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Antifungal Therapy for Patients with Leukemia — Are We Ready for Stewardship?
Invasive fungal infections are difficult to diagnose in patients with hematologic malignancy or after hematopoietic stem cell transplant (HSCT); moreover, these infections are often unresponsive to treatment. Patients receive prophylactic antifungals which are frequently escalated to treatment despite diagnostic uncertainty. Investigators in London queried electronic records to capture treatment courses and categorize the strength of indications among 298 patients who had undergone chemotherapy or HSCT in 2019–2022.
Among 298 patients accruing 24,074 inpatient days, 95% received mold-active antifungal prophylaxis. In all, 288 treatment episodes were recorded, including antifungal therapy for invasive fungal infection that was proven or probable (71 patients), possible (102 patients), or did not meet diagnostic criteria (115 patients). A reading of “indeterminate” for invasive fungal infection on thoracic computed tomography contributed to the initiation of antifungal therapy in patients who otherwise did not meet consensus criteria for invasive fungal infections.
Comment
As a clinician who provides ID consults for this patient population, I am familiar with the issues concerning uncertain diagnosis of fungal infections as well as the catastrophic outcomes in patients whose therapy is started late in the disease course. Achieving the right balance is hard — and as long as the diagnostics remain suboptimal, we will need to treat our patients to avoid missing their infections. However, from a stewardship perspective, the bulk of antifungal therapy is given for prophylaxis (which has been well documented to lower risk for invasive fungal infections). As such, it's unclear to me that curtailing escalation of antifungals is a worthwhile goal in these high-risk patients with uncertain diagnoses. The first step should be to increase the sensitivity and specificity of diagnostic testing.
Citation(s)
Author:
Houston H et al.
Title:
Patterns and drivers of antifungal prescribing in acute leukaemia: A retrospective cohort study.
Source:
Open Forum Infect Dis
2024
Mar
1; [e-pub].
(Abstract/FREE Full Text)
Empfohlen von
Anna Wald, MD, MPH