Antifungal Prophylaxis: Why, What and How?

Abstract

41st Annual Meeting of the European Society for Blood and Marrow Transplantation (EBMT 2015), Istanbul, Turkey, 22-25 March 2015 The European Society for Blood and Marrow Transplantation (EBMT) is the leading scientific society for professionals involved in hematopoietic stem-cell transplantation (HSCT) and represents 563 transplant centers from 57 countries within and outside Europe. Each year, the EBMT Annual Meeting brings together over 4,500 scientists, physicians, nurses, biologists, technicians and patients to discuss scientific data that build on past achievements in the field of HSCT. The procedure offers the chance of long-term remission of hematological and lymphoid cancers, but patients are at increased risk of serious infections, especially after allogeneic HSCT. These infections include the invasive fungal infections that were among the important topics discussed during EBMT 2015.

Candidaemia in haematological malignancy patients from a SEIFEM study: Epidemiological patterns according to antifungal prophylaxis

“…Despite the introduction of newer antifungal agents, 24 candidaemia (the most common form of invasive candidiasis) is associated with unacceptably high mortality rates 25 . To reduce the burden of candidaemia and Candida‐ related mortality in high‐risk patients (especially AML or HSCT patients), haematology and/or HSCT units in many hospitals are increasingly adopting systemic antifungal prophylaxis 4 . A comparison of two large SEIFEM studies conducted in two 5‐year periods (1999‐2003 and 2011‐2015) showed a significant decrease in the overall incidence of candidaemia in patients who received chemotherapy for haematology malignancies (170/9258 [1.8%] vs 135/16 529 [0.8%]; P < .001) 10 .…”

“…Since 2005, the European Conference in Infections in Leukaemia (ECIL) designed evidence‐based clinical guidelines to improve the management of patients at high risk of infectious complications due to the treatment of leukaemia or following HSCT 4 . The latest ECIL guidelines included the use of mould‐active antifungal prophylaxis to prevent IFD 4 .…”

“…Since 2005, the European Conference in Infections in Leukaemia (ECIL) designed evidence‐based clinical guidelines to improve the management of patients at high risk of infectious complications due to the treatment of leukaemia or following HSCT 4 . The latest ECIL guidelines included the use of mould‐active antifungal prophylaxis to prevent IFD 4 . In 2018, using the IDSA grading system, posaconazole became the drug of choice (A‐I), whereas fluconazole received a B‐I recommendation, for primary antifungal prophylaxis in adult patients undergoing intensive chemotherapy for AML or myelodysplastic syndrome 33 .…”

“…Unlike fluconazole, both itraconazole and voriconazole have a B‐I recommendation for antifungal prophylaxis when the baseline incidence of invasive mould infections is high 33 . However, the apparent superiority of posaconazole counterbalances the need for therapeutic drug monitoring, 4 despite the recently introduced oral tablet formulation that enables more patients to achieve therapeutic serum levels 24 . The reasons why physicians from the present study’s haematology centres chose to use (20 centres) or not use (six centres) an antifungal prophylactic strategy, as well as to use azoles (or a type of azole), echinocandins, or amphotericin B for prophylaxis, are unknown.…”

“…Consequently, the success of long‐term remission achieved by haematopoietic stem‐cell transplantation (HSCT) in these patients clashes with the high risk for IFD in (allogeneic or autologous) HSCT recipients due to the chemotherapy‐induced neutropenia 3 . This situation has provided the basis for applying antifungal prophylaxis not only in HSCT recipients 4 but, preferably, in other high‐risk haematological patients such as those with acute myeloid leukaemia (AML) or myelodysplasia undergoing intensive chemotherapy 5 …”