears to be much lower and the syndrome seems to be less severe with other forms of cryptococcosis—such as lymphadenitis, cutaneous abscesses, and bony lesions—than with cryptococcal meningitis.⁷⁰ Management of IRIS with other forms of cryptococcosis is similar to that for IRIS associated with cryptococcal meningitis, including continuing ART, initiating or continuing antifungal therapy (AIII), and only considering the use of corticosteroids if clinical symptoms are severe (CIII).

Managing Treatment Failure

Treatment failure is defined as (1) a lack of clinical improvement and continued positive cultures after 2 weeks of appropriate therapy that has included management of increased ICP, or (2) relapse after an initial clinical response, defined as recurrence of symptoms with a positive CSF culture after ≥4 weeks of treatment. Primary fluconazole resistance in Cryptococcus isolates has been reported in the United States but is uncommon.⁷¹ Therefore, susceptibility testing is not recommended routinely for initial management of cryptococcosis. However, if treatment failure or relapse occurs, Cryptococcus isolates should undergo antifungal susceptibility testing. Robust clinical data are lacking, but strains of Cryptococcus with fluconazole minimum inhibitory concentrations (MIC) ≥16 µg/mL are considered not fully susceptible.^72,73

Optimal therapy for patients with treatment failure has not been established. If treatment failure occurs after induction with alternative regimens, preferred regimens should be started. Furthermore, those initially treated with an amphotericin B formulation should remain on this agent until clinical response occurs. In this setting, liposomal amphotericin B (3–6 mg/kg daily) or amphotericin B lipid complex (5 mg/kg daily) is better tolerated and has greater efficacy than the deoxycholate formulation^28,74,75 and should be considered when initial treatment with other regimens fails (AII).

In the setting of treatment failure or relapse, verifying CSF culture sterility at the completion of re-induction therapy is critical (AIII). After CSF sterility is achieved, outpatient consolidation therapy should consist of fluconazole at a higher dose of 1,200 mg per day and optimization of ART. For Cryptococcus with decreased azole-susceptibility (i.e., ≥16 µg/mL MIC for fluconazole), adjunctive weekly amphotericin B administration during consolidation therapy may be considered (BIII).⁷³ Higher doses of fluconazole (i.e., >1,200 mg per day) in combination with flucytosine 25 mg/kg four times per day also may be considered (BI). The newer triazoles—posaconazole, voriconazole, and isavuconazole—have activity against Cryptococcus spp. in vitro and may have a role in salvage therapy,^46-48 but they offer no specific advantages over fluconazole unless in vitro susceptibility testing indicates only high-level fluconazole resistance. Most clinical failures are not due to antifungal drug resistance but rather result from inadequate induction therapy, nonadherence, drug‑drug interactions that decrease the serum concentrations of fluconazole (e.g., with rifampin), or the development of paradoxical IRIS. Failures also may occur with high fungal burden disease and/or severe immunosuppression of host.

Preventing Recurrence

When to Start Maintenance Therapy

People who have completed 10 weeks of induction and consolidation therapy for cryptococcal meningitis or disseminated cryptococcosis should be treated with chronic maintenance or suppressive therapy with fluconazole 200 mg per day for at least 1 year (AI). Itraconazole is inferior to fluconazole for preventing relapse of cryptococcal disease and should generally not be considered (CI).^{45 73} For people in whom susceptibility studies have been performed and the fluconazole MIC is ≥16 µg/mL, the fluconazole dose may be increased to 400 mg per day (BIII). Failure to administer this secondary prophylaxis for an entire year is the most common reason for subsequent relapse of cryptococcal disease.⁷⁶

When to Stop Maintenance Therapy

Data evaluating relapse after successful antifungal therapy for cryptococcosis and discontinuation of maintenance therapy while on ART are limited. In a European study, recurrences of cryptococcosis were not found among 39 participants on potent ART whose antifungal therapy was discontinued. In this cohort, when maintenance therapy was stopped, the median CD4 count was 297 cells/mm³, the median HIV RNA concentration was <500 copies/mL, and the median time on potent ART was 25 months.⁷⁷ A prospective randomized study of 60 people in Thailand documented no recurrences of cryptococcosis during 48 weeks of follow-up among 22 patients whose antifungal therapy was discontinued after reaching a CD4 count >100 cells/mm³ with a sustained undetectable HIV RNA level for 3 months on potent ART.⁷⁸ Given these data and inference from data on discontinuation of secondary prophylaxis for other HIV-associated OIs, it is reasonable to discontinue maintenance therapy after at least 1 year from initiation of antifungal therapy in people whose CD4 counts are ≥100 cells/mm³ with undetectable viral loads on ART (BII).⁷⁹ Maintenance therapy should be reinitiated if the CD4 count decreases to <100 cells/mm³ (AIII).

