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Frost J, Gornicec M, Reisinger AC, Eller P, Hoenigl M, Prattes J. COVID-19 associated Pulmonary Aspergillosis in Patients Admitted to the Intensive Care Unit: Impact of Antifungal Prophylaxis. Mycopathologia 2024; 189:3. [PMID: 38217742 PMCID: PMC10787678 DOI: 10.1007/s11046-023-00809-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/07/2023] [Indexed: 01/15/2024]
Abstract
Early after the beginning of the coronavirus disease 2019 (COVID-19)-pandemic, it was observed that critically ill patients in the intensive care unit (ICU) were susceptible to developing secondary fungal infections, particularly COVID-19 associated pulmonary aspergillosis (CAPA). Here we report our local experience on the impact of mold active antifungal prophylaxis on CAPA occurrence in critically ill COVID-19 patients. This is a monocentric, prospective cohort study including all consecutive patients with COVID-19 associated acute respiratory failure who were admitted to our local medical ICU. Based on the treating physician's discretion, patients may have received antifungal prophylaxis or not. All patients were retrospectively characterized as having CAPA according to the 2020 ECMM/ISHAM consensus definitions. Seventy-seven patients were admitted to our medical ICU during April 2020 and May 2021 and included in the study. The majority of patients received invasive-mechanical ventilation (61%). Fifty-three patients (68.8%) received posaconazole prophylaxis. Six cases of probable CAPA were diagnosed within clinical routine management. All six cases were diagnosed in the non-prophylaxis group. The incidence of CAPA in the overall study cohort was 0.57 events per 100 ICU days and 2.20 events per 100 ICU days in the non-prophylaxis group. No difference of cumulative 84-days survival could be observed between the two groups (p = 0.115). In this monocentric cohort, application of posaconazole prophylaxis in patients with COVID-19 associated respiratory failure did significantly reduce the rate of CAPA.
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Affiliation(s)
- Jonas Frost
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
| | - Maximilian Gornicec
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
| | - Alexander C Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Philipp Eller
- Intensive Care Unit, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria.
- BioTechMed Graz, Graz, Austria.
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Lopes LM, Nucci M, Portugal RD. Toxicity and outcome of adults with acute myeloid leukemia receiving consolidation with high-dose cytarabine. Hematol Transfus Cell Ther 2023:S2531-1379(23)00161-X. [PMID: 37684163 DOI: 10.1016/j.htct.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/15/2022] [Accepted: 07/20/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION High-dose cytarabine is considered standard of care as consolidation chemotherapy in adults with acute myeloid leukemia (AML) who are not eligible for allogeneic hematopoietic cell transplantation, but may be associated with significant toxicity. We evaluated the toxicity associated with high-dose cytarabine given as consolidation in AML patients treated at a Brazilian public hospital. METHODS We retrospectively reviewed the charts of all patients with AML treated between 2008 and 2020 who obtained complete remission (CR) after one cycle of induction chemotherapy and received consolidation with at least one cycle of high-dose cytarabine (defined as 3 g/m2 every 12 h days 1, 3 and 5). RESULTS Among 61 patients who received induction remission, 32 obtained CR and 28 received at least one cycle of high-dose cytarabine, for a total of 67 cycles (median 2 cycles per patient, range 1 - 4). In 45 cycles (67.2%) the patient was discharged after the end of chemotherapy, with a median of 6 days at home (range 3 - 8). Readmission occurred in 31 of the 45 cycles (68.9%). The most frequent toxicities were febrile neutropenia (56.7%), nausea and vomiting (23.9%), oral mucositis (14.9%) and diarrhea (11.9%). Bacteremia was documented in 13 cycles (34.2%). There were three cases of typhlitis and two of invasive fungal disease (aspergillosis and candidemia). Four patients died (14.3%), with two deaths considered treatment-related (candidemia and typhlitis). CONCLUSION In the setting of a Brazilian public hospital, high-dose cytarabine as consolidation therapy is feasible, with manageable toxicity profile.
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Affiliation(s)
- Lais Moreira Lopes
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil; Grupo Oncoclínicas, São Paulo, SP, Brazil.
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Chen EC, Liu Y, Harris CE, Winer ES, Wadleigh M, Lane AA, Vedula RS, Lindsley RC, Copson KM, Charles A, Marty F, Neuberg D, DeAngelo DJ, Stone RM, Luskin MR, Issa NC, Garcia JS. Outcomes of antifungal prophylaxis for newly diagnosed AML patients treated with a hypomethylating agent and venetoclax. Leuk Lymphoma 2022; 63:1934-1941. [PMID: 35289704 PMCID: PMC9481998 DOI: 10.1080/10428194.2022.2047964] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Antifungal prophylaxis (AFP) is recommended for acute myeloid leukemia (AML) patients receiving the combination of venetoclax (VEN) and a hypomethylating agent (HMA), but the benefit of this practice is unclear. We identified 131 patients with newly diagnosed AML who received frontline VEN/HMA and evaluated the use of AFP and its association with invasive fungal infections (IFIs) and AML outcomes. Seventeen percent of our patients received AFP at any time. Overall incidence of any IFI ('possible,' 'probable,' or 'proven' infection, as defined by the European Mycoses Study Group) was 13%, and the incidence did not differ based on AFP use (p=.74). Median overall survival did not differ based on AFP use or lack thereof (8.1 vs. 12.5 months, respectively; p=.14). Our findings suggest that, at an institution where the incidence of fungal infections is low, there does not appear to be a role for AFP in newly diagnosed AML patients receiving VEN/HMA.
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Affiliation(s)
- Evan C. Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Yiwen Liu
- Department of Data Science, Dana-Farber Cancer Institute
| | | | - Eric S. Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Andrew A. Lane
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Rahul S. Vedula
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | | | - Kevin M. Copson
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Anne Charles
- Department of Medical Oncology, Dana-Farber Cancer Institute
| | - Francisco Marty
- Division of Infectious Disease, Brigham and Women’s Hospital
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute
| | | | | | | | - Nicolas C. Issa
- Division of Infectious Disease, Brigham and Women’s Hospital
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4
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Strand AM, Alexander BD, Sarpong E, Wong JR, Engemann A, Rizzieri D, Wu Y, Johnson MD. Real World Effectiveness of Antifungal Prophylaxis with Posaconazole as the Primary Agent in Patients with Hematological Malignancies. Mycoses 2022; 65:1050-1060. [PMID: 35816393 DOI: 10.1111/myc.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
Background and Objectives Patients undergoing induction/re-induction chemotherapy for hematologic malignancies (HM) are at risk for invasive fungal infections (IFIs). In 2015, Duke University Hospital (DUH) implemented a new standardized fungal prophylaxis protocol for adult patients undergoing induction chemotherapy for Acute Lymphocytic Leukemia, Acute Myelocytic Leukemia, and Myelodysplastic Syndrome. This study assessed the impact of protocol implementation on (1) use of antifungal prophylaxis, throughout the at-risk period and (2) patient outcomes such as IFI and mortality. METHODS Retrospective, observational study of adult HM patients admitted to DUH for induction/re-induction chemotherapy pre- (7/1/2013-12/31/2014) and post- (1/1/2015-10/31/2016) implementation of standardized antifungal prophylaxis protocol (which recommended posaconazole as the first-line agent). Patients were followed for up to 100 days after initiation of induction chemotherapy to evaluate use of antifungal prophylaxis and patient outcomes. RESULTS 218 patients with hematologic malignancies were included (90 pre,128 post). Use of antifungal prophylaxis increased from 81.1% (pre) to 97.7% (post) (p<0.0001). Overall, 71% received posaconazole as initial antifungal prophylaxis (64.4% pre, 75.7% post). Approximately one-fourth of patients (25.6%, pre vs 26.6%, post) developed an IFI (proven/probable or possible using modified EORTC definitions) (p=0.868); 100-day mortality remained stable (18.9% pre vs 18.8% post, respectively p=0.979). Lack of antifungal prophylaxis and older age (≥60 years) were associated with higher risk of IFI. CONCLUSION Implementation of a standardized protocol with posaconazole as the primary agent was associated with increased use of antifungal prophylaxis among patients undergoing induction/re-induction chemotherapy for hematologic malignancies in our hospital. Lack of antifungal prophylaxis was an independent predictor of IFIs, underscoring the importance of prophylaxis in this at-risk population.
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Affiliation(s)
- Andrew M Strand
- Duke University Medical Center, Durham, NC, USA.,Tufts Medical Center, Boston, MA, USA
| | | | | | | | - Ashley Engemann
- Duke University Medical Center, Durham, NC, USA.,Medexus Pharmaceuticals. Inc
| | - David Rizzieri
- Duke University Medical Center, Durham, NC, USA.,Novant Health Cancer Institute, Charlotte, NC, USA
| | - Yuan Wu
- Duke University Medical Center, Durham, NC, USA
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Howard A, Hope W. CON: Serum biomarker monitoring should not replace primary antifungal chemoprophylaxis in patients with acute leukaemia receiving systemic anti-cancer therapy. JAC Antimicrob Resist 2022; 4:dlac081. [PMID: 35891676 PMCID: PMC9305492 DOI: 10.1093/jacamr/dlac081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Primary antifungal chemoprophylaxis (PAC) is the widespread strategy of choice for the prevention of invasive fungal disease in patients with acute leukaemia (AL). Twice-weekly monitoring of the serum biomarkers (SBM) galactomannan and 1,3-β-d-glucan has been proposed as an alternative prevention strategy to PAC for these patients. This paper outlines the arguments for why PAC should remain as the standard of care in AL, instead of switching to twice-weekly SBM. Arguments put forward in favour of PAC are the strength of evidence for its safety, cost-effectiveness and adaptability, and its adoption by multiple international guidelines as standard of care. The potential implications of PAC for drug interactions and antifungal resistance are also discussed. The drawbacks of twice-weekly SBM are appraised, including missed or delayed diagnoses, unnecessary investigations, deferral of systemic anti-cancer therapy and increased pressure on laboratory services.
