Posaconazole vs. fluconazole or itraconazole prophylaxis in patients with neutropenia

Posaconazole effectiveness in rare invasive fungal infections: A systematic literature review

INTRODUCTION

Mucormycosis, hyalohyphomycosis, chromoblastomycosis, and fungal mycetoma are rare invasive fungal infections (IFIs) that cause significant morbidity and mortality in immunocompromised patients. Few effective treatment options are available for these IFIs.

METHODS

We performed a systematic literature review of MEDLINE and Embase to identify studies published from 2005 (year of posaconazole approval) to 22 October 2022, reporting the efficacy/effectiveness of posaconazole monotherapy or combination therapy for treating mucormycosis, hyalohyphomycosis, chromoblastomycosis, and mycetoma. Positive outcomes or positive clinical outcomes were defined as reporting of a positive efficacy/effectiveness measure (i.e. no relapse, response, cure, radiological improvement, clinical/symptom improvement, or survived therapy).

RESULTS

Of 3207 articles identified (after removing duplicates), 533 articles (mostly case reports) were included. Positive clinical outcomes with posaconazole therapy were observed in most patients with mucormycosis (74.8%, 1197/1601), hyalohyphomycosis (58.5%, 62/106), chromoblastomycosis (90.5%, 19/21), and mycetoma (100%, 5/5). Overall survival was around 70% or greater across the IFIs examined. Positive response was higher in second-line monotherapy than first-line monotherapy in mucormycosis and chromoblastomycosis. Higher mortality was observed with combination therapy than monotherapy in mucormycosis and hyalohyphomycosis infections (except for first-line use in mucormycosis). Positive clinical outcome was 78.6% and overall survival was 78.6% in 323 coronavirus disease-associated mucormycosis infection cases.

CONCLUSIONS

Despite the rarity of these IFIs, substantial data have been published since posaconazole was initially approved in 2005, and the real-world case reports demonstrate that posaconazole is an effective therapeutic option alone or in combination for the treatment of these rare IFIs.

Safety run-in and part 1 of GIMEMA AML1718: venetoclax combined with FLAI as induction treatment in non-low-risk AML

ABSTRACT

The standard induction treatment for acute myeloid leukemia (AML) has limited efficacy for patients with non-low-risk AML. We conducted a multicenter study phase 1b/2, Gruppo Italiano Malattie EMatologiche dell'Adulto AML1718, to investigate the safety and efficacy of venetoclax (VEN) combined with fludarabine, cytarabine, and idarubicin (V-FLAI) as an induction therapy for patients with non-low-risk AML aged <65 years and at intermediate or high European LeukemiaNet risk. After a safety run-in, patients were randomly allocated to VEN 400 mg or VEN 600 mg cohorts. The primary objectives were safety and composite complete remission (bone marrow blasts of <5% with any recovery). We report a predefined interim analysis after 57 patients. Median exposure to VEN during induction was 22 days. Effectiveness and safety were similar between VEN 400 mg and VEN 600 mg cohorts. The 60-day mortality rate was 5.8%. Prolonged aplasia was observed in patients receiving high doses of cytarabine during consolidation. Composite CR was achieved in 84% of patients. With a median follow-up of 20.6 months, 1-year overall survival was 71%, 1-year disease-free survival was 66.2%, and 1-year cumulative incidence of relapse was 24%. V-FLAI is an effective induction therapy for young and fit patients. Fifty-five more patients will be enrolled in part 2; they will receive VEN 400 mg + FLAI as predefined and will be evaluated centrally for measurable residual disease. This trial was registered at www.clinicaltrials.gov as #NCT03455504.

Simultaneous determination of busulfan, fludarabine, phenytoin, and posaconazole in plasma from patients undergoing hematopoietic stem cell transplantation

A simple, fast, sample-saving, and sensitive liquid chromatography-tandem mass spectrometry method was established with a linear range adjusted by in-source collision-induced dissociation. Notably, this could simultaneously determine busulfan, fludarabine, phenytoin, and posaconazole in plasma from children, each having unique physical and chemical properties. The procedure necessitated only 20 μL of plasma and involved a simple protein precipitation process. Chromatographic separation was accomplished on a reversed-phase column (C18, 50 × 2.1 mm, 2.6 μm) through gradient elution utilizing water (containing 0.1 % formic acid and 2 mM ammonium acetate) and acetonitrile (containing 0.1 % formic acid) as the mobile phase. An injection volume of 2 μL was utilized, with a total run time of 3.6 min. Mass spectrum acquisition was performed on a Triple Quad™ 4500MD tandem mass spectrometer with an electrospray ionization source in positive mode. Moreover, in-source collision-induced dissociation was used to adjust the linear range of phenytoin due to its excessive response. The calibration curves ranged from 20 to 2560 ng/mL for busulfan, 10-1280 ng/mL for fludarabine, 0.4-51.2 μg/mL for phenytoin, and 0.1-12.8 μg/mL for posaconazole, with mean r2 greater than 0.997. In addition, the method underwent rigorous validation following the European Medicines Agency guidelines, demonstrating exceptional accuracy (90.5 %-106.7 %) and precision (2.0 %-13.0 %). Furthermore, its applicability to atypical matrices, including hemolytic and hyperlipidemic plasma, was thoroughly assessed. As such, this approach was effectively utilized for the therapeutic drug monitoring of busulfan, fludarabine, phenytoin, and posaconazole for children undergoing hematopoietic stem cell transplantation.

Ratifying the efficacy and safety of intensive induction chemotherapy for acute myeloid leukaemia by the Australasian Leukaemia & Lymphoma Group consensus approach

BACKGROUND

After pharmaceutical benefits scheme approval of midostaurin for fms-like tyrosine kinase 3 (FLT3)-mutated acute myeloid leukaemia (AML) in 2018, the Australasian Leukaemia & Lymphoma Group (ALLG) proposed a consensus approach to AML induction with 7+3 chemotherapy (7 days of infusional cytarabine with three doses of anthracycline) to align with future clinical trial protocols.

AIMS

To determine the efficacy and safety of idarubicin-based 7+3 induction ± midostaurin (per ALLG recommendations) in a real-world, tertiary hospital setting.

METHODS

Data were prospectively collected for all patients assessed for front-line AML treatment. Disease risk and response assessments were defined by European LeukaemiaNet 2017 guidelines. Efficacy and safety endpoints included complete remission (CR) rates, composite CR rates, event-free survival (EFS), overall survival (OS), induction mortality, duration of cytopenias and intensive care unit (ICU) utilisation. Analysis was planned following completion of ≥50 inductions and 5-year aggregated experience.

RESULTS

Between 2018 and 2023, 58 patients (median age 49 years) received 7+3 induction with CR and induction mortality rates of 88% (95% confidence interval (95% CI): 77-95%) and 1.7% (95% CI: 0-9%) respectively. At a median of 24.6 months of follow-up, median OS was 17.6 months for adverse-risk versus not reached for non-adverse-risk patients (P = 0.03). FLT3-mutated patients demonstrated an 89% CR rate (95% CI: 67%-99%) with comparable 4-year EFS (65%) and OS (68%) to FLT3-wild-type patients. Safety across 58 induction and 139 consolidation cycles was acceptable, with a single death and a 21% ICU admission rate (95% CI: 11%-33%) during induction.

CONCLUSIONS

Idarubicin-based 7+3 induction with contemporary supportive care yields good safety and CR rates, including in midostaurin-treated FLT3-mutated patients. Survival outcomes for adverse-risk AML patients remain suboptimal.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

[Management of febrile neutropenia]

Febrile neutropenia is a medical emergency requiring rapid and rigorous management considering the risk of severe infection. Febrile neutropenia is a frequent complication in patients receiving chemotherapy. Initial assessment is vital in order to decide the follow-up (outpatient treatment, conventional care or intensive care unit) and to initiate adapted antibiotic therapy as soon as possible. Depending on the infectious syndrome (clinically documented, microbiologically documented or undocumented), antibiotic therapy should be adapted or discontinued, considering the recovery from aplasia and absence of fever. Antifungal agents are not systematically used and its use should be discussed according to the context. G-CSF should be used prophylactically, and is not an adjunct to antibiotic therapy for febrile neutropenia. Granulocyte transfusions are exceptionnally indicated and its use should be discussed on a case-by-case basis. Standard precautions are adequate for the majority of patients, with the exception of specific situations.

Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation

With the aim to reduce the incidence of invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the ECIL group recommends the use of drugs active against molds such as posaconazole instead of fluconazole in high-risk (HR) IFI patients. But data to support this recommendation are poor. The aim of this monocentric study was to compare retrospectively the use of fluconazole (n = 96) vs. posaconazole (n = 63), as primary antifungal prophylaxis within the first 90 days (D) post-transplant in a cohort of patients at HR-IFI (n = 159). HR-IFI was defined by the use of an alternative donor, post-transplant cyclophosphamide and/or sequential conditioning regimen, and/or an active disease at transplant or a previous allo-HSCT. Incidences of D90, 6-month, 1-year and 2-year CI of IFI as well as D90 primary prophylaxis failure (IFI resulting in the initiation of a curative antifungal therapy or a permanent discontinuation of the prophylaxis for toxicity) were similar between both groups. However, the number of probable/proven IFI that occurred between D0 and D90 was the double in the fluco group (9 vs. 4). Also, no proven IFI (vs. 4) or mucormycoses (vs. 1) or IFI related death (vs. 4) occurred in the posa group in the first 90 days. Posaconazole thus appears to be a good option to prevent IFI after allo-HSCT in patients at HR-IFI.

Relationship between posaconazole concentrations and clinical outcomes in paediatric cancer and haematopoietic stem cell transplant recipients

BACKGROUND

Posaconazole is used to prevent and treat invasive fungal infections (IFIs) in immunocompromised children, including those undergoing cancer treatment or HSCT. Despite differences in pharmacokinetics and IFI epidemiology between children and adults, therapeutic targets established in adult studies are often applied to children.

OBJECTIVES

This systematic review evaluated the correlation between serum posaconazole concentrations and clinical outcomes of IFI prophylaxis and treatment in children with malignancies or HSCT recipients.

METHODS

Four databases (Cochrane, Embase, MEDLINE and PubMed) were searched for studies involving children (≤18 years old) receiving cancer treatment or HSCT that reported posaconazole serum concentrations and treatment outcomes. Animal studies, those primarily in adult (>18 years old) populations, non-malignant conditions (excluding HSCT), case reports, letters, editorials, conference abstracts and narrative reviews were excluded. Bias was assessed using the Newcastle-Ottawa scale.

RESULTS

Nineteen studies were included: 12 reported outcomes of posaconazole prophylaxis; two of treatment; and five of both. For prophylaxis, breakthrough IFIs occurred in 1%-12% of children. All but one occurred with serum concentrations of ≤0.7 mg/L. For treatment, no clear association was observed between a trough concentration of >1.0 mg/L and treatment efficacy, with poor outcomes reported for serum concentrations ranging between 0.2 and 4.8 mg/L. Overall, quality of evidence was poor (medium to high risk of bias for 18 papers, low risk for 1 paper) and there was variation in IFI definitions across studies.

CONCLUSIONS

This review supports current recommendations for posaconazole prophylaxis in paediatric oncology and HSCT recipients. The absence of a clear correlation found between serum trough concentrations and treatment efficacy highlights the need for further studies to determine optimal therapeutic targets for treatment.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Incidence of Breakthrough Fungal Infections in Patients With Isavuconazole Prophylaxis: A Systematic Review and Meta-analysis

Background

Isavuconazole (ISA) is a newer triazole that has activity against most mold species and has been utilized for prophylaxis as well as treatment in patients with hematologic malignancies (HM) and hematopoietic stem cell transplant (HSCT). However, several studies have documented breakthrough invasive fungal infections (bIFIs). Thus, we conducted a systematic review and meta-analysis to investigate the incidence of bIFIs among patients receiving ISA prophylaxis.

Methods

We conducted a systematic review and meta-analysis of the published literature using the concept of ISA, HSCT, and HM from 5 search engines. In patients with HSCT and HM, the pooled incidence of bIFI while undergoing ISA prophylaxis was calculated via the DerSimonian-Laird random effect model.

Results

The systematic review and meta-analysis included 35 and 19 studies, respectively. In total, 991 patients were identified as using ISA prophylaxis, and the majority had either acute myeloid leukemia or myelodysplastic syndrome (69.9%). The pooled incidence of proven/probable bIFI was 7% (95% CI, 4%-12%, I2 = 55%). The most common pathogen was Aspergillus species (43.1%), followed by Candida (22.4%) and Mucorales (12.1%). In 19 studies, mortality rates were documented and ranged between 0% and 100%; the majority of which were >50%.

Conclusions

In patients with HM or HSCT, we found a high incidence of bIFI while undergoing ISA prophylaxis, with high mortality. Given the lack of randomized clinical trials evaluating ISA in this indication, its role in prophylaxis remains unclear.

Allogeneic Hematopoietic Stem Cell Transplantation Despite Severe Fusarium solani Infection in a Lung Transplanted Patient-A Case Report

Solid-organ transplant patients require prolonged immunosuppression, increasing their risk of hematologic disorders. For these conditions, allogeneic hematopoietic stem cell transplantation (HSCT) is a potential treatment, but it carries significant risk of treatment-related mortality due to the high possibility of developing rare infectious complications. We report a case of a 55-years-old male with a history of bilateral lung transplantation for extrinsic allergic alveolitis in 2015, who developed acute myeloid leukemia/myelodysplastic syndrome (AML/MDS) with TP53 mutation seven years later. During induction therapy, he experienced systemic fungal infection caused by Fusarium solani and he underwent HSCT conditioning with active intravitreal fungal infection. It is noteworthy that cases of patients undergoing HSCT after a prior lung transplant are exceedingly rare. The medical literature primarily documents cases where HSCT is performed first, followed by lung complications. Cases with the opposite timeline are extremely uncommon, and there is limited data on their outcomes; thus, the patient depicted here may help management and decision making of physicians facing this rare sequence of diseases and treatments.

Systematic Review of Neuropsychiatric Toxicity in Second Generation Antifungals With an Illustrative Case Report

BACKGROUND

Second-generation triazole antifungals are extended-spectrum drugs that act against yeasts, molds, and dimorphic fungi. These agents include voriconazole, posaconazole, and isavuconazole. Voriconazole may cause neuropsychiatric toxicity such as hallucinations. However, regarding neuropsychiatric toxicity related to posaconazole and isavuconazole, the literature remains poor.

OBJECTIVE

The present study reports a case of neuropsychiatric toxicity induced by posaconazole and isavuconazole triazole antifungals as well as the results of a systematic review on neuropsychiatric toxicity related to second-generation triazole antifungals.

METHODS

A systematic search of Medline electronic databases used MeSH headings and equivalent terms for second-generation triazole antifungals, delirium, hallucinations, and neurotoxicity. The selection of relevant records was performed by 2 independent reviewers. Epidemiological studies, observational studies, and case reports were included.

RESULTS

A total of 20 articles were included in the systematic review, comprising 11 case reports and 9 observational studies. All observational studies were related to voriconazole neuropsychiatric toxicity, particularly hallucinations; the estimated frequency of occurrence varied from 13.9% to 24%. Putative mechanisms of second-generation triazole antifungals neuropsychiatric toxicity include a disruption of cholesterol homeostasis in the brain, an inhibition of transient receptor potential melastatin 1 in retinal cells, and a drug-induced phospholiposis. A supra-therapeutic blood concentration of these agents as well as a drug interaction could also be involved.

CONCLUSIONS

In the present study, we reported for the first time, to our knowledge, a patient presenting with neuropsychiatric toxicity potentially related to posaconazole and isavuconazole. In a systematic review, we identified various mechanisms involved in the development of second-generation triazole antifungals neuropsychiatric toxicity. However, there remains to be extensive investigation.

Efficacy and safety of posaconazole and liposomal amphotericin B use for prophylaxis of invasive fungal infections in a paediatric and young adult haemato-oncological population

BACKGROUND

The prevention of invasive fungal infections (IFIs) is crucial for paediatric haemato-oncological patients. This study evaluates the clinical efficacy and side-effects of posaconazole and liposomal amphotericin B (L-AmB) as primary prophylaxis.

MATERIALS AND METHODS

This cohort study included patients aged 3 months to 21 years who received posaconazole or L-AmB (5 mg/kg twice weekly) as prophylaxis from January 2017 to March 2022 at the Hemato-oncological Pediatric Unit, University Hospital of Padua, Italy. Outcomes included adverse events and IFI diagnoses after the start of prophylaxis. Separate analyses were performed for patients with ALL and non-ALL diagnoses, and high-risk and low-risk groups. Cumulative incidence was calculated using the Kaplan-Meier estimator, with significant differences assessed using the log-rank test. Hazard ratios (HR) were estimated using Cox regression.

