Treating invasive aspergillosis in patients with hematologic malignancy: diagnostic-driven approach versus empiric therapies

Abstract

BackgroundEarly antifungal therapy for invasive aspergillosis (IA) has been associated with improved outcome. Traditionally, of empiric antifungal therapy has been used for clinically suspected IA. We compared outcomes of patients with hematologic malignancy and IA who were treated with voriconazole using the diagnostic driven DDA (DDA-Vori) that includes galactomannan testing vs. empiric therapy with a non-voriconazole-containing regimen (EMP-non-Vori) or empiric therapy with voriconazole (EMP-Vori).MethodsWe retrospectively reviewed the medical records of 342 hematologic malignancy patients diagnosed with proven, or probable IA between July 1993 and February 2016 at our medical center who received at least 7 days of DDA-Vori, EMP-Vori, or EMP-non-Vori. Outcome assessment included response to therapy (clinical and radiographic), all-cause mortality, and IA-attributable mortality.ResultsBy multivariate analysis, factors predictive of a favorable response included localized/sinus IA vs. disseminated/pulmonary IA (p < 0.0001), not receiving white blood cell transfusion (p < 0.01), and DDA-Vori vs. EMP-non-Vori (p < 0.0001). In contrast, predictors of mortality within 6 weeks of initiating IA therapy included disseminated/pulmonary infection vs. localized/sinus IA (p < 0.01), not undergoing stem cell transplantation within 1 year before IA (p = 0.01), and EMP-non-Vori vs. DDA-Vori (p < 0.001).ConclusionsDDA-Vori was associated with better outcome (response and survival) compared with EMP-non-Vori and with equivalent outcome to EMP-Vori in hematologic malignancy patients. These outcomes associated with the implementation of DDA could lead to a reduction in the unnecessary costs and adverse events associated with the widespread use of empiric therapy.

Baseline Chest Computed Tomography as Standard of Care in High-Risk Hematology Patients

“…Early diagnosis and treatment are crucial in the management of IPA to improve patient outcome [8,9]. However, IA is still a frequently missed diagnosis in hematological patients [10].…”

Comparison of the Performance of Two Galactomannan Detection Tests: Platelia Aspergillus Ag and Aspergillus Galactomannan Ag Virclia Monotest

“…In addition, culture-based procedures are of relatively low benefit and often have ambiguous interpretation ( 6 , 13 ). Furthermore, histological confirmation is limited by the difficulty of obtaining tissue samples, and PCR techniques have important limitations ( 1 , 3 , 14 – 16 ). This explains the need to use biomarkers such as 1–3 β-D glucan or GLM in blood or BAL fluid samples ( 6 , 10 , 17 – 25 ).…”

A Systematic Review to Assess the Relationship between Disseminated Cerebral Aspergillosis, Leukemias and Lymphomas, and Their Respective Therapeutics

“…The addition of anti-fungal prophylaxis is thought to contribute to the overall reduction of IPA cases amongst immunocompromised individuals [ 97 , 98 ]. Further, anti-fungal prophylaxis in HM patients is a positive predictor of survival in breakthrough cases of IPA [ 97 , 100 ]. The number of HM patients prescribed antifungal drugs prophylactically typically ranges from ~15–45% [ 101 , 102 ].…”

“…Further still, treatment with voriconazole resulted in significantly fewer adverse events. Another study examining the inclusion or exclusion of voriconazole in the treatment of IPA in HM patients found the overall mortality of those receiving voriconazole to be 5%, significantly lower than the 49% mortality rate associated without voriconazole [ 100 ]. By and large, in the population of disseminated CA disclosed herein, AmB was the number one therapeutic prescribed, whether singularly or in combination.…”