Clinically driven diagnostic antifungal approach in neutropenic patients: a prospective feasibility study.
OBJECTIVE
Preemptive strategies in neutropenic patients based on serum galactomannan (GM) -guided triggering of diagnostic work-up may be time-consuming and expensive when applied to the entire population. We have assessed the feasibility of a clinically driven diagnostic strategy without GM screening.


METHODS
Patients with neutropenic fever underwent a baseline diagnostic work-up (BDWU; three blood cultures and other examinations as indicated). An intensive diagnostic work-up (IDWU; GM for 3 days, chest computed tomography and other examinations as indicated) was reserved for patients with 4 days of persisting or relapsing fever or with other clinical findings possibly related to an invasive fungal diseaser (IFD). Antifungal therapy was administered to patients diagnosed with IFD and empirically (negative IDWU) only to those with persisting neutropenic fever and worsening clinical conditions.


RESULTS
Of 220 neutropenia episodes, fever occurred in 159 cases and recurred in 28 cases. Overall, 49 IFDs were diagnosed (two by BDWU and 47 by IDWU) during 48 episodes (21.8%). Diagnostic-driven therapy was administered to 48 patients with IFDs; one patient with zygomycosis died without treatment. Only one patient received empirical therapy. IDWU was required in 40% of neutropenia episodes, and only 1.4 mean blood samples per neutropenia episode were tested for GM. Our strategy allowed a 43% reduction in antifungal treatments compared with a standard empirical approach. At 3-month follow-up, 63% of patients with IFD survived, and no undetected IFDs were found.


CONCLUSIONS
A clinically driven diagnostic approach in selected neutropenia episodes offered effective antifungal control and reduced the exposure to unnecessary antifungal treatment.
Dipartimento di Ematologia Oncologia, Anatomia Patologica e Medicina Rigenerativa, Azienda Policlinico Umberto I, Sapienza University, Rome, Italy. girmenia@bce.uniroma1.it
Corrado
C
Girmenia
Alessandra
A
Micozzi
Giuseppe
G
Gentile
Stefania
S
Santilli
Eva
E
Arleo
Luisa
L
Cardarelli
Saveria
S
Capria
Clara
C
Minotti
Claudio
C
Cartoni
Simonetta
S
Brocchieri
Vito
V
Guerrisi
Giovanna
G
Meloni
Robin
R
Foà
Pietro
P
Martino
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use*; D001228:Aspergillosis / Q000150:complications*; D001230:Aspergillus / Q000472:pathogenicity*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D019337:Hematologic Neoplasms / Q000150:complications* / Q000382:microbiology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009503:Neutropenia / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult
D000935:Antifungal Agents