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CNS 1.14 Candida meningitis

Content version
U-287.2
Updated
10/20/2025 - 12:44

Recommendations

≥ 18 years

Indications: meningitis with Candida spp.
Dosage Remarks
1st choice
liposomal amphotericin B (Ambisome) iv 3 mg/kg once daily

+

flucytosine iv 25 mg/kg 4 times daily

Please contact the microbiologist/infectious diseases physician

Duration: based on discussion in the mycology MDT

TDM is required for flucytosine: TDM monograph flucytosine: Flucytosine (5-FC) (tdm-monografie.org)
2nd choice
fluconazole iv 800 mg once daily

For toxicity and proven susceptibility to fluconazole.

Fluconazole — if candidemia is present, also add an echinocandin; see also MYC1.1 candidemia.

In renal impairment: dose adjustment in consultation with the pharmacist.

Duration: based on discussion in the mycology MDT.
≥ 18 years

Indications: step-down treatment for Candida meningitis
Dosage Remarks
1st choice
fluconazole iv loading dose 800 mg, then 400 mg once daily

Indication: step-down treatment, see*

Duration: based on discussion in the mycology MDT
1st choice alternative
voriconazole iv loading dose 6 mg/kg, then 4 mg/kg twice daily

For fluconazole resistance guided by susceptibility testing

 

Duration: based on discussion in the mycology MDT

Comments

Flucytosine:

  • TDM monograph flucytosine: Flucytosine (5-FC) (tdm-monografie.org)
  • Flucytosine is contraindicated in patients with dihydropyrimidine dehydrogenase (DPD) deficiency. However, pre-testing is not necessary given the rarity of this deficiency.

 

* After ≥5 days of echinocandin therapy and in clinically improved, haemodynamically stabilised patients, with negative follow-up blood cultures and documented susceptibility. This does not apply to C. glabrata, C. krusei, or to patients with Candida endocarditis, intravascular candidiasis, non-removed central venous lines, or prosthesis-associated candidiasis.