Recommendations for the treatment of established fungal infections

Abstract

Evidence-based guidelines for the treatment of established fungal infections in the adult haematology/oncology setting were developed by a national consensus working group representing clinicians, pharmacists and microbiologists. These updated guidelines replace the previous guidelines published in the Internal Medicine Journal by Slavin et al. in 2004. The guidelines are pathogen-specific and cover the treatment of the most common fungal infections including candidiasis, aspergillosis, cryptococcosis, zygomycosis, fusariosis, scedosporiosis, and dermatophytosis. Recommendations are provided for management of refractory disease or salvage therapies, and special sites of infections such as the cerebral nervous system and the eye. Because of the widespread use newer broad-spectrum triazoles in prophylaxis and empiric therapy, these guidelines should be implemented in concert with the updated prophylaxis and empiric therapy guidelines published by this group. This section of the guidelines is dedicated to the management of established invasive antifungal infections (IFI) in the adult haematology/oncology setting. Our recommendations are based on the antifungal agents licensed for use in Australia at the time of writing, and are organized according to pathogen.Where there is a radiological abnormality on computed tomography (CT)/high resolution computed tomography (HRCT) without early microbiological confirmation, clinicians should consider the most common clinical scenario. Microbiological confirmation with histology and/or culture should be pursued in all cases where the patient's clinical status permits additional investigations, such as bronchoscopy and/or biopsy. Newer diagnostic modalities such as polymerase chain reaction (PCR), galactomannan (GM) testing and molecular sequencing, are becoming increasingly available, particularly at specialist centres, and will play an increasing role in identifying probable and proven fungal infections. They are discussed in detail in the previous section of the guidelines by Morrissey et al.When considering the possibility of mould infections, Aspergillus is still the most likely organism within the Australasian setting.

Consensus guidelines for the treatment of yeast infections in the haematology, oncology and intensive care setting, 2014

“…These recommendations update those published previously 1 and are based on antifungal agents currently licensed for use in Australia. Invasive yeast diseases are categorised under the headings of invasive candidiasis, cryptococcosis and uncommon yeast infections.…”

Voriconazole for secondary prophylaxis of invasive fungal infections in allogeneic stem cell transplant recipients: results of the VOSIFI study

“…Among the new broad-spectrum azoles, voriconazole has demonstrated favorable results in candidemia, 27 and is a standard for the first-line treatment of acute invasive aspergillosis. 13,[28][29][30][31] Extensive clinical experience has also shown that voriconazole is effective against Scedosporium spp. and Fusarium spp.…”

Treatment of invasive fungal infections

“…Zygomycetes belong to the order of Mucorales comprising the genera of Rhizopus, Mucor, Rhizomucor, Absidia and Cunninghammella. Examples of pathogenetic species are Rhizopus arrhizus, Mucor circinelloides, Rhizomucor pusillus, Cunninghamella bertholletia and Absidia corymbifera [31]. Along with malignancies, immuno-suppressive therapy including high-dose corticosteroids, diabetes, iron overload and treatment with the iron chelator deferoxamine, which can be used as a siderophore by the fungi, are major risk factors for the acquisition of zygomycosis.…”

“…Posaconazole is an option for salvage therapy but is not eff ective against Absidia corymbifera and Rhizopus oryzae. Iron starvation by the iron chelator deferasirox in combination with lipid-formulated amphotericin B and hyperbaric oxygen are evaluated in clinical trials [31]. Infections with Scedosporium apiospermum are treated with voriconazole.…”