Abstract
Rationale for guideline update Six years after the Southern African HIV Clinicians Society cryptococcal disease guideline was published in 2013, cryptococcal meningitis (CM) remains an important cause of mortality among antiretroviral treatment (ART)-naive and ART-experienced HIV-seropositive adults in South Africa.1,2 Several important practice-changing developments led us to update the guideline to diagnose, prevent and manage this common fungal opportunistic infection. The World Health Organization (WHO) published a guideline for advanced HIV disease in 2017 and a guideline relevant to resource-limited settings for HIV-associated CM in 2018.3,4 Cryptococcal antigen (CrAg) screening and pre-emptive treatment reduced all-cause mortality among ambulatory participants in a randomised clinical trial in Zambia and Uganda.5 Following an evaluation of reflex versus provider-initiated screening, national reflex laboratory CrAg screening was implemented in South Africa in 2016.6,7 Recently completed clinical trials conducted in resource-limited settings have provided evidence for the best first-line antifungal regimens for CM and the role of corticosteroids in CM.8,9 Finally, international and local advocacy efforts have resulted in increasing, yet still limited, access to flucytosine and a reduced cost of liposomal amphotericin B for the treatment of CM.10
Highlights
Rationale for guideline updateSix years after the Southern African HIV Clinicians Society cryptococcal disease guideline was published in 2013, cryptococcal meningitis (CM) remains an important cause of mortality among antiretroviral treatment (ART)-naïve and ART-experienced HIV-seropositive adults in South Africa.[1,2] Several important practice-changing developments led us to update the guideline to diagnose, prevent and manage this common fungal opportunistic infection
Reflex laboratory Cryptococcal antigen (CrAg) screening is recommended as the preferred approach in South Africa, alternative approaches may be more suitable for other countries in Southern Africa
A manometer is the most accurate way to measure raised intracranial pressure, we have suggested alternative options for assessment of elevated pressure when it is unavailable
Summary
Six years after the Southern African HIV Clinicians Society cryptococcal disease guideline was published in 2013, cryptococcal meningitis (CM) remains an important cause of mortality among antiretroviral treatment (ART)-naïve and ART-experienced HIV-seropositive adults in South Africa.[1,2] Several important practice-changing developments led us to update the guideline to diagnose, prevent and manage this common fungal opportunistic infection. We recommend immediate referral for LP in all patients with a new positive blood CrAg test who initiated ART within the 4-week period prior to the CrAg test. Among those with a negative CSF CrAg test (i.e. in whom CM is excluded), ART is recommended to be continued and fluconazole pre-emptive therapy should be initiated. Among those with a new diagnosis of CM during the first 4 weeks of ART, the guideline panel thought that there was clinical equipoise in terms of a decision to continue or interrupt ART. Antifungal susceptibility testing is recommended if a patient has a single relapse episode of CM and other causes have been excluded
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