title: Treatment of invasive fungal infections in cancer patients-updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO).
abstract: The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient's risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.
authors.affiliation: Interdisziplinäres Zentrum für Palliativmedizin, Agaplesion Markus Krankenhaus, Wilhelm Epstein-Straße 4, 60431, Frankfurt, Germany, smousset@gmx.net.
authors.forename: Sabine
authors.initials: S
authors.lastname: Mousset
authors.forename: Dieter
authors.initials: D
authors.lastname: Buchheidt
authors.forename: Werner
authors.initials: W
authors.lastname: Heinz
authors.forename: Markus
authors.initials: M
authors.lastname: Ruhnke
authors.forename: Oliver A
authors.initials: OA
authors.lastname: Cornely
authors.forename: Gerlinde
authors.initials: G
authors.lastname: Egerer
authors.forename: William
authors.initials: W
authors.lastname: Krüger
authors.forename: Hartmut
authors.initials: H
authors.lastname: Link
authors.forename: Silke
authors.initials: S
authors.lastname: Neumann
authors.forename: Helmut
authors.initials: H
authors.lastname: Ostermann
authors.forename: Jens
authors.initials: J
authors.lastname: Panse
authors.forename: Olaf
authors.initials: O
authors.lastname: Penack
authors.forename: Christina
authors.initials: C
authors.lastname: Rieger
authors.forename: Martin
authors.initials: M
authors.lastname: Schmidt-Hieber
authors.forename: Gerda
authors.initials: G
authors.lastname: Silling
authors.forename: Thomas
authors.initials: T
authors.lastname: Südhoff
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Ullmann
authors.forename: Hans-Heinrich
authors.initials: HH
authors.lastname: Wolf
authors.forename: Georg
authors.initials: G
authors.lastname: Maschmeyer
authors.forename: Angelika
authors.initials: A
authors.lastname: Böhme
mesh_terms: D000666:Amphotericin B / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D058365:Candidiasis, Invasive / Q000188:drug therapy / Q000209:etiology; D055499:Catheter-Related Infections / Q000188:drug therapy / Q000517:prevention & control; D064146:Chemotherapy-Induced Febrile Neutropenia / Q000150:complications; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D016903:Drug Monitoring; D004359:Drug Therapy, Combination; D054714:Echinocandins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D016469:Fungemia / Q000188:drug therapy / Q000517:prevention & control; D006801:Humans; D016867:Immunocompromised Host; D007167:Immunotherapy; D055744:Invasive Pulmonary Aspergillosis / Q000188:drug therapy / Q000209:etiology / Q000601:surgery; D009181:Mycoses / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery / Q000628:therapy; D009369:Neoplasms / Q000150:complications*; D016879:Salvage Therapy; D014230:Triazoles / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D054714:Echinocandins; D014230:Triazoles; D000666:Amphotericin B
references.citation: Interact Cardiovasc Thorac Surg. 2008 Oct;7(5):771-6
references.pmid: 18573846
references.citation: Haematologica. 2004 Feb;89(2):207-14
references.pmid: 15003897
references.citation: Clin Infect Dis. 1998 Dec;27(6):1406-12
references.pmid: 9868651
references.citation: Mycoses. 2007 May;50(3):196-200
references.pmid: 17472616
references.citation: Clin Infect Dis. 2001 Mar 15;32(6):851-4
references.pmid: 11247707
references.citation: Mycoses. 2008 Jan;51(1):74-8
references.pmid: 18076600
references.citation: Clin Infect Dis. 1992 Dec;15(6):1003-18
references.pmid: 1457631
references.citation: Clin Microbiol Infect. 2011 Dec;17(12):1859-67
references.pmid: 21199154
references.citation: J Clin Microbiol. 2003 Feb;41(2):911
references.pmid: 12574315
references.citation: Cancer. 2004 Dec 15;101(12):2859-65
references.pmid: 15529309
references.citation: Clin Infect Dis. 2002 Aug 1;35(3):E35-6
references.pmid: 12115115
references.citation: Clin Infect Dis. 2011 May;52(9):1144-55
references.pmid: 21467021
references.citation: Cancer. 2004 Oct 1;101(7):1594-600