RESULTS

Fifty-one patients received posaconazole, and 37 received L-AmB. Adverse events occurred in 26% of L-AmB patients and 5.6% of posaconazole patients. IFI breakthrough events were similar in both groups (four events each). In ALL patients, 41% experienced adverse events with L-AmB, compared to 5% with posaconazole. After 1 year, the probability of adverse events was lower in the posaconazole group (54% versus 65%, P < 0.001). Overall, posaconazole was associated with a 91% lower risk of adverse events (HR: 0.07, P < 0.001). Among high-risk patients, IFI breakthrough rates were similar between groups (P = 0.964).

CONCLUSIONS

Posaconazole was associated with fewer adverse events than L-AmB, and both drugs showed similar efficacy in preventing IFI breakthroughs, making posaconazole a viable alternative for primary prophylaxis.

Invasive Aspergillosis in the Current Era

Despite significant advances, aspergillosis remains a critical health concern, with an evolving epidemiology and expanding populations of at-risk patients. Historically, fewer than 10 Aspergillus species were considered clinically significant. However, advancements in diagnostic technologies, such as DNA sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, have identified previously unrecognized "cryptic" Aspergillus species. This clinical review highlights the current epidemiology, risk factors, pathogenesis, clinical presentation, diagnosis, and invasive aspergillosis (IA) treatment. Diagnosing IA necessitates a multifaceted approach, integrating clinical evaluation, imaging studies, microbiological culture, serologic tests, and advanced molecular techniques.

Evidence-based clinical standard for the diagnosis and treatment of invasive lung aspergillosis in the patient with oncohematologic disease

Aspergillosis is a disease caused by the filamentous fungus Aspergillus spp. with a spectrum of clinical presentation that includes invasive and noninvasive forms. The invasive clinical presentation of aspergillosis most frequently affects people with compromised immune systems. In patients with oncohematologic pathology, invasive lung aspergillosis is a significant opportunistic mycosis, because it occurs frequently and has a major impact on morbidity, mortality, and high costs. The global problem of antimicrobial resistance, to which improper use of antifungals contributes, has put Aspergilus spp. in the spotlight, so it is important to generate guidelines for guidance in the proper use of antifungals in the management of invasive lung aspergillosis, to obtain better clinical outcomes and promote rational use of antifungals. This guideline contains recommendations for diagnosing and treating invasive lung aspergillosis in patients with oncohematologic disease, based on evidence and defined through a participatory process of expert consensus, for the Latin American context.

Outcome Analysis of Breakthrough Invasive Aspergillosis on Anti-Mold Azole Prophylaxis and Treatment: 30-Year Experience in Hematologic Malignancy Patients

BACKGROUND

Anti-mold azoles have improved the outcomes of invasive aspergillosis (IA) when used therapeutically, but they are extensively used as prophylaxis. There are limited data regarding the outcomes of patients with hematologic malignancy who develop breakthrough IA on anti-mold azoles. We aimed to determine whether breakthrough IA on azole prophylaxis shows worse outcomes compared to no prophylaxis.

METHODS

We compared outcomes including therapy response and mortality between antifungal regimens in hematologic malignancy patients with IA between July 1993 and July 2023.

RESULTS

Compared to an amphotericin B-containing regimen (AMB), an anti-mold azole as the primary therapy was independently associated with successful response at the end of therapy (OR = 4.38, p < 0.0001), protective against 42-day IA-associated mortality (OR = 0.51, p = 0.024) or all cause mortality (OR = 0.35, p < 0.0001), and protective against 84-day mortality, both IA-associated (OR = 0.50, p = 0.01) and all-cause mortality (OR = 0.27, p < 0.0001). Azole prophylaxis was independently associated with higher IA-associated mortality at 42 days (OR = 1.91, p = 0.012) and 84 days (OR = 2.03, p = 0.004), compared to fluconazole or no prophylaxis.

CONCLUSIONS

Patients with breakthrough IA on anti-mold azole prophylaxis show a worse prognosis than those on other or no prophylaxis, possibly related to the emergence of azole resistance due to their widespread use as prophylaxis agents. On the other hand, anti-mold azole primary therapy is superior to AMB therapy in the treatment of IA.

Risk beyond neutropenia: insights into neutrophil migration from newly diagnosed AML until late after allogeneic stem cell transplantation

Quantification of neutrophil counts is the most relevant assessment of cellular immunity in clinical practice. Patients with neutropenia are considered at risk and are categorized according to its severity. The incidence of febrile neutropenia varies, but patients with acute myeloid leukemia are traditionally considered at high risk, especially following myelotoxic treatments. To provide additional functional parameters, we investigated the ex vivo migration properties and morphology of neutrophils in 10 patients with acute myeloid leukemia using single-cell video-microscopy and discovered, in addition to neutropenia, highly pathological neutrophil migration patterns and polarization defects in patients with untreated acute myeloid leukemia. Neutrophil speed was the most sensitive parameter and significantly lower at leukemia diagnosis (9.067 vs 15.810 µm/min, P = 0.0025) compared to healthy controls (n = 46). Hematological remission was associated with improved neutrophil migration profiles, but these ultimately normalized only after hematopoietic cell transplantation. Five patients were followed up for long-term effects of hematopoietic cell transplantation for up to 24 mo. This is the first longitudinal ex vivo neutrophil migration study in patients with acute myeloid leukemia, followed by allogeneic hematopoietic cell transplantation. It identified functional neutrophil impairments beyond routine quantitative assessments, adding to the well-known quantitative impairment of neutropenia. HCT can reestablish functional neutrophils with healthy migration profiles in these patients.

Invasive Fungal Disease After Chimeric Antigen Receptor-T Immunotherapy in Adult and Pediatric Patients

Invasive fungal diseases (IFDs) have been documented among the causes of post-chimeric antigen receptor-T (CAR-T) cell immunotherapy complications, with the incidence of IFDs in CAR-T cell therapy recipients being measured between 0% and 10%, globally. IFDs are notorious for their potentially life-threatening nature and challenging diagnosis and treatment. In this review, we searched the recent literature aiming to examine the risk factors and epidemiology of IFDs post-CAR-T infusion. Moreover, the role of antifungal prophylaxis is investigated. CAR-T cell therapy recipients are especially vulnerable to IFDs due to several risk factors that contribute to the patient's immunosuppression. Those include the underlying hematological malignancies, the lymphodepleting chemotherapy administered before the treatment, existing leukopenia and hypogammaglobinemia, and the use of high-dose corticosteroids and interleukin-6 blockers as countermeasures for immune effector cell-associated neurotoxicity syndrome and cytokine release syndrome, respectively. IFDs mostly occur within the first 60 days following the infusion of the T cells, but cases even a year after the infusion have been described. Aspergillus spp., Candida spp., and Pneumocystis jirovecii are the main cause of these infections following CAR-T cell therapy. More real-world data regarding the epidemiology of IFDs and the role of antifungal prophylaxis in this population are essential.

Decreased Frequency and Improved Outcomes in Invasive Aspergillosis Caused by Aspergillus terreus After the Introduction of Anti-Mold Azole Agents: A 30-Year Study at a Tertiary Cancer Center

Invasive aspergillosis (IA) is a significant cause of morbidity and mortality in patients with hematological malignancy (HM) and hematopoietic stem cell transplant (HSCT) recipients. Aspergillus terreus is associated with worse outcomes than non-terreus Aspergillus species. Since the introduction of anti-mold azoles in 2002, there have been limited data on the etiology of IA. We retrospectively compared characteristics, antifungal treatments, and outcomes between patients with HM or HSCT infected with A. terreus and those with non-terreus Aspergillus between July 1993 and July 2023. We also examined trends over time in rates of A. terreus and outcomes of this infection. A total of 699 patients with culture-documented IA were analyzed, 537 with non-terreus species and 162 with A. terreus. Types of underlying malignancy, neutropenia, graft-versus-host disease, and anti-mold prophylaxis were similar between the groups. ICU stays and mechanical ventilation were more common among patients with A. terreus (p = 0.002 and 0.003, respectively). The rate of A. terreus decreased significantly from 35.9% during 1993-2003 to 11.2% during 2004-2013 and 16.7% during 2014-2023 (p < 0.0001 each). IA caused by A. terreus showed significant improvements in response to therapy and in overall and IA-associated mortality in the last two decades compared to the first (p < 0.0001). In conclusion, the increased use of anti-mold azoles after 2003 improved outcomes for HM patients with IA caused by A. terreus.

