Prophylactic flucanozole for BMT – pro

Flucanozole prophylaxis for post-transpalnt patients is standrd and supported by a number of guidelines. The duration of prophylaxis is recommended to be from the first day of transplantation and until engraftment, usually around 30 days, or until 7 days after the absolute neutrophil count rises over 1000. This is based on randomized Phase III trials which I also reference, although it is fairly old at this time.

Candidal infection is the most common fungal disease in transplant recipients. It is largely due to reactivation of endogenous fungi. Therefore, because most patients who develop candidal disease are colonized before bone marrow transplant, preventing exposure to Candida is not possible. Making the situation even more difficult, approximately 40% of transplant patients with invasive candidal infections have negative blood cultures, which makes the presence of the infection difficult to diagnose and emphasizes the importance of prevention.

Two controlled trials have demonstrated the efficacy of prophylactic fluconazole to prevent invasive systemic fungal infections. In these trials, fluconazole given at a dose of 400 mg/day IV or PO for approximately the first 3 months posttransplant reduced systemic fungal infections from a range of 16% to 18% to a range of 3% to 7%. On the basis of these trials, the IDSA recommends that fluconazole be administered until engraftment.

More recently, a concern for emerging flicanozole resistance raised new questions about the wisdom of this strategy; however, it remains recommended by guidelines and the CDC.

Goodman JL, Winston DJ, Greenfield RA, et al: A controlled trial of fluconazole to prevent fungal infections in patients undergoing bone marrow transplantation. N Engl J Med 1992 Mar 26; 326(13): 845-51

Dictar MO, Maiolo E, Alexander B, et al: Mycoses in the transplanted patient. Med Mycol 2000; 38 Suppl 1: 251-8

Recommendations and Reports
Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation MMWR, October 20, 2000 / 49(RR10);1-128

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