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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.