TREATMENT OF FUNGAL VENTRICULITIS WITH INTRAVENTRICULAR AMPHOTERICIN B IN A NEONATE.

Skelly, C.

TREATMENT OF FUNGAL VENTRICULITIS WITH INTRAVENTRICULAR AMPHOTERICIN B IN A NEONATE.

All Authors

Skelly, C.

LTHT Author

Skelly, Chloe

LTHT Department

Medicines Management & Pharmacy Services
Paediatric Pharmacy

Non Medic

Specialist Clinical Pharmacist

Publication Date

2025

Item Type

Conference Abstract

Abstract

Aim To treat invasive fungal ventriculitis in a pre-term infant with the use of intraventricular amphotericin B (Fungizone?). Background Our neonatal patient was born at a gestational age (GA) of 23+3. At a corrected gestational age (CGA) of 34+1 the patient was found to have Candida growth from a neck wound, penile and ear swabs. The patient had a history of ventriculitis, ventricular dilatation and cystic lesions within the brain. An MRI indicated that the lesions could be caused by Candida infection and the patient was started on fluconazole infusion at a dose of 12 mg/kg once daily. After one week, a cranial ultrasound scan (CrUSS) showed increasing ventricular dilatation and fluconazole was switched to intravenous liposomal amphotericin B (Ambisome?) at a dose of 5 mg/kg once daily. Candida antigen test was positive at >500 pg/mL suggesting systemic infection and the cerebrospinal fluid was positive for Candida albicans sensitive to fluconazole and Ambisome?. On microbiology recommendation IV fluconazole was added, to continue for 4 weeks after the last positive CSF culture followed by a repeat MRI. This showed some improvement in parenchymal lesions but also new lesions and ongoing obstruction within ventricles. The case was discussed at MDT and the decision was made to commence intraventricular Amphotericin B via the ventricular access device (VAD). This was submitted to the Drug and Therapeutics group and approved. Administration Fungizone? was chosen as the preferred formulation for intraventricular therapy based on adult studies and other limited use in older children. We sought advice about dosing and administration from another hospital that had given Fungizone ? via the intraventricular route in an older child and they shared data with us. The literature was reviewed by the pharmacy infection team, neurosurgical team and microbiology to establish a safe starting dose that would be increased incrementally up to the maximum tolerated dose. Treatment was started at 0.01 mg on day 1, increasing to 0.03 mg on day 3, 0.06 mg on day 5, then up to 0.1 mg on day 7.1 2 Treatment was continued at 0.1 mg every other day to assess tolerance and then gradually increased up to maximum of 0.5 mg every other day. The maximum concentration found within the literature was 0.25 mg/mL so we initially diluted volumes in 1 mL.2 The volume within the VAD is approximately 0.5 mL, therefore, a 1 mL volume would flush through the VAD and into the ventricles. This volume was discussed with neurosurgeons and deemed acceptable based on expected intraventricular space within a neonate. At higher doses, we used a 2 mL volume so as not to exceed 0.25 mg/ mL concentration. Outcome The patient tolerated therapy well. Anticipated side effects from the literature are nausea/vomiting and headache.1 The patient remained comfortable throughout therapy and did not show signs of pain or distress based on neonatal pain scoring systems. Unfortunately, while subsequent MRI scans do not show progression of disease and CSF cultures remain negative, cystic lesions remain. An MDT decision was made to stop therapy after 3 months.