Announcement

Collapse
No announcement yet.

CDC - Interim Treatment Guidance for Central Nervous System (CNS) and/or Parameningeal Infections Associated with Injection of Potentially Contaminated Steroid Products - October 16, 2012

Collapse
This is a sticky topic.
X
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • CDC - Interim Treatment Guidance for Central Nervous System (CNS) and/or Parameningeal Infections Associated with Injection of Potentially Contaminated Steroid Products - October 16, 2012

    This is an UPDATED VERSION. Please disregard previous.

    Interim Treatment Guidance for Central Nervous System (CNS) and/or Parameningeal Infections Associated with Injection of Potentially Contaminated Steroid Products

    October 16, 2012 11:15 AM EDT
    These recommendations are based upon growing evidence that Exserohilum rostratum (a brown-black mold) is the predominant pathogen in this outbreak, and expert opinion and published literature indicating that voriconazole may be effective in treating infections due to brown-black molds, as well as infections due to Aspergillus species. Recommendations are also based on considerations related to the anatomic site of infection and pharmacokinetics of antifungal agents. CDC continues to consult with national experts on treatment options for fungal CNS and/or parameningeal infections in patients associated with this cluster.
    This is interim guidance for treatment of adult patients with CNS and/or parameningeal infections associated with injections of potentially contaminated steroid products from the New England Compounding Center. Interim guidance may change as new information becomes available.
    • Consult an infectious disease physician to assist with diagnosis, management, and follow–up, which may be complex and prolonged.
    • Initiate empiric antifungal therapy after collecting cerebrospinal fluid for culture using the following regimen in addition to routine empiric treatment protocols to cover for potential bacterial pathogens until the etiology of the patient’s CNS and/or parameningeal infection has been identified:
      • Voriconazole, preferably at a dose of 6 mg/kg every 12 hours<sup>1</sup>
        • Voriconazole should be continued at a dose of 6 mg/kg every 12 hours, whenever possible, for the duration of treatment. This dose is recommended because ensuring adequate penetration of voriconazole into the CNS is critical.
        • Regular monitoring of serum voriconazole concentrations (e.g., at a weekly interval) is recommended, aiming for trough levels of 2-5 mcg/ml.
        • Patients with more severe disease should be started on voriconazole IV.
        • Patients with mild disease may be started on oral voriconazole at the provider’s discretion. The above target serum levels of voriconazole are readily achievable using the oral form but may require a slightly higher dose and make take longer to achieve if unforeseen problems with gastro-intestinal intolerance or poor absorption are encountered.
        • If provider wants to transition patients initially started on IV voriconazole therapy to oral therapy, this should be done only after a patient is clinically stable or improving, as long as no contraindications to oral therapy exist.
        • Providers and patients should be aware of and monitor for potential adverse effects of voriconazole, including (but not limited to) hepatic toxicity and neurotoxicity.
        • Providers should carefully consider and manage the potential for voriconazole drug interactions in all patients.
      • Providers should consider giving liposomal amphotericin B in addition to voriconazole to patients who present with severe disease, and patients started initially on voriconazole monotherapy who do not improve or who experience clinical deterioration.
        • When used, liposomal amphotericin B should preferably be given at a dose of 7.5 mg/kg IV daily (higher than standard dose). The liposomal preparation of amphotericin B [AmBisome] is preferred over other lipid formulations because of better CNS penetration. If nephrotoxicity is a potential concern, particularly in older patients, the dose may be decreased to 5 mg/kg IV daily. Administration of 1L normal saline prior to infusion may be considered to minimize risk of nephrotoxicity. Providers and patients should be aware of and monitor for potential adverse effects of amphotericin B.
        • Avoid routine use of intrathecal amphotericin B, either the deoxycholate or the lipid formulations, due to limited data on its use and associated toxicities.
        • There is currently no clear evidence for the use of adjuvant steroid therapy.


    • Adequate duration of antifungal treatment is unknown, but patients likely will require prolonged therapy tailored by the clinical response to treatment. Individual management decisions, including choice of long-term antifungal regimen, should be made in consultation with infectious diseases physicians experienced in the treatment of fungal infections. Although the adequate duration of therapy is unknown and will likely vary substantially depending upon individual patient circumstances, a minimum of 3 months of antifungal treatment should be considered. Treatment will likely need to continue for longer than 3 months in patients with more severe disease, bone infection, underlying immunosuppression, etc. Clinicians should be vigilant for potential relapse of infection after completion of therapy.
    • Consideration should be given to obtaining spine imaging studies in patients in whom vertebral osteomyelitis/discitis or epidural abscess are concerns. These complications will prolong the duration of therapy.
    • At this time, CDC does not recommend empiric antifungal therapy for symptomatic patients who have normal cerebrospinal fluid laboratory examination. These patients should be closely monitored and re-evaluated for progression of symptoms. Should the patient have progression of symptoms, a lumbar puncture should be repeated immediately, using a different site than was used for the epidural injection when possible.