Special Considerations During Pregnancy

The diagnosis of cryptococcal infections in pregnant individuals is the same as that in individuals who are not pregnant. Treatment should be initiated promptly after a diagnosis is confirmed, with attention to management of increased ICP. During the postpartum period, anti-inflammatory responses in pregnancy (enhancement of Th2 and suppression of Th1 cytokines) are reversed and may lead to overt clinical manifestations of a previously asymptomatic cryptococcal infection resembling IRIS.^80-82 Close collaboration between obstetric and infectious disease experts is recommended. With CNS cryptococcal infection, the recommendation in nonpregnant individuals is to defer ART initiation for 4 to 6 weeks after antifungal agents are started to reduce the risk of IRIS; in pregnancy, however, starting ART as expeditiously as possible is associated with lower risk of perinatal transmission of HIV. In the presence of CNS cryptococcal infection, decisions about the timing of ART initiation should be made after consultation with the pregnant person, maternal-fetal medicine specialists, and infectious disease specialists. If ART is started sooner than generally recommended in nonpregnant individuals, close monitoring for IRIS should be implemented with a low threshold for treatment for IRIS. For pregnant people with non-CNS cryptococcosis, the risk of IRIS appears to be lower, and a delay in ART initiation of no longer than 2 weeks after starting antifungal therapy is recommended.

Extensive clinical experience with amphotericin B deoxycholate has not been associated with teratogenicity, and this remains a preferred therapy for cryptococcosis in the first trimester of pregnancy (AIII). Although there is less experience in pregnancy with lipid formulations of amphotericin B, these products have been associated with less nephrotoxicity and electrolyte abnormalities than amphotericin B deoxycholate and are an alternative as a preferred therapy for the initial regimen for the treatment of cryptococcal meningoencephalitis, disseminated disease, or severe pulmonary cryptococcosis in pregnant people (AIII). Optimal dosing of liposomal amphotericin B in pregnancy is unknown. A recent review of dosing strategies in pregnancy recommended use of ideal body weight rather than total body weight to minimize risk of adverse effects to the fetus while maintaining efficacy (BII).⁸³ Neonates born to women on chronic amphotericin B at delivery may be at increased risk for renal toxicity and electrolyte abnormalities and should be appropriately evaluated as newborns.⁸⁴

Flucytosine use should be considered only when the benefits outweigh the risks to the pregnant person and fetus and should be delayed until after the first trimester when feasible (AIII). In animal studies, flucytosine is teratogenic and may be associated with cleft palate and other bone abnormalities. Flucytosine use in pregnancy is limited to case reports and small series, although normal outcomes have been described.^85-87

In general, azole antifungals should be avoided during the first trimester of pregnancy unless the benefit outweighs the risk (BIII). Fluconazole has teratogenic potential in the first trimester. Congenital malformations similar to those observed in animals exposed to the drug—including craniofacial and limb abnormalities—have been reported in infants born to mothers who received fluconazole at doses of ≥400 mg per day throughout or beyond the first trimester of pregnancy.⁸⁸ Furthermore, animal data suggest that moderate alcohol consumption during pregnancy may increase the potency of fluconazole, resulting in increased risk of craniofacial defects.⁸⁹

Most of the studies regarding effects of fluconazole in pregnancy have involved low doses and short-term exposure. A recent meta-analysis describing birth defects in infants exposed to fluconazole during the first trimester evaluated nine cohort, case-control or randomized controlled studies, including 53,407 fluconazole-exposed pregnant people and 3,319,353 unexposed pregnant individuals.⁹⁰ Maternal exposure to fluconazole was correlated with an increased prevalence of heart defects in infants for both low dose (≤150 mg) (odds ratio [OR] 1.95; 95% CI, 1.18–3.21; P = 0.01) or any dose (OR 1.79; 95% CI, 1.18–2.71; P = 0.01). No association was found between either low- or high-dose fluconazole exposure and orofacial, CNS, genitourinary, musculoskeletal, or gastrointestinal defects.⁹¹ One registry-based cohort study⁹² of 7,352 women reported a threefold increase in incidence of Tetralogy of Fallot, and a large population-based case-control study⁹³ specifically noted an increase in transposition of the great arteries (OR 7.56, 95% CI, 1.22–35.45). The latter study also suggested an increase in cleft lip with cleft palate (OR 5.53; 95% CI, 1.68–‍18.24). In three nested case-control studies using data from the Quebec Prescription Drug Insurance database, there was an increased prevalence of cardiac septal closure anomalies for maternal fluconazole doses greater than 150 mg during pregnancy (OR 1.81; 95% CI, 1.04–3.14).⁹⁴ A recent population-based cohort study (included in the meta-analysis) of 1,969,954 pregnancies, including 37,650 pregnancies exposed to fluconazole, found an increased risk of musculoskeletal malformations following exposure to fluconazole during the first trimester of pregnancy (risk of 52.1 per 10,000 pregnancies exposed to fluconazole versus 37.3 per 10,000 pregnancies exposed to topical azoles).⁹⁵