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Affiliation(s)
- Alex Howard
- Liverpool University Hospitals NHS Foundation Trust , Prescot Street, Liverpool, L7 8XP , UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool , Liverpool, L69 3BX , UK
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Elmonofy O, Ghanem M, Abdelwahab M, Mubarak FA. A prospective case series on rhino orbital cerebral mucormycosis in Egypt: Epidemiology, systemic implications, and treatment. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Horowitz JG, Gawrys GW, Lee GC, Ramirez BA, Elledge CM, Shaughnessy PJ. Early antimicrobial prophylaxis in autologous stem cell transplant recipients: Conventional versus an absolute neutrophil count-driven approach. Transpl Infect Dis 2021; 23:e13689. [PMID: 34255395 PMCID: PMC9285346 DOI: 10.1111/tid.13689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Background Autologous hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of developing life‐threatening infections. There is discordance in published recommendations for timing of pre‐ and post‐transplant antimicrobial prophylaxis in this patient population, and these recommendations are unsubstantiated by any published comparative analyses. Methods An observational, pre‐ and post‐intervention study of consecutive autologous HSCT recipients was conducted over a 2‐year period. In the pre‐intervention cohort, antimicrobial prophylaxis was initiated on the day prior to transplant. In the post‐intervention cohort, antimicrobials were initiated once absolute neutrophil count (ANC) reached ≤500 cells/mm3. The primary outcome assessed was frequency of febrile occurrences. Secondary outcomes included total days of prophylaxis, positive blood cultures, all‐cause mortality, Clostridioides difficile infection rates, and length of stay. Results A total of 208 patients were included in the final analysis, with 105 and 103 patients in the pre‐ and post‐intervention cohorts, respectively. The majority of patients included were male. Lower rates of fever occurrences were observed in the post‐intervention cohort (83% pre‐ vs. 69% post‐intervention; p = 0.019). A significant reduction in the mean antibacterial days per patient was identified (9.7 vs. 4.6 days; p < 0.001). Other than lower rates of febrile neutropenia in the post‐intervention cohort, no differences were identified in secondary outcomes. In multivariable analyses, ANC‐driven prophylaxis was independently associated with decreased febrile events. Conclusions Delaying prophylaxis until severe neutropenia was not associated with increased febrile events or other secondary clinical outcomes evaluated. This approach is associated with a significant reduction in antimicrobial exposure.
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Affiliation(s)
- Justin G Horowitz
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Gerard W Gawrys
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Grace C Lee
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA.,Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brittney A Ramirez
- Department of Pharmacy Services, Methodist Healthcare System, San Antonio, Texas, USA.,College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Carole M Elledge
- Adult Blood and Marrow Stem Cell Transplantation, Methodist Healthcare System, San Antonio, Texas, USA
| | - Paul J Shaughnessy
- Adult Blood and Marrow Stem Cell Transplantation, Texas Transplant Institute, San Antonio, Texas, USA
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Sayed SA, Hassan EAB, Abdel Hameed MR, Agban MN, Mohammed Saleh MF, Mohammed HH, Abdel-Aal ABM, Elgendy SG. Ketorolac-fluconazole: A New Combination Reverting Resistance in Candida albicans from Acute Myeloid Leukemia Patients on Induction Chemotherapy: In vitro Study. J Blood Med 2021; 12:465-474. [PMID: 34163275 PMCID: PMC8214543 DOI: 10.2147/jbm.s302158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Candida albicans is a significant source of morbidity and mortality for patients with acute myeloid leukemia (AML). Prolonged use of fluconazole as empirical antifungal prophylaxis in AML patients leads to overexpression of efflux pump genes that resulted in the emergence of azole-resistant species. Consequently, the introduction of a new strategy to improve the management of C. albicans infections is an urgent need. Nonsteroidal anti-inflammatory drug (NSAID) ketorolac is associated with a reduction in cancer relapses. The present study was performed to investigate the use of ketorolac-fluconazole combination to reverse fluconazole resistance in C. albicans isolated from AML patients on induction chemotherapy. PATIENTS AND METHODS One hundred and seventy AML patients were evaluated. Fifty C. albicans were isolated and subjected to disc diffusion assay and broth microdilution for fluconazole alone and combined with different concentrations of ketorolac. Efflux pump gene (CDR1, CDR2, and MDR1) expressions were quantified by real-time PCR. RESULTS The tested ketorolac acted synergistically with fluconazole against resistant C. albicans with the minimum inhibitory concentration (MIC) of fluconazole decreased from >160 μg/mL to 0.3-1.25 μg/mL in (93.8%) of resistant isolates with fractional inhibitory concentration index (FICI) value of 0.25. The majority of the resistant isolates overexpressed CDR1 (71.1%) and MDR1 (60%). CONCLUSION Ketorolac-fluconazole in vitro combination would be a promising strategy for further clinical in vivo trials to overcome fluconazole resistance in AML patients on induction chemotherapy.
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Affiliation(s)
- Shereen A Sayed
- Department of Microbiology and Immunology, Faculty of Veterinary Medicine, Assiut University, Assiut, Egypt
| | - Ehsan A B Hassan
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Muhamad R Abdel Hameed
- Department of Internal Medicine & Hematology Unit, Assiut University Hospitals and Bone Marrow Transplantation Unit, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Michael N Agban
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa F Mohammed Saleh
- Department of Internal Medicine & Hematology Unit, Assiut University Hospitals and Bone Marrow Transplantation Unit, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Hayam H Mohammed
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Abu-Baker M Abdel-Aal
- Department of Organic Chemistry, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Sherein G Elgendy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Yang E, Choi EJ, Park HS, Lee SO, Choi SH, Kim YS, Lee JH, Lee JH, Lee KH, Kim SH. Comparison of invasive fungal diseases between patients with acute myeloid leukemia receiving posaconazole prophylaxis and those not receiving prophylaxis: A single-center, observational, case-control study in South Korea. Medicine (Baltimore) 2021; 100:e25448. [PMID: 34011022 PMCID: PMC8137049 DOI: 10.1097/md.0000000000025448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/17/2021] [Indexed: 01/05/2023] Open
Abstract
Posaconazole prophylaxis is effective in decreasing the incidence of invasive fungal diseases (IFDs) in patients with acute myeloid leukemia (AML). However, the use of antifungal prophylaxis varies in real-life practice, and only a small number of studies have compared the incidence of IFDs between those receiving posaconazole prophylaxis and those without prophylaxis. We compared the clinical characteristics and outcomes of IFDs between patients with AML who received posaconazole prophylaxis and those without antifungal prophylaxis.We reviewed the medical records of adult AML patients who underwent induction chemotherapy between June 2016 and October 2019 at Asan Medical Center (Seoul, South Korea), where posaconazole prophylaxis is not administered in patients with gastrointestinal symptoms that may hinder sufficient absorption of oral prophylactic agents, and in patients with abnormal liver functions considering the possible exacerbation of adverse events. Patients who received posaconazole prophylaxis for ≥7 days were included in the prophylaxis group. Clinical characteristics and outcomes including the incidence of IFDs were compared between the 2 groups.Of the 247 patients with AML who underwent induction chemotherapy, 162 (66%) received posaconazole prophylaxis and 85 (34%) did not receive any prophylaxis. The incidence of proven/probable IFD was significantly higher in the no prophylaxis group than in the prophylaxis group (9.4% [8/85] vs 2.5% [4/162], P = .03). Of the 8 cases of IFDs in the no prophylaxis group, 7 were mold infections and 1 was invasive candidiasis. Of the 4 cases of IFDs in the prophylaxis group, 3 were mold infections and 1 was invasive candidiasis. Patients with posaconazole prophylaxis less frequently received therapeutic antifungal therapy (2.5% vs 9.4%, P = .03) and had a longer median, duration from chemotherapy to antifungal therapy compared with the no prophylaxis group (18 vs 11 days, P < .01). The rate of IFD-related mortality was similar between the 2 groups (0.6% vs 0%, P > .99).Patients with AML who received posaconazole prophylaxis had a lower incidence of breakthrough IFDs compared with those who did not receive any prophylaxis. Invasive mold infection was the most common IFD regardless of antifungal prophylaxis.
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Affiliation(s)
- Eunmi Yang
- Department of Infectious Diseases
- Present affiliation: Department of Infectious Diseases, Seoul Medical Center, Seoul, Republic of Korea
| | - Eun-Ji Choi
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Han-Seung Park
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | | | | | | | - Jung-Hee Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Je-Hwan Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
| | - Kyoo-Hyung Lee
- Hematology, Asan Medical Center, University of Ulsan College of Medicine
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Guarana M, Nucci M, Barreiros G, Valeri J, Almeida C, Nouér SA. Early versus Late Fluconazole Prophylaxis in Autologous Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:681.e1-681.e5. [PMID: 33964515 DOI: 10.1016/j.jtct.2021.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 11/27/2022]
Abstract
Candidemia is a major complication in hematopoietic cell transplantation (HCT), and antifungal prophylaxis with fluconazole decreases the incidence of this complication. We compared 2 strategies for fluconazole prophylaxis in patients with hematologic malignancy undergoing autologous HCT between 1997 and 2017. From 1997 to 2003, fluconazole prophylaxis (400 mg/d) was given to all HCTs, started with the conditioning regimen (early prophylaxis), and given until neutrophil engraftment or the need of non-prophylactic antifungal therapy. From 2004 on, fluconazole (400mg daily) was started only if (and when) the patient developed oral mucositis (late prophylaxis). Among 571 HCT, 270 received early prophylaxis, 112 received late prophylaxis, and 189 did not receive fluconazole because they did not develop oral mucositis. The incidence of candidemia was 1.8% in the early prophylaxis group, 0% in the late prophylaxis group, and 1.1% in the no prophylaxis group (P = .31). Among patients receiving fluconazole, the median duration of prophylaxis was 17 days (range, 6-36 days) in the early prophylaxis group and 6 days (range, 2-16 days) in the late prophylaxis group (P < .001). The initiation of fluconazole prophylaxis guided by the occurrence of oral mucositis (late prophylaxis) was as good as early fluconazole prophylaxis.
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Affiliation(s)
- Mariana Guarana
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Gloria Barreiros
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Julio Valeri
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cecilia Almeida
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Zeng H, Wu Z, Yu B, Wang B, Wu C, Wu J, Lai J, Gao X, Chen J. Network meta-analysis of triazole, polyene, and echinocandin antifungal agents in invasive fungal infection prophylaxis in patients with hematological malignancies. BMC Cancer 2021; 21:404. [PMID: 33853560 PMCID: PMC8048157 DOI: 10.1186/s12885-021-07973-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIM Triazole, polyene, and echinocandin antifungal agents are extensively used to treat invasive fungal infections (IFIs); however, the optimal prophylaxis option is not clear. This study aimed to determine the optimal agent against IFIs for patients with hematological malignancies. METHODS Randomized controlled trials (RCTs) comparing the effectiveness of triazole, polyene, and echinocandin antifungal agents with each other or placebo for IFIs in patients with hematological malignancies were searched. This Bayesian network meta-analysis was performed for all agents. RESULTS The network meta-analyses showed that all triazoles, amphotericin B, and caspofungin, but not micafungin, reduced IFIs. Posaconazole was superior to fluconazole [odds ratio (OR), 0.30; 95% credible interval (CrI), 0.12-0.60], itraconazole (OR, 0.40; 95% CrI, 0.15-0.85), and amphotericin B (OR, 4.97; 95% CrI, 1.73-11.35). It also reduced all-cause mortality compared with fluconazole (OR, 0.35; 95% CrI, 0.08-0.96) and itraconazole (OR, 0.33; 95% CrI, 0.07-0.94), and reduced the risk of adverse events compared with fluconazole (OR, 0.02; 95% CrI, 0.00-0.03), itraconazole (OR, 0.01; 95% CrI, 0.00-0.02), posaconazole (OR, 0.02; 95% CrI, 0.00-0.03), voriconazole (OR, 0.005; 95% CrI, 0.00 to 0.01), amphotericin B (OR, 0.004; 95% CrI, 0.00-0.01), and caspofungin (OR, 0.05; 95% CrI, 0.00-0.42) despite no significant difference in the need for empirical treatment and the proportion of successful treatment. CONCLUSIONS Posaconazole might be an optimal prophylaxis agent because it reduced IFIs, all-cause mortality, and adverse events, despite no difference in the need for empirical treatment and the proportion of successful treatment.
