Antifungal prophylaxis in bone marrow transplantation

The role of primary antifungal prophylaxis in patients with haematological malignancies

Invasive fungal infections (IFIs) represent important complications in patients with haematological malignancies. Chemoprevention of IFIs may play an important role in this setting, but in the past decades the majority of antifungal drugs utilized demonstrated poor efficacy, particularly in the prevention of invasive aspergillosis. The new triazoles are very useful antifungal drugs, more suitable for prophylaxis of IFIs than amphotericin B and echinocandins. In this review, the main clinical data about antifungal prophylaxis with fluconazole, itraconazole, voriconazole and posaconazole are analysed. At present, posaconazole appears to be the most efficacious azole in antifungal prophylaxis, particularly in patients with acute myeloid leukaemia.

Early tooth loss due to cyclic neutropenia: long-term follow-up of one patient

In young patients with abnormal loosening of teeth and periodontal breakdown, dental professionals should consider a wide range of etiological factors/diseases, analyze differential diagnoses, and make appropriate referrals. The long-term oral and dental follow-up of a female patient diagnosed in early infancy with cyclic neutropenia is reviewed, and recommendations for care are discussed.

T cell vaccination in mice with invasive pulmonary aspergillosis

Aspergillus fumigatus, an opportunistic fungal pathogen, is responsible for multiple airway diseases of an allergic and a nonallergic nature. In a murine model of invasive pulmonary aspergillosis, resistance is associated with a decreased lung inflammatory pathology and the occurrence of an IL-12-dependent Th1-type reactivity that are both impaired by IL-4. In the present study we assess the ability of Aspergillus crude culture filtrate Ags and the recombinant allergen Asp f 2 to induce protective antifungal responses in mice with invasive pulmonary aspergillosis. Similar to what occurred upon nasal exposure to viable A. fumigatus conidia, treatment of immunocompetent mice with Aspergillus crude culture filtrate Ags resulted in the development of local and peripheral protective Th1 memory responses, mediated by Ag-specific CD4+ T cells producing IFN-gamma and IL-2 capable of conferring protection upon adoptive transfer to naive recipients. Protective Th1 responses could not be observed in mice deficient of IFN-gamma or IL-12 and did not occur in response to Asp f 2, which, on the contrary, elicited high level production of inhibitory IL-4. The results show that Ags of Aspergillus exist with the ability to induce both Th1- and Th2-type reactivity during infection, a finding that suggests a possible mechanism through which potentially protective immune responses are inhibited in mice with the infection. However, the occurrence of Th1-mediated resistance upon vaccination with Aspergillus crude culture filtrate Ags, suggests the existence of fungal Ags useful as a candidate vaccine against invasive pulmonary aspergillosis.

The effect of prophylactic fluconazole on the clinical spectrum of fungal diseases in bone marrow transplant recipients with special attention to hepatic candidiasis. An autopsy study of 355 patients

We reviewed 355 autopsies performed between 1990 and 1994 at a major marrow transplant center to determine whether fluconazole prophylaxis prevented visceral fungal infection. Fluconazole prophylaxis was defined by a minimum of 5 prophylactic doses. Fungal infection (any site) was found in 40% of patients transplanted and autopsied at the center. Overall, the proportion of autopsies with any fungal infection was not different for those patients receiving no fluconazole prophylaxis versus those with prophylactic fluconazole. With fluconazole prophylaxis, candidal infections were less frequent, decreasing from 27% to 8%, while Aspergillus infections were more frequent, increasing from 18% to 29%. No increase in deaths related to non-albicans Candida infections was seen. Of the 329 patients with livers examined, hepatic infection caused by Candida species was significantly less common in patients who had received fluconazole. Fungal liver infection was found in 31 patients (9%), 16% of those who were not treated with fluconazole and 3% of those who were treated with fluconazole. Since patients with candidal infections died earlier after marrow transplant than patients with mold infections, we speculate that a longer length of survival may dispose toward acquisition of mold infections. Fluconazole prophylaxis in this cohort of marrow transplant patients undergoing autopsy resulted in a significant reduction in infection caused by Candida species and an increase in mold infections.