Side effects associated with itraconazole therapy

BACKGROUND

Itraconazole is the treatment of choice for many fungal infections, including histoplasmosis. While the tolerability of itraconazole has been described in short-term trial settings, there are few studies on side effects during long-term therapy. Fluconazole, which is usually thought to be less toxic, is associated with 52% toxicity in long-term treatment.

OBJECTIVES

To determine the frequency, types, and timing of side effects from itraconazole therapy, the resulting changes to treatment plans, and associations between patient characteristics and itraconazole serum levels with side effect status.

METHODS

We conducted a single-centre, retrospective study of adult patients with histoplasmosis receiving itraconazole therapy for at least 28 days from 2002 to 2021. Reported side effects were characterized, and propensity score matching was used to compare itraconazole serum levels between patients with and without side effects.

RESULTS

Sixty-three out of 227 (27.8%) patients experienced at least one side effect, the most common of which were hepatotoxicity (7.0%), nausea/vomiting (6.6%), and diarrhoea (6.2%). 12 (19.0%) patients with side effects underwent an itraconazole dose reduction and 29 (46.0%) had itraconazole discontinued. The median time to side effect was 45 days. Median itraconazole serum levels were significantly higher among patients with side effects than in a propensity score-matched population without side effects (2.9 versus 1.8 mcg/mL, P = 0.009).

CONCLUSIONS

Side effects were experienced by approximately one-quarter of patients with histoplasmosis receiving long-term itraconazole therapy. About two-thirds of these patients had a therapeutic intervention. Itraconazole resulted in a lower frequency of side effects than fluconazole, as measured in other studies.

Therapeutic drug monitoring of azole antifungal agents

Deep-seated mycoses are generally opportunistic infections that are difficult to diagnose and treat. They are expected to increase with the spread of advanced medical care and aging populations, thus highlighting the need for safe, effective, and rapid drug-based treatments. Depending on a patient's age, sex, underlying diseases, and immune system status, therapeutic drug monitoring (TDM) may be important for assessing variable pharmacokinetic parameters, as well as preventing drug-drug interactions, adverse events, and breakthrough infections caused by fungal resistance. Azole antifungal agents play an important role in the prevention and treatment of deep-seated fungal infections, with each azoles having its own unique pharmacokinetic properties and specific adverse events. Therefore, it is necessary to use national and international guidelines to build evidence for the expansion of TDM indications. This review focuses on the clinical utility and future perspectives of TDM using azole antifungal agents, in the context of recent evidence in the literature.

Genomic profiling of circulating tumor DNA for childhood cancers

The utility of circulating tumor DNA (ctDNA) analysis has not been well-established for disease detection and monitoring of childhood cancers, especially leukemias. We developed PeCan-Seq, a deep sequencing method targeting diverse somatic genomic variants in cell-free samples in childhood cancer. Plasma samples were collected at diagnosis from 233 children with hematologic, solid and brain tumors. All children with hematologic malignancy (n = 177) had detectable ctDNA at diagnosis. The median ctDNA fraction was 0.77, and 97% of 789 expected tumor variants were identified, including sequence mutations, copy number variations, and structural variations responsible for oncogenic fusions. In contrast, ctDNA was detected in 19 of 38 solid tumor patients and 1 of 18 brain tumor patients. Somatic variants from ctDNA were correlated with minimal residual disease levels as determined by flow cytometry in serial plasma samples from patients with B-cell acute lymphoblastic leukemia (B-ALL). We showcase multi-tumor detection by ctDNA analysis for a patient with concurrent B-ALL and neuroblastoma. In conclusion, PeCan-seq sensitively identified heterogeneous ctDNA alterations from 1 mL plasma for childhood hematologic malignancies and a subset of solid tumors. PeCan-seq provides a robust, non-invasive approach to augment comprehensive genomic profiling at diagnosis and mutation-specific detection during disease monitoring.

Recalcitrant tinea capitis in WHIM syndrome

WHIM syndrome is a rare primary immunodeficiency typically caused by autosomal dominant activating mutations in the CXCR4 gene. WHIM refers to warts, hypogammaglobulinaemia, infections and myelokathexis, which are the primary phenotypes of the syndrome. Here we describe a case of tinea capitis in a patient with WHIM syndrome that was unresponsive to multiple systemic antifungal treatments for over 10 years. The patient's recalcitrant tinea infection was ultimately cured after treatment with posaconazole. These findings suggest that the CXCR4 defects in WHIM syndrome may confer susceptibility to dermatophyte infections.

Strategies for the prophylaxis of invasive fungal diseases in acute myeloid leukemia patients undergoing Bcl-2 inhibitor venetoclax treatment

Patients with acute myeloid leukemia (AML) are at high risk of developing invasive fungal disease (IFD) with high morbidity and attributable mortality, including those who were received Venetoclax treatment. Venetoclax, a new oral Bcl-2 inhibitor, targets tumor cells' ability to induce apoptosis. It is the only one which is approved by Food and Drug Administration (FDA) for treating newly diagnosed AML patients who are 75 years of age or older and are ineligible for intensive induction chemotherapy due to existing comorbidities. It has been shown that venetoclax-based regimens raise the risk of invasive fungal diseases (IFD) for AML patients in clinical practice. Because it can lead to prolonged and profound neutropenia in AML patients, with IFD incidence rates ranging from 5.1 % to 32 %, resulting in higher mortality rates. Because of drug-drug interactions between Venetoclax and partial antifungal agents, to choose anti-fungal prophylaxis and to adjust the dosage of agents rationally for AML patients seems crucial to physicians to those who are undergoing venetoclax-based chemotherapy. Therefore, this review aims to summary the mechanism and characteristic of IFD in AML patients and provide practical clinical suggestions and details for the prophylaxis of IFD in AML patients suffering Venetoclax-based treatment.

Breakthrough Invasive Mold Infections in Hematologic Cases: Relevance of the Host's Factors

Background

Breakthrough invasive mold infections (bIMIs) are life-threatening complications in hematologic cases. Most previous studies in this field covered the whole spectrum of fungal pathogens, including yeasts, and antifungal agents.

Methods

We conducted a retrospective study including all hematologic cases of patients diagnosed with a bIMI while receiving a mold-active antifungal agent at our center between January 2017 and June 2022.

Results

Overall 37 patients were diagnosed with bIMI: 6 (16.2%) proven, 18 (48.6%) probable, and 13 (35.1%) possible. The highest incidence rate was found for micafungin (1.31 bIMI episodes per 1000 treatment-days), although with no significant differences across antifungal agents. Most patients (90.9%) for whom therapeutic drug monitoring was performed exhibited adequate through levels. Ten (27.0%) patients had undergone allogeneic hematopoietic stem cell transplantation. Aspergillus species was the most common pathogen in cases with microbiological identification. Regarding risk factors, 67.6% had severe neutropenia at diagnosis and 40.5% had received high-intensity chemotherapy. Rates of clinical response and attributable mortality by day +30 were 64.9% and 23.3%, respectively. Poorer performance status, higher Charlson Comorbidity index, older age, and higher C-reactive protein by day +7 were associated with 30-day attributable mortality.

Conclusions

Aspergillus was the predominant pathogen in our cohort of bIMIs, with a significant proportion of episodes occurring despite adequate triazole levels. Thirty-day attributable mortality was lower than previously reported. Poorer performance status, higher comorbidity burden, and older age had a relevant role in the outcome of bIMI.

Comprehensive Review of Environmental Surveillance for Azole-Resistant Aspergillus fumigatus: A Practical Roadmap for Hospital Clinicians and Infection Control Teams

As azole-resistant Aspergillus fumigatus emerges globally, healthcare facilities face mounting challenges in managing invasive aspergillosis. This review synthesizes worldwide azole resistance data to reveal profound regional variability, demonstrating that findings from other regions cannot be directly extrapolated to local settings. Consequently, hospital-level environmental surveillance is crucial for tailoring interventions to local epidemiology and detecting resistant strains in real-time. We outline practical approaches-encompassing sampling site prioritization, diagnostic workflows (culture-based and molecular), and PDCA-driven continuous improvement-so that even resource-limited facilities can manage resistant isolates more effectively. By linking real-time surveillance findings with clinical decisions, hospitals can tailor antifungal stewardship programs and swiftly adjust prophylaxis or treatment regimens. Our approach aims to enable accurate, ongoing evaluations of emerging resistance patterns, ensuring that institutions maintain efficient and adaptive programs. Ultimately, we advocate for sustained, collaborative efforts worldwide, where facilities adapt protocols to local conditions, share data through international networks, and contribute to a global knowledge base on resistance mechanisms. Through consistent application of these recommendations, healthcare systems can better preserve azole efficacy, safeguard immunocompromised populations, and refine infection control practices in the face of evolving challenges.