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Affiliation(s)
- Huilan Zeng
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Zhuman Wu
- Emergency Department, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Bing Yu
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Bo Wang
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Chengnian Wu
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Jie Wu
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Jing Lai
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Xiaoyan Gao
- Department of Hematology, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China
| | - Jie Chen
- Department of Urology Surgery, the First Affiliated Hospital of Jinan University, No.613 West Huangpu street, Guangzhou, 510630, P. R. China.
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8th European Conference on Infections in Leukaemia: 2020 guidelines for the diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e254-e269. [PMID: 33811813 DOI: 10.1016/s1470-2045(20)30723-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
Paediatric patients with cancer and those undergoing allogeneic haematopoietic cell transplantation have an increased susceptibility to invasive fungal diseases. In addition to differences in underlying conditions and comorbidities relative to adults, invasive fungal diseases in infants, children, and adolescents are unique in terms of their epidemiology, the validity of current diagnostic methods, the pharmacology and dosing of antifungal agents, and the absence of phase 3 clinical trials to provide data to guide evidence-based interventions. To re-examine the state of knowledge and to further improve invasive fungal disease diagnosis, prevention, and management, the 8th European Conference on Infections in Leukaemia (ECIL-8) reconvened a Paediatric Group to review the literature and to formulate updated recommendations according to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) grading system, which are summarised in this Review.
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13
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Christopeit M, Schmidt-Hieber M, Sprute R, Buchheidt D, Hentrich M, Karthaus M, Penack O, Ruhnke M, Weissinger F, Cornely OA, Maschmeyer G. Prophylaxis, diagnosis and therapy of infections in patients undergoing high-dose chemotherapy and autologous haematopoietic stem cell transplantation. 2020 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2020; 100:321-336. [PMID: 33079221 PMCID: PMC7572248 DOI: 10.1007/s00277-020-04297-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022]
Abstract
To ensure the safety of high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT), evidence-based recommendations on infectious complications after HDC/ASCT are given. This guideline not only focuses on patients with haematological malignancies but also addresses the specifics of HDC/ASCT patients with solid tumours or autoimmune disorders. In addition to HBV and HCV, HEV screening is nowadays mandatory prior to ASCT. For patients with HBs antigen and/or anti-HBc antibody positivity, HBV nucleic acid testing is strongly recommended for 6 months after HDC/ASCT or for the duration of a respective maintenance therapy. Prevention of VZV reactivation by vaccination is strongly recommended. Cotrimoxazole for the prevention of Pneumocystis jirovecii is supported. Invasive fungal diseases are less frequent after HDC/ASCT, therefore, primary systemic antifungal prophylaxis is not recommended. Data do not support a benefit of protective room ventilation e.g. HEPA filtration. Thus, AGIHO only supports this technique with marginal strength. Fluoroquinolone prophylaxis is recommended to prevent bacterial infections, although a survival advantage has not been demonstrated.
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Affiliation(s)
- Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany.
| | - Martin Schmidt-Hieber
- Department of Hematology and Oncology, Carl-Thiem-Klinikum, Cottbus, Cottbus, Germany
| | - Rosanne Sprute
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Marcus Hentrich
- Department of Medicine III-Hematology/Oncology, Red Cross Hospital, Munich, Germany
| | - Meinolf Karthaus
- Department of Internal Medicine, Hematology and Oncology, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Olaf Penack
- Department of Internal Medicine, Division of Hematology and Oncology, Charité Universitätsmedizin Berlin, Campus Rudolf Virchow, Berlin, Germany
| | - Markus Ruhnke
- Department of Hematology, Oncology and Palliative Medicine, Helios Hospital Aue, Aue, Germany
| | - Florian Weissinger
- Department of Internal Medicine, Hematology, Oncology, Stem Cell Transplantation and Palliative Medicine, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Georg Maschmeyer
- Klinikum Ernst von Bergmann, Department of Hematology, Oncology and Palliative Care, Potsdam, Germany
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Wang J, Zhou M, Xu JY, Zhou RF, Chen B, Wan Y. Comparison of Antifungal Prophylaxis Drugs in Patients With Hematological Disease or Undergoing Hematopoietic Stem Cell Transplantation: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2020; 3:e2017652. [PMID: 33030550 PMCID: PMC7545296 DOI: 10.1001/jamanetworkopen.2020.17652] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Several antifungal drugs are available for antifungal prophylaxis in patients with hematological disease or who are undergoing hematopoietic stem cell transplantation (HSCT). OBJECTIVE To summarize the evidence on the efficacy and adverse effects of antifungal agents using an integrated comparison. DATA SOURCES Medline, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials were searched to collect all relevant evidence published in randomized clinical trials that assessed antifungal prophylaxis in patients with hematological disease. Sources were search from inception up to October 2019. STUDY SELECTION Studies that compared any antifungal agent with a placebo, no antifungal agent, or another antifungal agent among patients with hematological disease or undergoing HSCT were included. Of 39 709 studies identified, 69 met the criteria for inclusion. DATA EXTRACTION AND SYNTHESIS The outcome from each study was estimated using the relative risk (RR) with 95% CIs. The Mantel-Haenszel random-effects model was used. The reliability and validity of the networks were estimated by addressing inconsistencies in the evidence from comparative studies of different treatments. Data were analyzed from December 2019 to February 2020. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Network Meta-analysis (PRISMA-NMA) guideline. MAIN OUTCOMES AND MEASURES The primary outcomes were invasive fungal infections (IFIs) and mortality. The secondary outcomes were fungal infections, proven IFIs, invasive candidiasis, invasive aspergillosis, fungi-related death, and withdrawal owing to adverse effects of the drug. RESULTS We identified 69 randomized clinical trials that reported comparisons of 12 treatments with at total of 14 789 patients. Posaconazole was the treatment associated with the best probability of success against IFIs (surface under the cumulative ranking curve, 86.7%; mean rank, 2.5). Posaconazole treatment was associated with a significant reduction in IFIs (RR, 0.57; 95% CI, 0.42-0.79) and invasive aspergillosis (RR, 0.36; 95% CI, 0.15-0.85) compared with placebo. Voriconazole was associated with a significant reduction in invasive candidiasis (RR, 0.15; 95% CI, 0.09-0.26) compared with placebo. However, posaconazole was associated with a higher incidence of withdrawal because of the adverse effects of the drug (surface under the cumulative ranking curve, 17.5%; mean rank, 9.2). In subgroup analyses considering efficacy and tolerance, voriconazole might be the best choice for patients undergoing HSCT, especially allogenic HSCT; however, posaconazole was ranked as the best choice for patients with acute myeloid leukemia or myelodysplastic syndrome. CONCLUSIONS AND RELEVANCE These findings suggest that voriconazole may be the best prophylaxis option for patients undergoing HSCT, and posaconazole may be the best prophylaxis option for patients with acute myeloid leukemia or myelodysplastic syndrome.
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Affiliation(s)
- Jing Wang
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- The Pq Laboratory of Micro/Nano BiomeDx, Department of Biomedical Engineering, Binghamton University – SUNY, Binghamton, New York
| | - Min Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jing-Yan Xu
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Rong-Fu Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Bing Chen
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yuan Wan
- The Pq Laboratory of Micro/Nano BiomeDx, Department of Biomedical Engineering, Binghamton University – SUNY, Binghamton, New York
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15
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Signorelli J, Lei M, Lam J, Jalbut M, Amrein PC, Fathi AT, Hobbs G, Hock H, McAfee SL, Letourneau AR, Narayan R, Brunner A. Incidence of Invasive Fungal Infections in Acute Myeloid Leukemia Without Antifungal Prophylaxis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e883-e889. [PMID: 32917574 DOI: 10.1016/j.clml.2020.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antifungal prophylaxis during induction for acute myeloid leukemia (AML) varies according to local rates of invasive fungal infections (IFIs). We evaluated fluconazole prophylaxis and no antifungal prophylaxis, as a natural interrupted time-series study to assess survival and infection complications. PATIENTS AND METHODS We identified patients with AML ≥ 18 years old undergoing induction chemotherapy during 2 time periods: period 1, fluconazole prophylaxis from August 1, 2013 to September 30, 2015, and period 2, no prophylaxis from October 1, 2015 to December 31, 2017. The primary outcome was incidence of proven or probable IFI. Secondary outcomes included types of IFIs and 60-day overall survival (OS). IFI was defined by the 2002 European Organization for Research and Treatment of Cancer/Mycoses Study Group Consensus criteria. RESULTS One hundred forty-four patients received induction chemotherapy over the 2 time periods. In the prophylaxis versus no-prophylaxis groups, the rate of proven or probable IFIs was 4 (5%) of 87 versus 12 (21%) of 57 (P = .01). The total number of proven IFIs was 3 (3%) of 87 versus 4 (7%) of 57 (P = .44), whereas probable IFIs were 1 (1%) of 87 versus 8 (14%) of 57 (P < .01). No difference was observed in fungemia. Incidence of IFIs was too low to detect resistance patterns. OS at 60 days was improved in with fluconazole prophylaxis compared with no prophylaxis (hazard ratio, 0.329; 95% confidence interval, 0.12-0.89; P = .028). CONCLUSION Observed rates of proven or probable IFI were lower in the fluconazole prophylaxis group versus the no-prophylaxis group. Sixty-day OS was higher with fluconazole prophylaxis. Further study is required to evaluate how fluconazole may impart the differences in survival seen in this analysis.
