The duration of therapy for cryptococcal meningitis during HIV infection can generally divided into three phases: the acute period, the early maintenance peroid and the late maintenance period.
Most patients can receive intensive therapy with Ampho B for 2 weeks followed by early maintenance with fluconazole at high dose (400 mg daily) for about 10 weeks. Thereafter, fluconazole at 200 mg daily is used to avoid recurrence.
IF intensive therapy is not working (continued signs/symptoms of high intracranial pressure (ICP), clinical worsening), prolonged therapy with Ampho B is indicated until improvements are seen before graduating to maintenance treatment periods. High ICP is what kills most patients and this may require heroic measures (serial spinal taps, shunts).
If Ampho B is not available, high doses of fluconazole for a longer duration (i.e. 800 mg daily for 6 weeks) is recommended as the acute period treatment.
Flucytosine is advised to accompany Ampho B or fluconazole acute period treatment as it has been found to prevent recurrences.
Itraconazole is not as effective as fluconazole but if it is all you have, I would use it (at least 200 mg twice a day).
In patients who start ART and can mainfest a persistent (>3 months) increase in CD4 cell counts to above 100, stopping of late maintenance phase fluconazole is safe.
DW