references.pmid: 15378491
references.citation: J Antimicrob Chemother. 2006 Jan;57(1):127-34
references.pmid: 16308418
references.citation: Clin Infect Dis. 2009 Mar 1;48(5):503-35
references.pmid: 19191635
references.citation: Expert Rev Anti Infect Ther. 2005 Oct;3(5):775-85
references.pmid: 16207169
references.citation: Clin Infect Dis. 2005 May 1;40 Suppl 6:S401-8
references.pmid: 15809926
references.citation: Curr Drug Targets. 2006 Apr;7(4):495-504
references.pmid: 16611037
references.citation: CNS Drugs. 2007;21(8):659-76
references.pmid: 17630818
references.citation: Clin Microbiol Infect. 2012 Dec;18 Suppl 7:53-67
references.pmid: 23137137
references.citation: Blood. 2010 Dec 9;116(24):5111-8
references.pmid: 20826719
references.citation: J Antimicrob Chemother. 2007 Aug;60(2):363-9
references.pmid: 17526917
references.citation: Clin Infect Dis. 1992 Nov;15(5):781-7
references.pmid: 1445976
references.citation: Med Mycol. 2009 Jun;47(4):351-8
references.pmid: 19301173
references.citation: J Pediatr Hematol Oncol. 2005 May;27(5):283-5
references.pmid: 15891566
references.citation: N Engl J Med. 2007 Jun 14;356(24):2472-82
references.pmid: 17568028
references.citation: Scand J Infect Dis. 2004;36(6-7):453-5
references.pmid: 15307567
references.citation: Clin Infect Dis. 2012 Jan 1;54(1):121-8
references.pmid: 22052885
references.citation: Clin Infect Dis. 2004 Dec 1;39(11):1563-71
references.pmid: 15578352
references.citation: Clin Infect Dis. 2006 Dec 15;43(12):1580-4
references.pmid: 17109292
references.citation: J Antimicrob Chemother. 2010 Feb;65(2):296-302
references.pmid: 20008047
references.citation: Med Mycol. 2010 May;48(3):511-7
references.pmid: 19824881
references.citation: Ann Intern Med. 1988 Jan;108(1):88-100
references.pmid: 3276268
references.citation: Clin Infect Dis. 1999 May;28(5):1071-9
references.pmid: 10452637
references.citation: Antimicrob Agents Chemother. 2010 Oct;54(10):4446-50
references.pmid: 20625156
references.citation: Cancer. 2008 Mar 15;112(6):1282-7
references.pmid: 18224662
references.citation: Haematologica. 2006 Oct;91(10):1422-3
references.pmid: 17018396
references.citation: Haematologica. 2012 Mar;97(3):464-71
references.pmid: 22058202
references.citation: Clin Infect Dis. 1999 Dec;29(6):1402-7
references.pmid: 10585786
references.citation: Clin Infect Dis. 2006 Jul 1;43(1):25-31
references.pmid: 16758414
references.citation: Clin Infect Dis. 2012 Oct;55(8):1080-7
references.pmid: 22761409
references.citation: Clin Infect Dis. 2004 May 1;38(9):1237-42
references.pmid: 15127334
references.citation: Med Mycol. 2009 Jun;47(4):343-50
references.pmid: 19085456
references.citation: J Clin Pathol. 1996 Jan;49(1):93-4
references.pmid: 8666698
references.citation: Lancet. 2007 May 5;369(9572):1519-1527
references.pmid: 17482982
references.citation: Infect Dis Clin North Am. 2002 Jun;16(2):273-95, vii-viii
references.pmid: 12092473
references.citation: Haematologica. 2010 Apr;95(4):644-50
references.pmid: 19850903
references.citation: Infection. 2011 Jun;39(3):201-10
references.pmid: 21512792
references.citation: Bone Marrow Transplant. 2008 Nov;42(10):679-84
references.pmid: 18695660
references.citation: Clin Infect Dis. 2008 Nov 1;47(9):1176-84
references.pmid: 18808352
references.citation: Clin Infect Dis. 2007 Jan 1;44(1):2-12
references.pmid: 17143808
references.citation: Cancer. 2006 Dec 15;107(12):2888-97
references.pmid: 17103444
references.citation: Leukemia. 2008 Mar;22(3):496-503
references.pmid: 18094720
references.citation: Eur J Clin Microbiol Infect Dis. 2001 Jul;20(7):460-6
references.pmid: 11561801
references.citation: Eur J Clin Microbiol Infect Dis. 2012 Jun;31(6):1173-9
references.pmid: 21971820
references.citation: Ann Hematol. 2005 Oct;84(11):734-41
references.pmid: 15951986
references.citation: Clin Infect Dis. 2009 Jul 1;49(1):e11-7
references.pmid: 19489711
references.citation: Cancer. 2007 Apr 15;109(8):1532-5