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Affiliation(s)
| | - Matthew Lei
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Jenna Lam
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Marla Jalbut
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Philip C Amrein
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amir T Fathi
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gabriela Hobbs
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Hanno Hock
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Steven Lawrence McAfee
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Alyssa R Letourneau
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Rupa Narayan
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew Brunner
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
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16
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Arad-Cohen N, Rowe JM, Shachor-Meyouhas Y. Pharmacological prophylaxis of infection in pediatric acute myeloid leukemia patients. Expert Opin Pharmacother 2020; 21:193-205. [PMID: 31914337 DOI: 10.1080/14656566.2019.1701654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Pediatric patients treated for acute myeloid leukemia (AML) are at high risk of developing severe infectious complications. The choice of an optimum supportive treatment should be based on local epidemiology, as well as intensity and toxicity of the anti-leukemic therapy applied.Areas covered: This review presents an overview of recently published studies focusing on the prevention of infection in pediatric AML patients. PubMed has been systematically searched for clinical trials, reviews, and meta-analyses published in the last 10 years. The focus of this article will be limited to primary prophylaxis only, while secondary prophylaxis is beyond the scope of the current review.Expert opinion: Although anti-bacterial agents may decrease the bacterial infection burden, there is no consensus regarding prophylactic use. To that end, there is a need for further randomized controlled trials to establish the precise role of anti-bacterial prophylaxis in pediatric AML patients. The prophylactic use of anti-fungal agents is strongly recommended for all AML patients. Since the contribution of hematopoietic growth factors to improved survival has not been demonstrated, they should not be routinely applied. Decisions regarding an appropriate prophylactic strategy should be taken in collaboration with the infectious disease experts and pharmacology team.
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Affiliation(s)
- Nira Arad-Cohen
- Pediatric Hematology-Oncology Department, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Jacob M Rowe
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus Haifa, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yael Shachor-Meyouhas
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Ruth Rappaport Children's Hospital Haifa, Israel
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17
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Maertens JA, Girmenia C, Brüggemann RJ, Duarte RF, Kibbler CC, Ljungman P, Racil Z, Ribaud P, Slavin MA, Cornely OA, Peter Donnelly J, Cordonnier C. European guidelines for primary antifungal prophylaxis in adult haematology patients: summary of the updated recommendations from the European Conference on Infections in Leukaemia. J Antimicrob Chemother 2019; 73:3221-3230. [PMID: 30085172 DOI: 10.1093/jac/dky286] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The European Conference on Infections in Leukaemia (ECIL) updated its guidelines on antifungal prophylaxis for adults using the grading system of IDSA. The guidelines were extended to provide recommendations for other haematological diseases besides AML and recipients of an allogeneic haematopoietic stem cell transplantation (HSCT). Posaconazole remains the drug of choice when the incidence of invasive mould diseases exceeds 8%. For patients undergoing remission-induction chemotherapy for AML and myelodysplastic syndrome (MDS), fluconazole can still offer an alternative provided it forms part of an integrated care strategy that includes screening with biomarkers and imaging. Similarly, aerosolized liposomal amphotericin B combined with fluconazole can be considered for patients at high risk of invasive mould diseases but other formulations of the polyene are discouraged. Fluconazole is still recommended as primary prophylaxis for patients at low risk of invasive mould diseases during the pre-engraftment phase of allogeneic HSCT whereas only a moderate recommendation could be made for itraconazole, posaconazole and voriconazole for patients at high risk. Posaconazole is strongly recommended for preventing invasive mould disease post-engraftment but only when graft-versus-host disease (GvHD) was accompanied by other risk factors such as its severity, use of an alternative donor or when unresponsive to standard corticosteroid therapy. The need for primary prophylaxis for other patient groups was less clear and should be defined by the estimated risk of invasive fungal disease (IFD).
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Affiliation(s)
- Johan A Maertens
- Department of Haematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Corrado Girmenia
- Department of Haematology, Azienda Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | - Per Ljungman
- Departments of Haematology and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Division of Haematology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Zdenek Racil
- Department of Internal Medicine - Haematology and Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | - Patricia Ribaud
- Quality Unit, Pôle PréBloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany.,Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Catherine Cordonnier
- Hopital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Department of Haematology, Créteil, France.,Université Paris-Est-Créteil, Créteil, France
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Impact of oral voriconazole during chemotherapy for acute myeloid leukemia and myelodysplastic syndrome: a Japanese nationwide retrospective cohort study. Int J Clin Oncol 2019; 24:1449-1458. [DOI: 10.1007/s10147-019-01506-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/02/2019] [Indexed: 01/11/2023]
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19
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Micafungin prophylaxis for acute leukemia patients undergoing induction chemotherapy. BMC Cancer 2019; 19:358. [PMID: 30991992 PMCID: PMC6469030 DOI: 10.1186/s12885-019-5557-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/31/2019] [Indexed: 01/17/2023] Open
Abstract
Background Micafungin is a well-tolerated and effective prophylactic antifungal agent used in hematologic diseases. In this prospective trial, we evaluated the efficacy and safety of prophylactic micafungin during first induction chemotherapy in patients with acute leukemia. We also compared outcomes of prophylactic micafungin with those of prophylactic posaconazole in acute myeloid leukemia (AML). Methods Medically fit patients with newly diagnosed acute leukemia received 50 mg micafungin intravenously once daily from the initiation of first induction chemotherapy to recovery of neutrophil count, suspected fungal infection, or unacceptable drug-related toxicity (Clinicaltrials.gov number, NCT02440178). The primary end point was incidence of invasive fungal infection, and the secondary end points were adverse events of prophylactic micafungin and mortality during induction therapy. Results The 65 patients (median age = 51 years, male:female = 34:31) enrolled in this study had diagnoses of AML (33, 50.8%), acute lymphoblastic leukemia (31, 47.7%), and acute biphenotypic leukemia (1, 1.5%). Median duration of micafungin treatment was 24 days (range 1–68), with proven invasive fungal disease in one patient (1.5%) and possible fungal infection in two patients (3.1%). Three of the patients (4.6%) experienced the following adverse events, but all events were tolerable: liver function abnormality (Grade 2, n = 1; Grade 3, n = 1) and allergic reaction (Grade 2, n = 1). Three patients died during induction therapy, and invasive aspergillosis pneumonia was the cause of death for one of those patients. Overall, 19 patients (29.2%) discontinued prophylactic micafungin, and 18 (27.7%) patients switched to another antifungal agent. We observed no fungal infections caused by amphotericin B-resistant organisms. In AML patients, outcomes of prophylactic micafungin during induction chemotherapy did not differ significantly with those of prophylactic posaconazole with regard to incidence of fungal infections, rate of discontinuation, or safety. Conclusions Our study demonstrates that prophylactic micafungin is safe and effective in patients with acute leukemia undergoing induction chemotherapy. Outcomes in patients with AML were similar to those of prophylactic posaconazole, indicating the usefulness of micafungin as a prophylactic antifungal agent during induction chemotherapy for AML. Trial registration Clinicaltrials.gov NCT02440178, registered May 12th 2015.
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20
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Morris AL, Naeem M, Murray T, Sen J, Thomas T, Daniels E, DeGregory K, Lewis J, Keng M. Establishing an Antifungal Program to Reduce Invasive Fungal Infections in Patients With Acute Myeloid Leukemia Receiving Induction and Reinduction Chemotherapy. J Oncol Pract 2018; 14:JOP1800307. [PMID: 30433844 DOI: 10.1200/jop.18.00307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Twenty percent of patients with acute myeloid leukemia (AML) undergoing induction or reinduction chemotherapy at the University of Virginia Health System from May 2011 to August 2014 had a proven or probable invasive fungal infection (IFI). The purpose of our initiative was to reduce the percentage of proven or probable IFIs in patients with AML undergoing induction or reinduction chemotherapy at the University of Virginia Health System to 10% or less by June 2017, in concordance with national averages. METHODS: A multidisciplinary team was formed to lead the comprehensive quality improvement (QI) initiative. The team generated both current process state and ideal process state workflow diagrams, a cause-and-effect diagram, and a Pareto diagram to determine the most relevant etiology for proven or probable IFIs in patients with AML undergoing induction or reinduction chemotherapy. RESULTS: Analysis led to the creation of a program standardizing antifungal prophylaxis in this patient population, along with a suggested work-up for recalcitrant fevers. Through two tests of change (Plan-Do-Study-Act cycles 1 and 2), the QI initiative was able to effectively reduce the proven or probable IFI rate to 0% since program implementation in August 2016, thus surpassing both QI initiative goals and national rates of IFI. Mean length of stay (LOS) decreased by 3.4 days, and median intensive care unit LOS decreased by 2 days. CONCLUSION: Creation of a standardized antifungal prophylaxis program led to a marked decrease in LOS and the proven or probable IFI rate of patients with AML undergoing induction or reinduction chemotherapy.
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Affiliation(s)
- Amy L Morris
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Mohammed Naeem
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Torey Murray
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Jeremy Sen
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Tanya Thomas
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Elizabeth Daniels
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Kathlene DeGregory
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Jessica Lewis
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
| | - Michael Keng
- University of Virginia Health System, Charlottesville, VA; Atlanta Cancer Care, Atlanta, GA; and Medical University of South Carolina, Charleston, SC
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21
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Primary Fungal Prophylaxis in Hematological Malignancy: a Network Meta-Analysis of Randomized Controlled Trials. Antimicrob Agents Chemother 2018; 62:AAC.00355-18. [PMID: 29866872 DOI: 10.1128/aac.00355-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/19/2018] [Indexed: 12/19/2022] Open
Abstract
Several new antifungal agents have become available for primary fungal prophylaxis of neutropenia fever in hematological malignancy patients. Our aim was to synthesize all evidence on efficacy and enable an integrated comparison of all current treatments. We performed a systematic literature review to identify all publicly available evidence from randomized controlled trials (RCT). We searched Embase, PubMed, the Cochrane Central Register of Controlled Clinical Trials, and the www.ClinicalTrials.gov website. In total, 54 RCTs were identified, including 13 treatment options. The evidence was synthesized using a network meta-analysis. Relative risk (RR) was adopted. Posaconazole was ranked highest in effectiveness for primary prophylaxis, being the most favorable in terms of (i) the RR for reduction of invasive fungal infection (0.19; 95% confidence interval [CI], 0.11 to 0.36) and (ii) the probability of being the best option (94% of the cumulative ranking). Posaconazole also demonstrated its efficacy in preventing invasive aspergillosis and proven fungal infections, with RR of 0.13 (CI, 0.03 to 0.65) and 0.14 (CI, 0.05 to 0.38), respectively. However, there was no significant difference among all of the antifungal agents in all-cause mortality and overall adverse events. Our network meta-analysis provided an integrated overview of the relative efficacy of all available treatment options for primary fungal prophylaxis for neutropenic fever in hematological malignancy patients under myelosuppressive chemotherapy or hematopoietic cell transplantation. On the basis of this analysis, posaconazole seems to be the most effective prophylaxis option until additional data from head-to-head randomized controlled trials become available.