Efficacy and Safety Assessment of Antifungal Prophylaxis with Posaconazole Using Therapeutic Drug Monitoring in Pediatric Patients with Oncohematological Disorders-A Single-Centre Study

INTRODUCTION

Posaconazole is recommended for prophylaxis in pediatric immunocompromised patients. Due to its variability in bioavailability and drug-to-drug interactions, EBMT recommends regimens based on therapeutic drug monitoring (TDM).

MATERIALS AND METHODS

In total, 171 oncohematological pediatric patients on posaconazole prophylaxis were included. Full pharmacokinetic posaconazole profiles were assessed in 51 children. The efficacy and safety of posaconazole was evaluated by measuring the drug concentration, with dose modification attempted in patients with suboptimal results. The influence of modifying factors on the posaconazole plasma concentration (PPC) was investigated.

RESULTS

An insufficient PPC was the main issue, but no significant increase in prophylaxis failure was reported. The modification of the dosage resulted in the optimization of PPC in 50% of patients. No significant correlation between age, gender, diagnosis or the posaconazole dosage and the PPC was found. HCT, total parenteral nutrition and diarrhea were associated with a lower PPC. Hypoalbuminemia was related to both higher and lower PPC. The concomitant administration of specified drugs significantly impacted the PPC.

CONCLUSIONS

TDM allows the identification of patients receiving non-optimal treatment and offers an opportunity to improve the efficacy and safety of the therapy. However, further research involving larger patient groups and longer observation periods are needed to determine the optimal dosing and target PPC in pediatric patients.

Effects of CYP3A5 polymorphism and renal impairment on the drug interaction between venetoclax and fluconazole in acute myeloid leukaemia patients

The aim of this study was to investigate the effects of renal function and CYP3A5 polymorphism on the drug interaction between venetoclax and fluconazole in thirty acute myeloid leukaemia patients.The area under the plasma concentration-time curve (AUC) and trough concentration (C0) of venetoclax and the fluconazole C0 were obtained from plasma samples on day 7 after initiation of venetoclax 200 mg/day combined with fluconazole.The fluconazole C0 values in patients with moderate and severe renal impairment were significantly higher than those in patients with normal or mild impairment (median values 7037, 6234, and 4813 ng/mL, respectively, P = 0.026).In patients with CYP3A5*3/*3 genotype, the AUC0-24 and C0 of venetoclax were not associated with fluconazole C0; however, in patients with a CYP3A5*1 allele, a significant positive correlation was observed between venetoclax C0 and fluconazole C0 (r = 0.782, P = 0.004).The metabolism of venetoclax by CYP3A4 is inhibited even at low fluconazole C0. In patients with a CYP3A5*1 allele, CYP3A5 is inhibited when high fluconazole C0 is induced by renal impairment.The dose of fluconazole for prophylaxis may be 100 mg in patients with severe renal impairment receiving venetoclax therapy.

A multivariable prediction model for invasive pulmonary aspergillosis in immunocompromised patients with acute respiratory failure (IPA-GRRR-OH score)

PURPOSE

Invasive pulmonary aspergillosis (IPA) is a life-threatening opportunistic infection in immunocompromised patients. The diagnosis is often made late, with mortality reaching 90% when mechanical ventilation is needed. We sought to develop and validate a risk prediction model for the diagnosis of IPA.

METHODS

We used two independent datasets of immunocompromised patients with acute respiratory failure admitted to 12 intensive care units (ICUs). The derivation dataset include 3262 patients. Factors associated with probable or proven IPA were identified, and a risk prediction model was developed. This model was then validated in a prospective dataset (776 patients).

RESULTS

IPA prevalence was 4.5% (146/3262) and 3.3% (26/776), in the derivation and the validation cohorts, respectively. The final model included eight variables constitutive of the IPA-GRRR-OH score: type of immunosuppression, high-dose or long-term corticosteroids, neutropenia, the presence of structural lung disease, time from symptoms onset to ICU admission > 7 days, hemoptysis, focal alveolar pattern on the chest imaging, and viral co-infection. The median score [IQR] was 2 [1-3] in the derivation and 1 [0-3] in the validation cohort. The best cutoff score for IPA diagnosis was 4 (sensitivity 23.1%; specificity 90.5%; negative predictive value 91.4%). Discrimination and calibration were good in both the derivation (AUC 0.72 [0.68-0.76]) and the validation cohort (AUC 0.85 [0.76-0.93]).

CONCLUSION

The IPA-GRRR-OH is a clinical score, easily available at ICU admission, which reliably predicts IPA in immunocompromised patients with acute respiratory failure. Studies to demonstrate benefits from the bedside implementation of this score are warranted.

Acute myeloid leukemia management and research in 2025

The first 5 decades of research in acute myeloid leukemia (AML) were dominated by the cytarabine plus anthracyclines backbone, with advances in strategies including allogeneic hematopoietic stem cell transplantation, high-dose cytarabine, supportive care measures, and targeted therapies for the subset of patients with acute promyelocytic leukemia. Since 2017, a turning point in AML research, 12 agents have received regulatory approval for AML in the United States: venetoclax (BCL2 inhibitor); gemtuzumab ozogamicin (CD33 antibody-drug conjugate); midostaurin, gilteritinib, and quizartinib (fms-like tyrosine kinase 3 inhibitors); ivosidenib, olutasidenib, and enasidenib (isocitrate dehydrogenase 1 and 2 inhibitors); oral azacitidine (a partially absorbable formulation); CPX351 (liposomal encapsulation of cytarabine:daunorubicin at a molar ratio of 5:1); glasdegib (hedgehog inhibitor); and recently revumenib (menin inhibitor; approved November 2024). Oral decitabine-cedazuridine, which is approved as a bioequivalent alternative to parenteral hypomethylating agents in myelodysplastic syndrome, can be used for the same purpose in AML. Menin inhibitors, CD123 antibody-drug conjugates, and other antibodies targeting CD123, CD33, and other surface markers are showing promising results. Herein, the authors review the frontline and later line therapies in AML and discuss important research directions.

Posaconazole for Prevention of COVID-19-Associated Pulmonary Aspergillosis in Mechanically Ventilated Patients: A European Multicentre Case-Control Study (POSACOVID)

BACKGROUND

This study investigated the impact of posaconazole (POSA) prophylaxis in COVID-19 patients with acute respiratory failure receiving systemic corticosteroids on the risk for the development of COVID-19-associated pulmonary aspergillosis (CAPA).

METHODS

The primary aim of this prospective, multicentre, case-control study was to assess whether application of POSA prophylaxis in mechanically ventilated COVID-19 patients reduces the risk for CAPA development. All consecutive patients from centre 1 (cases) who received POSA prophylaxis as standard-of-care were matched to one subject from centre 2 and centre 3 who did not receive any antifungal prophylaxis, using propensity score matching for the following variables: (i) age, (ii) sex, (iii) treatment with tocilizumab and (iv) time at risk.

RESULTS

Eighty-three consecutive patients receiving POSA prophylaxis were identified at centre 1 and matched to 166 controls. In the matched cohort, incidence rates of CAPA were 1.69 (centre 1), 0.84 (centre 2) and 7.18 (centre 3) events per 1000 ICU days. In multivariable logistic regression analysis, the presence of an EORTC/MSGERC risk factor at ICU admission (OR 4.35) and centre 3 versus centre 1 (OR 6.07; 95% CI 1.76-20.91; p = 0.004) were associated with an increased risk of CAPA. No increased risk of CAPA was registered for centre 2 versus centre 1.

CONCLUSIONS

The impact of POSA prophylaxis depends on the baseline CAPA incidence rate, which varies widely between centres. Future trials should therefore investigate targeted antifungal prophylaxis (e.g., stratified for high-prevalence centres or high-risk patients) in COVID-19 patients.

TRIAL REGISTRATION

NCT05065658.

Real-world study of isavuconazole adverse events based on pharmacovigilance spontaneous reporting systems

BACKGROUND

Isavuconazole is a novel second-generation triazole antifungal agent.We conducted a retrospective investigation to analyze the occurrence of adverse events (AEs) associated with isavuconazole in real-world clinical use by data-mining self-reporting databases, aiming to provide comprehensive data for its safe and effective clinical application.

RESEARCH DESIGN AND METHODS

All data obtained from the VigiBase, the EudraVigilance and the FAERS database. In the FAERS database, data mining algorithms, including reporting odds ratio (ROR) and proportional reporting ratio (PRR), were utilized to detect adverse event (AE) signals.

