A Single Center Experience for Antifungal Prophylaxis in Patients with Acute Myelogenous Leukemia

Incidence of Invasive Fungal Infections in Acute Myeloid Leukemia Without Antifungal Prophylaxis

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.

Invasive Fungal Infections in Patients with Acute Myeloid Leukemia Undergoing Intensive Chemotherapy

Patients with hematological malignancies are severely immunocompromised and are at high risk of invasive fungal infection (IFI), particularly those undergoing remission-induction chemotherapy for acute myeloid leukemia (AML). IFIs are a major cause of morbidity and mortality in such patients. We planned to study the incidence of IFI in patients with AML undergoing intensive chemotherapy and receiving antifungal prophylaxis. We retrospectively reviewed consecutive 46 patients with non-M3 AML, who received induction chemotherapy and systemic antifungal prophylaxis. None of the patients had IFI at the time of initiation of the chemotherapy. Patients were monitored for the occurrence of IFI using high-resolution computerized tomography of the chest or para-nasal sinus and test for galactomannan antigen on serum or broncho-alveolar lavage and were followed up for 90 days. Of the 46 patients on intensive chemotherapies, 41, 4 and 1 patients were started on posaconazole, amphotericin B and voriconazole prophylaxis, respectively. The occurrence of possible and probable IFI was observed in 16 and 4 patients respectively, in which 19 patients were on posaconazole and 1 patient was on amphotericin-B prophylaxis. Overall mortality in the study population was 11 (23.9%). Four out of 20 patients died with IFI but none of the death was attributable to IFI. IFI still remains a significant cause of morbidity and mortality in patients with AML despite universal use of antifungal prophylaxis. With effective pharmacotherapy, the mortality due to IFI is preventable. Appropriate antifungal prophylaxis strategy still needs to be developed through larger and prospective studies.

The importance of risk factors for the prediction of patients with invasive pulmonary aspergillosis

OBJECTIVE

Invasive pulmonary aspergillosis (IPA) is a major challenge in the management of immunocompromised patients. Despite all the advances in diagnosis, it remains a problem. The purpose of our study was to investigate the risk factors associated with IPA seen in patients with hematological malignancies.

METHOD

A total of 152 febrile neutropenia (FEN) patients with hematological malignancies aged over 18 years and receiving high-dose chemotherapy or stem cell transplant between January 1, 2010, and December 31, 2012 were included in the study. Sixty-five (65) cases with IPA according to the European Organization for the Research and Treatment of Cancer and Infectious Diseases Mycoses Study Group criteria were enrolled as the case group, while 87 patients without IPA development during concomitant monitoring were enrolled as the control group. Incidence of IPA was 21.4% (3/14) in patients receiving bone marrow transplant (allogeneic 2, autologous 1) and those cases were also added into the case group. The two groups were compared in terms of demographic, clinical and laboratory findings and risk factors associated with IPA investigated retrospectively.

RESULTS

Presence of relapse of primary disease, neutropenia for more than 3 weeks, presence of bacterial infection, and non-administration of antifungal prophylaxis were identified as risk factors associated with IPA.

CONCLUSION

It may be possible to reduce the incidence of the disease by eliminating preventable risk factors. Predicting those risks would, per se, enable early diagnosis and treatment and, thus, the mortality rate of these patients would unquestionably decline.