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[Primary antifungal prophylaxis in oncohematological patients: who, when, and with what?]
Fabián Herrera1, Claudia Salgueira2, Patricia Costantini3
1Sección Infectología, Departamento de Medicina Interna, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Argentina.
Abstract:
Invasive fungal infections (IFI) are among the main infectious complications in patients with hematological malignancies and with hematopoietic stem cell transplant (HSCT), causing high morbidity and mortality and significantly increasing the healthcare cost and hospital stay. The epidemiology of IFIs has changed in recent decades, with filamentous fungi, particularly Aspergillus spp., being the main etiological agents. There are multiple risk factors for having an IFI; however, the most important are profound and prolonged neutropenia and severe cellular immunodeficiency. For this reason, the population at greatest risk is made up of patients with acute leukemias, myelodysplasias and allogeneic HSCT with graft-versus-host disease (GVHD) treated with corticosteroids. Numerous randomized clinical trials and meta-analyses have shown that primary antifungal prophylaxis (AFP) significantly reduces the incidence of IFI, particularly those caused by Candida spp. and Aspergillus spp., IFI-related mortality, and overall mortality in some group of patients. Likewise, in high-risk patients, where a high incidence of IFI is expected, it is a cost-effective strategy. Several antifungals have demonstrated clinical benefit. They can be used as a AFP strategy in different settings, presenting advantages and disadvantages that must be taken into account in each case. For this, national and international scientific societies have issued recommendations for the indication of AFP. Aspects related to the different antifungals' clinical efficacy are analyzed considering the population at risk, the potential disadvantages, timing, and form of administration.
Insights
Primary antifungal prophylaxis (AFP) significantly reduces invasive fungal infections (IFI) incidence and mortality in high-risk patients undergoing chemotherapy or stem cell transplant. Antifungal choice requires careful consideration of patient factors and drug properties.
Area of Science:
- Hematology
- Infectious Diseases
- Mycology
Background:
- Invasive fungal infections (IFI) are a major cause of morbidity and mortality in patients with hematological malignancies and after hematopoietic stem cell transplant (HSCT).
- The epidemiology of IFIs has shifted, with filamentous fungi like Aspergillus spp. becoming predominant etiological agents.
- Profound neutropenia and severe cellular immunodeficiency are key risk factors, particularly in acute leukemia, myelodysplasia, and allogeneic HSCT patients with graft-versus-host disease (GVHD) treated with corticosteroids.
Purpose of the Study:
- To review the evidence supporting primary antifungal prophylaxis (AFP) in high-risk patients.
- To analyze the clinical efficacy, advantages, and disadvantages of various antifungal agents used for AFP.
- To highlight the importance of national and international recommendations for AFP indication.
Main Methods:
- Review of numerous randomized clinical trials and meta-analyses on antifungal prophylaxis.
- Analysis of epidemiological trends in invasive fungal infections.
- Evaluation of clinical benefits and drawbacks of different antifungal agents.
Main Results:
- Primary antifungal prophylaxis (AFP) significantly reduces the incidence of IFI, especially those caused by Candida spp. and Aspergillus spp.
- AFP decreases IFI-related mortality and, in some patient groups, overall mortality.
- AFP is a cost-effective strategy in high-risk populations where IFI incidence is expected to be high.
Conclusions:
- AFP is a crucial strategy for managing invasive fungal infections in immunocompromised patients.
- The selection of antifungal agents for prophylaxis should consider patient-specific risk factors, drug efficacy, and potential adverse effects.
- Adherence to scientific society guidelines is essential for optimal AFP implementation.
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