RESULTS

A total of 4,105 AE reports related to isavuconazole were retrieved from these databases. The highest proportion of AE reports was observed in individuals aged between 18-64 years old. The general disorders and administration site conditions system organ class accounted for the largest number of reported cases. The system organ classes with most signals and reports included general disorders and administration site conditions, blood and lymphatic system disorders as well as investigations related to hepatobiliary disorders. Notably high ROR and PRR values were observed for AE signals associated with hepatobiliary disorders.

CONCLUSION

Isavuconazole has fewer interactions and less liver, kidney and cardiac toxicity than other triazole antibiotics. The identification of novel AEs necessitates meticulous attention and further investigation and analysis.

Combining azole antifungals with venetoclax plus azacitidine in patients with newly diagnosed acute myeloid leukemia

The combination of venetoclax (VEN) with hypomethylating agents (HMAs) improves survival in patients with acute myeloid leukemia (AML) and may cause neutropenia requiring combined antifungal therapy or prophylaxis. The inhibition of cytochrome P450 activity by azole antifungal agents leads to elevated blood concentrations of VEN. This study aimed to evaluate the efficacy and safety of venetoclax plus azacitidine (AZA) with azoles in newly diagnosed AML patients. The primary endpoints included complete remission (CR), complete remission with incomplete blood cell recovery (CRi), composite CR (CRc, CR + CRi), blood cell recovery time and incidence of infections. The CRc was 50.0% in the azole group and 56% in the nonazole group (p > 0.05). In the azole group, the median recovery times for patients with ANC >500 cells/mm3 and ANC >1,000 cells/mm3 were 19 and 25 days, respectively. For the nonazole group, the corresponding times were 16 and 19 days (p < 0.05). In the azole group, the median durations for patients with a PLT >50,000/mm3 and >100,000/mm3 were 18 and 20 days, respectively. For the nonazole group, the corresponding times were 16 and 19 days (p > 0.05). The incidences of fungal and bacterial infections were not significantly different (30.8% vs 26.1% and 50.0% vs 56.0%) (p > 0.05). The cost-effectiveness ratio of the azole group is lower. There was no significant difference between VEN + AZA with or without azole in terms of efficacy, infection, or partial hematological toxicity. However, the combination of azoles may prolong the neutrophil recovery time. Azole combination could reduce the amount of venetoclax and improve health economics.

Pacritinib and concurrent azole antifungal therapy is deliverable in patients with hematologic malignancies

OBJECTIVE

Pacritinib is a novel kinase inhibitor approved for the treatment of adults with intermediate or high-risk primary or secondary myelofibrosis. Strong and moderate CYP3A4 inhibitors, such as some azole antifungals, are contraindicated or recommended to be avoided in combination with pacritinib, respectively. We aim to report our experience in patients who received pacritinib with concurrent azole antifungal therapy.

DATA SOURCES

We queried for patients with hematologic malignancies in the electronic medical record who received concurrent pacritinib and azole antifungal therapy.

DATA SUMMARY

There were five cases of concurrent pacritinib and azole antifungal therapy in which none of the patients experienced grade 3 or higher non-hematologic toxicities. Some patients required dose modifications and/or interruptions in pacritinib therapy.

CONCLUSION

This is the first clinical experience describing concurrent pacritinib and azole antifungals. Our experience shows that in the setting where this interaction cannot be avoided, concurrent administration is feasible with close monitoring and possible empiric dose reductions in select patients.

Posaconazole gastro-resistant tablets for preventing invasive fungal disease after haematopoietic stem cell transplantation: a propensity-matched cohort study

OBJECTIVES

To evaluate posaconazole (POS) gastro-resistant tablets for preventing invasive fungal disease (IFD) in haematopoietic stem cell transplantation (HSCT) patients and analyse POS plasma concentrations.

METHODS

A single-arm trial was designed with a historical cohort as a control. Patients aged 13 years and older undergoing HSCT at the HSCT Center of Blood Diseases Hospital, Chinese Academy of Medical Sciences between December 2020 and May 2022 were enrolled, prospectively taking POS gastro-resistant tablets orally from day 1 to day 90 post-transplant and monitoring plasma concentrations. We also identified a retrospective cohort treated with alternative antifungal prophylaxis between January 2018 and December 2020, matched using propensity score methods. The primary outcome was the cumulative incidence of IFD at day 90 post-transplant.

RESULTS

The prospective study involved 144 patients receiving POS gastro-resistant tablets for IFD prevention, contrasting with 287 patients receiving non-POS tablets. By day 90 post-transplant, the POS tablet group exhibited a significantly lower cumulative incidence of IFD (2.81%; 95% CI, 0.09-5.50% vs. 7.69%; 95% CI, 4.60-10.78%; p 0.044). Adverse events were comparable between the groups with liver changes in 33/144 (22.92%) vs. 84/287 (29.27%) (p 0.162), and renal injuries in 15/144 (10.41%) vs. 37/287 (12.89%) (p 0.457). Mean POS plasma concentrations on days 4, 8, 15, and 22 post-administration were 930.97 ng/mL, 1143.97 ng/mL, 1569.8 ng/mL, and 1652.57 ng/mL, respectively.

DISCUSSION

Patients administered POS gastro-resistant tablets for antifungal prophylaxis experienced a lower cumulative incidence of IFD. POS plasma concentrations in HSCT patients stabilized by day 15 of medication.

Management of febrile neutropenia: consensus of the Brazilian Association of Hematology, Blood Transfusion and Cell Therapy - ABHH

Febrile neutropenia is a major complication of the treatment of patients with hematologic diseases. Recent epidemiologic changes, with an increase in infection caused by drug-resistant bacteria, represent a major challenge for the proper management of febrile neutropenia. The impact of these changes in the epidemiology of infection may vary according to the region. In this document we present recommendations from the Infectious Diseases Committee of the Brazilian Association of Hematology, Blood Transfusion and Cell Therapy (ABHH) for the management of febrile neutropenia in hematologic patients. The consensus was developed by ten experts in the field, using the Delphi methodology. In the document we provide recommendations for the initial workup, prophylaxis, empiric antibiotic and antifungal therapy, modifications in the empiric regimen and criteria for discontinuing antimicrobial therapy.

Infections and antimicrobial prophylaxis in patients with myelodysplastic syndromes

Infectious complications are an important cause of morbidity and mortality in patients with myelodysplastic syndromes (MDS). Preventing infections could significantly improve both survival and quality of life. Unfortunately, both infections and antimicrobial prophylaxis in patients with MDS are incompletely assessed due to the heterogeneity of disorders included in each publication, changing definitions over time, and lack of standardized prophylaxis practices. Despite these limitations, some basic statements can be made. Infections in MDS are associated with neutropenia. Patients with lower-risk (LR) MDS tend to have fewer infections compared to patients with higher-risk (HR) MDS, which may be related to the different prevalence of neutropenia in the 2 groups. Pneumonia is the most common infection, and bacteria are the most common pathogens. Invasive fungal infections (IFI) are uncommon. Reactivation of latent viruses are rare. With the limited data available, we agree that antibacterial prophylaxis can be considered in patients with HR-MDS during severe neutropenia and early cycles of therapy when infections are most likely to occur. Given the low prevalence of IFI and viral reactivation, antimicrobial prophylaxis for these pathogens is less likely to be advantageous for most patients, although antifungal prophylaxis with activity against mold is commonly used in patients with persistent, profound neutropenia. Ultimately, improved data collection regarding infections and antimicrobial prophylaxis is needed to improve care for patients with MDS.

Optimizing antimicrobial prophylaxis strategies in acute leukemia patients: Assessing the efficacy of fluconazole

BACKGROUND

Acute myeloid (AML) and promyelocytic (APL) leukemia patients are at high risk for infection and mortality. While guidance for infection prevention is provided by the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO), each institution may vary in antimicrobial prophylaxis prescribing practices. The discrepancy may be explained by medication intolerance, cost, and low incidence of mold infections in leukemia patients. A recent meta-analysis demonstrated mortality benefits with the use of posaconazole, which was adopted by the NCCN. Despite known risks, it is unclear whether universal mold-active coverage is indicated for all AML and APL patients.

OBJECTIVE

To assess the incidence of breakthrough infections in AML and APL patients.

METHODS

This was a single-center, retrospective chart review of AML and APL patients receiving induction therapy at Baylor St Luke's Medical Center (BSLMC) between January 2019 and October 2021. The primary outcome assessed the incidence of breakthrough infections. Descriptive statistics were used to summarize the data.

