Fungal meningitis medical therapy: Difference between revisions
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|''[[Cryptococcus]]'' | |''[[Cryptococcus]]'' | ||
|'''HIV-infection''' | |'''[[Human Immunodeficiency Virus (HIV)|HIV-infection]]''' | ||
'''''(Induction/consolidation)''''': | '''''(Induction/consolidation)''''': | ||
* [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day IV '''plus''' [[flucytosine]] 25 mg/kg PO QID for at least 2 weeks | * [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day IV '''plus''' [[flucytosine]] 25 mg/kg PO QID for at least 2 weeks | ||
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* Lipid formulations of [[amphotericin B]] may be substituted for [[Amphotericin B]] [[deoxycholate]] if necessary: [[liposomal amphotericin B]] 3-4 mg/kg/day IV and [[amphotericin B]] lipid complex 5 mg/kg/day IV. | * Lipid formulations of [[amphotericin B]] may be substituted for [[Amphotericin B]] [[deoxycholate]] if necessary: [[liposomal amphotericin B]] 3-4 mg/kg/day IV and [[amphotericin B]] lipid complex 5 mg/kg/day IV. | ||
'''''(Maintenance):''''' | '''''(Maintenance):''''' | ||
* Fluconazole 200 mg/day | * [[Fluconazole]] 200 mg/day | ||
'''''Solid organ transplant:''''' | '''''Solid organ transplant:''''' | ||
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{{then}} [[fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) for 8 weeks {{then}} [[fluconazole]] 200-400 mg/day for 6-12 months | {{then}} [[fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) for 8 weeks {{then}} [[fluconazole]] 200-400 mg/day for 6-12 months | ||
'''''Non-HIV, non-organ transplant:''''' | '''''Non-[[HIV]], non-[[organ transplant]]:''''' | ||
* [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day IV plus [[flucytosine]] 25 mg/kg QID for at least 4 weeks | * [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day IV plus [[flucytosine]] 25 mg/kg QID for at least 4 weeks | ||
{{then}} [[fluconazole]] 200 mg/day (3 mg/kg) for 6-12 months | {{then}} [[fluconazole]] 200 mg/day (3 mg/kg) for 6-12 months | ||
|'''HIV-infection''' | |'''[[HIV]]-infection''' | ||
'''''(Induction/consolidation):''''' | '''''(Induction/consolidation):''''' | ||
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{{then}} 4 mg/kg q12h; further conversion to oral therapy may be considered. | {{then}} 4 mg/kg q12h; further conversion to oral therapy may be considered. | ||
* Typical oral dosing is 200 mg q12h but is dependent on therapeutic drug monitoring. | * Typical oral dosing is 200 mg q12h but is dependent on therapeutic drug monitoring. | ||
* Total duration of therapy has not been defined. Multiple factors must be considered, including extent of disease, response to therapy, and underlying immune status of the host. | * Total duration of therapy has not been defined. Multiple factors must be considered, including extent of disease, response to therapy, and underlying [[Immune system|immune status]] of the host. | ||
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* [[Liposomal amphotericin B]] 3-5 mg/kg/day IV, [[amphotericin B]] lipid complex 5 mg/kg/day IV, [[itraconazole]] 200 mg PO BID, or [[posaconazole]] 200 mg PO q6h. | * [[Liposomal amphotericin B]] 3-5 mg/kg/day IV, [[amphotericin B]] lipid complex 5 mg/kg/day IV, [[itraconazole]] 200 mg PO BID, or [[posaconazole]] 200 mg PO q6h. | ||
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* Lipid formulations of [[Amphotericin B]] 3-5 mg/kg/day +/− [[Flucytosine]] 25 mg/kg QID for ∼3 weeks | * Lipid formulations of [[Amphotericin B]] 3-5 mg/kg/day +/− [[Flucytosine]] 25 mg/kg QID for ∼3 weeks | ||
{{then}} [[Fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) | {{then}} [[Fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) | ||
* Treatment continued until clinical signs and symptoms resolved and CNS and radiographic abnormalities have normalized. | * Treatment continued until clinical signs and symptoms resolved and [[CNS]] and radiographic abnormalities have normalized. | ||
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* [[Fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) | * [[Fluconazole]] 400-800 mg/day PO/IV (6-12 mg/kg/day) | ||
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* [[Intrathecal]] [[amphotericin B]] [[deoxycholate]]. dosing ranges from 0.1 to 1.5 mg per dose given daily to weekly. | * [[Intrathecal]] [[amphotericin B]] [[deoxycholate]]. dosing ranges from 0.1 to 1.5 mg per dose given daily to weekly. | ||
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|'' | |''tfExserohilum'' | ||
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* [[Voriconazole]] 6 mg/kg IV every 12h with assessment of [[voriconazole]] trough concentrations on day 5 of therapy with adjustment to achieve trough of 2-5 mcg/ml. | * [[Voriconazole]] 6 mg/kg IV every 12h with assessment of [[voriconazole]] trough concentrations on day 5 of therapy with adjustment to achieve trough of 2-5 mcg/ml. | ||
