P-1746. Use of Intrathecal Amphotericin for Coccidioidal Meningitis

Abstract Background Cases of coccidioidomycosis are increasing dramatically in the U.S. The utility of intrathecal (IT) amphotericin in treating coccidioidal meningitis (CM) in the era of azole therapy is unknown. We sought to understand how IT therapy is associated with mortality.1A:Patients Receiving IT Amphotericin, by Quarter, From Time of Diagnosis1B:Patients NOT Receiving IT Amphotericin, By Quarter, from Time of Diagnosis Methods We conducted a retrospective chart review of adult patients with laboratory-proven CM seen at Stanford Hospital and Clinics by an Infectious Diseases physician from 2008-2023.Table 1:Baseline demographics and CM treatmentsTable 2:Cox Proportional Hazard Model for Mortality Results 57 patients met inclusion criteria. All patients received azole therapy. Twenty-seven of those patients (47.4%) additionally received IT amphotericin. Patients receiving IT therapy had higher rates of IV amphotericin use (88.9% vs. 56.7%, p = 0.02) and corticosteroid use (51.9% vs. 26.7%, p = 0.09), and higher median therapeutic switches per year (0.84 vs. 0.44, p = 0.01). An unadjusted Kaplan-Meier curve demonstrated a five-year mortality rate of 26.7% in the IT amphotericin group, compared to 6.7% in non-receiver group, p = 0.28. A Cox regression revealed that older age at diagnosis (HR 1.07, 95% CI 1.03-1.11), receipt of IT amphotericin (HR 13.9, 95% CI 1.93-100.48), and corticosteroid use (HR 8.3, 95% CI 1.92-35.4) were significantly associated with mortality, with a significant interaction between IT amphotericin and corticosteroids (interaction HR 0.14, 95% CI 0.02-0.97). Conclusion Patients who received IT amphotericin had higher mortality rates than those who did not, likely reflecting disease refractory to treatment. More therapies are needed for those who have disease progression on azole therapy. Disclosures All Authors: No reported disclosures