Critical review of current clinical practice guidelines for antifungal therapy in paediatric haematology and oncology

Antifungal Prophylaxis Utilization and the Associated Clinical Outcomes Among Pediatric Patients with Hematological Malignancies or Undergoing Hematopoietic Stem Cell Transplantation

Background/Objectives: Invasive fungal infections (IFIs) are a prevalent complication of intensive chemotherapy and hematopoietic stem cell transplantation (HSCT) in the pediatric population and are associated with high morbidity and mortality. We aimed to identify the utilization of antifungal prophylaxis prescriptions and the associated clinical outcomes. Methods: A retrospective study included children (≤18 years old) diagnosed with hematological malignancies or undergoing HSCT who are at high risk for developing IFI and received systemic antifungal therapy between January 2018 and April 2024 at Sultan Qaboos University Hospital (SQUH), Oman. Results: A powered sample of 222 patients was included, and 208 (93.69%) received antifungal prophylaxis. Among those who received prophylaxis, 148 (66.67%) received appropriate prophylaxis, 86.06% (n = 179) received appropriate dosage. The patients who did not receive antifungal prophylaxis had higher rates of inpatient IFI requiring treatment (85.71% versus 12.02%, p < 0.01), a longer median length of hospital stay (LOS) (67.5 days versus 10 days, p = 0.015), and more incidence of 90-day all-cause mortality (21.43% versus 2.88%, p < 0.01) than those who received antifungal prophylaxis. Survival analysis demonstrated that these patients had a 12% higher risk for earlier death. Also, being on antifungal prophylaxis reduces the odds of inpatient IFI requiring treatment, with an adjusted odds ratio (aOR) of 0.13 [95% CI: 0.019-0.801]. Conclusions: Antifungal prophylaxis utilization was high, and it markedly decreases the occurrence and enhances the prognosis of IFI. Nonetheless, inconsistencies in practice and a lack of pediatric-specific data underscore the necessity for uniform guidelines and additional research to strengthen preventative methods in this population, and proper TDM utilization could provide more robust insights.

Classification performance of administrative coding data for detection of invasive fungal infection in paediatric cancer patients

BACKGROUND

Invasive fungal infection (IFI) detection requires application of complex case definitions by trained staff. Administrative coding data (ICD-10-AM) may provide a simplified method for IFI surveillance, but accuracy of case ascertainment in children with cancer is unknown.

OBJECTIVE

To determine the classification performance of ICD-10-AM codes for detecting IFI using a gold-standard dataset (r-TERIFIC) of confirmed IFIs in paediatric cancer patients at a quaternary referral centre (Royal Children's Hospital) in Victoria, Australia from 1st April 2004 to 31st December 2013.

METHODS

ICD-10-AM codes denoting IFI in paediatric patients (<18-years) with haematologic or solid tumour malignancies were extracted from the Victorian Admitted Episodes Dataset and linked to the r-TERIFIC dataset. Sensitivity, positive predictive value (PPV) and the F1 scores of the ICD-10-AM codes were calculated.

RESULTS

Of 1,671 evaluable patients, 113 (6.76%) had confirmed IFI diagnoses according to gold-standard criteria, while 114 (6.82%) cases were identified using the codes. Of the clinical IFI cases, 68 were in receipt of ≥1 ICD-10-AM code(s) for IFI, corresponding to an overall sensitivity, PPV and F1 score of 60%, respectively. Sensitivity was highest for proven IFI (77% [95% CI: 58-90]; F1 = 47%) and invasive candidiasis (83% [95% CI: 61-95]; F1 = 76%) and lowest for other/unspecified IFI (20% [95% CI: 5.05-72%]; F1 = 5.00%). The most frequent misclassification was coding of invasive aspergillosis as invasive candidiasis.

CONCLUSION

ICD-10-AM codes demonstrate moderate sensitivity and PPV to detect IFI in children with cancer. However, specific subsets of proven IFI and invasive candidiasis (codes B37.x) are more accurately coded.