What is the best antifungal treatment for cerebral abscess due to fungal infections?

From the Guidelines

The best antifungal treatment for cerebral abscess due to fungal infections is liposomal amphotericin B at a dosage of 3–5 mg/kg daily, with or without flucytosine at a dosage of 25 mg/kg 4 times daily, as recommended by the Infectious Diseases Society of America 1. This treatment approach is based on the most recent and highest quality evidence available, which prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients with cerebral abscesses due to fungal infections. The use of liposomal amphotericin B is favored due to its decreased risk of nephrotoxicity and higher levels attained in the brain compared to other formulations 1. Flucytosine is added to the treatment regimen because of its in vitro synergism with amphotericin B and excellent CSF concentrations achieved, although its toxic effects on bone marrow and liver must be carefully monitored 1. The treatment duration is typically prolonged, ranging from several weeks to months, depending on clinical and radiological response, and may be followed by step-down therapy with fluconazole 1. Surgical intervention, such as removal of infected devices, is also crucial in the management of cerebral abscesses due to fungal infections, particularly for eradicating the infection and reducing the fungal burden 1. It is essential to note that the choice of antifungal agent should be guided by the specific fungal pathogen identified, as different fungi have varying susceptibilities to different antifungals 1. Adjunctive measures, including management of increased intracranial pressure, seizure prophylaxis, and addressing underlying immunosuppression, are also crucial in improving treatment outcomes. Key points to consider in the treatment of cerebral abscesses due to fungal infections include:

• The importance of prompt and effective antifungal therapy to reduce morbidity and mortality
• The need for surgical intervention to remove infected devices and reduce fungal burden
• The use of liposomal amphotericin B and flucytosine as first-line treatment for Candida infections
• The potential for step-down therapy with fluconazole after initial treatment with liposomal amphotericin B and flucytosine
• The importance of monitoring for toxic effects and adjusting treatment accordingly.

From the Research

Antifungal Treatment Options for Cerebral Abscess

The treatment of cerebral abscess due to fungal infections often involves a combination of surgical intervention and antifungal therapy. Some of the antifungal agents used in the treatment of cerebral abscess include:

• Amphotericin B, which can be administered intravenously or intrathecally 2, 3
• Voriconazole, a newer azole that has been shown to penetrate the blood-cerebrospinal fluid barrier and achieve effective fungicidal concentrations 4
• Posaconazole, which is used in the treatment of mucormycosis 3
• Fluconazole, which can be used in the treatment of candidal infections 5

Treatment Approaches

The treatment approach for cerebral abscess due to fungal infections often involves:

• Surgical intervention, such as radical debridement or drainage of the abscess 2, 6, 5
• Antifungal therapy, which can be administered systemically or locally 2, 3
• Combination therapy, which involves the use of multiple antifungal agents and/or surgical intervention 3, 6

Specific Fungal Infections

The treatment of cerebral abscess due to specific fungal infections, such as:

• Aspergillus, which can be treated with voriconazole or amphotericin B 2, 4
• Mucormycosis, which can be treated with amphotericin B, posaconazole, and surgical resection 3
• Candidal infections, which can be treated with fluconazole or amphotericin B 5