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Antifungal prophylaxis in bone marrow transplant
1University of California, San Francisco, USA.
Abstract:
The benefits of fungal prophylaxis with fluconazole in BMT patients appear to outweigh the risks of a possible increase in colonization and infection by C. krusei or T. glabrata. Disseminated fungal infections caused by C. tropicalis and C. albicans have a 38.8% mortality rate, and these infections may be prevented by the prophylactic use of fluconazole. C. krusei and T. glabrata infections generally do not contribute to increased mortality, and most patients infected by these organisms recover after appropriate antifungal therapy. The use of amphotericin B as prophylaxis may have some efficacy. One retrospective study found low-dose amphotericin B therapy to be effective in preventing Candida infections, but results from a placebo-controlled, randomized prospective trial with 0.1 mg/kg/d failed to support this claim. Low-dose amphotericin B prophylaxis (0.1-0.25 mg/kg/d) shows promise against aspergillosis, an opportunistic infection associated with high morbidity and mortality. The literature suggests the possible value of using oral or intravenous fluconazole 200-400 mg/d or intravenous amphotericin B 0.1-0.25 mg/kg/d as antifungal prophylaxis in patients after autologous or allogeneic BMT. Many questions remain unanswered, however. These studies described the potential decrease in morbidity and mortality of BMT patients with the use of either fluconazole or amphotericin B, but it is not known whether all patients after BMT or only those at high risk of fungal infection may benefit from prophylaxis. Optimal dosing of either antifungal agent has not been defined in the studies. Clinicians should be aware of the possible increase in colonization by less pathogenic fungal species, such as C. krusel and T. glabrata, when prescribing fluconazole prophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)
Insights
Fungal prophylaxis with fluconazole in bone marrow transplant (BMT) patients offers benefits that outweigh risks. Fluconazole can prevent deadly fungal infections, though it may increase colonization by less pathogenic fungi.
Area of Science:
- Mycology
- Hematology
- Infectious Diseases
Background:
- Disseminated fungal infections in bone marrow transplant (BMT) patients, particularly those caused by Candida tropicalis and Candida albicans, are associated with a significant mortality rate of 38.8%.
- Prophylactic use of fluconazole is suggested to prevent these life-threatening infections.
- Infections caused by Candida krusei and Torulopsis glabrata typically do not increase mortality and are manageable with appropriate antifungal therapy.
Purpose of the Study:
- To evaluate the benefits and risks of antifungal prophylaxis in patients undergoing BMT.
- To assess the efficacy of fluconazole and amphotericin B in preventing fungal infections post-BMT.
- To review the current literature on optimal antifungal prophylaxis strategies for BMT recipients.
Main Methods:
- Literature review of studies on antifungal prophylaxis in BMT patients.
- Analysis of data regarding mortality rates associated with different fungal species.
- Comparison of prophylactic efficacy between fluconazole and amphotericin B.
Main Results:
- Fluconazole prophylaxis appears to outweigh the risks of increased colonization by less pathogenic fungi (C. krusei, T. glabrata).
- Fluconazole can prevent disseminated fungal infections with high mortality rates.
- Low-dose amphotericin B shows some promise against aspergillosis but has conflicting evidence regarding overall Candida infection prevention.
Conclusions:
- Oral or intravenous fluconazole (200-400 mg/d) or intravenous amphotericin B (0.1-0.25 mg/kg/d) may be valuable for antifungal prophylaxis in BMT patients.
- Further research is needed to determine optimal dosing and identify patient subgroups who benefit most from prophylaxis.
- Clinicians must be aware of the potential for increased colonization by less pathogenic fungi with fluconazole use.