Primary prevention

In general, avoidance of exposure to fungal pathogens is not realistic; but avoidance of circumstances likely to lead to prolonged heavy exposure (e.g., contact with pigeon guano [Cryptococcus neoformans] or disturbed soil in highly endemic areas [Cryptococcus immitis, Histoplasma capsulatum]) is reasonable, especially for immunosuppressed patients. 

Antiretroviral therapy

Early and effective antiretroviral therapy in patients with HIV may prevent occurrence of fungal meningitis.

Antiretroviral therapy remains the most effective prophylaxis to prevent HIV-associated cryptococcal disease.

Antifungal therapy

Patients presenting with advanced HIV infection, a CD4 count <100 cells/microliter, and who have a positive cryptococcal antigen test result should be given preemptive antifungal therapy to prevent the development of invasive cryptococcal disease before initiating or reinitiating antiretroviral therapy.[71][72] Antifungal therapy may also be considered at a higher CD4 count threshold of <200 cells/microliter.[71]

Although primary antifungal prophylaxis with either fluconazole or itraconazole reduces the incidence of cryptococcal meningitis in patients with advanced HIV disease and reduces deaths due to cryptococcal disease, it has no clear effect on overall mortality.[73] [ Cochrane Clinical Answers logo ] In settings where antigen screening is not available, the World Health Organization recommends initiating fluconazole primary prophylaxis in people with HIV infection and a CD4 count <100 cells/mm³.[71]

Prophylaxis for histoplasmosis with itraconazole is recommended in HIV-infected patients with CD4 cell counts <150 cells/microliter who are at high risk because of occupational exposure, or who are resident in specific endemic areas where the incidence is >10 cases per 100 patient-years.[72] Prophylaxis with itraconazole may also be appropriate in specific circumstances in other immunosuppressed patients, such as organ transplant patients or those taking immunosuppression medicine such as corticosteroids.

For patients with HIV living in the coccidioidal-endemic region, primary antifungal prophylaxis is not recommended to prevent coccidioidomycosis.[74] Fluconazole prophylaxis is, however, recommended for organ transplant patients without active coccidioidomycosis who are in the endemic area.[74]

Primary prophylaxis against invasive candidiasis is indicated in selected high-risk patient groups.[75] Primary prophylaxis may be indicated in patients with prolonged neutropenia or high-risk bone marrow, and in solid-organ transplant recipients and selected intensive care unit patients where there are high rates of disease. Fluconazole, and azole antifungals with additional activity against mold infections, have been used in these settings. In very low birthweight infants (<1.5 kg), chemoprophylaxis with fluconazole and oral nystatin is considered to be an effective practice to prevent neonatal fungal infections.[76] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

Use of this content is subject to our disclaimer