Fungal prophylaxis in intensive chemotherapy – pro
Candida spp. and Aspergillus spp. are the most important fungal pathogens contributing to significant morbidity and mortality in immunocompromised patients. Yeast infections are mainly caused by fungi colonising the gastrointestinal tract, which overgrow under antibacterial treatment and subsequently invade tissue and blood vessels during neutropenia.
Much of the clinical data evaluating the efficacy and safety of antifungal prophylaxis has been generated in cancer patients. The choice of antifungal agent for prophylaxis in this population remains controversial. However, azole compounds such as clotrimazole, ketoconazole and fluconazole appear to be more effective and better tolerated than nystatin suspension. Fluconazole is the drug of choice for prevention of relapse of cryptococcal meningitis in patients with AIDS and bone amrrow transpalntation; its utility in other intensive chemotherapy patients is not defined. In 2009, Infectious Diseases Working Party of the German Society for Haematology and Oncology reviewed all avaialble evidence and recommended prophylaxis only for several immunocomprised patient types: Fluconazole 400 mg/d improved the incidence rates of invasive fungal infections and attributable mortality in allogeneic stem cell recipients. Posaconazole 600 mg/d reduced the incidence of IFI and attributable mortality in allogeneic stem cell recipients with severe graft versus host disease, and in patients with acute myelogenous leukemia or myelodysplastic syndrome additionally reduced overall mortality. Aerosolized liposomal amphotericin B reduced the incidence rate of invasive pulmonary aspergillosis. Posaconazole 600 mg/d is recommended in patients with acute myelogenous leukemia/myelodysplastic syndrome or undergoing allogeneic stem cell recipients with graft versus host disease for the prevention of invasive fungal infections and attributable mortality (Level A I). Fluconazole 400 mg/d is recommended in allogeneic stem cell recipients until development of graft versus host disease only (Level A I). Aerosolized liposomal amphotericin B is recommended during prolonged neutropenia (Level B II).
There is currently no widely accepted recommendation to prophylax cancer patients on intensive chemotherapy.
W. H. Krüger et al, Antimicrobial prophylaxis in allogeneic bone marrow transplantation. Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Oncology Annals of Oncology 2005 16(8):1381-1390;
Reents, SD Goodwin, and V Singh
Antifungal prophylaxis in immunocompromised hosts
Ann Pharmacother ;27:53-60.
Oliver A. Cornely, Angelika Böhme, Dieter Buchheidt, Hermann Einsele, Werner J. Heinz, Meinolf Karthaus, Stefan W. Krause, William Krüger, Georg Maschmeyer, Olaf Penack, Jörg Ritter, Markus Ruhnke, Michael Sandherr, Michal Sieniawski, Jörg-Janne Vehreschild, Hans-Heinrich Wolf, and Andrew J. Ullmann
Primary prophylaxis of invasive fungal infections in patients with hematologic malignancies. Recommendations of the Infectious Diseases Working Party of the German Society for Haematology and Oncology
Haematologica 2009 94: 113-122; published online before print as doi:10.3324/haematol.11665