RESULTS

A total of 55 patients were included and 54 (98%) had prolonged neutropenia with a median duration of 30 days. Five patients (9.3%) experienced breakthrough infections during induction while 21 individuals (38.9%) during the follow-up period. Aspergillus infections occurred in three patients receiving nonmold coverage compared to none on mold-active agents (p = 1.0) with no statistical difference in mortality.

CONCLUSION

Despite the majority of patients not receiving mold-active prophylaxis, nonmold-active prophylaxis may be sufficient with consideration of low aspergillosis incidence.

Human cytomegalovirus infection among febrile hematological cancer patients at the Uganda Cancer Institute

Hematological cancers, including Leukemias and Lymphomas, and their associated chemotherapy and disease-specific factors, are linked to impaired granulocyte function and numbers, increasing the risk of opportunistic infections, often presenting as fever. Human cytomegalovirus (HCMV) is one of the significant opportunistic infections in these patients, but limited data exists on its seroprevalence and active infection burden among febrile hematological cancer patients in Uganda. We conducted a cross-sectional study from June to August 2017 at the Uganda Cancer Institute (UCI). Blood samples from 161 febrile hematological cancer patients were collected. HCMV exposure was assessed using indirect enzyme-linked immunosorbent assay for IgG and IgM antibodies, and active infection was confirmed with PCR testing and gel electrophoresis. IgG positivity indicated previous exposure, while positive IgM or PCR results indicated active infection. Overall, HCMV seroprevalence based on IgG and/or IgM positivity was 106/161 (66%). IgG alone, IgM alone, and combined IgG/IgM positivity prevalence rates were 57/161 (35.4%), 22/161 (13.6%), and 27/161 (16.7%), respectively. HCMV DNA PCR was positive in 5 of the 161 (3%) samples. Among PCR-positive patients, one (20%) was positive for IgG alone, two (40%) for IgM alone, and two (40%) for both IgG and IgM. Active infection based on positive IgM and HCMV DNA PCR was found in 23 of the 161 (14.3%) patients. Two-thirds of febrile patients with hematological malignancies in Uganda had been exposed to HCMV infection, with 14.3% showing active infection. Routine testing for active HCMV infection among febrile hematological cancer patients at the UCI is essential for timely and appropriate antiviral treatment.

IMPORTANCE

In this paper, we demonstrated that over two-thirds of feverish patients with blood cancers such as leukemia at the Uganda Cancer Institute are already exposed to a type of virus infection called the human cytomegalovirus (HCMV), and 14% of the patients have active disease due to this virus. This was confirmed through finding blood samples testing positive for a type of protective antibody called IgM and also upon virus DNA detection in the blood of those patients. Routine testing for this virus is not usually done in the study settings. Our findings reveal and emphasize the importance of routinely testing blood samples for active infection with this virus among the feverish patients with blood cancers in the study settings, and prompt initiation of antiviral treatment of the actively infected patients.

Invasive fungal disease and antifungal prophylaxis in children with acute leukaemia: a multicentre retrospective Australian cohort study

Background

Invasive fungal disease (IFD) is a significant complication for children receiving treatment for leukaemia, contributing to morbidity and mortality. Recent regional paediatric epidemiological IFD data are lacking. Additionally uncertainty remains regarding the optimal prophylactic approach in this context.

Methods

In a multi-centre Australian cohort study of children diagnosed with de novo acute leukaemia between 1st January 2017 and 30th June 2020, we characterised antifungal prophylaxis prescribing and IFD prevalence. Impact of antifungal prophylaxis was assessed using Kaplan Meier curves and Cox-proportional hazards regression adjusting for known IFD risk factors.

Findings

A total of 434 children were included (47.2% female; median age 5.0 years, median follow-up 240 days). This cohort included 351 children with ALL (214 high-risk [HR-ALL]; 137 standard-risk [SR-ALL]), and 73 with AML. The prevalence of proven/probable IFD was 6.8% for AML, 14.0% for HR-ALL and 4.4% for SR-ALL. A mould was implicated as the causative pathogen in almost two thirds of cases. Antifungal prophylaxis was prescribed in 98.7% of chemotherapy cycles for AML, 56.7% for HR-ALL and 14.9% for SR-ALL. A mould-active agent was used in 77.4% of AML cycles and 21.2% of HR-ALL cycles. Mould-active prophylaxis was associated with a lower risk of IFD overall and increased IFD-free survival in AML.

Interpretation

These data demonstrate the persistent high regional burden of IFD in children with HR-ALL, and the potential for mould-active prophylaxis to ameliorate this. Strategies to increase uptake of appropriate prophylaxis are required in this cohort.

Funding

This study was supported by a Perth Children's Hospital Foundation grant (PCHF9973).

Aspergillus calidoustus and Talaromyces columbinus infections in chronic graft-versus-host disease

Advancements in allogeneic haematopoietic stem cell transplant (alloHSCT) procedures have improved patient outcomes over the last two decades, though invasive fungal infections (IFIs) remain a significant risk. The incidence of IFIs in alloHSCT recipients is estimated at 6%, with a mortality rate of 13%, and Aspergillus species are the most common pathogens involved. Posaconazole is effective in preventing IFIs post-transplant and is standard care during neutropenia or when managing graft-versus-host disease (GvHD) with high-dose steroids. However, azole prophylaxis may cause resistant Aspergillus species like A. calidoustus, which are difficult to treat. We report a case from our institution where a patient developed a dual infection with Aspergillus calidoustus and Talaromyces columbinus after alloHSCT and posaconazole prophylaxis. While A. calidoustus is known to cause IFIs in HSCT recipients, T. columbinus represents a previously unreported occurrence in medical literature. This case underscores the importance of a multifaceted diagnostic strategy, integrating BAL diagnosis, mycological cultures, direct microscopy, fungal speciation, susceptibility testing, and biomarkers. These comprehensive approaches are indispensable for accurate pathogen identification and effective management of IFIs with appropriate antifungal agents.

Effectiveness of high efficiency particulate (HEPA) air condition combined with the antifungal prophylaxis on incidence, morbidity and mortality of invasive fungal infections in patients with acute myeloid leukemia: a retrospective single-center study

Introduction

Our monocentric and retrospective study aimed to investigate the clinical effectivity of HEPA filters in combination with the antifungal drug prophylaxis in patients with AML undergoing intensive chemotherapy and allogeneic stem cell transplantation (SCT).

Methods/Results

We included 177 patients between 2005 and 2015 representing a total of 372 in-hospital stays, 179 in the HEPA cohort (+HEPA) and 193 in the cohort without HEPA filters (-HEPA). No significant additional benefit of HEPA filtration on the risk reduction of IFI was observed. HEPA filtration did not significantly affect the risk of intensive care unit (ICU) admissions or early mortality rates. In patients who received allogeneic SCT in first complete remission with antifungal drug prophylaxis during prior induction treatment, a numerical but not significant improvement in long-term overall survival was noted in the +HEPA cohort compared to the -HEPA cohort (55% to 66%, p = 0.396). For better depicting of the clinical reality, we determined the so-called clinical suspected IFI (csIFI) -defined as cases with antifungal treatment after recommended prophylaxis without fulfilling current EORTC criteria. Especially in patients with a high risk for second IFI, significant risk reduction of csIFI and frequency of ICU admissions was observed when voriconazole was used as secondary antifungal prophylaxis. (csIFI, adjusted effect: OR 0.41, 95% CI (0.21 - 0.82), p = 0.01; csIFI, subgroup-specific effect: OR 0.35, 95% CI (0.15 - 0.78), p = 0.01; ICU, adjusted effect: OR 0.44, 95 CI (0.19 - 1.01), p = 0.05; respectively).

Discussion

In summary, the study suggests the efficacy of secondary antifungal prophylaxis in preventing IFI in AML patients undergoing intensive treatment. The addition of HEPA filtration also demonstrated additional numerous benefits in reducing the frequency of IFI-associated complications.

Population Pharmacokinetic Modeling of Posaconazole in Japanese Patients Receiving Fungal Prophylaxis

BACKGROUND

Posaconazole is a vital drug to treat and prevent invasive fungal infections. Several factors, such as sex, body weight, total serum proteins, dietary intake, and severe mucositis, affect posaconazole pharmacokinetics (PKs). However, the relevance of other factors that affect the PKs of posaconazole in hematopoietic stem cell transplantation (HSCT) is unknown. This study explored factors influencing the PKs of posaconazole in HSCT recipients and nontransplant patients with hematological diseases.

