(523) Intrathecal Caspofungin: A Last Resort Therapy for Resistant Candida auris Ventriculitis

Introduction: Candida auris (C. auris) is an emerging, prevalent, and invasive fungal species that is highly resistant to typical treatment modalities. Drug resistance is multifactorial in part due to its genetic coding, and also due to ability to form biofilms. The global mortality from C. Auris fungemia is roughly 30-60%. We will describe the challenges and successful management of a patient with a multi-drug resistant (MDR) C. auris CNS shunt infection

Description: A 54-year-old male presented to ICU for encephalopathy secondary to hemorrhagic necrotizing pancreatitis. His course was complicated by an infected retroperitoneal hematoma with septic shock requiring an exploratory laparotomy and VRE ventriculitis requiring ventriculo-atrial (VA) shunt. His ICU course got further complicated by C. auris fungemia. Likely, Candida auris spread to CSF via VA shunt. VA shunt was removed and extraventricular drain (EVD) was placed. Systemic voriconzaole and flucytosine failed to clear C.auris in CSF. C. auris is a known MDR organism, and this strain had variable susceptibilities which isn’t atypical for C. auris as it has several variants. The strain in our patient was resistant to amphotericin B and azoles. It was susceptible to echinocandins, with micafungin or caspofungin being the ID recommendation for treatment. However, echinocandins do not cross the blood brain barrier. Between the pharmacist and intensive care team, a recommendation of the use of intrathecal caspofungin as a few case reports have discussed the successful use of intrathecal caspofungin for C. auris ventriculitis. Through the EVD, caspofungin was instilled intrathecally and surveillance cultures were drawn for monitoring clearance. Patient improved clinically and CSF cultures cleared post therapy

Discussion: Our patent developed a C. auris fungemia secondary to an intra-abdominal source that resulted in migration through his ventriculo-atrial shunt leading to ventriculitis. The shunt was externalized to an EVD. MDR C Auris in ventricular space further complicated the management in this patient. Intrathecal caspofungin via EVD was successful in treating our patient. Individual case reports can be a valuable tool for providing new insights and earlier approach to treatment modalities