Multi-center Comparison of Fluconazole (UK-49,858) and Amphotericin B as Treatment for Acute Cryptococcal Meningitis

Inclusion Criteria Concurrent Medication: Allowed: Immunosuppressant therapy. Cyclosporin plasma concentrations should be monitored and appropriate dosage adjustments made when used with amphotericin B or fluconazole. Antiviral therapy. Prophylaxis for Pneumocystis carinii pneumonia. Treatment of intercurrent opportunistic infection as long as no investigational agent, or approved agent for an investigational indication, is used. Antipyretics, hydrocortisone, or meperidine to prevent or ameliorate side effects associated with amphotericin B. Concurrent Treatment: Allowed: - Radiation therapy for mucocutaneous Kaposi's sarcoma. Patients must have: Written informed consent obtained from the patient or from the patient's legal guardian. One of the following: (1) Tentative identification of Cryptococcus neoformans in culture of lumbar cerebrospinal fluid (CSF). Results of baseline cultures need not be available when therapy is begun, but therapy is discontinued if the baseline CSF culture is later found to be negative for C. neoformans, or (2) Clinical and CSF findings (cell count, protein, glucose) compatible with cryptococcal meningitis plus one of the following: (a) Positive CSF India ink examination, (b) Culture or biopsy evidence of extraneural cryptococcal infection, (c) Positive serum of CSF cryptococcal antigen test, or increase in titer for previously treated patients with suspected relapse, or (d) Biopsy evidence of central nervous system cryptococcal infection. Treatment status of either no prior systemic antifungal therapy for cryptococcosis or relapse after prior therapy. The success of prior therapy must have been documented by negative CSF culture at the end of therapy. Prior Medication: Allowed within 4 weeks of study entry: - Successful prior therapy for cryptococcosis, but no more than 1 mg/kg/week amphotericin B. Allowed: Immunosuppressant therapy. Antiviral therapy. Prophylaxis for Pneumocystis carinii pneumonia. Exclusion Criteria Co-existing Condition: Excluded: Acute or chronic meningitis based on any etiology other than cryptococcosis. History of allergy to or intolerance of imidazoles, or amphotericin B. Moderate or severe liver disease defined as any one or more of the following: SGOT or SGPT > 5 x upper limit of normal, total bilirubin > 2.5 mg/dl, prothrombin time > 5 seconds over control, or alkaline phosphatase > 2 x upper limit of normal. Comatose patients. Concurrent Medication: Excluded: Drugs with low therapeutic ratios that undergo hepatic metabolism may not be used with fluconazole until possible drug interactions have been clarified. Coumarin-type anticoagulants. Oral hypoglycemics. Barbiturates. Immunostimulants. Investigational drugs or approved (licensed) drugs for investigational indications. Systemic antifungal agent other than the assigned study drug. Concurrent Treatment: Excluded: Lymphocyte replacement. Prior Medication: Excluded within 4 weeks of study entry: More than 1 mg/kg/week amphotericin B. Patients unlikely to survive more than 2 weeks.