P-1746. Use of Intrathecal Amphotericin for Coccidioidal Meningitis

TL;DR

This study examines whether intrathecal amphotericin improves survival in patients with coccidioidal meningitis, finding that its use is linked to higher mortality rates.

Contribution

The study provides new insights into the association between intrathecal amphotericin use and mortality in coccidioidal meningitis patients in the azole therapy era.

Findings

Patients receiving intrathecal amphotericin had a higher five-year mortality rate (26.7%) compared to non-receivers (6.7%).

Intrathecal amphotericin use was significantly associated with increased mortality in a Cox regression model.

Older age and corticosteroid use were also significant predictors of mortality.

Abstract

Cases of coccidioidomycosis are increasing dramatically in the U.S. The utility of intrathecal (IT) amphotericin in treating coccidioidal meningitis (CM) in the era of azole therapy is unknown. We sought to understand how IT therapy is associated with mortality.1A:Patients Receiving IT Amphotericin, by Quarter, From Time of Diagnosis1B:Patients NOT Receiving IT Amphotericin, By Quarter, from Time of Diagnosis

Patients Receiving IT Amphotericin, by Quarter, From Time of Diagnosis

Patients NOT Receiving IT Amphotericin, By Quarter, from Time of Diagnosis

We conducted a retrospective chart review of adult patients with laboratory-proven CM seen at Stanford Hospital and Clinics by an Infectious Diseases physician from 2008-2023.Table 1:Baseline demographics and CM treatmentsTable 2:Cox Proportional Hazard Model for Mortality

Baseline demographics and CM treatments

Cox Proportional Hazard Model for Mortality

57 patients met inclusion criteria. All patients received azole therapy. Twenty-seven of those patients (47.4%) additionally received IT amphotericin. Patients receiving IT therapy had higher rates of IV amphotericin use (88.9% vs. 56.7%, p = 0.02) and corticosteroid use (51.9% vs. 26.7%, p = 0.09), and higher median therapeutic switches per year (0.84 vs. 0.44, p = 0.01). An unadjusted Kaplan-Meier curve demonstrated a five-year mortality rate of 26.7% in the IT amphotericin group, compared to 6.7% in non-receiver group, p = 0.28. A Cox regression revealed that older age at diagnosis (HR 1.07, 95% CI 1.03-1.11), receipt of IT amphotericin (HR 13.9, 95% CI 1.93-100.48), and corticosteroid use (HR 8.3, 95% CI 1.92-35.4) were significantly associated with mortality, with a significant interaction between IT amphotericin and corticosteroids (interaction HR 0.14, 95% CI 0.02-0.97).

Patients who received IT amphotericin had higher mortality rates than those who did not, likely reflecting disease refractory to treatment. More therapies are needed for those who have disease progression on azole therapy.

All Authors: No reported disclosures

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