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22
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Schauwvlieghe AFAD, de Jonge N, van Dijk K, Verweij PE, Brüggemann RJ, Biemond BJ, Bart A, von dem Borne PA, Verbon A, van der Beek MT, Demandt AMP, Oudhuis GJ, Cornelissen JJ, van der Velden WJFM, Span LFR, Kampinga GA, Bruns AH, Vonk AG, Haas PJA, Doorduijn JK, Rijnders BJA. The diagnosis and treatment of invasive aspergillosis in Dutch haematology units facing a rapidly increasing prevalence of azole-resistance. A nationwide survey and rationale for the DB-MSG 002 study protocol. Mycoses 2018; 61:656-664. [PMID: 29687483 DOI: 10.1111/myc.12788] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 02/05/2023]
Abstract
Patients with haematological malignancies are at risk for invasive fungal diseases (IFD). A survey was conducted in all Dutch academic haematology centres on their current diagnostic, prophylactic and therapeutic approach towards IFD in the context of azole-resistance. In all 8 centres, a haematologist and microbiologist filled in the questionnaire that focused on different subgroups of haematology patients. Fungal prophylaxis during neutropaenia was directed against Candida and consisted of fluconazole and/or amphotericin B suspension. Mould-active prophylaxis was given to acute myeloid leukaemia patients during chemotherapy in 2 of 8 centres. All centres used azole prophylaxis in a subset of patients with graft-versus-host disease. A uniform approach towards the diagnosis and treatment of IFD and in particular azole-resistant Aspergillus fumigatus was lacking. In 2017, all centres agreed to implement a uniform diagnostic and treatment algorithm regarding invasive aspergillosis with a central role for comprehensive diagnostics and PCR-based detection of azole-resistance. This study (DB-MSG 002) will re-evaluate this algorithm when 280 patients have been treated. A heterogeneous approach towards antifungal prophylaxis, diagnosis and treatment was apparent in the Netherlands. Facing triazole-resistance, consensus was reached on the implementation of a uniform diagnostic approach in all 8 centres.
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Affiliation(s)
- Alexander F A D Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nick de Jonge
- Department of Haematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart J Biemond
- Department of Haematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Aldert Bart
- Department of Medical Microbiology (CINIMA), Academic Medical Center, Amsterdam, The Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelies Verbon
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Martha T van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Astrid M P Demandt
- Department of Haematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Guy J Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan J Cornelissen
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Lambert F R Span
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anke H Bruns
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alieke G Vonk
- Department of Medical Microbiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter-Jan A Haas
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeanette K Doorduijn
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
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Real-Life Challenges to the Use of Antifungal Agents in Hematology Patients. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pergam SA. Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:279-294. [PMID: 28477639 DOI: 10.1016/j.ccm.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.
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Affiliation(s)
- Steven A Pergam
- Vaccine & Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Infection Prevention, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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Rubinstein SM, Culos KA, Savani B, Satyanarayana G. Foiling fungal disease post hematopoietic cell transplant: review of prophylactic strategies. Bone Marrow Transplant 2017; 53:123-128. [PMID: 29058698 DOI: 10.1038/bmt.2017.222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 11/10/2022]
Abstract
Hematopoietic cell transplantation (HCT) offers definitive management for a wide variety of malignant and nonmalignant diseases. Conditioning regimens and therapies used to prevent and treat GvHD are immune suppressive, often increasing the risk of developing fungal disease due to yeasts or molds. Antifungal prophylaxis may be useful in preventing morbidity and mortality during and after HCT. In this article, we review the epidemiology and current literature regarding strategies for prevention of invasive fungal disease (IFD) in the pre-engraftment and post-engraftment settings, and propose future direction for scientific discovery.
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Affiliation(s)
- S M Rubinstein
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K A Culos
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - B Savani
- Division of Hematology/Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - G Satyanarayana
- Division of Infectious Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Irikuchi J, Imai T, Tanaka M, Tanuma M, Orii T, Kato T. Meta-analysis on the Influence of Antifungal Spectrum on Effectiveness of Empirical Antifungal Therapy for Febrile Neutropenia. YAKUGAKU ZASSHI 2017; 137:1117-1127. [DOI: 10.1248/yakushi.16-00216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital
| | | | | | - Takao Orii
- Department of Pharmacy, NTT Medical Center Tokyo
- Department of Pharmacy, Kawakita General Hospital
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Abstract
PURPOSE OF REVIEW Improved management of infectious complications of acute myeloid leukemia (AML) has contributed substantially to the success of care over the past half century. An important approach to reducing infectious complications during the induction period of chemotherapy involves the use of prophylactic antibacterial, antiviral, and antifungal agents targeting likely pathogens. RECENT FINDINGS There is not a one-size-fits-all approach to prophylaxis; every patient undergoing induction therapy should be evaluated individually and within the context of local microbiologic epidemiology and host risk factors. Pharmacologic and non-pharmacologic interventions as well as novel diagnostic platforms can help mitigate the risk of life-threatening infection in patients with AML who undergo induction chemotherapy.
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Affiliation(s)
- Matthew W McCarthy
- Division of General Internal Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, Box 331, New York, NY, 10065, USA.
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Medical Mycology Research Laboratory, Weill Cornell Medical Center, New York, NY, USA
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Nakashima K, Aoshima M, Nakashita T, Hara M, Otsuki A, Noma S, Misawa M, Otsuka Y, Motojima S. Low-dose trimethoprim-sulfamethoxazole treatment for pneumocystis pneumonia in non-human immunodeficiency virus-infected immunocompromised patients: A single-center retrospective observational cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:810-820. [PMID: 28779879 DOI: 10.1016/j.jmii.2017.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/15/2017] [Accepted: 07/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE The efficacy of low-dose trimethoprim-sulfamethoxazole (TMP-SMX) may be acceptable for the treatment of pneumocystis pneumonia (PCP) in non-human immunodeficiency virus (HIV)-infected patients, with a low incidence of adverse reactions. This study is aimed to evaluate the efficacy and safety of such a regimen for the treatment of non-HIV PCP. METHODS We retrospectively enrolled 24 consecutive patients diagnosed with non-HIV PCP who were treated with low-dose TMP-SMX (TMP, 4-10 mg/kg/day; SMX, 20-50 mg/kg/day). Data of the conventional-dose treatment were used as reference. The primary endpoints were the 30- and 180-day survival rates from the day of treatment, and secondary endpoints were the incidence of each adverse reaction and dropout rate from the initial TMP-SMX regimen. The survival rate was estimated using the Kaplan-Meier method with 95% confidence interval (CI). RESULTS The median age of patients was 72 years (54.2% men), and connective tissue disease was the most frequent underlying disease (66.7%) in the low-dose group. The 30- and 180-day survival rates were 95.8% (95% CI: 88.2-100.0%) and 91.0% (95% CI: 79.9%-100.0%), respectively, in the low-dose group and 69.0% (95% CI: 54.0%-88.0%) and 51.5% (95% CI: 36.1%-73.4%), respectively, in the conventional-dose group. The total adverse reaction rate was 58.3% in the low-dose group and 72.4% in the conventional-dose group. A total of 75.0% of patients in the low-dose group and 31.0% in the conventional-dose group completed treatment with the initial regimen. CONCLUSION Low-dose TMP-SMX may be a treatment option for patients with non-HIV PCP.
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Affiliation(s)
- Kei Nakashima
- Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan.
| | - Masahiro Aoshima
- Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Tamao Nakashita
- Department of Rheumatology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Masahiko Hara
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ayumu Otsuki
- Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Satoshi Noma
- Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Masafumi Misawa
- Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Yoshihito Otsuka
- Department of Laboratory Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Shinji Motojima
- Department of Rheumatology, Kameda Medical Center, Kamogawa, Chiba, Japan
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Boğa C, Bolaman Z, Çağırgan S, Karadoğan İ, Özcan MA, Özkalemkaş F, Saba R, Sönmez M, Şenol E, Akan H, Akova M. Recommendations for Risk Categorization and Prophylaxis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Expert Opinion (TEO-4). Turk J Haematol 2017; 32:100-17. [PMID: 26316478 PMCID: PMC4451478 DOI: 10.4274/tjh.2014.0277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This is the last of a series of articles on invasive fungal infections prepared by opinion leaders in Turkey. The aim of these articles is to guide clinicians in managing invasive fungal diseases in hematological malignancies and stem cell transplantation based on the available best evidence in this field. The previous articles summarized the diagnosis and treatment of invasive fungal disease and this article aims to explain the risk categorization and guide the antifungal prophylaxis in invasive fungal disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hamdi Akan
- Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey Phone: +90 532 424 26 40 E-mail:
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Miyao K, Sawa M, Kurata M, Suzuki R, Sakemura R, Sakai T, Kato T, Sahashi S, Tsushita N, Ozawa Y, Tsuzuki M, Kohno A, Adachi T, Watanabe K, Ohbayashi K, Inagaki Y, Atsuta Y, Emi N. A multicenter phase 2 study of empirical low-dose liposomal amphotericin B in patients with refractory febrile neutropenia. Int J Hematol 2016; 105:79-86. [DOI: 10.1007/s12185-016-2095-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 11/29/2022]
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Shah A, Ganesan P, Radhakrishnan V, Kannan K, Rajendranath R, Mahajan V, Vijayakumar V, Ganesan T, Sagar TG. Voriconazole is a safe and effective anti-fungal prophylactic agent during induction therapy of acute myeloid leukemia. Indian J Med Paediatr Oncol 2016; 37:53-8. [PMID: 27051159 PMCID: PMC4795377 DOI: 10.4103/0971-5851.177032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Antifungal prophylaxis (AFP) reduces the incidence of invasive fungal infections (IFIs) during induction therapy of acute myeloid leukemia (AML). Posaconazole is considered the standard of care. Voriconazole, a generic cheaper alternative is a newer generation azole with broad anti-fungal activity. There is limited data on the use of voriconazole as a prophylactic drug. Materials and Methods: A single-center, prospective study was performed during which patients with AML undergoing induction chemotherapy received voriconazole as AFP (April 2012 to February 2014). Outcomes were compared with historical patients who received fluconazole as AFP (January 2011-March 2012, n = 66). Results: Seventy-five patients with AML (median age: 17 years [range: 1-75]; male:female 1.6:1) received voriconazole as AFP. The incidence of proven/probable/possible (ppp) IFI was 6.6% (5/75). Voriconazole and fluconazole cohorts were well-matched with respect to baseline characteristics. Voriconazole (when compared to fluconazole) reduced the incidence of pppIFI (5/75, 6.6% vs. 19/66, 29%; P < 0.001), need to start therapeutic (empiric + pppIFI) antifungals (26/75, 34% vs. 51/66, 48%; P < 0.001) and delayed the start of therapeutic antifungals in those who needed it (day 16 vs. day 10; P < 0.001). Mortality due to IFI was also reduced with the use of voriconazole (1/75, 1.3% vs. 6/66, 9%; P = 0.0507), but this was not significant. Three patients discontinued voriconazole due to side-effects. Conclusion: Voriconazole is an effective and safe oral agent for IFI prophylaxis during induction therapy of AML. Availability of generic equivalents makes this a more economical alternative to posaconazole.