A nationwide cohort study in Denmark⁹⁶ found that exposure to oral fluconazole during pregnancy was associated with an increased risk of spontaneous abortion compared with unexposed pregnancies (n = 16,561, HR, 1.48; 95% CI, 1.23–1.77) or those with topical azole exposure only (n = 5,646, HR 1.62; 95% CI, 1.26–2.07). Similarly, the nested case-control studies in Canada (n = 320, 868 pregnancies) found that exposure to oral fluconazole during pregnancy was associated with an increased risk of spontaneous abortion compared with unexposed pregnancies, and that risk was greater with higher dose of fluconazole exposure (adjusted odds ratio [aOR] with ≤150 mg 2.23, 95% CI, 1.96–2.54; aOR with >150 mg 3.20; 95% CI, 2.73–3.75).⁹⁴ However, a cohort study using Swedish and Norwegian registry data (n = 1,485,316 pregnancies) found no association between fluconazole use during pregnancy and risk of stillbirth or neonatal death.⁹⁷ The meta-analysis noted above also found no association between fluconazole exposure and risk of abortion or stillbirth.⁹⁰ Most of the studies regarding effects of fluconazole during pregnancy have involved low doses of the drug and short-term exposure.

On the basis of reported birth defects, the use of fluconazole in the first trimester should be considered only if the benefits clearly outweigh the risks (CIII). For pregnant people, amphotericin B should be continued throughout the first trimester if possible (AIII). After the first trimester, switching to oral fluconazole may be considered if appropriate clinically for consolidation or maintenance therapy (CIII).

Although there have been case reports of birth defects in infants exposed to itraconazole, a recent systematic review and meta-analysis of four cohort studies involving 971,450 pregnant women with 1,311 exposures, found no significant difference in the overall risk of birth defects between those with maternal exposure to itraconazole and those not exposed.⁹⁸ While limb and congenital heart defects were the most common defects seen, they were within the rates of the defects published by EUROCAT (the European network of population-based registries for epidemiological surveillance of congenital anomalies). However, the rate of eye defects was higher than that published by EUROCAT. There was no difference in the rates of spontaneous abortion or stillbirth from itraconazole exposure.

Voriconazole (at doses lower than recommended human doses), posaconazole, and isavuconazole are teratogenic and embryotoxic in animals; no adequately controlled studies have assessed their teratogenicity and embryotoxicity in humans. Voriconazole, posaconazole, and isavuconazole are not recommended for use during pregnancy, especially in the first trimester (CIII).

