The efficacy of voriconazole in the treatment of 192 fungal central nervous system infections: a retrospective analysis

Abstract

The efficacy of voriconazole against fungal central nervous system (CNS) infections was examined retrospectively. Voriconazole-treated patients with proven (137) or probable (55) CNS infections were identified in the voriconazole database (114) and the literature (78). Investigator-determined success was a complete or partial response. Survival was calculated from the start of voriconazole therapy. The patients' age range was <1-81years (median 43) and 127 (66%) were male. Aspergillus spp. (63%) and Scedosporium spp. (18%) predominated, but 12 other genera were recorded. Underlying conditions were haematopoietic stem cell transplantation (HSCT, 35), haematologic malignancy (HM, 35), solid-organ transplantation (SOT, 25), chronic immunosuppression (CI, 40) and other conditions (OC, 57). The median voriconazole therapy duration was 93days (range 1-1,128), with success in 93 patients (48%). Only 35 patients received primary therapy, with success in 63% versus 45% for salvage (p=0.06 NS). Underlying conditions influenced success; HSCT 14%, HM 54%, SOT 40%, CI 45% and OC 72% (p<0.001). Additional antifungal combination therapy (37 patients) gave a trend towards an improved response rate (p=0.09) and superior survival (p=0.0149), while patients receiving neurosurgical interventions (72) showed superior responses (p=0.0174) and survival (p=0.0399). In all, 49% of patients died, 71% (67/94) due to fungal infection. The overall median survival was 297days (range 3 to >2,000). Paediatric (p=0.014) and literature patients (p<0.001) exhibited superior survival compared with adults and voriconazole database patients, respectively. Voriconazole shows encouraging efficacy against various CNS fungal infections. Combination therapy and/or CNS surgery may improve outcomes.