Recommendations for Risk Categorization and Prophylaxis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Expert Opinion (TEO-4)

Antifungal prophylaxis in high-risk patients with hematologic malignancy: a comparison of practice and guidelines in Türkiye

Background/aim

Primary antifungal prophylaxis (AFP) is as considered the gold standard therapy for patients with hematologic malignancies based on the available guidelines. The aim behind this study was to investigate the level of guideline knowledge and the translation of guideline recommendations into real-life settings among physicians in Türkiye.

Materials and methods

In this prospective, observational study, the physicians' knowledge of AFP guideline recommendations for patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing first remission-induction (Group I) or graft-versus-host-disease (GvHD) after allogeneic stem cell transplant (Group II) was compared with clinical practice via an 11-item multiple-choice questionnaire evaluating the patients in whom AFP was initiated, the timing, the AFP duration, and the drugs used.

Results

The mean patient age was 48.3 years and 79% had AML/MDS. AFP was initiated in 75.3% of Group I patients on the first day of induction chemotherapy before baseline and in 26.2% of Group II patients at baseline. For 98.8% of the Group I patients, the physician's plan was to continue AFP until recovery from neutropenia and complete remission (CR), whereas it was to be used during immunosuppression in Group II. The median (IQR) duration of AFP was 0.8 (0.5-1.9) and 5.5 (2.4-8.1) months for Groups I and II, respectively. Breakthrough invasive fungal infections (bIFIs) were observed in 35.8% and 14.3% of Groups I and II, respectively.The mean survey scores were 8.5 ± 2.3 for the AML/MDS patient group and 9.9 ± 3.2 for the GvHD patient group. Most of the surveyed sites adhered to the guidelines from the European Conference on Infections in Leukemia (80.6%), followed by the fever and neutropenia guidelines of the Infectious Diseases Society of America (51.6%). Posaconazole was the drug of choice in both groups (96.8% in Group I vs. 71% in Groups II).

Conclusion

The data indicate an inconsistency between real-life clinical practice and the guideline recommendations for primary AFP and bIFI management in high-risk patients with hematologic malignancies in Türkiye.

Fluconazole is as effective as other anti-mold agents in preventing early invasive fungal disease after allogeneic stem cell transplantation: assessment of antifungal therapy in haematological disease in China

BACKGROUND

The introduction of mold-active antifungal drugs has led clinicians to reconsider the use of fluconazole for preventing invasive fungal disease (IFD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In this study of recipients of allo-HSCT, we evaluated the effects of different antifungal prophylaxes on the incidence of IFD at different times after transplantation.

METHODS

Among the 1,401 patients registered in the prospective China Assessment of Antifungal Therapy in Haematological Disease (CAESAR) study database, there were 661 eligible patients who received primary antifungal prophylaxis. The incidence of IFD at different times after transplantation (early, late, and very late) and overall survival were compared for patients who received different drugs.

RESULTS

The overall incidence of probable IFD was 7.0% in the fluconazole group, 12.6% in the itraconazole group, 1.4% in the voriconazole group, and 5.2% in the micafungin group (P=0.0379). However, the four groups had no significant differences in early, late, or very late IFD. The risk factors associated with IFD were neutropenia for more than 14 days, age greater than 18 years, and receipt of transplantation from an alternative (unrelated and haploidentical) donor (P<0.05). Sub-group analysis of alternative donors indicated that the efficacy of fluconazole was similar to the other three drugs in preventing early IFD.

CONCLUSIONS

Our results suggest that the efficacy of fluconazole is similar to that of mold-active drugs in preventing early IFD in HSCT patients, even in high-risk patients receiving transplantation from alternative donors. Further prospective randomized studies are needed to confirm this conclusion.

Estimated burden of serious human fungal diseases in Turkey

The current number of fungal infections occurring each year in Turkey is unknown. We estimated the burden of serious human fungal diseases based on the population at risk, existing epidemiological data from 1920 to 2017 and modelling previously described by the LIFE program (http://www.LIFE-worldwide.org). Among the population of Turkey (80.8 million in 2017), approximately 1 785 811 (2.21%) people are estimated to suffer from a serious fungal infection each year. The model used predicts high prevalences of allergic fungal rhinosinusitis episodes (312 994 cases) (392/100 000), of severe asthma with fungal sensitisation (42 989 cases) (53.20 cases/100 000 adults per year), of allergic bronchopulmonary aspergillosis (32 594 cases) (40.33/100 000), of fungal keratitis (26 671 cases) (33/100 000) and of chronic pulmonary aspergillosis (5890 cases) (7.29/100 000). The estimated annual incidence for invasive aspergillosis is lower (3911 cases) (4.84/100 000 annually). Among about 22.5 million women aged 15-50 years, recurrent vulvovaginal candidiasis is estimated to occur in 1 350 371 (3342/100 000) females. The burden of three superficial fungal infections was also estimated: tinea pedis (1.79 million), tinea capitis (43 900) and onychomycosis (1.73 million). Given that the modelling estimates reported in the current study might be substantially under- or overestimated, formal epidemiological and comprehensive surveillance studies are required to validate or modify these estimates.