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Exserohilum rostratum

Interim guidance from the Centers for Disease Control and Prevention (CDC) for treatment of adult patients in the 2012 outbreak of fungal meningitis from contaminated steroid products recommends starting empiric antifungal therapy after collecting CSF for culture. In addition, routine empiric treatment protocols for potential bacterial pathogens should be followed until the etiology of the patient’s infection has been identified.^[4]

For empiric antifungal therapy, the CDC recommends voriconazole, preferably at a dose of 6 mg/kg every 12 hours, continued for the duration of treatment. Serum voriconazole concentrations should be monitored regularly (eg, weekly), with a target trough level of 2-5 mcg/ml.

For patients with more severe disease, voriconazole should be given intravenously. Patients can be transitioned to oral therapy once they achieve clinical stability or demonstrate improvement. Patients with mild disease may be started on oral voriconazole but may require a slightly higher dose and a longer period of time to achieve recommended serum levels.

Potential adverse effects of voriconazole include, but are not limited to, hepatic toxicity and neurotoxicity. In addition, voriconazole has the potential to cause drug interactions.

In patients who present with severe disease or who show deterioration or no improvement on voriconazole, liposomal amphotericin B can be added to the regimen. The CDC recommends using a higher-than-usual dose, 7.5 mg/kg IV daily, although 5 mg/kg can be given if nephrotoxicity is a potential concern (eg, in older patients). Nephrotoxicity risk can be minimized by preceding the amphotericin dose with an infusion of 1 L of normal saline.

Because of limited data, the CDC recommends avoiding routine use of intrathecal amphotericin B. Similarly, no clear evidence currently exists regarding adjuvant steroid therapy in these cases.

Continuing antifungal treatment for at least 3 months should be considered. The adequate duration of therapy is unknown and is likely to vary substantially from patient to patient; consequently, decisions about therapy should be made in consultation with an infectious disease specialist with experience in the treatment of fungal infections. Relapse of infection after completion of therapy is a potential risk.

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