Refractory Aspergillus pneumonia in patients with acute leukemia

Abstract

BACKGROUNDPulmonary aspergillosis and other invasive fungal infections (IFIs) commonly complicate the management of patients with acute leukemia. Standard amphotericin‐based therapies may be ineffective for many patients and the available salvage agents (itraconazole and caspofungin) are reported to possess only moderate activity against resistant infections. Laboratory evidence suggests a synergistic interaction between amphotericin and caspofungin. The authors treated a group of patients with amphotericin‐refractory IFIs with the combination of caspofungin and amphotericin (or liposomal amphotericin).METHODSA retrospective evaluation of patients with amphotericin‐resistant IFIs was conducted. Diagnosis was based on clinical, radiographic, and when available, microbiologic data. Response to combination antifungal therapy was graded as either favorable or unfavorable. Favorable responses included improvement of both clinical and radiographic signs of fungal pneumonia. All other responses were graded as unfavorable.RESULTSThirty patients were included in this analysis. Twenty‐six patients had acute leukemia. Based on recently published criteria, the IFIs were classified as proven in 6 patients, probable in 4 patients, and possible in 20 patients. The median duration and dose of amphotericin monotherapy were 12 days (range, 4–65 days) and 7.8 mg/kg (range, 4.2–66.1 mg/kg), respectively. The median duration of combination therapy was 24 days (range, 3–74 days). Eighteen patients (60%) experienced a favorable antifungal response. Twenty patients with acute leukemia received combination therapy for fungal pneumonias arising during intensive chemotherapy treatments. Favorable responses were observed in 15 of these patients (75%), and antifungal response did not depend on the response of the underlying leukemia. Survival to hospital discharge was significantly better (P < 0.001) in patients having a favorable response. Mild to moderate nephrotoxicity was noted in 50% of patients, necessitating the substitution of liposomal amphotericin. Mild elevation of alkaline phosphatase levels occurred in 30% of patients. Caspofungin was temporarily withheld from one patient who developed moderate but reversible biochemical hepatotoxicity.CONCLUSIONSThe antifungal combination of caspofungin and amphotericin can be administered safely to high‐risk patients with hematologic malignancies. Although an absolute assessment of efficacy is limited by the design of this study, encouraging outcomes were noted for many patients. The authors plan to evaluate this regimen further in a randomized clinical trial. Cancer 2003;97:1025–32. © 2003 American Cancer Society.DOI 10.1002/cncr.11115

How to manage aspergillosis in non-neutropenic intensive care unit patients

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“…The caspofungin + L-AmB was more successful as primary therapy (53% response rate), but not statistically different than salvage therapy. Another retrospective evaluation included 30 patients with hematologic malignancies and definite (n=6), probable (n=4), and possible (n=20) pulmonary IA that progressed despite AmB or L-AmB, including 4 patients with progressive disease despite AmB + itraconazole [51]. Patients were on AmB for an average of 12 days before adding caspofungin, and the median duration of combination therapy was 24 days.…”