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Preemptive Versus Empirical Antifungal Therapy for High-Risk, Febrile, Neutropenic Solid Tumor Patients in an LMIC

Omnia Al-Qadi1, Lobna Shalaby1,2, Mervat El Anany3

  • 1Pediatric Oncology Department and Pediatric Stem Cell Transplantation Unit, Children's Cancer Hospital Egypt (CCHE 57357), Cairo, Egypt.

Pediatric Blood & Cancer
|December 30, 2025
PubMed
Abstract

Insights

A preemptive antifungal strategy for pediatric cancer patients with neutropenic fever significantly reduced antifungal use without impacting invasive fungal infection rates or mortality. This approach is feasible and improves overall survival.

Area of Science:

  • Pediatric Oncology
  • Infectious Diseases
  • Pharmacoeconomics

Background:

  • Neutropenic fever management in pediatric cancer patients often relies on empiric antifungal therapy.
  • Preemptive antifungal therapy presents a rational alternative to reduce toxicity, resistance, and costs.
  • Implementation of preemptive strategies in the Middle East and North Africa (MENA) region requires further investigation.

Purpose of the Study:

  • To evaluate the feasibility and outcomes of a preemptive antifungal strategy compared to empiric therapy in pediatric patients with solid tumors and prolonged neutropenia.
  • To assess the impact on invasive fungal infection (IFI) incidence, IFI-attributable mortality, antifungal utilization, and overall survival.
  • To provide data on preemptive antifungal therapy in the MENA region.

Main Methods:

  • A prospective non-inferiority cohort study involving pediatric patients with solid tumors and prolonged neutropenia.
  • Comparison of outcomes between a prospectively managed preemptive strategy cohort and a retrospectively analyzed historical empiric therapy cohort.
  • Primary endpoints included cumulative incidence of invasive fungal infection (IFI) and IFI-attributable mortality.

Main Results:

  • The preemptive group (422 episodes) showed a comparable incidence of IFI to the empiric group (338 episodes) (4.5% vs. 5.6%, p=0.5).
  • Antifungal use was significantly lower in the preemptive group (5.0% vs. 58.0%, p < 0.001).
  • Overall survival was higher in the preemptive group (98.9% vs. 94.6%), with no IFI-attributable mortality in either group.

Conclusions:

  • A preemptive strategy, particularly when combined with EIA/HRCT, is feasible for pediatric patients with solid tumors and prolonged neutropenia.
  • This strategy effectively reduces antifungal drug exposure without compromising patient outcomes.
  • The findings support the adoption of preemptive antifungal therapy to optimize treatment and resource utilization.
Keywords:
EIA/HRCT‐based preemptive strategyLMICMENAinvasive fungal infectionneutropenic feverpediatric oncologypreemptive antifungal therapy

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