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Affiliation(s)
- Akash Shah
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | | | - Krishnarathinam Kannan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Rejiv Rajendranath
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Vandana Mahajan
- Department of Radiodiagnosis, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | | | - Trivadi Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Tenali Gnana Sagar
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
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Pham AN, Bubalo JS, Lewis JS. Comparison of posaconazole serum concentrations from haematological cancer patients on posaconazole tablet and oral suspension for treatment and prevention of invasive fungal infections. Mycoses 2016; 59:226-233. [PMID: 26742659 DOI: 10.1111/myc.12452] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/03/2015] [Accepted: 12/03/2015] [Indexed: 12/18/2022]
Abstract
Posaconazole tablet formulation (PTF) was developed to optimise bioavailability. This study compared posaconazole levels between patients on the PTF and oral suspension formulation (OSF). We also examined factors that may impact posaconazole levels. The primary and secondary objectives were analysed by comparing trough levels and attainment of target level between the formulation groups. For the 86 patients on PTF and 176 on OSF, the mean first levels was 1.32 μg ml-1 (SD = 0.69) and 0.81 μg ml-1 (SD = 0.59), P < 0.0001 respectively. PTF group was more likely to achieve levels ≥0.7 μg ml-1 than OSF group (OR 7.97 [95 CI; 3.75-16.93], P < 0.0001). Levels from patients on PTF and with presence of acid suppression, GI GVHD, mucositis or diarrhoea were not statistically different from those without these factors. For PTF, no correlation was found between patient's weight (kg) and levels (R2 = 0.0536, P = 0.035). The incidences of elevation in ALT/AST or Tbili were similar between the formulation groups. In conclusion, PTF should be considered the preferred formulation because it demonstrated better absorption than the OSF. Patients on PTF for prophylaxis are more likely to attain target level and may not routinely require therapeutic drug monitoring during prophylaxis.
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Affiliation(s)
- Aaron N Pham
- Department of Pharmacy Services, Oregon Health & Science University Hospital and Clinics, Portland, OR, USA
| | - Joseph S Bubalo
- Department of Pharmacy Services, Oregon Health & Science University Hospital and Clinics, Portland, OR, USA
| | - James S Lewis
- Department of Pharmacy Services, Oregon Health & Science University Hospital and Clinics, Portland, OR, USA
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Zhao YJ, Khoo AL, Tan G, Teng M, Tee C, Tan BH, Ong B, Lim BP, Chai LYA. Network Meta-analysis and Pharmacoeconomic Evaluation of Fluconazole, Itraconazole, Posaconazole, and Voriconazole in Invasive Fungal Infection Prophylaxis. Antimicrob Agents Chemother 2016; 60:376-86. [PMID: 26525782 PMCID: PMC4704197 DOI: 10.1128/aac.01985-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 10/22/2015] [Indexed: 11/20/2022] Open
Abstract
Invasive fungal infections (IFIs) are associated with high mortality rates and large economic burdens. Triazole prophylaxis is used for at-risk patients with hematological malignancies or stem cell transplants. We evaluated both the efficacy and the cost-effectiveness of triazole prophylaxis. A network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating fluconazole, itraconazole capsule and solution, posaconazole, and voriconazole was conducted. The outcomes of interest included the incidences of IFIs and deaths. This was coupled with a cost-effectiveness analysis from patient perspective over a lifetime horizon. Probabilities of transitions between health states were derived from the NMA. Resource use and costs were obtained from the Singapore health care institution. Data on 5,505 participants in 21 RCTs were included. Other than itraconazole capsule, all triazole antifungals were effective in reducing IFIs. Posaconazole was better than fluconazole (odds ratio [OR], 0.35 [95% confidence interval [CI], 0.16 to 0.73]) and itraconazole capsule (OR, 0.25 [95% CI, 0.06 to 0.97]), but not voriconazole (OR, 1.31 [95% CI, 0.43 to 4.01]), in preventing IFIs. Posaconazole significantly reduced all-cause deaths, compared to placebo, fluconazole, and itraconazole solution (OR, 0.49 to 0.54 [95% CI, 0.28 to 0.88]). The incremental cost-effectiveness ratio for itraconazole solution was lower than that for posaconazole (Singapore dollars [SGD] 12,546 versus SGD 26,817 per IFI avoided and SGD 5,844 versus SGD 12,423 per LY saved) for transplant patients. For leukemia patients, itraconazole solution was the dominant strategy. Voriconazole was dominated by posaconazole. All triazole antifungals except itraconazole capsule were effective in preventing IFIs. Posaconazole was more efficacious in reducing IFIs and all-cause deaths than were fluconazole and itraconazole. Both itraconazole solution and posaconazole were cost-effective in the Singapore health care setting.
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Affiliation(s)
- Ying Jiao Zhao
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Gloria Tan
- Pharmacoeconomics and Drug Utilisation, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Monica Teng
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Caroline Tee
- Department of Pharmacy, National University Health System, Singapore
| | - Ban Hock Tan
- Department of General Internal Medicine and Infectious Diseases, Singapore General Hospital, Singapore
| | - Benjamin Ong
- Pharmacoeconomics and Drug Utilisation, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Louis Yi Ann Chai
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore
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Wang L, Hu J, Sun Y, Huang H, Chen J, Li J, Ma J, Li J, Liang Y, Wang J, Li Y, Yu K, Hu J, Jin J, Wang C, Wu D, Xiao Y, Huang X. Does High-Dose Cytarabine Cause More Fungal Infection in Patients With Acute Myeloid Leukemia Undergoing Consolidation Therapy: A Multicenter, Prospective, Observational Study in China. Medicine (Baltimore) 2016; 95:e2560. [PMID: 26825897 PMCID: PMC5291567 DOI: 10.1097/md.0000000000002560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Invasive fungal infection (IFI) remains as a significant cause of morbidity and mortality in patients with acute myelogenous leukemia (AML). Here, we report the subgroup analysis of China Assessment of Antifungal Therapy in Haematological Disease (CAESAR) study to evaluate the risk of IFI in patients with AML in 1st remission receiving high-dose cytarabine (HiDAC) as consolidation. A total of 638 patients with AML in 1st complete remission were selected from the database. Among them, 130 patients received HiDAC alone with total dose of 2-3 g/m(2) × 6 while 508 patients received multiple-agent combination chemotherapy (multiagent chemo group). The patients' characteristics were generally not different but more patients in HiDAC group had peripherally inserted central catheter (61.5% vs 44.5%, P = 0.002). The median duration of neutropenia was 8.0 days in both HiDAC (2-20) and multiagent chemo group (2-28). Number of patients with prolonged neutropenia (>14 days) tended to be more in multiagent chemo group but not significant different (16.3% vs 8.8%, respectively). There was no significant difference between 2 groups in persistent neutropenic fever (40.8% vs 33.1%), antifungal treatment (11.5% vs 11.4%), and incidence of proven/probable IFI (4 probable in HiDAC vs 1 proven/4 probable in multiagent chemo, P = 0.35) or possible IFI. As to the clinical outcome in terms of duration of hospitalization and death in remission, there was a trend of shorter duration of hospitalization in HiDAC (19 days, 3-70) compare to multiagent chemo group (21 days, 1-367, P = 0.057) while no death documented in HiDAC group and only 2 patients died in the multiagent chemo group (0.4%). As to risk factors associated with IFI in all 638 patients, there was a trend of more IFI in patients with severe neutropenia (3.0%, P = 0.089) and previous history of IFI (3.85%, P = 0.086) while the antifungal prophylaxis was not associated significantly reduced IFI. Overall, our data support the perception that HiDAC alone as consolidation in first remission AML patients was well tolerated and not associated with increased hematological toxicity and IFI than conventional combination chemotherapy. Antifungal prophylaxis may not necessary except for patients with previous history of IFI.
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Affiliation(s)
- Ling Wang
- From the Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai (LW, JH); Peking University Institute of Hematology, Peking University, People's Hospital, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing (YS, XH); The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou (HH, JJ); Shanghai Children's Medical Center, Shanghai (JC); Jiangsu Province Hospital, Nanjing (JL); Harbin Hematologic Tumor Institution, Harbin (JM); The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou (JL); Tangdu Hospital, Fourth Military Medical University, Xi'an (YL); Changhai Hospital of the Second Military Medical University, Shanghai (JW); The First Affiliated Hospital of China Medical University, Shengyang (YL); The First Affiliated Hospital of Wenzhou Medical College, Wenzhou (KY); Fujian Medical University Union Hospital, Fuzhou (JH); The First People's Hospital of Shanghai, Shanghai (CW); The First Affiliated Hospital of Soochow University, Suzhou (DW); and The General Hospital of Guangzhou Military Command of PLA, Guangzhou, People's Republic of China (YX)
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Jeong SH, Kim DY, Jang JH, Mun YC, Choi CW, Kim SH, Kim JS, Park JS. Efficacy and safety of micafungin versus intravenous itraconazole as empirical antifungal therapy for febrile neutropenic patients with hematological malignancies: a randomized, controlled, prospective, multicenter study. Ann Hematol 2015; 95:337-44. [PMID: 26596974 PMCID: PMC4710659 DOI: 10.1007/s00277-015-2545-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 11/01/2015] [Indexed: 12/04/2022]
Abstract
Micafungin, a clinically important echinocandin antifungal drug, needs to be investigated as empirical therapy in febrile neutropenia in comparison with azole compounds. A prospective randomized study was conducted to compare clinical outcomes between micafungin and intravenous itraconazole as an empirical therapy for febrile neutropenia in hematological malignancies. The antifungal drug (micafungin 100 mg or itraconazole 200 mg IV once daily) was given for high fever that was sustained despite the administration of appropriate antibiotics. Treatment success was determined by composite end points based on breakthrough invasive fungal infection (IFI), survival, premature discontinuation, defervescence, and treatment of baseline fungal infection. Duration of fever, hospital stay, and overall survival (OS) were studied. A total of 153 patients were randomized to receive micafungin or itraconazole. The overall success rate was 7.1 % point higher in the micafungin group (64.4 vs. 57.3 %, p = 0.404), satisfying the statistical criteria for the non-inferiority of micafungin. The duration of fever and hospital stay were significantly shorter in the micafungin group (6 vs. 7 days, p = 0.014; 22 vs. 27 days, p = 0.033, respectively). Grade 3 adverse events including hyperbilirubinemia (2 vs. 7), elevation of transaminase levels (2 vs. 4), electrolyte imbalance (1 vs. 2), atrial fibrillation (1 vs. 0), and anaphylaxis (1 vs. 0) occurred in 7 and 13 patients in the micafungin (10.4 %) and itraconazole (18.8 %) groups, respectively. Micafungin, when compared with itraconazole, had favorably comparable success rate and toxicity profiles on febrile neutropenia in patients with hematological malignancies. In addition, it showed superior effect on shortening the hospital stay.