References

1. Aberg J, WG. P. Cryptococcosis. In: AIDS Therapy. M. H. Dolin R, Saag MS, ed. New York, NY: Churchill Livingstone; 2002:498-510.
2. Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992–2000. Clin Infect Dis. 2003;36(6):789-794. Available at: https://pubmed.ncbi.nlm.nih.gov/12627365.
3. Rajasingham R, Govender NP, Jordan A, et al. The global burden of HIV-associated cryptococcal infection in adults in 2020: a modelling analysis. Lancet Infect Dis. 2022;22(12):1748-1755. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36049486.
4. Pyrgos V, Seitz AE, Steiner CA, Prevots DR, Williamson PR. Epidemiology of cryptococcal meningitis in the US: 1997–2009. PLoS One. 2013;8(2):e56269. Available at: https://www.pubmed.ncbi.nlm.nih.gov/23457543.
5. Maziarz EK, Perfect JR. Cryptococcosis. Infect Dis Clin North Am. 2016;30(1):179-206. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26897067.
6. Rhein J, Hullsiek KH, Evans EE, et al. Detrimental outcomes of unmasking cryptococcal meningitis with recent ART initiation. Open Forum Infect Dis. 2018;5(8):ofy122. Available at: https://www.pubmed.ncbi.nlm.nih.gov/30094292.
7. Graybill JR, Sobel J, Saag M, et al. Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis. The NIAID Mycoses Study Group and AIDS Cooperative Treatment Groups. Clin Infect Dis. 2000;30(1):47-54. Available at: https://www.pubmed.ncbi.nlm.nih.gov/10619732.
8. Bicanic T, Brouwer AE, Meintjes G, et al. Relationship of cerebrospinal fluid pressure, fungal burden and outcome in patients with cryptococcal meningitis undergoing serial lumbar punctures. AIDS. 2009;23(6):701-706. Available at: https://pubmed.ncbi.nlm.nih.gov/19279443.
9. Boulware DR, Rolfes MA, Rajasingham R, et al. Multisite validation of cryptococcal antigen lateral flow assay and quantification by laser thermal contrast. Emerg Infect Dis. 2014;20(1):45-53. Available at: https://www.pubmed.ncbi.nlm.nih.gov/24378231.
10. Ssebambulidde K, Bangdiwala AS, Kwizera R, et al. Symptomatic cryptococcal antigenemia presenting as early cryptococcal meningitis with negative cerebral spinal fluid analysis. Clin Infect Dis. 2019;68(12):2094-2098. Available at: https://www.pubmed.ncbi.nlm.nih.gov/30256903.
11. French N, Gray K, Watera C, et al. Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults. AIDS. 2002;16(7):1031-1038. Available at: https://www.pubmed.ncbi.nlm.nih.gov/11953469.
12. Powderly WG, Cloud GA, Dismukes WE, Saag MS. Measurement of cryptococcal antigen in serum and cerebrospinal fluid: value in the management of AIDS-associated cryptococcal meningitis. Clin Infect Dis. 1994;18(5):789-792. Available at: https://www.pubmed.ncbi.nlm.nih.gov/8075272.
13. Beyene T, Zewde AG, Balcha A, et al. Inadequacy of high-dose fluconazole monotherapy among cerebrospinal fluid cryptococcal antigen (CrAg)-positive human immunodeficiency virus-infected persons in an Ethiopian CrAg screening program. Clin Infect Dis. 2017;65(12):2126-2129. Available at: https://www.pubmed.ncbi.nlm.nih.gov/29020172.
14. Wake RM, Britz E, Sriruttan C, et al. High cryptococcal antigen titers in blood are predictive of subclinical cryptococcal meningitis among human immunodeficiency virus-infected patients. Clin Infect Dis. 2018;66(5):686-692. Available at: https://www.pubmed.ncbi.nlm.nih.gov/29028998.
15. Rhein J, Bahr NC, Hemmert AC, et al. Diagnostic performance of a multiplex PCR assay for meningitis in an HIV-infected population in Uganda. Diagn Microbiol Infect Dis. 2016;84(3):268-273. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26711635.
16. Hanson KE, Slechta ES, Killpack JA, et al. Preclinical assessment of a fully automated multiplex PCR panel for detection of central nervous system pathogens. J Clin Microbiol. 2016;54(3):785-787. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26719436.
17. Leber AL, Everhart K, Balada-Llasat JM, et al. Multicenter evaluation of BioFire FilmArray Meningitis/Encephalitis Panel for detection of bacteria, viruses, and yeast in cerebrospinal fluid specimens. J Clin Microbiol. 2016;54(9):2251-2261. Available at: https://www.pubmed.ncbi.nlm.nih.gov/27335149.
18. O'Halloran JA, Franklin A, Lainhart W, Burnham CA, Powderly W, Dubberke E. Pitfalls associated with the use of molecular diagnostic panels in the diagnosis of cryptococcal meningitis. Open Forum Infect Dis. 2017;4(4):ofx242. Available at: https://pubmed.ncbi.nlm.nih.gov/29255738.
19. Kassi FK, Drakulovski P, Bellet V, et al. Cryptococcus genetic diversity and mixed infections in Ivorian HIV patients: a follow up study. PLoS Negl Trop Dis. 2019;13(11):e0007812. Available at: https://www.pubmed.ncbi.nlm.nih.gov/31738768.
20. Desnos-Ollivier M, Patel S, Spaulding AR, et al. Mixed infections and in vivo evolution in the human fungal pathogen Cryptococcus neoformans. mBio. 2010;1(1). Available at: https://www.pubmed.ncbi.nlm.nih.gov/20689742.
