One of the major questions is what to do about patients who have been exposed to the contaminated steroid products but show no or only mild symptoms.
"Before administering preventive therapy, we must consider the potential adverse effects of both diagnostic evaluation and antifungal therapy," Shoham and Marr wrote, because both lumbar puncture and the current preferred drug regimens—voriconazol and amphotericin B—have numerous side effects, cross reactions with other drugs and over-the-counter products, and adverse reactions.
"While caring for patients potentially exposed to contaminated medication, we have seen symptomatic complications due to lumbar puncture, including symptoms related to changes in intracranial pressure and cerebrospinal fluid leaks," the wrote.
"The question has been asked, 'why don't we just give an antifungal to everybody that's been exposed, because this is such a catastrophic infection,'" Shoham says. "So we talk about the risks of the anti-fungal drugs that we have. Some of the 14,000 people exposed will never get an infection at all, maybe 98%. But about 2% have."
Shoham adds that the drug that seems most effective so far, voriconazol, "is a wonderful, wonderful drug that has saved many lives. And I've seen it save lives myself. However, it is a drug with substantial drug-drug interactions, and anytime anyone is prescribing it they must first look at everything the patient has been taking, even herbal medications and over-the-counter drugs they may pick up in non-traditional locations."