Consensus guidelines for the use of empiric and diagnostic‐driven antifungal treatment strategies in haematological malignancy, 2014

Abstract

Invasive fungal disease (IFD) causes significant morbidity and mortality in patients undergoing allogeneic haemopoietic stem cell transplantation or chemotherapy for haematological malignancy. Much of these adverse outcomes are due to the limited ability of traditional diagnostic tests (i.e. culture and histology) to make an early and accurate diagnosis. As persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients despite broad‐spectrum antibiotics have been associated with the development of IFD, most centres have traditionally administered empiric antifungal therapy (EAFT) to patients with PFUO. However, use of an EAFT strategy has not been shown to have an overall survival benefit and is associated with excessive antifungal therapy use. As a result, the focus has shifted to developing more sensitive and specific diagnostic tests for early and more targeted antifungal treatment. These tests, including the galactomannan enzyme‐linked immunosorbent assay and Aspergillus polymerase chain reaction (PCR), have enabled the development of diagnostic‐driven antifungal treatment (DDAT) strategies, which have been shown to be safe and feasible, reducing antifungal usage. In addition, the development of effective antifungal prophylactic strategies has changed the landscape in terms of the incidence and types of IFD that clinicians have encountered. In this review, we examine the current role of EAFT and provide up‐to‐date data on the newer diagnostic tests and algorithms available for use in EAFT and DDAT strategies, within the context of patient risk and type of antifungal prophylaxis used.

Utility of bronchoalveolar lavage in diagnosing respiratory tract infections in patients with hematological malignancies: are invasive diagnostics still needed?

“…Its usefulness is limited by low sensitivity, but a negative test is valuable for excluding PJP (23). Diagnosing IFD remains a challenge (4,19,24), but BAL is still a valuable tool in diagnosing this lethal condition in immunocompromised patients.…”

An overview of infectious complications after allogeneic hematopoietic stem cell transplantation

“…According to this risk stratification, the suggested approach is the administration of mold-active prophylaxis in the high risk group, which has almost higher than 10% incidence of invasive fungal infection, and an anti-Candida prophylaxis in the moderate risk group [39]. However, the choice of using prophylaxis or not may also depend on institutional factors, such as overall incidence of invasive aspergillosis and availability and effective utilization of diagnostic-driven anti-fungal treatment (DDAT) strategies [40,41].…”

“…However, they are impractical, since their results take a long time. DDAT strategies involve the utilization of highly sensitive and specific diagnostic tests, such as serological and molecular methods for detecting Aspergillus and imaging modalities including computed tomography (CT) of thorax [41]. Aspergillus galactomannan antigen and beta-D-glucan detection are novel serological methods used in surveillance.…”

Critical review of current clinical practice guidelines for antifungal therapy in paediatric haematology and oncology

“…We were pleased that a previous version of the Australasian paediatric antifungal guidelines (2007) was included [3], yet note that the comprehensive update of paediatric and adult Australian and New Zealand antifungal guidelines were omitted [4][5][6][7][8][9][10][11][12]. Published in December 2014, these expanded guidelines included manuscripts on prophylaxis, empiric and diagnostic-driven antifungal strategies, treatment of yeast, invasive mould and Pneumocystis jirovecii infection.…”