METHODS

The authors conducted a single-institution, retrospective study. Forty-two Japanese inpatients receiving oral posaconazole tablets as prophylaxis for fungal infections were enrolled in this study. A one-compartment model with first-order absorption was used as the structural pharmacokinetic model. A population PK (PopPK) analysis was performed using a nonlinear mixed-effects modeling program, using a first-order conditional estimation method with interactions. Perl-speaks-NONMEM and R were used to evaluate the goodness of fit and visualize the output.

RESULTS

In 29% of the enrolled patients, the serum concentration of posaconazole was <0.5 mcg/mL, considered the effective range. PopPK analysis revealed that the patient had undergone HSCT within 1 year, diarrhea occurred more than 5 times a day, and aspartate aminotransferase were covariates that influenced apparent clearance (CL/F). The CL/F of posaconazole was 1.43-fold higher after HSCT and 1.26-fold higher during diarrhea.

CONCLUSIONS

PopPK analysis revealed that HSCT, diarrhea, and aspartate aminotransferase were factors associated with the CL/F of posaconazole. The trough concentration of posaconazole may be below the therapeutic range in a few patients with diarrhea and/or after HSCT. As invasive fungal infections in patients with hematologic diseases can be life-threatening, therapeutic drug monitoring of posaconazole is strongly recommended, and patients should be carefully monitored.

Challenges and considerations for antifungal prophylaxis in children with acute myeloid leukemia

INTRODUCTION

Children receiving treatment for acute myeloid leukemia (AML) are at high risk of invasive fungal disease (IFD). Evidence from pediatric studies support the efficacy of antifungal prophylaxis in reducing the burden of IFD in children receiving therapy for AML, yet existing antifungal agents have specific limitations and comparative data to inform the optimal prophylactic approach are lacking.

AREAS COVERED

This review summarizes the epidemiology of invasive fungal disease (IFD) and current antifungal prophylaxis recommendations for children with acute myeloid leukemia (AML). Challenges with currently available antifungal agents and considerations related to the changing landscape of AML therapy are reviewed. A keyword search was conducted to identify pediatric studies regarding IFD and antifungal prophylaxis in children with AML up to December 2023.

EXPERT OPINION

Children undergoing treatment for AML are recommended to receive antifungal prophylaxis to reduce risk of IFD, with tolerability, pharmacokinetics, feasibility of administration, and drug interactions all factors that require consideration in this context. With increased use of novel targeted agents for AML therapy, together with the development of new antifungal agents, data from well-designed clinical studies to optimize prophylactic approaches will be essential to limit the burden of IFD in this vulnerable cohort.

Exhaled Breath Condensate Surveillance for Aspergillus in Acute Leukemia-a Pilot Trial

Invasive fungal infections in patients with leukemia carry a high mortality rate, but early diagnosis has the potential to modify this natural history. A novel screening method using Aspergillus droplet-digital polymerase chain reaction in exhaled breath condensate may have a similar performance to serum galactomannan screening. Larger studies, including other molds, are necessary.

Concomitant use of calcitonin gene-related peptide (CGRP) antagonists with azole antifungals in patients with hematological malignancies

OBJECTIVE

Small molecule calcitonin gene-related peptide (CGRP) antagonists such as rimegepant, ubrogepant, and atogepant have been approved for migraine treatment and/or prevention. These molecules are metabolized by cytochrome P-450 3A4 (CYP3A4) enzymes in vivo, hence they are contraindicated or recommended to be avoided in combination with strong/moderate CYP3A4 inhibitors, namely posaconazole (strong) and isavuconazonium (moderate). However, no literature has been published on the impact this interaction has on patient safety and tolerability. In this case series, we report five cases in which CGRP antagonists and azole antifungal therapy were given concurrently, to provide real-world outcomes of this interaction.

DATA SOURCES

Electronic medical records at our hospital system were reviewed between January 2021 and December 2023 to find patients who met the criteria of hematological malignancy, taking CGRP-antagonist and azole antifungal therapy. Records were then further investigated to find cases where CGRP antagonists and azole antifungals were used concomitantly.

DATA SUMMARY

Concurrent use of CGRP antagonists and azole antifungal therapy was feasible for patients with migraines and hematological malignancies. None of the patients experienced any grade 3 or higher non-hematological toxicity from the proposed over-exposure to CGRP antagonist. The combination was well tolerated without any need for therapy discontinuation or dose modifications.

CONCLUSIONS

It is recommended to follow the manufacturers' guidance on drug interactions, however, in the setting where there are no other options, concomitant use of CGRP antagonists with azole antifungals is possible with monitoring and observation for adverse effects.

Individualized medication of venetoclax based on therapeutic drug monitoring in Chinese acute myeloid leukemia patients using an HPLC method

OBJECTIVE

The aim of this study was to establish a simple and sensitive high-performance liquid chromatography method for therapeutic drug monitoring of venetoclax (VEN) and optimize regimens.

METHODS

The analysis required the extraction of a 50 μl plasma sample and the precipitation of proteins using acetonitrile extraction. The chromatographic method employed a mobile phase of acetonitrile: 0.5% KH 2 PO 4 (pH 3.5) (60/40, v/v) on a Diamond C 18 (4.6 mm × 250 mm, 5 μm) column at a flow rate of 1.0 ml/min. The quantitative method was validated based on standards described in 'Bioanalytical Method Validation: Guidance for Industry' published by the US Food and Drug Administration (FDA).

RESULTS

The calibration curve was linear ( R2  = 0.9998) over the range of 75-4800 ng/ml, with limits of quantification of 25 ng/ml. The coefficients of intraday and interday validation, specificity, recovery, and stability all met the criteria of FDA guidance. The method was successfully applied to analyze VEN concentrations in 30 cases of acute myeloid leukemia patients. The peak concentration ( Cmax ) was 1881.19 ± 756.61 ng/ml, while the trough concentration ( Cmin ) was 1212.69 ± 767.92 ng/ml in acute myeloid leukemia patients.

CONCLUSION

Our study establishes a simple, precise, and sensitive high-performance liquid chromatography method for monitoring VEN and confirms its applicability for therapeutic drug monitoring of VEN in hematological cancers.

Current status and research directions in acute myeloid leukemia

The understanding of the molecular pathobiology of acute myeloid leukemia (AML) has spurred the identification of therapeutic targets and the development of corresponding novel targeted therapies. Since 2017, twelve agents have been approved for the treatment of AML subsets: the BCL2 inhibitor venetoclax; the CD33 antibody drug conjugate gemtuzumab ozogamicin; three FLT3 inhibitors (midostaurin, gilteritinib, quizartinib); three IDH inhibitors (ivosidenib and olutasidenib targeting IDH1 mutations; enasidenib targeting IDH2 mutations); two oral hypomethylating agents (oral poorly absorbable azacitidine; fully absorbable decitabine-cedazuridine [latter approved as an alternative to parenteral hypomethylating agents in myelodysplastic syndrome and chronic myelomonocytic leukemia but commonly used in AML]); and CPX-351 (encapsulated liposomal 5:1 molar ratio of cytarabine and daunorubicin), and glasdegib (hedgehog inhibitor). Other targeted therapies (menin inhibitors, CD123 antibody-drug conjugates) are showing promising results. To achieve optimal results in such a rare and heterogeneous entity as AML requires expertise, familiarity with this rare cancer, and the access to, and delivery of disparate therapies under rigorous supportive care conditions. In this review, we update the standard-of-care and investigational therapies and outline promising current and future research directions.

How can we optimize antifungal use and stewardship in the treatment of acute leukemia?

INTRODUCTION

The global need for antifungal stewardship is driven by spreading antimicrobial and antifungal resistance. Triazoles are the only oral and relatively well-tolerated class of antifungal medications, and usage is associated with acquired resistance and species replacement with intrinsically resistant organisms. On a per-patient basis, hematology patients are the largest inpatient consumers of antifungal drugs, but are also the most vulnerable to invasive fungal disease.

AREAS COVERED

In this review we discuss available and forthcoming antifungal drugs, antifungal prophylaxis and empiric antifungal therapy, and how a screening based and diagnostic-driven approach may be used to reduce antifungal consumption. Finally, we discuss components of an antifungal stewardship program, interventions that can be employed, and how impact can be measured. The search methodology consisted of searching PubMed for journal articles using the term antifungal stewardship plus program, intervention, performance measure or outcome before 1 January 2024.

EXPERT OPINION

Initial focus should be on implementing effective antifungal stewardship programs by developing and implementing local guidelines and using interventions, such as post-prescription review and feedback, which are known to be effective. Technologies such as microbiome analysis and machine learning may allow the development of truly individualized risk-factor-based approaches to antifungal stewardship in the future.