Antifungal prophylaxis during neutropenia and immunodeficiency

Fungal infections represent a major source of morbidity and mortality in patients with almost all types of immunodeficiencies. These infections may be nosocomial (aspergillosis) or community acquired (cryptococcosis), or both (candidiasis). Endemic mycoses such as histoplasmosis, coccidioidomycosis, and penicilliosis may infect many immunocompromised hosts in some geographic areas and thereby create major public health problems. With the wide availability of oral azoles, antifungal prophylactic strategies have been extensively developed. However, only a few well-designed studies involving strict criteria have been performed, mostly in patients with hematological malignancies or AIDS. In these situations, the best dose and duration of administration of the antifungal drug often remain to be determined. In high-risk neutropenic or bone marrow transplant patients, fluconazole is effective for the prevention of superficial and/or systemic candidal infections but is not always able to prolong overall survival and potentially selects less susceptible or resistant Candida spp. Primary prophylaxis against aspergillosis remains investigative. At present, no standard general recommendation for primary antifungal prophylaxis can be proposed for AIDS patients or transplant recipients. However, for persistently immunocompromised patients who previously experienced a noncandidal systemic fungal infection, prolonged suppressive antifungal therapy is often indicated to prevent a relapse. Better strategies for controlling immune deficiencies should also help to avoid some potentially life-threatening deep mycoses. When prescribing antifungal prophylaxis, physicians should be aware of the potential emergence of resistant strains, drug-drug interactions, and the cost. Well-designed, randomized, multicenter clinical trials in high-risk immunocompromised hosts are urgently needed to better define how to prevent severe invasive mycoses.

[Preventive antimycotic therapy of neutropenic and immunosuppressed patients]

Fungal infections are of increasing importance in severely neutropenic and immunosuppressed patients because of their high incidence and their high mortality once systemic dissemination has occurred. Various prophylactic strategies have been developed that include environmental measures as well as topical and systemic antimycotic prophylaxis. In this review the causative pathogens and patients at risk for developing fungal infections will be identified. Specific strategies will be discussed for each patient population and suggestions made for areas of future research.

[Antifungal prophylaxis in neutropenic cancer patients and in allogeneic bone marrow transplantation]

Severe and prolonged neutropenia and fungal colonization during the long term administration of broad-spectrum antibiotics are well known factors increasing the risk of invasive fungal infections. This is in particular true in patients undergoing allgeneic bone marrow transplantation due to the intensity of the conditioning regimen, the immuno-suppressive effect of allografting and the administration of immunosuppressive agents to prevent graft-versus-host-disease. Therefore, strategies in the prevention of fungal infections decreasing the morbidity and mortality in patients with hematological malignancies need to be developed. In this review, we discussed fungal infections an important cause of morbidity and mortality in patients with hematological disorders and attempted to provide some insights in the current status of antifungal prophylaxis.

Aspergillus infection in single and double lung transplant recipients

To investigate the clinical manifestations of Aspergillus infections in lung transplant recipients, we reviewed the mycology and autopsy reports of all double (DLT=93) and single (SLT=48) lung transplant recipients from November 1983 to May 1993. Positive Aspergillus cultures were identified in 22% of the recipients (DLT=21, SLT=10). Colonization alone was present in 19 recipients (DLT=16, SLT=3). Complicated Aspergillus infection included Aspergillus bronchitis (DLT=1, SLT=1), aspergilloma (SLT=2), pulmonary invasive aspergillosis (DLT=1, SLT=2), disseminated aspergillosis (DLT=1, SLT=2), empyema (DLT=1), and a retroperitoneal abscess (DLT=1). Symptoms were seen only in patients with complicated lung infections and CXR abnormalities began in the native lung of four SLT recipients. Twenty patients survived (DLT=17, SLT=3) and 11 died (DLT=4, SLT=7) of disseminated aspergillosis (SLT=2), pulmonary invasive disease (DLT=1), bronchiolitis obliterans (DLT=2, SLT=2, CMV pneumonitis (SLT=1), diffuse alveolar damage (SLT=2), and hyperacute rejection (DLT=1). Complicated infection and mortality were more common in SLTs than DLTs (P<0.05). We conclude that infection with Aspergillus is not infrequent in the lung transplantation population. Single lung recipients develop more complicated infection than double lung recipients after Aspergillus infection with native lung being a potential source of infection.