    For additional information on antifungal drugs


    <sup>1</sup>Dose adjustments may be needed for certain patients, including (but not necessarily limited to): children, for patients < 40 kg, and patients with hepatic impairment. Oral voriconazole should be taken at least one hour before or after a meal. Consult an infectious diseases specialist and refer to the manufacturer’s instructions.


    Contact Us:

    • Centers for Disease Control and Prevention
      1600 Clifton Rd
      Atlanta, GA 30333
    • 800-CDC-INFO
      (800-232-4636)
      TTY: (888) 232-6348
    • New Hours of Operation
      8am-8pm ET/Monday-Friday
      Closed Holidays
    • cdcinfo@cdc.gov





  • #2
    Re: CDC - Interim Treatment Guidance for Central Nervous System (CNS) and/or Parameningeal Infections Associated with Injection of Potentially Contaminated Steroid Products - October 16, 2012

    This is an updated version referred to in the CDC HAN dated Oct. 23rd (see thread here).

    Multistate Fungal Meningitis Outbreak Investigation

    Interim Treatment Guidance for Central Nervous System (CNS) and Parameningeal Infections Associated with Injection of Contaminated Steroid Products

    October 23, 2012 9:00 PM EDT

    Rationale:

    This is interim guidance for treatment of adult patients with CNS infections (including meningitis *1) and/or parameningeal infections associated with injections of contaminated steroid products from the New England Compounding Center. Interim guidance may change as new information becomes available.

    These recommendations are based upon growing evidence that Exserohilum rostratum (a brown-black mold) is the predominant pathogen in this outbreak, and expert opinion and published literature indicating that voriconazole may be effective in treating infections due to brown-black molds as well as infections due to Aspergillus species. Recommendations are also based on considerations related to the anatomic site of infection and pharmacokinetics of antifungal agents. CDC continues to consult with national experts about treatment options for fungal CNS and parameningeal infections in patients associated with this outbreak.


    Infectious Diseases Physician Consultation:
    • Consult an infectious diseases physician to assist with patient diagnosis, management, and follow-up, which may be complex and prolonged.



    Diagnostic Considerations:


    • Note that a negative fungal culture or negative fungal polymerase chain reaction (PCR) test from a diagnostic specimen obtained from a CNS or parameningeal site does not rule out infection. Active fungal infection may be present even when these tests are negative.
    • Because some patients who have fungal meningitis may also have or may develop epidural abscess, discitis, or vertebral osteomyelitis, usually heralded by persistent back pain, consideration should be given to obtaining spine imaging of the area that is painful. These types of complications will likely prolong therapy and may also require surgical intervention.



    Empiric Antifungal Therapy:
    • Initiate empiric antifungal therapy (after collecting cerebrospinal fluid for culture) using the following regimen, in addition to routine empiric treatment protocols for other pathogens, until the etiology of the patient’s CNS and/or parameningeal infection has been identified.
    • Providers should give voriconazole, preferably at a dose of 6 milligrams per kilogram (mg/kg) every 12 hours *2. This dose is recommended because ensuring adequate penetration of voriconazole into the CNS is critical.
    • A blood specimen for serum voriconazole trough level measurement should be collected on the 5th day of voriconazole treatment, and the dose of voriconazole should be adjusted based on this trough level, aiming for a trough level range of 2 to 5 micrograms per milliliter (mcg/ml). Serum voriconazole trough levels greater than 5 mcg/ml should be avoided because of the risk of neurotoxicity and other drug-related adverse events.
    • Regular monitoring of serum voriconazole trough levels once per week should occur for the initial 4-6 weeks of voriconazole treatment and when dose adjustments are made. Dose adjustments should be made as needed to maintain serum voriconazole trough levels within the range of 2 to 5 mcg/ml.
    • In most cases it is suggested that patients should be started on intravenous (IV) voriconazole. If the provider wants to transition patients initially treated with IV voriconazole to oral voriconazole, this should be done only after a patient is clinically stable or improving, as long as no contraindications to oral therapy exist.
    • Although it is recommended that most patients with CNS or parameningeal infections be started on IV voriconazole, patients with mild disease who are able to take oral voriconazole as prescribed and who are able to be monitored closely may be started on oral voriconazole at the provider’s discretion. Patients on oral voriconazole should be treated with a dose of 6 mg/kg every 12 hours, with monitoring of serum voriconazole trough levels as above and dose adjustment as necessary. The target range for serum voriconazole trough levels (2 to 5 mcg/ml) is readily achievable using the oral form of the drug, but may require a slightly higher dose and may take longer to achieve if unforeseen problems with gastrointestinal intolerance or poor absorption are encountered.
    • Providers and patients should be aware of and monitor for potential adverse effects of voriconazole, including (but not limited to) hepatic toxicity and neurotoxicity. Liver function tests should be closely monitored. The occurrence of hallucinations may be an indication of neurotoxicity and elevated serum voriconazole levels, and should prompt collection of a blood specimen for serum voriconazole trough level measurement and voriconazole dose adjustment.
    • Providers should carefully consider and manage the potential for voriconazole drug interactions in all patients.