* IV therapy should be initiated in most cases with transition to PO therapy once improving and clinically stable. | * IV therapy should be initiated in most cases with transition to PO therapy once improving and clinically stable. | ||
* Total duration of therapy is unknown and will depend on extent of infection, response to therapy, and underlying immune status of the host. | * Total duration of therapy is unknown and will depend on extent of infection, response to therapy, and underlying [[Immune system|immune status]] of the host. | ||
* Minimum duration of 3-6 months. | * Minimum duration of 3-6 months. | ||
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* [[Liposomal amphotericin B]] 5 mg/kg/day IV for 4-6 weeks | * [[Liposomal amphotericin B]] 5 mg/kg/day IV for 4-6 weeks | ||
{{then}} [[itraconazole]] 200 mg BID to TID for at least 1 year and until resolution of [[CSF]] abnormalities including ''[[Histoplasma capsulatum|Histoplasma]]'' | {{then}} [[itraconazole]] 200 mg BID to TID for at least 1 year and until resolution of [[CSF]] abnormalities including ''[[Histoplasma capsulatum|Histoplasma]]'' [[antigen]] levels. | ||
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* [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day is an alternative to [[liposomal amphotericin B]] in patients at low risk of [[nephrotoxicity]]. | * [[Amphotericin B]] [[deoxycholate]] 0.7-1.0 mg/kg/day is an alternative to [[liposomal amphotericin B]] in patients at low risk of [[nephrotoxicity]]. | ||
Revision as of 22:18, 6 April 2017
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Fungal meningitis Microchapters |
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Fungal meningitis medical therapy On the Web |
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Risk calculators and risk factors for Fungal meningitis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby
Overview
Fungal meningitis, such as cryptococcal meningitis, is treated with long courses of high dose antifungals. In addition, frequent lumbar punctures are recommended in order to relieve the increased intracranial pressure[1].
Medical Therapy
- The treatment of fungal meningitis, such as cryptococcal meningitis, is a long course of high dose antifungals. The most commonly administered antifungals are amphotericin B and flucytosine[2]. Other antifungals that can be used are miconazole and fluconazole.
- Increased intracranial pressure is a common finding in fungal meningitis. Therefore, it is recommended to do frequent, ideally daily, lumbar punctures to relieve the intracranial pressure.[1]
Antimicrobial Regimens
Pathogen-directed antimicrobial therapy
The pathogen specific antifungal therapy for fungal meningitis is shown in the table below:[3][4][5]
| ANTIFUNGAL THERAPY IN FUNGAL MENINGITIS | ||
|---|---|---|
| Type of fungal meningitis | Preferred therapy | Alternate therapy |
| Cryptococcus | HIV-infection
(Induction/consolidation):
THEN fluconazole 400 mg/day PO/IV (6 mg/kg/day);
(Maintenance):
Solid organ transplant:
THEN fluconazole 400-800 mg/day PO/IV (6-12 mg/kg/day) for 8 weeks THEN fluconazole 200-400 mg/day for 6-12 months Non-HIV, non-organ transplant:
THEN fluconazole 200 mg/day (3 mg/kg) for 6-12 months |
HIV-infection
(Induction/consolidation):
(Maintenance):
Solid organ transplant:
Non-HIV, non-organ transplant:
|
| Aspergillus |
THEN 4 mg/kg q12h; further conversion to oral therapy may be considered.
|
|
| Candida |
THEN Fluconazole 400-800 mg/day PO/IV (6-12 mg/kg/day)
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| Blastomyces |
THEN Fluconazole 800 mg/day PO/IV
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| Coccidioides |
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| tfExserohilum |
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| Histoplasma |
THEN itraconazole 200 mg BID to TID for at least 1 year and until resolution of CSF abnormalities including Histoplasma antigen levels. |
|
| KEY:
IV, intravenous; PO, per os, oral administration; BID, twice daily; TID, three times daily; QID, four times daily; | ||
References
- ↑ 1.0 1.1 Bicanic T, Harrison TS (2004). "Cryptococcal meningitis". Br Med Bull. 72: 99–118. doi:10.1093/bmb/ldh043. PMID 15838017.
- ↑ Gottfredsson M, Perfect JR (2000). "Fungal meningitis". Seminars in Neurology. 20 (3): 307–22. doi:10.1055/s-2000-9394. PMID 11051295.
- ↑ Bariola JR, Perry P, Pappas PG, Proia L, Shealey W, Wright PW; et al. (2010). "Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era". Clin Infect Dis. 50 (6): 797–804. doi:10.1086/650579. PMID 20166817.
- ↑ Wheat LJ, Musial CE, Jenny-Avital E (2005). "Diagnosis and management of central nervous system histoplasmosis". Clin Infect Dis. 40 (6): 844–52. doi:10.1086/427880. PMID 15736018.
- ↑ Morgand M, Rammaert B, Poirée S, Bougnoux ME, Tran H, Kania R; et al. (2015). "Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole". Antimicrob Agents Chemother. 59 (12): 7857–61. doi:10.1128/AAC.01506-15. PMC 4649149. PMID 26392507.