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Affiliation(s)
- Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University Hospital, Ajou Univesity School of Medicine, Suwon, South Korea
| | - Dae Young Kim
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Ho Jang
- Division of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans Univerity School of Medicine, Seoul, South Korea
| | - Chul Won Choi
- Division of Oncology-Hematology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joon Seong Park
- Department of Hematology-Oncology, Ajou University Hospital, Ajou Univesity School of Medicine, Suwon, South Korea.
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Primary antifungal prophylaxis during curative-intent therapy for acute myeloid leukemia. Blood 2015; 126:2790-7. [PMID: 26504183 DOI: 10.1182/blood-2015-07-627323] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/21/2015] [Indexed: 11/20/2022] Open
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Miceli MH, Perissinotti AJ, Kauffman CA, Couriel DR. Serum posaconazole levels among haematological cancer patients taking extended release tablets is affected by body weight and diarrhoea: single centre retrospective analysis. Mycoses 2015; 58:432-6. [DOI: 10.1111/myc.12339] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 03/02/2015] [Accepted: 03/24/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Marisa H. Miceli
- Division of Infectious Diseases; Department of Internal Medicine; University of Michigan Health System; Ann Arbor MI
| | | | - Carol A. Kauffman
- Division of Infectious Diseases; Department of Internal Medicine; University of Michigan Health System; Ann Arbor MI
- Veterans Affairs Ann Arbor Healthcare System; Ann Arbor MI
| | - Daniel R. Couriel
- Division of Hematology/Oncology; Department of Internal Medicine; University of Michigan Health System; Ann Arbor MI
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Frange P, Bougnoux ME, Lanternier F, Neven B, Moshous D, Angebault C, Lortholary O, Blanche S. An update on pediatric invasive aspergillosis. Med Mal Infect 2015; 45:189-98. [DOI: 10.1016/j.medmal.2015.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 04/09/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
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Vazin A, Davarpanah MA, Ghalesoltani S. Antifungal agent utilization evaluation in hospitalized neutropenic cancer patients at a large teaching hospital. Drug Healthc Patient Saf 2015; 7:97-102. [PMID: 26064070 PMCID: PMC4457220 DOI: 10.2147/dhps.s80762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To evaluate pattern of using of three antifungal drugs: fluconazole, amphotericin B and voriconazole, at the hematology-oncology and bone marrow transplant wards of one large teaching hospital. In a prospective cross-sectional study, we evaluated the appropriateness of using antifungal drugs in patients, using Infectious Disease Society of America (IDSA) and National Comprehensive Cancer Network (NCCN) guidelines. All the data were recorded daily by a pharmacist in a form designed by a clinical pharmacist and infectious diseases specialist, for antifungals usage, administration, and monitoring. During the study, 116 patients were enrolled. Indications of prescribing amphotericin B, fluconazole, and voriconazole were appropriate according to guidelines in 83.4%, 80.6%, and 76.9% respectively. The duration of treatments were appropriate according to guidelines in 75%, 64.5%, and 71.1% respectively. The dose of voriconazole was appropriate according to guidelines in 46.2% of patients. None of the patients received salt loading before administration of amphotericin B. The most considerable problems with the mentioned antifungals were about the indications and duration of treatment. In addition, prehydration for amphotericin B and dosage of voriconazole were not completely compatible with the mentioned guidelines. A suitable combination of controlling the use of antifungals and educational programs could be essential for improving the general process of using antifungal drugs at our hospital.
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Affiliation(s)
- Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Setareh Ghalesoltani
- International Branch of Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Abraha I, Cherubini A, Cozzolino F, De Florio R, Luchetta ML, Rimland JM, Folletti I, Marchesi M, Germani A, Orso M, Eusebi P, Montedori A. Deviation from intention to treat analysis in randomised trials and treatment effect estimates: meta-epidemiological study. BMJ 2015; 350:h2445. [PMID: 26016488 PMCID: PMC4445790 DOI: 10.1136/bmj.h2445] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To examine whether deviation from the standard intention to treat analysis has an influence on treatment effect estimates of randomised trials. DESIGN Meta-epidemiological study. DATA SOURCES Medline, via PubMed, searched between 2006 and 2010; 43 systematic reviews of interventions and 310 randomised trials were included. ELIGIBILITY CRITERIA FOR SELECTING STUDIES From each year searched, random selection of 5% of intervention reviews with a meta-analysis that included at least one trial that deviated from the standard intention to treat approach. Basic characteristics of the systematic reviews and randomised trials were extracted. Information on the reporting of intention to treat analysis, outcome data, risk of bias items, post-randomisation exclusions, and funding were extracted from each trial. Trials were classified as: ITT (reporting the standard intention to treat approach), mITT (reporting a deviation from the standard approach), and no ITT (reporting no approach). Within each meta-analysis, treatment effects were compared between mITT and ITT trials, and between mITT and no ITT trials. The ratio of odds ratios was calculated (value <1 indicated larger treatment effects in mITT trials than in other trial categories). RESULTS 50 meta-analyses and 322 comparisons of randomised trials (from 84 ITT trials, 118 mITT trials, and 108 no ITT trials; 12 trials contributed twice to the analysis) were examined. Compared with ITT trials, mITT trials showed a larger intervention effect (pooled ratio of odds ratios 0.83 (95% confidence interval 0.71 to 0.96), P=0.01; between meta-analyses variance τ(2)=0.13). Adjustments for sample size, type of centre, funding, items of risk of bias, post-randomisation exclusions, and variance of log odds ratio yielded consistent results (0.80 (0.69 to 0.94), P=0.005; τ(2)=0.08). After exclusion of five influential studies, results remained consistent (0.85 (0.75 to 0.98); τ(2)=0.08). The comparison between mITT trials and no ITT trials showed no statistical difference between the two groups (adjusted ratio of odds ratios 0.92 (0.70 to 1.23); τ(2)=0.57). CONCLUSIONS Trials that deviated from the intention to treat analysis showed larger intervention effects than trials that reported the standard approach. Where an intention to treat analysis is impossible to perform, authors should clearly report who is included in the analysis and attempt to perform multiple imputations.
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Affiliation(s)
- Iosief Abraha
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology, 06124 Perugia, Italy
| | - Antonio Cherubini
- Geriatrics and Geriatric Emergency Care, Italian National Research Centre on Aging Ancona, Italy
| | - Francesco Cozzolino
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology, 06124 Perugia, Italy
| | | | | | - Joseph M Rimland
- Geriatrics and Geriatric Emergency Care, Italian National Research Centre on Aging Ancona, Italy
| | - Ilenia Folletti
- Department of Clinical and Experimental Medicine, University of Perugia, Perugia
| | - Mauro Marchesi
- Transfusion Medicine Service, Azienda Ospedaliera di Perugia, Perugia
| | - Antonella Germani
- Transfusion Medicine Service, Azienda Ospedaliera di Perugia, Perugia
| | - Massimiliano Orso
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology, 06124 Perugia, Italy
| | - Paolo Eusebi
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology, 06124 Perugia, Italy
| | - Alessandro Montedori
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology, 06124 Perugia, Italy
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Cohen N, Seo SK. Role of antimicrobial prophylaxis during treatment of adults with acute leukemia. Int J Hematol Oncol 2015. [DOI: 10.2217/ijh.15.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Patients with acute leukemia (AL) are at high risk for developing bacterial, viral and fungal infections during chemotherapy. Because these infections cause considerable morbidity and mortality, prevention is attractive. In recent decades, several trials have established the benefit of prophylactic antimicrobials in patients with AL. Administration of prophylactic fluoroquinolone, acyclovir and triazole is recommended in neutropenic patients with AL by both the USA and European national guidelines. The potential for antimicrobial resistance as a long-term consequence of prophylaxis, however, is a concern. The recent development of nonculture-based diagnostic tests for invasive fungal infections has made early diagnosis and targeted treatment a promising future strategy as an alternative to mold-active prophylaxis.
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Affiliation(s)
- Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Susan K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Weekly use of fluconazole as prophylaxis in haematological patients at risk for invasive candidiasis. BMC Infect Dis 2014; 14:573. [PMID: 25384689 PMCID: PMC4233028 DOI: 10.1186/s12879-014-0573-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 10/17/2014] [Indexed: 01/08/2023] Open
Abstract
Background The goal was to determine whether one medical centres’ unique antifungal prophylactic regimen for patients at high risk for invasive candidiasis because of their haematological malignancies, haematopoietic stem cell transplants, or high-dose chemotherapy might lead ultimately to a higher incidence of infection, to increasing fluconazole resistance, or to a shift in the predominant strain of Candida in invasive fungal episodes. Methods Data were collected retrospectively, for a ten-year period from ONKO-KISS surveillance records, and from hospital, medical, and pharmacy records and then evaluated with respect to incidence of fungal infection episodes, emergence of antifungal drug resistance, and predominance of specific Candida strains in isolate cultures. Fisher’s exact test and linear regression were used to compare minimum inhibitory concentrations and to compare the incidence of different Candida isolates, respectively. Results The incidence of infection remained quite stable over 10 years with a median of 0.67 episodes/1000 bed days. Overall, Candida glabrata was the predominant species with 29% followed by C. albicans and C. krusei (14% each). No significant increment of non-albicans Candida species with decreased fluconazole susceptibility was perceived over this decade. Conclusions Once weekly administration of 400 mg of fluconazole to prevent candidaemia appears to have no negative impact on the efficacy as a prophylaxis when compared to standard of care (400 mg of fluconazole daily). Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0573-5) contains supplementary material, which is available to authorized users.