Amphotericin B infusion-related toxicity: comparison of two- and four-hour infusions

OBJECTIVE

To investigate the influence of infusion duration on infusion-related adverse effects (IRAEs) associated with prophylactic or treatment regimens of amphotericin B in patients with leukemia/bone marrow transplant (BMT).

DESIGN

Randomized, double-blind, 2-arm, complete crossover, prospective clinical trial.

SETTING

A university-affiliated tertiary care teaching hospital.

PARTICIPANTS

The study population consisted of 25 consecutive patients with leukemia/BMT who received 162 prophylactic regimen infusions and 169 treatment regimen infusions of amphotericin B via a central line. Prior to each infusion all patients received a parenteral IRAE prophylaxis regimen of diphenhydramine 25 mg and hydrocortisone 25 mg. No test doses or incremental amphotericin B doses were administered. Patients were monitored closely for IRAEs, which were documented by using a standardized data collection form.

MAIN OUTCOME MEASURES

The incidence and nature of IRAEs during a 6-hour monitoring period following the initiation of each infusion was measured. Patients served as their own controls. IRAEs were compared according to infusion duration and therapeutic indication.

RESULTS

Three hundred and thirty-one 2- and 4-hour amphotericin B infusions were administered. We found no difference between 2- and 4-hour infusions in the incidence and severity of IRAEs, including overall events (29% of 166 2-hour infusions vs. 25% of 165 4-hour infusions), chill scores (8% of 166 2-hour infusions vs. 7% of 165 4-hour infusions; highest score 7 vs. 6), nausea and vomiting (7% vs. 12%; highest score 4 in both groups), fever (3% vs. 2%), highest temperature increase (2.4 vs. 1.6 degrees C), systolic hypotension (6% vs. 2%), greatest decrease from baseline (40 vs. 62 mm Hg), diastolic hypotension (5% vs. 3%), and greatest decrease (30 vs. 28 mm Hg) (p > 0.05). Overall, IRAEs were less common in prophylactic treatment regimens (35 events [22%] in 162 infusions) than in treatment regimens (55 events [32%] in 169 infusions) (p < 0.05).

CONCLUSIONS

This study demonstrates that patients with leukemia/BMT without myocardial or renal dysfunction who receive hydrocortisone and diphenhydramine as premedications can tolerate 2-hour central line infusions of prophylactic or treatment regimens of amphotericin B as well as 4-hour infusions.

Antifungal Prophylaxis in Severely Neutropenic Patients: How Much Fluconazole is Necessary?

OBJECTIVES: To evaluate the efficacy of low dose fluconazole treatment for the prevention of yeast colonization and infection in severely neutropenic patients. METHODS: An open randomized trial, comparing fluconazole (100 mg per day) with nystatin (800,000 IU per day), in a University Hospital setting. RESULTS: Antifungal prophylaxis was given during the period of neutropenia, defined as less than 500 polymorphonuclear cells (PMN)/mm3). Thirty-six patients were randomly assigned to fluconazole and 33 to nystatin treatment groups. New oropharyngeal colonizations were significantly reduced by fluconazole (P=0.005), and oropharyngeal infections occurred less frequently in the fluconazole group (3% versus 16%, P=0.07). Stool colonization was identical between both groups. Systemic fungal infections were rare; one fluconazole patient had pulmonary aspergillosis and one nystatin patient developped Candida pseudotropicalis fungemia. Empiric amphotericin B was given with the same frequency in both groups. No side effects were associated with fluconazole. However, the administration of nystatin became impossible for three patients because of vomiting and lack of compliance. CONCLUSIONS: Fluconazole (100 mg per day) is more effective than nystatin for the prevention of oropharyngeal yeast colonization. Comparison with results in the literature suggests that a 100-mg dose of fluconazole has similar effects to 200 or 400 mg per day.

