Utilization of Intravenous Posaconazole in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplant

Pediatric patients undergoing hematopoietic stem cell transplant (HSCT) are at high risk for fungal infections, including Candida, Aspergillus, and Mucorales, necessitating the use of broad-spectrum antifungal agents such as posaconazole for prophylaxis and at times for treatment of invasive fungal infections. When first approved, posaconazole was limited to an immediate-release oral suspension, which exhibited unreliable absorption dependent on co-administration with high-fat meals. During HSCT, patients commonly have significant nausea, vomiting, and decreased enteral intake, making this formulation particularly challenging. In 2014, intravenous (IV) posaconazole became available with its first approval only for adult patients, as there were no data on its use in pediatric patients. This approval has since been expanded to include pediatric patients as young as 2 yr of age. In terms of dosing, however, clinical practice experience supports a significantly higher starting dose than the manufacturer-recommended 6 mg/kg/dose. Current literature involving the use of IV posaconazole in pediatric HSCT patients is limited to studies with small sample sizes and varying dose ranges recommended to achieve posaconazole target levels. Describe the safety and efficacy of IV posaconazole for prophylaxis and treatment of invasive fungal infections in pediatric HSCT patients. This was a single-center, retrospective chart review of pediatric HSCT patients who received IV posaconazole from January 1, 2015, to August 1, 2023. One hundred eighty-two patients were identified as receiving at least one dose of IV posaconazole, and 109 were included in the final analysis. Of these, 105 (96.3%, 95% confidence interval [0.924, 1.01]) patients were able to achieve their target level within a single course of IV posaconazole, defined as continuous treatment with an interruption of no more than 5 days. The median weight-based dose after therapeutic dose adjustments (if necessary), achieving their target level was 10 mg/kg for both prophylaxis and treatment. Additionally, a median fixed dose of 300 mg for prophylaxis (patients weighing ≥30 kg) and 400 mg (patients weighing ≥40 kg) for treatment were able to achieve target levels. Seventy-eight patients received IV posaconazole for prophylaxis, with three patients (3.8%) requiring an escalation to treatment dosing of an antifungal. Thirty-one patients received IV posaconazole for treatment of either probable (n = 21, 19.3%) or proven fungal infection (n = 10, 9.2%). A total of 22 patients discontinued IV posaconazole due to an adverse event, with hepatic dysfunction being the most common reason (n = 19, 86%). Thirteen patients were able to restart posaconazole after resolution of liver function tests. There was not an association between high levels and discontinuation due to an adverse event. Administration of a loading dose of IV posaconazole at 10 mg/kg every 12 h for two doses, followed by a maintenance dose of 10 mg/kg every 24 h was an effective starting dose for achieving target levels for prophylaxis and treatment in pediatric HSCT recipients. The most common adverse event leading to discontinuation of IV posaconazole was hepatic dysfunction, but a substantial portion of these patients were able to restart posaconazole without repeated issue. To our knowledge, this was the largest study to date evaluating the efficacy of IV posaconazole in pediatric HSCT patients.