Intrathecal Baclofen Pump Refill in Fungemia
An intrathecal baclofen pump should NOT be refilled in a patient with active fungemia until the infection is cleared, as fungal catheter-related bloodstream infections require device removal and antifungal therapy according to IDSA guidelines. 1
Primary Management Algorithm
Immediate Actions Required
Remove the intrathecal pump system entirely when fungemia is documented, as all prospective studies demonstrate that catheter retention with Candida infections worsens outcomes 1, 2, 3
Initiate systemic antifungal therapy immediately for all cases of catheter-related fungemia, even if clinical symptoms resolve after device removal 1, 2
Do NOT attempt pump refill or salvage during active fungemia, as salvage rates for fungal infections with systemic therapy and antibiotic lock techniques are only approximately 30%, making routine salvage not recommended 1
Preventing Baclofen Withdrawal Crisis
The critical concern is avoiding intrathecal baclofen withdrawal syndrome, which can be catastrophic and life-threatening, typically evolving over 1-3 days 1
Bridging strategy while managing fungemia:
Externalize the existing pump after removal by reconnecting it to a new or existing lumbar drain, allowing continued intrathecal baclofen administration while treating the fungal infection 4
Titrate intrathecal dose down by 20-50% per day based on clinical response over approximately 6 days while transitioning to alternative management 4
Administer high-dose intravenous benzodiazepines or oral baclofen as supportive measures if immediate intrathecal resumption is not possible, though acute withdrawal may still occur with oral baclofen 1
Antifungal Treatment Specifications
For hemodynamically stable patients: Fluconazole 400 mg daily is appropriate for azole-susceptible Candida species 1, 2
For azole-resistant species (C. krusei, C. glabrata): Use echinocandins (caspofungin 70 mg loading then 50 mg daily, micafungin 100 mg daily, or anidulafungin 200 mg loading then 100 mg daily) or lipid formulations of amphotericin B (3-5 mg/kg daily) 1, 3
Duration: Continue antifungal therapy for 14 days after the last positive blood culture and resolution of symptoms 1, 2
Timing of Pump Replacement
Wait for documented clearance with negative blood cultures for at least 14 days after completing antifungal therapy before considering new pump implantation 1, 2
Obtain repeat blood cultures to confirm eradication before any new device placement 1, 5
Critical Pitfalls to Avoid
Never refill the pump during active fungemia, as this maintains the infected foreign body and perpetuates the bloodstream infection 1
Do not delay pump removal in fungal infections, as this is associated with persistent candidemia, septic thrombophlebitis, and endocarditis 1
Do not use fluconazole for C. krusei, which has intrinsic resistance to azoles 3
Do not underestimate baclofen withdrawal risk, as it can occur even at doses as low as 260 μg/day and may be fulminant if not recognized 1, 4