Antifungal prophylaxis and therapy in patients with hematological malignancies and hematopoietic stem cell transplant recipients.
Patients with acute leukemia and hematopoietic stem cell transplant recipients are at risk of a spectrum of invasive fungal diseases corresponding to the type and intensity of immunosuppression. The development of newer antifungal agents has broadened therapeutic options. In the 1990s, lipid formulations of amphotericin B became widely used as safer alternatives to amphotericin B deoxycholate. In addition, fluconazole was shown to be beneficial as a yeast-active prophylaxis in hematopoietic stem cell transplant recipients. In the past decade, the antifungal armamentarium was further enhanced with the availability of extended-spectrum azoles and echinocandins. The development of effective broad-spectrum antifungal agents has led to their use as prophylaxis rather than delaying treatment until clinical signs of infection manifest. Antigen-based and PCR-based diagnostic adjuncts facilitate earlier detection of invasive fungal diseases compared with conventional culture, and have been incorporated into strategies in which initiation or modification of an antifungal regimen is targeted to patients with the highest likelihood of having fungal disease. Here, we review the pharmacological data and major clinical trials that guide the use of antifungals, as well as areas of uncertainty and future perspectives.
Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
Nikolaos G
NG
Almyroudis
Brahm H
BH
Segal
D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001393:Azoles / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D054714:Echinocandins / Q000627:therapeutic use; D015725:Fluconazole / Q000627:therapeutic use; D019337:Hematologic Neoplasms / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D009181:Mycoses / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D015003:Yeasts / Q000187:drug effects*
D000935:Antifungal Agents; D001393:Azoles; D054714:Echinocandins; D000666:Amphotericin B; D015725:Fluconazole