Australian Dental Research Fund Trebitsch Scholarship. Efficacy of antifungal prophylaxis in bone marrow transplantation

Oral candidal infection is a common problem in bone marrow transplantation. This prospective study compared the effectiveness of antifungal prophylaxis with topical antifungals (nystatin and amphotericin B suspensions) versus oral fluconazole in 196 patients undergoing bone marrow transplantation. Oral candidosis occurred frequently in the group receiving topical antifungals (61/113, 54%), but was rare in the group receiving fluconazole (6/83, 7%). The difference in efficacy between the two groups was highly significant (p < 0.00001). There was no difference in the incidence of suspected systemic fungal infection between the two groups. While nausea was a problem with antifungal suspensions, no significant adverse reactions to fluconazole occurred. Because of greater efficacy in preventing oral candidosis and better patient tolerance, oral fluconazole is preferred to antifungal suspensions for prophylactic use in patients undergoing bone marrow transplantation.

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Comparison of fluconazole with oral polyenes in the prevention of fungal infections in neutropenic patients. A prospective, randomized, single-center study

The goal of this prospective randomized single-center study was the comparison of safety and efficacy of high-dose oral/intravenous fluconazole (400 mg daily) (group A) with oral nystatin plus miconazole inhalations (group B) in the prevention of fungal infections on a hemato-oncological isolation Ward. Of 157 patients admitted to the isolation ward during the study period only 90 (57%) were eligible for randomization; 22 (14%) had a fungal infection at admission. Of the 90 randomized patients, 89 were evaluable, 43 in group A and 46 in group B. The age, sex, diagnosis, planned therapy and risk factors for fungal infections at admission as well as the duration of neutropenia were in the same proportions in both groups. Oral thrush and mucocutaneous candidiasis were prevented in all patients of both groups, and 29 patients (32%: 17 in group A, 12 in group B) were discharged after successful prophylaxis (NS). Empiric amphotericin B was given according to predetermined criteria to 45 patients (51%: 23 group A, 22 group B; NS). Fluconazole significantly delayed the time before the start of intravenous amphotericin B. It was begun after a median of 10 days (0-45 days, range) of neutropenia below 0.5 x 10(9) granulocytes/l in group A and 7.5 days (0-26, range) in group B (P < 0.05). The duration of successful prophylaxis was significantly longer in group A (26 days median) than in group B (21 days, median) (P < 0.05). Systematic fungal infection was documented in 3 patients (1 group A, 2 group B; NS).

Aspergillus antigenuria compared to antigenemia in bone marrow transplant recipients

The detection of galactomannan antigen in urine was investigated in 26 bone marrow transplant recipients using an Aspergillus latex agglutination test (Pastorex). After modification of the method, which was originally devised for serum testing, the detection limit in native urine was approximately 20 ng/ml. Antigen was found in 79 (36.4%) of 217 serial urine samples, compared to 40 (11.8%) of 340 serum samples. As a rule, antigenuria preceded antigenemia and was more persistent. The sensitivity, specificity, positive predictive value and negative predictive value of antigenuria for autopsy-proven aspergillosis and clinically suspected Aspergillus infection were 57%, 53%, 31% and 77%, respectively, while those of antigenemia were 43%, 53%, 25% and 71%. It is concluded that urine testing is more reliable than serum testing for the detection of Aspergillus galactomannan. The detection of antigen, however, whether in serum or in urine, allows no clear distinction between Aspergillus infection and exposure to non-infectious Aspergillus antigens.

Value of antifungal prophylaxis with antifungal drugs against oropharyngeal candidiasis in cancer patients

This report focuses on the value of antifungal prophylaxis with antifungal drugs in preventing oropharyngeal candidiasis. Randomised trials comparing non-AIDS immunocompromised patients receiving or not an oral antifungal agent were reviewed. Colonisation of the throat with Candida albicans is a risk factor, principally when cultures for this species of yeasts remain positive after initiation of the prophylaxis. The results of the trials were meta-analysed and we obtained a combined odds ratio for developing oropharyngeal candidiasis of 0.15 when under antifungal prophylaxis (confidence interval at 95%:0.10-0.22, chi 2 statistic of 90.77, P < 0.0001). We conclude that there is a strong beneficial effect of antifungal prophylaxis against the occurrence of oropharyngeal candidiasis. However, up to now, no study has correctly assessed the value of nystatin as a prophylactic agent against oropharyngeal candidiasis.

