Treatment of mycoses in cancer patients

Invasive fungal infections are becoming increasingly frequent among immunocompromised patients and especially among cancer patients. The most common pathogens identified are Candida species, Aspergillus species, Cryptococcus neoformans, and Mucor species. Amphotericin B remains the mainstay of antifungal therapy. However, the toxicity of this drug may limit its use and, in addition, both failures and relapses have been reported. 5-Fluorocytosine and imidazoles, such as miconazole and ketoconazole, have been shown to be active, mainly on yeast organisms. The emergence of 5-fluorocytosine-resistant strains warrants caution for its administration as a single agent. The specific role of ketoconazole has not yet been established in large studies. In our experience, ketoconazole seems to be effective in the treatment of severe oral candidiasis in non-neutropenic cancer patients. Moreover, ketoconazole administered prophylactically to neutropenic patients decreases the number of positive surveillance cultures in these patients. The rare incidence of major toxicity and the ability to administer ketoconazole orally represent also major arguments for further investigation of ketoconazole activity by prospective controlled studies.