21. McKenney J, Bauman S, Neary B, et al. Prevalence, correlates, and outcomes of cryptococcal antigen positivity among patients with AIDS, United States, 1986–2012. Clin Infect Dis. 2015;60(6):959-965. Available at: https://www.pubmed.ncbi.nlm.nih.gov/25422390.
22. Chang CC, Harrison TS, Bicanic TA, et al. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. Lancet Infect Dis. 2024;24(8):e495-e512. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38346436.
23. Rajasingham R, Wake RM, Beyene T, Katende A, Letang E, Boulware DR. Cryptococcal meningitis diagnostics and screening in the era of point-of-care laboratory testing. J Clin Microbiol. 2019;57(1):In Press. doi: 10.1128/JCM.01238-01218. Available at: https://www.pubmed.ncbi.nlm.nih.gov/30257903.
24. McKinsey DS, Wheat LJ, Cloud GA, et al. Itraconazole prophylaxis for fungal infections in patients with advanced human immunodeficiency virus infection: randomized, placebo-controlled, double-blind study. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Clin Infect Dis. 1999;28(5):1049-1056. Available at: https://www.pubmed.ncbi.nlm.nih.gov/10452633.
25. Powderly WG, Finkelstein D, Feinberg J, et al. A randomized trial comparing fluconazole with clotrimazole troches for the prevention of fungal infections in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group. N Engl J Med. 1995;332(11):700-705. Available at: https://pubmed.ncbi.nlm.nih.gov/7854376.
26. Awotiwon AA, Johnson S, Rutherford GW, Meintjes G, Eshun-Wilson I. Primary antifungal prophylaxis for cryptococcal disease in HIV-positive people. Cochrane Database Syst Rev. 2018;8(8):CD004773. Available at: https://www.pubmed.ncbi.nlm.nih.gov/30156270.
27. van der Horst CM, Saag MS, Cloud GA, et al. Treatment of cryptococcal meningitis associated with the acquired immunodeficiency syndrome. National Institute of Allergy and Infectious Diseases Mycoses Study Group and AIDS Clinical Trials Group. N Engl J Med. 1997;337(1):15-21. Available at: https://www.pubmed.ncbi.nlm.nih.gov/9203426.
28. Hamill RJ, Sobel JD, El-Sadr W, et al. Comparison of 2 doses of liposomal amphotericin B and conventional amphotericin B deoxycholate for treatment of AIDS-associated acute cryptococcal meningitis: a randomized, double-blind clinical trial of efficacy and safety. Clin Infect Dis. 2010;51(2):225-232. Available at: https://www.pubmed.ncbi.nlm.nih.gov/20536366.
29. Baddour LM, Perfect JR, Ostrosky-Zeichner L. Successful use of amphotericin B lipid complex in the treatment of cryptococcosis. Clin Infect Dis. 2005;40 Suppl 6:S409-413. Available at: https://www.pubmed.ncbi.nlm.nih.gov/15809927.
30. Molloy SF, Kanyama C, Heyderman RS, et al. Antifungal combinations for treatment of cryptococcal meningitis in Africa. N Engl J Med. 2018;378(11):1004-1017. Available at: https://www.pubmed.ncbi.nlm.nih.gov/29539274.
31. Jarvis JN, Leeme TB, Molefi M, et al. Short-course high-dose liposomal amphotericin B for human immunodeficiency virus-associated cryptococcal meningitis: a phase 2 randomized controlled trial. Clin Infect Dis. 2019;68(3):393-401. Available at: https://www.pubmed.ncbi.nlm.nih.gov/29945252.
32. Kanyama C, Molloy SF, Chan AK, et al. One-year mortality outcomes from the Advancing Cryptococcal Meningitis Treatment for Africa trial of cryptococcal meningitis treatment in Malawi. Clin Infect Dis. 2020;70(3):521-524. Available at: https://www.pubmed.ncbi.nlm.nih.gov/31155650.
33. Jarvis JN, Lawrence DS, Meya DB, et al. Single-dose liposomal amphotericin B treatment for cryptococcal meningitis. N Engl J Med. 2022;386(12):1109-1120. Available at: https://www.pubmed.ncbi.nlm.nih.gov/35320642.
34. Dromer F, Mathoulin-Pelissier S, Launay O, Lortholary O, French Cryptococcosis Study Group. Determinants of disease presentation and outcome during cryptococcosis: the CryptoA/D study. PLoS Med. 2007;4(2):e21. Available at: https://www.pubmed.ncbi.nlm.nih.gov/17284154.
35. Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis. 2000;30(4):710-718. Available at: https://pubmed.ncbi.nlm.nih.gov/10770733.
36. Dromer F, Bernede-Bauduin C, Guillemot D, Lortholary O, French Cryptococcosis Study Group. Major role for amphotericin B-flucytosine combination in severe cryptococcosis. PLoS One. 2008;3(8):e2870. Available at: https://www.pubmed.ncbi.nlm.nih.gov/18682846.
37. Day JN, Chau TT, Wolbers M, et al. Combination antifungal therapy for cryptococcal meningitis. N Engl J Med. 2013;368(14):1291-1302. Available at: https://www.pubmed.ncbi.nlm.nih.gov/23550668.
38. Larsen RA, Bozzette SA, Jones BE, et al. Fluconazole combined with flucytosine for treatment of cryptococcal meningitis in patients with AIDS. Clin Infect Dis. 1994;19(4):741-745. Available at: https://www.pubmed.ncbi.nlm.nih.gov/7803641.
39. Bicanic T, Meintjes G, Wood R, et al. Fungal burden, early fungicidal activity, and outcome in cryptococcal meningitis in antiretroviral-naive or antiretroviral-experienced patients treated with amphotericin B or fluconazole. Clin Infect Dis. 2007;45(1):76-80. Available at: https://pubmed.ncbi.nlm.nih.gov/17554704.