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Tragiannidis A, Tsoulas C, Groll AH. Invasive candidiasis and candidaemia in neonates and children: update on current guidelines. Mycoses 2014; 58:10-21. [PMID: 25350572 DOI: 10.1111/myc.12268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/03/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
Invasive candidiasis (IC) and candidaemia are leading causes of infectious morbidity and mortality among immunocompromised paediatric patients and those admitted to intensive care units. Despite improvements in diagnosis, prevention and treatment, both mortality rates and the economic burden of disease still remain high. To address this issue, several international societies and organisations have proposed guidelines for the management of IC/candidaemia in both neonates and children. In this article, we review current recommendations of the Infectious Diseases Society of America, the European Conference on Infection in Leukaemia, the European Society of Clinical Microbiology and Infectious Diseases and the German Speaking Mycological Society/Paul-Ehrlich Society for Chemotherapy for the management and prevention of IC/candidaemia in children and neonates.
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Affiliation(s)
- Athanasios Tragiannidis
- Hematology Oncology Unit, 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Gøtzsche PC, Johansen HK. Routine versus selective antifungal administration for control of fungal infections in patients with cancer. Cochrane Database Syst Rev 2014; 2014:CD000026. [PMID: 25188768 PMCID: PMC6457640 DOI: 10.1002/14651858.cd000026.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Systemic fungal infection is considered to be an important cause of morbidity and mortality in cancer patients, particularly those with neutropenia. Antifungal drugs are often given prophylactically, or empirically to patients with persistent fever. OBJECTIVES To assess whether commonly used antifungal drugs decrease mortality in cancer patients with neutropenia. SEARCH METHODS We searched PubMed from 1966 to 7 July 2014 and the reference lists of identified articles. SELECTION CRITERIA Randomised clinical trials of amphotericin B, fluconazole, ketoconazole, miconazole, itraconazole or voriconazole compared with placebo or no treatment in cancer patients with neutropenia. DATA COLLECTION AND ANALYSIS The two review authors independently assessed trial eligibility and risk of bias, and abstracted data. MAIN RESULTS Thirty-two trials involving 4287 patients were included. Prophylactic or empirical treatment with amphotericin B significantly decreased total mortality (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.96), whereas the estimated RRs for fluconazole, ketoconazole, miconazole, and itraconazole were close to 1.00. No eligible trials were found with voriconazole. Amphotericin B and fluconazole decreased mortality ascribed to fungal infection (RR 0.45, 95% CI 0.26 to 0.76 and RR 0.42, 95% CI 0.24 to 0.73, respectively). The incidence of invasive fungal infection decreased significantly with administration of amphotericin B (RR 0.41, 95% CI 0.24 to 0.73), fluconazole (RR 0.39, 95% CI 0.27 to 0.57) and itraconazole (RR 0.53, 95% CI 0.29 to 0.97), but not with ketoconazole or miconazole. Effect estimates were similar for those 13 trials that had adequate allocation concealment and were blinded. The reporting of harms was far too variable from trial to trial to allow a meaningful overview. For the 2011 and 2014 updates no additional trials were identified for inclusion. AUTHORS' CONCLUSIONS Intravenous amphotericin B was the only antifungal agent that reduced total mortality. It should therefore be preferred when prophylactic or empirical antifungal therapy is introduced in cancer patients with neutropenia.
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Affiliation(s)
- Peter C Gøtzsche
- RigshospitaletNordic Cochrane CentreBlegdamsvej 9, 7811CopenhagenDenmarkDK‐2100
| | - Helle Krogh Johansen
- RigshospitaletThe Nordic Cochrane CentreBlegdamsvej 9, 3343CopenhagenDenmarkDK 2100
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Takaoka K, Nannya Y, Shinohara A, Arai S, Nakamura F, Kurokawa M. A novel scoring system to predict the incidence of invasive fungal disease in salvage chemotherapies for malignant lymphoma. Ann Hematol 2014; 93:1637-44. [PMID: 24908330 DOI: 10.1007/s00277-014-2093-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/21/2014] [Indexed: 11/28/2022]
Abstract
The requirement of antifungal prophylaxis has not been established in the chemotherapies for malignant lymphoma. This study was conducted to explore the incidence of invasive fungal diseases (IFD) and their risk factors in patients receiving salvage therapies for malignant lymphoma. We retrospectively analyzed 177 consecutive patients who received these therapies (705 courses in total) at our institute. IFD were observed in 16 courses and the incidence was 2.3 %. A multivariate analysis showed that the factors associated with IFD were primary refractoriness (adjusted odds ratio (aOR), 4.22; 95 % confidence interval (CI), 1.38-13.0; p value = 0.012), two (aOR, 10.5, 95 % CI, 1.20-91.7; p = 0.033) or more (aOR, 26.2; 95 % CI, 3.27-210; p = 0.002) previous treatment lines, and the minimum neutrophil count during the therapies equal to or less than 500/μL (aOR, 9.69; 95 % CI, 1.25-74.9; p = 0.030). Using these factors, we created the IFD scoring model by assigning one point to each of primary refractoriness, two previous treatment lines and treatment that caused neutropenia (≤500/μL minimal neutrophil count) and two points to three or more previous treatment lines. The IFD incidence of lower risk group (IFD score <3) was 0.19 % and that of higher (IFD score ≥3) was 9.0 %. In conclusion, adequate prophylaxis for IFD might be required for patients with primary refractoriness, repeated therapies, or therapies which cause neutropenia. Furthermore, the IFD scoring model of this study underscores the need to account for disease and host factors in determining administration of adequate prophylaxis in salvage treatments for malignant lymphoma.
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Affiliation(s)
- Kensuke Takaoka
- Department of Hematology & Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo City, Tokyo, 1138655, Japan
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Science M, Robinson PD, MacDonald T, Rassekh SR, Dupuis LL, Sung L. Guideline for primary antifungal prophylaxis for pediatric patients with cancer or hematopoietic stem cell transplant recipients. Pediatr Blood Cancer 2014; 61:393-400. [PMID: 24424789 DOI: 10.1002/pbc.24847] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 10/14/2013] [Indexed: 12/30/2022]
Abstract
This guideline provides clinicians with evidence-based recommendations on the use of antifungal prophylaxis in children with cancer and undergoing hematopoietic stem cell transplantation (HSCT). Recommendations are divided into: (1) allogeneic HSCT (2) autologous HSCT (3) acute myeloid leukemia or myelodysplastic syndrome and (4) patients with malignancy and neutropenia for >7 days. A systematic review was conducted and evidence summaries compiled. The quality of evidence and strength of each recommendation was determined using GRADE. Implementation of these recommendations will require adaptation to local context. The contribution of this guideline in the prevention of invasive fungal infections requires prospective evaluation.
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Affiliation(s)
- Michelle Science
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton Health Sciences, Hamilton, Ontario
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Ziakas PD, Kourbeti IS, Mylonakis E. Systemic antifungal prophylaxis after hematopoietic stem cell transplantation: a meta-analysis. Clin Ther 2014; 36:292-306.e1. [PMID: 24439393 DOI: 10.1016/j.clinthera.2013.11.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/16/2013] [Accepted: 11/03/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hematopoietic stem transplant recipients are subject to increased risk for invasive fungal infections. OBJECTIVE This meta-analysis was undertaken to explore the comparative effectiveness of systemic antifungal prophylaxis in hematopoietic stem cell transplant recipients. METHODS We searched PubMed and The Cochrane Register of Randomized Controlled Trials up to March 2013 for randomized studies on systemic antifungal prophylaxis after hematopoietic stem cell transplantation. We performed a meta-analysis on the relative effectiveness of systemic antifungal prophylaxis on proven or probable invasive fungal infections using direct and indirect effects. Relative effectiveness was reported as odds ratio (OR) for invasive fungal infections, causative agent, empirical antifungal therapy, and withdrawals due to drug adverse events. RESULTS Twenty evaluable studies provided data on 4823 patients. The risk for invasive fungal infections while on prophylaxis was 5.1% (95% CI, 3.6-6.8%). In patients receiving fluconazole, risks of proven or probable invasive fungal infections (OR = 0.24; 95% CI, 0.11-0.50; number needed to treat [NNT] = 8), systemic candidiasis (OR = 0.11; 95% CI, 0.05-0.24; NNT = 7), and overall need for empiric antifungal treatment (OR = 0.60; 95% CI, 0.44-0.82; NNT = 8) were reduced compared with patients receiving placebo. Itraconazole was more effective than fluconazole for the prevention of aspergillosis (OR = 0.40; 95% CI, 0.19-0.83; NNT = 23) at the expense of more frequent withdrawals (OR = 3.01; 95% CI, 1.77-5.13; number needed to harm = 6). Micafungin was marginally more effective than fluconazole for the prevention of all mold infections (OR = 0.35; 95% CI, 0.10-1.18; NNT = 79) and invasive aspergillosis (OR = 0.19; 95% CI, 0.03-1.11; NNT = 78) and reducing the need for empiric antifungal treatment (OR = 0.40; 95% CI, 0.13-1.21; NNT = 8). There was a relative lack of comparisons between different antifungal prophylactic strategies, including the newer azoles, voriconazole and posaconazole, in this population. Direct effects derived from single studies showed marginally significant effects for voriconazole compared with fluconazole regarding invasive aspergillosis (OR = 0.50; 95% CI, 0.20-1.20; NNT = 35) and the need for empiric treatment (OR = 0.72; 95% CI, 0.50-1.06; NNT = 15). Voriconazole compared with itraconazole (OR = 0.59; 95% CI, 0.40-0.88; NNT = 8) and posaconazole compared with amphotericin B (OR = 0.28; 95% CI, 0.06-1.24, marginal significance; NNT = 3) were better regarding empirical antifungal treatment. CONCLUSIONS Even when on antifungal therapy, invasive fungal infection will develop in 1 of 20 patients undergoing hematopoietic stem cell transplantation. There is evidence for the comparable effectiveness of different antifungal drugs used for prophylaxis. Fluconazole is the most widely studied agent, but micafungin might prove to be more effective. There is a relative paucity of studies for the newer azoles, although both voriconazole and posaconazole give proof of their comparative or higher effectiveness to fluconazole in single randomized studies.
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Affiliation(s)
- Panayiotis D Ziakas
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island; Warren Alpert Medical School of Brown University, Rhode Island
| | - Irene S Kourbeti
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island; Warren Alpert Medical School of Brown University, Rhode Island
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island; Warren Alpert Medical School of Brown University, Rhode Island.
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Hicheri Y, Toma A, Maury S, Pautas C, Mallek-Kaci H, Cordonnier C. Updated guidelines for managing fungal diseases in hematology patients. Expert Rev Anti Infect Ther 2014; 8:1049-60. [DOI: 10.1586/eri.10.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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