Mteeveabout 7 years ago

*Treatment of Cryptococcal Meningitis* In my setup-Kenya. Share your views. ADULTS _Induction (2 weeks)_ Ampho B 0.7-1 mg/kg/day + Fluconazole 800 mg/day _Consolidation (8 weeks)_ Fluconazole 400-800 mg/day _Maintenance_ Fluconazole 200 mg/day till CD4 count > 200 cells/ml for at least 6 consecutive months *Alternatively give:* _Induction (2 weeks)_ Fluconazole 1200 mg daily _Consolidation (8 weeks)_ Fluconazole 800mg daily _Maintenance_ Fluconazole 200 mg/day till CD4 count > 200 cells/ml for at least 6 consecutive months CHILDREN _Induction (2 weeks)_ Ampho B 0.7-1mg/kg/day + Fluconazole 12mg/kg/day (upto max 800 mg/day) _Consolidation (8 weeks)_ Fluconazole 6-12mg/kg/day up to 400 to 800 mg/day _Maintenance_ Fluconazole 6mg/kg/day up to 200mg/day *Alternatively give:* _Induction (2 weeks)_ Fluconazole 12mg/kg/day (upto max 1200 mg/day) _Consolidation (8 weeks)_ Fluconazole 12mg/kg/day up to 800 mg/day _Maintenance_ Fluconazole 6mg/kg/day up to 200mg/day *When to start ART* In both children and adults....Defer ART until after completing 5 weeks of CM treatment and symptoms have resolved. *Managing and Monitoring for Amphotericin B Therapy* *_Adults*_ • Give 1 L of normal saline with 20 mmol of KCl over 2-4 hours before each controlled infusion of Ampho B given with 1 litre of 5% dextrose. Add 1-2 8 mEq KCl tablets orally twice daily. Very key. You can add one 8 mEq KCl tablets twice daily in the second week. Include magnesium supplementation at 250 mg tablets of magnesium trisilicate twice daily *_Adolescents and Children_* • Give 1 L of normal saline with 20 mmol of KCl over 2-4 hours before each controlled infusion of Ampo B. Darrows or *Ringer’s solutions* can also be used. • Avoid KCl replacement in patients with pre-existing renal impairment or hyperkalaemia *Managing hypokalaemia and raised creatinine levels* • Obtain a routine baseline and twice weekly potassium creatinine. - If K < 3.3 mmol/L, administer KCL 40 mmol in normal saline or 1-2 tablets of KCl 8 hourly. Add magnesium. Monitor potassium daily - If creatinine level increases > 2 fold, omit dose of Ampho B, increase hydration to 1L 8 hourly. If there’s improvement, re-start Ampho B at 0.7 mg/kg/day on alternate days. If no improvement, discontinue Ampho B, give Fluconazole 1200 mg/day. Monitor creatinine daily *Therapeutic lumbar punctures* • For all patients with symptomatic CM: perform daily theraputic lumbar punctures • If opening pressure is ≤ 40 cm: draw only enough CSF to reduce pressure to 20 cm • If opening pressure is > 40 cm: draw only enough CSF to reduce pressure by 50% • Continue daily LPs until pressure is normal for 3 consecutive days • Restart LPs if symptoms return • *Perform daily therapeutic LPs until severe headache subsides, removing 10-20ml of CSF each time if measurements of csf pressures isn't possible.*