40. Longley N, Muzoora C, Taseera K, et al. Dose response effect of high-dose fluconazole for HIV-associated cryptococcal meningitis in southwestern Uganda. Clin Infect Dis. 2008;47(12):1556-1561. Available at: https://pubmed.ncbi.nlm.nih.gov/18990067.
41. Kabanda T, Siedner MJ, Klausner JD, Muzoora C, Boulware DR. Point-of-care diagnosis and prognostication of cryptococcal meningitis with the cryptococcal antigen lateral flow assay on cerebrospinal fluid. Clin Infect Dis. 2014;58(1):113-116. Available at: https://www.pubmed.ncbi.nlm.nih.gov/24065327.
42. Aberg JA, Watson J, Segal M, Chang LW. Clinical utility of monitoring serum cryptococcal antigen (sCRAG) titers in patients with AIDS-related cryptococcal disease. HIV Clin Trials. 2000;1(1):1-6. Available at: https://www.pubmed.ncbi.nlm.nih.gov/11590483.
43. Pappas PG, Chetchotisakd P, Larsen RA, et al. A phase II randomized trial of amphotericin B alone or combined with fluconazole in the treatment of HIV-associated cryptococcal meningitis. Clin Infect Dis. 2009;48(12):1775-1783. Available at: https://www.pubmed.ncbi.nlm.nih.gov/19441980.
44. Rolfes MA, Rhein J, Schutz C, et al. Cerebrospinal fluid culture positivity and clinical outcomes after amphotericin-based induction therapy for cryptococcal meningitis. Open Forum Infect Dis. 2015;2(4):ofv157. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26716103.
45. Saag MS, Cloud GA, Graybill JR, et al. A comparison of itraconazole versus fluconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Clin Infect Dis. 1999;28(2):291-296. Available at: https://pubmed.ncbi.nlm.nih.gov/10064246.
46. Perfect JR, Marr KA, Walsh TJ, et al. Voriconazole treatment for less-common, emerging, or refractory fungal infections. Clin Infect Dis. 2003;36(9):1122-1131. Available at: https://www.pubmed.ncbi.nlm.nih.gov/12715306.
47. Pitisuttithum P, Negroni R, Graybill JR, et al. Activity of posaconazole in the treatment of central nervous system fungal infections. J Antimicrob Chemother. 2005;56(4):745-755. Available at: https://www.pubmed.ncbi.nlm.nih.gov/16135526.
48. Thompson GR, 3rd, Rendon A, Ribeiro Dos Santos R, et al. Isavuconazole treatment of cryptococcosis and dimorphic mycoses. Clin Infect Dis. 2016;63(3):356-362. Available at: https://www.pubmed.ncbi.nlm.nih.gov/27169478.
49. Powderly WG, Saag MS, Cloud GA, et al. A controlled trial of fluconazole or amphotericin B to prevent relapse of cryptococcal meningitis in patients with the acquired immunodeficiency syndrome. The NIAID AIDS Clinical Trials Group and Mycoses Study Group. N Engl J Med. 1992;326(12):793-798. Available at: https://pubmed.ncbi.nlm.nih.gov/1538722.
50. Faini D, Kalinjuma AV, Katende A, et al. Laboratory-reflex cryptococcal antigen screening is associated with a survival benefit in Tanzania. J Acquir Immune Defic Syndr. 2019;80(2):205-213. Available at: https://www.pubmed.ncbi.nlm.nih.gov/30422904.
51. Meya DB, Williamson PR. Cryptococcal disease in diverse hosts. N Engl J Med. 2024;390(17):1597-1610. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38692293.
52. Boulware DR, Meya DB, Muzoora C, et al. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med. 2014;370(26):2487-2498. Available at: https://www.pubmed.ncbi.nlm.nih.gov/24963568.
53. Scriven JE, Rhein J, Hullsiek KH, et al. Early ART after cryptococcal meningitis is associated with cerebrospinal fluid pleocytosis and macrophage activation in a multisite randomized trial. J Infect Dis. 2015;212(5):769-778. Available at: https://www.pubmed.ncbi.nlm.nih.gov/25651842.
54. Zhao H, Zhou M, Zheng Q, et al. Clinical features and outcomes of cryptococcemia patients with and without HIV infection. Mycoses. 2021;64(6):656-667. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33609302.
55. Ingle SM, Miro JM, May MT, et al. Early antiretroviral therapy not associated with higher cryptococcal meningitis mortality in people with human immunodeficiency virus in high-income countries: an international collaborative cohort study. Clin Infect Dis. 2023;77(1):64-73. Available at: https://www.pubmed.ncbi.nlm.nih.gov/36883578.
56. Boulware DR, Jarvis JN. Timing of antiretroviral therapy in cryptococcal meningitis: what we can (and cannot) learn from observational data. Clin Infect Dis. 2023;77(1):74-76. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36883585.
57. Chang CC, Dorasamy AA, Gosnell BI, et al. Clinical and mycological predictors of cryptococcosis-associated Immune reconstitution inflammatory syndrome (C-IRIS). AIDS. 2013. Available at: https://www.pubmed.ncbi.nlm.nih.gov/23525034.
58. Rolfes MA, Hullsiek KH, Rhein J, et al. The effect of therapeutic lumbar punctures on acute mortality from cryptococcal meningitis. Clin Infect Dis. 2014;59(11):1607-1614. Available at: https://www.pubmed.ncbi.nlm.nih.gov/25057102.
59. Fessler RD, Sobel J, Guyot L, et al. Management of elevated intracranial pressure in patients with cryptococcal meningitis. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17(2):137-142. Available at: https://www.pubmed.ncbi.nlm.nih.gov/9473014.
