Debate surfaces over preferred treatments for fungal meningitis outbreak

A leading epidemiologist recently suggested alternative treatments for the fungal meningitis outbreak late last year. To date, 46 deaths have been linked to contaminated steroids from compounding pharmacies.

David A. Stevens’ commentary was published online Feb. 5 ahead of print for Antimicrobial Agents and Chemotherapy. Dr. Stevens is professor (emeritus) of medicine, Stanford University Medical School, Stanford, Calif. and chief of the Division of Infectious Diseases and hospital epidemiologist, Santa Clara Valley Medical Center, San Jose, Calif.

Referring to various studies, Stevens says the Centers for Disease Control (CDC) should have recommended prophylactic treatment with oral antifungal drugs for all patients who were exposed to the fungal meningitis. “Each of us will need to consider whether a patient we see who was injected intrathecally with one of the contaminated lots would not be wise to take prophylaxis…after a procedure that has resulted in an impressive proportion of infections, with a high lethality,” Stevens wrote.

At the same time, Stevens noted that the prophylactic treatments only have an attack rate of about 4% so far. However, “extensive studies” document consistent potent activity of itraconazole and the comparable in vitro activity of voriconazole and itraconazole against the fungi in question, according to Stevens. “All three of the azoles [itraconazole, posaconazole, and voriconazole], and amphotericin B are active against Aspergillus fumigatus in vitro…” Stevens wrote.

However, in their opposing commentary, Peter G. Pappas, MD, with the University of Alabama-Birmingham’s Division of Infectious Diseases, and fellow researchers contradict Stevens’ conclusions.

 “In order to ensure good CSF penetration and achieve adequate therapeutic levels, high doses of voriconazole and liposomal AmB have been recommended. Not surprisingly, several clinicians have reported high rates of adverse events,” Pappas wrote.

“Therefore, clinicians must carefully weigh the benefit of treatment of asymptomatic patients with the significant expense associated with drug acquisition, monitoring drug levels and substantial drug-drug interactions,” Pappas added.