Early diagnosis and preemptive therapy of pulmonary mold infections in high-risk patients

Abstract

The management of pulmonary mold infections in at-risk patients is hampered by the difficulty in diagnosing these infections. Therefore, most practitioners rely on universal prophylaxis and on the early empirical use of antifungals, especially in neutropenic cancer patients and stem cell transplant recipients. However, a strategy of preemptive or diagnostic-driven antifungal therapy is being explored based on advances in imaging techniques and in fungal antigen detection methods. This article highlights the controversies surrounding the prevention and the early treatment of invasive mold infections in high-risk patients.

ESCMID guideline for the diagnosis and management of Candida diseases 2012: adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT)

“…The term ‘pre‐emptive treatment’ is associated more with filamentous fungi infections than with Candida ‐associated diseases. This approach is not driven by persistent fever or neutropenia but rather by galactomannan antigen detection in serum and/or BAL fluid or high‐resolution CT scan in high‐risk patients [58]. The role 1,3‐ ß ‐ d ‐glucan and PCR testing for aspergillosis/candidiasis remains controversial [59,60].…”

“…Whether or not any kind of infiltrate in the presence of Aspergillus galactomannan should trigger antifungal therapy is still debatable, although few experts would not add an antifungal agent in all of these situations. Some experts wait for Aspergillus associated typical radiographic signs [halo, wedge shaped, air crescent or cavity] before starting treatment [58]. Other authors are more flexible [61,62].…”

Galactomannan-guided preemptive vs. empirical antifungals in the persistently febrile neutropenic patient: a prospective randomized study

“…Such an approach, variously termed 'preemptive' and 'presumptive', represents an alternative to empirical antifungals. [16][17][18] It is modeled on the successful strategy against CMV in transplantation. 19 We employed prophylaxis in this study as it is the routine in our department for patients likely to experience prolonged neutropenia.…”

“…18 Because of the retrospective nature of this study, a bias cannot be excluded. 16 The use of diagnostic modalities to trigger antifungals has been shown to reduce the need for their use. In a non-randomized study, Maertens et al assayed GM daily in at-risk hematological patients, until neutropenia resolved.…”