Treatment of Candida auris Epidural Abscess
For Candida auris epidural abscess, initiate an echinocandin (caspofungin 70 mg loading dose then 50 mg daily, anidulafungin 200 mg loading dose then 100 mg daily, or micafungin 100 mg daily) combined with urgent surgical debridement, as echinocandins are the first-line therapy for C. auris infections given its extensive resistance to fluconazole and amphotericin B. 1
Initial Management Approach
Immediate Surgical Intervention
- Obtain urgent surgical consultation for decompression and debridement as soon as epidural abscess is suspected or confirmed, particularly if neurologic dysfunction is present 1
- Surgical debridement should be aggressive and extensive to optimize medical therapy outcomes, as antifungal options are generally less effective than antibiotics for bacterial infections 1
- A posterior approach via laminectomy is typically employed to decompress an epidural abscess, though this should be performed with caution for ventral epidural collections 1
Antifungal Therapy Selection
Primary therapy:
- Echinocandins are the first-line treatment for C. auris due to high susceptibility rates (90% to caspofungin, 98.2% to micafungin, 97.2% to anidulafungin) 1
- Standard echinocandin dosing: caspofungin 70 mg loading dose then 50 mg daily; anidulafungin 200 mg loading dose then 100 mg daily; or micafungin 100 mg daily 1
Alternative therapy:
- Liposomal amphotericin B (5 mg/kg daily) or amphotericin B deoxycholate (1 mg/kg daily) can be considered for persistent infection despite echinocandin treatment, though C. auris shows only 43.1% overall susceptibility to amphotericin B 1, 2, 3
- Fluconazole should NOT be used for C. auris given only 10.7% overall susceptibility 1
Combination therapy considerations:
- Adding flucytosine (25 mg/kg orally four times daily) to amphotericin B may be considered for CNS/epidural involvement, though this is extrapolated from general Candida CNS infection guidelines 1, 4
- Flucytosine must never be used as monotherapy due to rapid emergence of resistance 4
- Therapeutic drug monitoring is essential for flucytosine with target serum levels of 40-60 mg/mL 4
Critical Diagnostic and Monitoring Steps
Essential workup:
- Obtain intraoperative tissue cultures and blood cultures to confirm diagnosis and guide definitive therapy 5
- Perform imaging studies (MRI preferred) promptly when abscess is suspected 1
- Remove any indwelling catheters or devices if present 1
Surveillance during treatment:
- Monitor for clinical improvement including resolution of fever, pain, and neurologic symptoms 1
- Serial imaging may be necessary to ensure adequate source control 1
- Blood cultures should be repeated to document clearance 1
Duration of Therapy
- Continue antifungal therapy for at least 2 weeks after documented clearance from bloodstream (if candidemia present) and resolution of clinical signs 1
- For epidural abscess with adequate surgical drainage, treatment duration may be as short as 3 months when ESR normalizes, though this data is extrapolated from non-auris Candida species 2
- Therapy should continue until all signs, symptoms, and radiological abnormalities have resolved 1
Important Pitfalls and Caveats
Resistance concerns:
- C. auris exhibits extensive antifungal resistance with only 10.7% susceptibility to fluconazole and 43.1% to amphotericin B 1
- Echinocandin resistance can emerge, necessitating susceptibility testing when available 1
Surgical timing:
- Early surgical debridement is critical as delayed intervention correlates with worse neurologic outcomes 1, 5
- The combination of medical and surgical therapy is superior to medical therapy alone for epidural abscess 1, 2
Patient factors:
- FSEA typically occurs in immunocompromised patients with poor baseline health status, contributing to high mortality 5
- Concurrent vertebral osteomyelitis is common (89% in one series) and may require prolonged therapy 5
- Recurrent infection can occur, requiring vigilant follow-up 5