60. Newton PN, Thai le H, Tip NQ, et al. A randomized, double-blind, placebo-controlled trial of acetazolamide for the treatment of elevated intracranial pressure in cryptococcal meningitis. Clin Infect Dis. 2002;35(6):769-772. Available at: https://www.pubmed.ncbi.nlm.nih.gov/12203177.
61. Beardsley J, Wolbers M, Kibengo FM, et al. Adjunctive dexamethasone in HIV-associated cryptococcal meningitis. N Engl J Med. 2016;374(6):542-554. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26863355.
62. Bahr NC, Rolfes MA, Musubire A, et al. Standardized electrolyte supplementation and fluid management improves survival during amphotericin therapy for cryptococcal meningitis in resource-limited settings. Open Forum Infect Dis. 2014;1(2):ofu070. Available at: https://www.pubmed.ncbi.nlm.nih.gov/25734140.
63. Davis MR, Nguyen MH, Donnelley MA, Thompson GR, III. Tolerability of long-term fluconazole therapy. J Antimicrob Chemother. 2019;74(3):768-771. Available at: https://pubmed.ncbi.nlm.nih.gov/30535104.
64. Shelburne SA, 3rd, Darcourt J, White AC, Jr., et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis. 2005;40(7):1049-1052. Available at: https://pubmed.ncbi.nlm.nih.gov/15825000.
65. Muller M, Wandel S, Colebunders R, et al. Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10(4):251-261. Available at: https://www.pubmed.ncbi.nlm.nih.gov/20334848.
66. Boulware DR, Bonham SC, Meya DB, et al. Paucity of initial cerebrospinal fluid inflammation in cryptococcal meningitis is associated with subsequent immune reconstitution inflammatory syndrome. J Infect Dis. 2010;202(6):962-970. Available at: https://www.pubmed.ncbi.nlm.nih.gov/20677939.
67. Chang CC, Dorasamy AA, Gosnell BI, et al. Clinical and mycological predictors of cryptococcosis-associated immune reconstitution inflammatory syndrome. AIDS. 2013;27(13):2089-2099. Available at: https://www.pubmed.ncbi.nlm.nih.gov/23525034.
68. Haddow LJ, Colebunders R, Meintjes G, et al. Cryptococcal immune reconstitution inflammatory syndrome in HIV-1-infected individuals: proposed clinical case definitions. Lancet Infect Dis. 2010;10(11):791-802. Available at: https://www.pubmed.ncbi.nlm.nih.gov/21029993.
69. Boulware DR, Meya DB, Bergemann TL, et al. Clinical features and serum biomarkers in HIV immune reconstitution inflammatory syndrome after cryptococcal meningitis: a prospective cohort study. PLoS Med. 2010;7(12):e1000384. Available at: https://www.pubmed.ncbi.nlm.nih.gov/21253011.
70. Kuttiatt V, Sreenivasa P, Garg I, Shet A. Cryptococcal lymphadenitis and immune reconstitution inflammatory syndrome: current considerations. Scand J Infect Dis. 2011;43(8):664-668. Available at: https://www.pubmed.ncbi.nlm.nih.gov/21534892.
71. Brandt ME, Pfaller MA, Hajjeh RA, et al. Trends in antifungal drug susceptibility of Cryptococcus neoformans isolates in the United States: 1992 to 1994 and 1996 to 1998. Antimicrob Agents Chemother. 2001;45(11):3065-3069. Available at: https://www.pubmed.ncbi.nlm.nih.gov/11600357.
72. Witt MD, Lewis RJ, Larsen RA, et al. Identification of patients with acute AIDS-associated cryptococcal meningitis who can be effectively treated with fluconazole: the role of antifungal susceptibility testing. Clin Infect Dis. 1996;22(2):322-328. Available at: https://www.pubmed.ncbi.nlm.nih.gov/8838190.
73. Chesdachai S, Rajasingham R, Nicol MR, et al. Minimum inhibitory concentration distribution of fluconazole against Cryptococcus species and the Fluconazole Exposure Prediction Model. Open Forum Infect Dis. 2019;6(10). Available at: https://www.pubmed.ncbi.nlm.nih.gov/31420668.
74. Leenders AC, Reiss P, Portegies P, et al. Liposomal amphotericin B (AmBisome) compared with amphotericin B both followed by oral fluconazole in the treatment of AIDS-associated cryptococcal meningitis. AIDS. 1997;11(12):1463-1471. Available at: https://www.pubmed.ncbi.nlm.nih.gov/9342068.
75. Chen SC, Australasian Society for Infectious Diseases Mycoses Iterest G. Cryptococcosis in Australasia and the treatment of cryptococcal and other fungal infections with liposomal amphotericin B. J Antimicrob Chemother. 2002;49 Suppl 1(Suppl 1):57-61. Available at: https://www.pubmed.ncbi.nlm.nih.gov/11801583.
76. Jarvis JN, Meintjes G, Williams Z, Rebe K, Harrison TS. Symptomatic relapse of HIV-associated cryptococcal meningitis in South Africa: the role of inadequate secondary prophylaxis. S Afr Med J. 2010;100(6):378-382. Available at: https://www.pubmed.ncbi.nlm.nih.gov/20526411.
77. Kirk O, Reiss P, Uberti-Foppa C, et al. Safe interruption of maintenance therapy against previous infection with four common HIV-associated opportunistic pathogens during potent antiretroviral therapy. Ann Intern Med. 2002;137(4):239-250. Available at: https://www.pubmed.ncbi.nlm.nih.gov/12186514.
