Fungal meningitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby


Fungal meningitis, such as cryptococcal meningitis, is treated with long courses of high dose antifungals. In addition, frequent lumbar punctures are recommended in order to relieve the increased intracranial pressure[1].

Medical Therapy

Antimicrobial Regimens

Pathogen-directed antimicrobial therapy

The pathogen specific antifungal therapy for fungal meningitis is shown in the table below:[3][4][5]

Type of fungal meningitis Preferred therapy Alternate therapy
Cryptococcus HIV-infection


THEN fluconazole 400 mg/day PO/IV (6 mg/kg/day);


Solid organ transplant:

THEN fluconazole 400-800 mg/day PO/IV (6-12 mg/kg/day) for 8 weeks THEN fluconazole 200-400 mg/day for 6-12 months

Non-HIV, non-organ transplant:

THEN fluconazole 200 mg/day (3 mg/kg) for 6-12 months




Solid organ transplant:

  • If flucytosine not used, then consider extension of induction with lipid formulations of amphotericin B for at least 4-6 weeks.

Non-HIV, non-organ transplant:


THEN 4 mg/kg q12h; further conversion to oral therapy may be considered.

  • Typical oral dosing is 200 mg q12h but is dependent on therapeutic drug monitoring.
  • Total duration of therapy has not been defined. Multiple factors must be considered, including extent of disease, response to therapy, and underlying immune status of the host.

THEN Fluconazole 400-800 mg/day PO/IV (6-12 mg/kg/day)

  • Treatment continued until clinical signs and symptoms resolved and CNS and radiographic abnormalities have normalized.

THEN Fluconazole 800 mg/day PO/IV

  • Treatment for at least 12 months and until resolution of CSF abnormalities
  • Fluconazole 400 mg/day PO/IV. Some use higher doses of Fluconazole, up to 1,000 mg/day up-front.
  • Azole therapy is typically continued indefinitely.
  • Voriconazole 6 mg/kg IV every 12h with assessment of voriconazole trough concentrations on day 5 of therapy with adjustment to achieve trough of 2-5 mcg/ml.
  • IV therapy should be initiated in most cases with transition to PO therapy once improving and clinically stable.
  • Total duration of therapy is unknown and will depend on extent of infection, response to therapy, and underlying immune status of the host.
  • Minimum duration of 3-6 months.

THEN itraconazole 200 mg BID to TID for at least 1 year and until resolution of CSF abnormalities including Histoplasma antigen levels.


IV, intravenous;

PO, per os, oral administration;

BID, twice daily;

TID, three times daily;

QID, four times daily;


  1. 1.0 1.1 Bicanic T, Harrison TS (2004). "Cryptococcal meningitis". Br Med Bull. 72: 99–118. doi:10.1093/bmb/ldh043. PMID 15838017.
  2. Gottfredsson M, Perfect JR (2000). "Fungal meningitis". Seminars in Neurology. 20 (3): 307–22. doi:10.1055/s-2000-9394. PMID 11051295.
  3. Bariola JR, Perry P, Pappas PG, Proia L, Shealey W, Wright PW; et al. (2010). "Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era". Clin Infect Dis. 50 (6): 797–804. doi:10.1086/650579. PMID 20166817.
  4. Wheat LJ, Musial CE, Jenny-Avital E (2005). "Diagnosis and management of central nervous system histoplasmosis". Clin Infect Dis. 40 (6): 844–52. doi:10.1086/427880. PMID 15736018.
  5. Morgand M, Rammaert B, Poirée S, Bougnoux ME, Tran H, Kania R; et al. (2015). "Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole". Antimicrob Agents Chemother. 59 (12): 7857–61. doi:10.1128/AAC.01506-15. PMC 4649149. PMID 26392507.

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