Chemoprophylaxis for pulmonary aspergillosis during intensive chemotherapy

Three children who developed pulmonary aspergillosis while being treated for leukaemia or non-Hodgkin's lymphoma. Each child continued with intensive myelosuppressive chemotherapy regimens during the infection and each was successfully treated with antifungal prophylaxis based on itraconazole by mouth. Amphotericin B was also given during periods of severe neutropenia. No reactivation of the fungal infection was seen.

Tratamento pelo fluconazol de pacientes imuno-comprometidos com graves infecções fúngicas

Avaliou-se a eficácia do fluconazol no tratamento de infecções fúngicas em 108 pacientes imunocomprometidos. As doses iniciais variaram de 50 a mais de 400 mg/dia. Dos 108 pacientes, 57 (52,8%) tinham criptococose, 45 (41,7%) candidíase e 6 (5,5%) outras infecções fúngicas, sendo que 66,6% dos pacientes eram portadores de AIDS. Dos 57 pacientes com criptococose houve acometimento do SNC em 52 (91,2%); 39 de 43 pacientes com criptococose (90,7%) e 36 de 39 dos portadores de candidíase (92,3%) curaram ou tiveram boa evolução clínica. A erradicação do fungo ocorreu em 19 de 30 casos com criptococose (63,3%) e em 21 de 26 casos com candidíase (80,7%) que puderam ser avaliados. Onze dos 108 pacientes (10,2%) apresentaram reações adversas,principalmente gastrintestinais de pequena intensidade, porém um paciente apresentou envolvimento hepático na vigência de terapêutica com fluconazol. Conclui-se que o fluconazol é droga eficaz e de baixa toxicidade para tratar criptococose e candidíase, constituindo-se boa alternativa à terapêutica convencional com anfotericina B.

Prophylaxis and treatment of fungal infections with fluconazole in bone marrow transplant patients

In an open study 31 patients undergoing bone marrow transplantation for various haematological diseases received fluconazole as prophylaxis or treatment of fungal infections. In 26 of these patients an antecedent oral prophylaxis with polyene antimycotics had failed to prevent infections with Candida species. Five of the 31 patients received fluconazole as primary prophylaxis because of non-compliance for polyene antimycotics. Fluconazole was administered orally at a daily dose of 100 mg and 200 mg, respectively (n = 29), or intravenously at a dose of 100 mg and 400 mg (n = 2). Cure or efficient prophylaxis was achieved in 22/31 patients (71%) after a median of 52 (9 to 493+) treatment days. In three patients (10%) Candida was eradicated but the infection reappeared 14-28 days after cessation of the drug; in 6 patients (20%) the infection was persistent or progressive. Four patients developed lethal Aspergillus infection while on fluconazole medication. A moderate and reversible elevation of liver function tests under therapy was observed in 9 patients and was possibly attributable to fluconazole in three of them (10%). One patient developed tremor which resolved after cessation of fluconazole. No other adverse drug reactions could be noted. We conclude that fluconazole is a relatively safe and effective drug for the prevention and treatment of superficial and, possibly, deep Candida infections in severely immunocompromised patients. However, it is presumably without preventive value in Aspergillus infections.

Strategies for prevention of infection after cardiac transplantation

Infection remains a major cause of morbidity and mortality after cardiac transplantation. Most infections occur during the first few months after transplantation. Although late infection does occur, the risk of infection during maintenance immunosuppression is low in the absence of recurrent rejection that necessitates augmentation of suppression of the immune response. Before cardiac transplantation, the risk factors for infectious disease in potential candidates should be assessed. A detailed history of past infections should be elicited, and patients should be screened for the presence of active indolent infection. In addition, potential donors must be thoroughly assessed for organ-transmittable infection. Many common infections that may occur after cardiac transplantation can be prevented with the use of appropriate prophylactic regimens directed toward cytomegalovirus, Toxoplasma gondii, Pneumocystis carinii, and herpes simplex virus. Periodic surveillance serologic tests and cultures after cardiac transplantation facilitate early diagnosis and prompt institution of appropriate therapy.