    • Providers should consider giving liposomal amphotericin B in addition to voriconazole to patients who present with severe disease, and patients started initially on voriconazole monotherapy who do not improve or who experience clinical deterioration. Liposomal amphotericin B may also be considered as an alternative to voriconazole in patients who are unable to tolerate voriconazole.


    • When used, liposomal amphotericin B should be given at a dose of 5 to 6 mg/kg IV daily. The liposomal preparation of amphotericin B [AmBisome®] is preferred over other lipid formulations because of better CNS penetration. Nephrotoxicity is a common complication of amphotericin B therapy, including therapy with lipid formulations of amphotericin B. Kidney function and electrolytes should be monitored closely in patients receiving any amphotericin B formulation. Administration of 1 liter of normal saline IV prior to amphotericin B infusion may be considered to minimize risk of nephrotoxicity. Providers and patients should also be aware of and monitor for other potential adverse effects of amphotericin B formulations.
    • Higher doses of liposomal amphotericin B (7.5 mg/kg IV daily) may be considered for patients who are not improving, recognizing the potential for increased nephrotoxicity on this higher dose.
    • Avoid the routine use of intrathecal amphotericin B formulations, due to limited data on their use and associated toxicities.



    Considerations Regarding Duration of Antifungal Treatment:

    • Adequate duration of antifungal treatment is unknown, and patients likely will require prolonged therapy tailored by the clinical response to treatment. Individual patient management decisions, including choice of long-term antifungal treatment regimens, should be made in consultation with infectious diseases physicians experienced in the treatment of fungal infections. While adequate duration of therapy is unknown and will likely vary substantially depending upon individual patient circumstances, a minimum of 3 months of antifungal treatment should be considered. Treatment will likely need to continue for longer than 3 months in patients with more severe disease, bone infection, underlying immunosuppression, etc. Clinicians should be vigilant for potential relapse of infection after completion of therapy.



Empiric Antifungal Therapy for Symptomatic Patients with 5 or Fewer CSF White Blood Cells (WBC):
  • At this time, CDC does not recommend empiric antifungal therapy for symptomatic patients who have 5 or fewer WBC in the CSF at the time of diagnostic lumbar puncture. These patients should be closely monitored and re-evaluated for persistent symptoms. Should the patient have persistence of symptoms, a lumbar puncture should be repeated, using a different site than was used for the epidural injection when possible (recommended for any lumbar puncture when evaluating patients associated with this outbreak).


*1 Symptoms consistent with meningitis in addition to CSF WBC greater than 5 in a non-traumatic lumbar puncture. If a traumatic lumbar puncture is suspected, a corrected CSF WBC count can be calculated by subtracting one WBC for every 500 RBCs present in the CSF.

*2 Dose adjustments may be needed for certain patients, including (but not necessarily limited to): children (who often need a higher dose) and patients with hepatic impairment (who may need a lower dose). Dosing of voriconazole in obese patients should be discussed with an infectious diseases physician. Oral voriconazole should be taken at least one hour before or after a meal. Consult an infectious diseases specialist and refer to the manufacturer’s instructions.

For additional information on antifungal drugs:



"What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it." - Herbert Simon

"The benefits of education and of useful knowledge, generally diffused through a community, are essential to the preservation of a free government." - Sam Houston

Comment

    Working...
    X