78. Vibhagool A, Sungkanuparph S, Mootsikapun P, et al. Discontinuation of secondary prophylaxis for cryptococcal meningitis in human immunodeficiency virus-infected patients treated with highly active antiretroviral therapy: a prospective, multicenter, randomized study. Clin Infect Dis. 2003;36(10):1329-1331. Available at: https://www.pubmed.ncbi.nlm.nih.gov/12746781.
79. Mussini C, Pezzotti P, Miro JM, et al. Discontinuation of maintenance therapy for cryptococcal meningitis in patients with AIDS treated with highly active antiretroviral therapy: an international observational study. Clin Infect Dis. 2004;38(4):565-571. Available at: https://www.pubmed.ncbi.nlm.nih.gov/14765351.
80. Pastick KA, Nalintya E, Tugume L, et al. Cryptococcosis in pregnancy and the postpartum period: case series and systematic review with recommendations for management. Med Mycol. 2020;58(3):282-292. Available at: https://www.pubmed.ncbi.nlm.nih.gov/31689712.
81. Miyoshi S, Oda N, Gion Y, et al. Exacerbation of pulmonary cryptococcosis associated with enhancement of Th2 response in the postpartum period. J Infect Chemother. 2021;27(8):1248-1250. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33840597.
82. Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation of infections after pregnancy. Clin Infect Dis. 2007;45(9):1192-1199. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17918082.
83. O'Grady N, McManus D, Briggs N, Azar MM, Topal J, Davis MW. Dosing implications for liposomal amphotericin B in pregnancy. Pharmacotherapy. 2023;43(5):452-462. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36862037.
84. AmBisome® (amphotericin B) liposome for injection [package insert]. U.S. Food and Drug Administration. 2021. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/050740Orig1s033lbl.pdf.
85. Curole DN. Cryptococcal meningitis in pregnancy. J Reprod Med. 1981;26(6):317-319. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7252951.
86. Schonebeck J, Segerbrand E. Candida albicans septicaemia during first half of pregnancy successfully treated with 5-fluorocytosine. Br Med J. 1973;4(5888):337-338. Available at: https://www.ncbi.nlm.nih.gov/pubmed/4202261.
87. Philpot CR, Lo D. Cryptococcal meningitis in pregnancy. Med J Aust. 1972;2(18):1005-1007. Available at: https://www.ncbi.nlm.nih.gov/pubmed/4578877.
88. Pursley TJ, Blomquist IK, Abraham J, Andersen HF, Bartley JA. Fluconazole-induced congenital anomalies in three infants. Clin Infect Dis. 1996;22(2):336-340. Available at: https://www.pubmed.ncbi.nlm.nih.gov/8838193.
89. Metruccio F, Battistoni M, Di Renzo F, Moretto A, Menegola E. Moderate alcohol consumption during pregnancy increases potency of two different drugs (the antifungal fluconazole and the antiepileptic valproate) in inducing craniofacial defects: prediction by the in vitro rat whole embryo culture. Arch Toxicol. 2023;97(2):619-629. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36385218.
90. Budani MC, Fensore S, Di Marzio M, Tiboni GM. Maternal use of fluconazole and congenital malformations in the progeny: a meta-analysis of the literature. Reprod Toxicol. 2021;100:42-51. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33383164.
91. Zhang Z, Zhang X, Zhou YY, Jiang CM, Jiang HY. The safety of oral fluconazole during the first trimester of pregnancy: a systematic review and meta-analysis. BJOG. 2019;126(13):1546-1552. Available at: https://www.pubmed.ncbi.nlm.nih.gov/31446677.
92. Molgaard-Nielsen D, Pasternak B, Hviid A. Use of oral fluconazole during pregnancy and the risk of birth defects. N Engl J Med. 2013;369(9):830-839. Available at: https://www.pubmed.ncbi.nlm.nih.gov/23984730.
93. Howley MM, Carter TC, Browne ML, Romitti PA, Cunniff CM, Druschel CM. Fluconazole use and birth defects in the National Birth Defects Prevention Study. Am J Obstet Gynecol. 2016;214(5):657 e651-659. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26640069.
94. Berard A, Sheehy O, Zhao JP, et al. Associations between low- and high-dose oral fluconazole and pregnancy outcomes: 3 nested case-control studies. CMAJ. 2019;191(7):E179-E187. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30782643.
95. Zhu Y, Bateman BT, Gray KJ, et al. Oral fluconazole use in the first trimester and risk of congenital malformations: population based cohort study. BMJ. 2020;369:m1494. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32434758.
96. Mølgaard-Nielsen D, Svanstrom H, Melbye M, Hviid A, Pasternak B. Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA. 2016;315(1):58-67. Available at: https://www.pubmed.ncbi.nlm.nih.gov/26746458.
97. Pasternak B, Wintzell V, Furu K, Engeland A, Neovius M, Stephansson O. Oral fluconazole in pregnancy and risk of stillbirth and neonatal death. JAMA. 2018;319(22):2333-2335. Available at: https://www.pubmed.ncbi.nlm.nih.gov/29896619.
98. Liu D, Zhang C, Wu L, Zhang L, Zhang L. Fetal outcomes after maternal exposure to oral antifungal agents during pregnancy: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2020;148(1):6-13. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31691277.