Date Published: February 6, 2007
Publisher: PLoS Medicine
Author(s): John R Perfect
Abstract: Perfect discusses the implications of a national prospective study (the “CryptoA/D” study) of the factors influencing clinical presentation and outcome of patients with cryptococcosis.
Partial Text: In a new research article published in PLoS Medicine, Francoise Dromer and colleagues  report on a French national prospective study (the “CryptoA/D” study) of the factors influencing clinical presentation and outcome of patients with cryptococcosis (an infection caused by the pathogenic fungus Cryptococcus neoformans). This is just the type of prospective study that is needed to help us understand how we are doing in the management of a life-threatening infection. Often our randomized, blinded, and controlled studies do not reflect actual outcomes in the general medical community, because study participants are biased by a series of entry criteria and other issues. Thus, prospective studies to collect real-time data during clinical management become important gauges in how successful we are and may help us define what we need to improve.
Dromer and colleagues present a multicenter surveillance of an entire country’s experience of cryptococcosis management over a four-year period. Their study of 230 patients came to three major conclusions.
This study allows us to observe where we are in the management of cryptococcosis in the era of HAART (highly active antiretroviral therapy) and with access to current antifungal drugs and supportive care. Unfortunately, the failure rates remain substantial, with a mortality of about 12% at three months. Furthermore, there are undefined costs of care and morbidity from this infection. The question is: How do we do better?
The answer is we must perform careful evidence-based studies to address a series of important clinical questions on patients at high risk for failure (see Box 1). We can then adjust our treatment guidelines to better fit the individual patient. This evidence-based directed research strategy will be good for the future of medicine but does not necessarily help the patient today. Therefore, the basic message of Dromer et al. rings as true as the message from the prognostic studies of cryptococcal meningitis with amphotericin B treatment in 1974 . In the initial management of cryptococcosis, the assessment of the burden of yeasts in the host from its site of infection(s) to its quantity of yeasts determined through cultures, antigen loads, and radiographic appearances will give clinicians a prediction of the difficulties that they might face. Furthermore, the initial philosophy in the high-risk patient is to provide therapies that efficiently eliminate yeasts from the host. The sugar-coated killer whose sweetness sickens must be stripped away leaving only the underlying disease to deal with .