references.pmid: 17351937
references.citation: Cancer. 1986 Jul 15;58(2):366-71
references.pmid: 3719529
references.citation: Lancet Infect Dis. 2007 Oct;7(10):645-57
references.pmid: 17897607
references.citation: N Engl J Med. 2002 Aug 8;347(6):408-15
references.pmid: 12167683
references.citation: Med Pediatr Oncol. 2001 Aug;37(2):122-5
references.pmid: 11496350
references.citation: Cancer. 2003 Jul 15;98(2):315-9
references.pmid: 12872351
references.citation: N Engl J Med. 2002 Dec 19;347(25):2020-9
references.pmid: 12490683
references.citation: Eur J Cancer. 2011 Jan;47(1):8-32
references.pmid: 21095116
references.citation: Clin Infect Dis. 2003 Aug 1;37(3):415-25
references.pmid: 12884167
references.citation: Ther Drug Monit. 2008 Apr;30(2):167-72
references.pmid: 18367976
references.citation: Clin Infect Dis. 2012 Aug;55(3):381-90
references.pmid: 22610925
references.citation: Clin Microbiol Rev. 2008 Jan;21(1):157-97
references.pmid: 18202441
references.citation: Am J Med. 1996 Aug;101(2):170-6
references.pmid: 8757357
references.citation: Clin Infect Dis. 1996 Feb;22(2):315-21
references.pmid: 8838189
references.citation: Clin Infect Dis. 2002 Jan 1;34(1):7-14
references.pmid: 11731939
references.citation: Bone Marrow Transplant. 2005 Nov;36(10):873-7
references.pmid: 16113663
references.citation: Infection. 2008 Feb;36(1):68-70
references.pmid: 17882360
references.citation: Pediatr Infect Dis J. 1998 Feb;17(2):146-8
references.pmid: 9493812
references.citation: Am J Med. 1991 Aug;91(2):142-50
references.pmid: 1867240
references.citation: Clin Infect Dis. 2006 Aug 15;43(4):e39-41
references.pmid: 16838224
references.citation: Clin Infect Dis. 2009 Jun 15;48(12):1676-84
references.pmid: 19419331
references.citation: Clin Infect Dis. 2001 Mar 1;32(5):686-93
references.pmid: 11229835
references.citation: N Engl J Med. 2009 Apr 30;360(18):1870-84
references.pmid: 19403905
references.citation: Clin Infect Dis. 2005 Jul 1;41(1):60-6
references.pmid: 15937764
references.citation: Clin Infect Dis. 2010 Jun 15;50(12):1559-67
references.pmid: 20450350
references.citation: Clin Infect Dis. 2009 Feb 1;48(3):265-73
references.pmid: 19115967
references.citation: Int J Hematol. 2009 Jun;89(5):592-9
references.pmid: 19340528
references.citation: Haematologica. 2002 May;87(5):535-41
references.pmid: 12010669
references.citation: J Clin Oncol. 1997 Jan;15(1):139-47
references.pmid: 8996135
references.citation: Bone Marrow Transplant. 2009 Apr;43(7):553-61
references.pmid: 19079316
references.citation: Clin Infect Dis. 2008 Aug 1;47(3):364-71
references.pmid: 18558882
references.citation: Ann Thorac Surg. 1994 Apr;57(4):1044-50
references.pmid: 8166512
references.citation: Clin Infect Dis. 2010 Feb 1;50(3):291-322
references.pmid: 20047480
references.citation: Blood. 2005 Dec 15;106(13):4397-406
references.pmid: 16123217
references.citation: Clin Infect Dis. 2008 Feb 1;46(3):327-60
references.pmid: 18177225
references.citation: Clin Infect Dis. 1998 Jun;26(6):1383-96
references.pmid: 9636868
references.citation: J Infect. 2006 Nov;53(5):337-49
references.pmid: 16678903
references.citation: Cancer. 2007 Dec 15;110(12):2740-6
references.pmid: 17941026
references.citation: Clin Infect Dis. 2008 Sep 1;47(5):674-83
references.pmid: 18637757
references.citation: Eur J Clin Microbiol Infect Dis. 2004 Apr;23(4):317-22
references.pmid: 15029512
references.citation: Clin Infect Dis. 2001 Feb 1;32(3):358-66
references.pmid: 11170942
references.citation: Clin Infect Dis. 2003 May 15;36(10):1221-8
references.pmid: 12746765
references.citation: Int J Infect Dis. 2011 May;15(5):e350-6
references.pmid: 21397541
references.citation: Drug Resist Updat. 2003 Oct;6(5):257-69
references.pmid: 14643296
references.citation: Clin Infect Dis. 2005 May 1;40 Suppl 6:S384-91
references.pmid: 15809924
references.citation: Eur J Clin Microbiol Infect Dis. 2003 Feb;22(2):111-3
references.pmid: 12627286
references.citation: Clin Infect Dis. 2005 May 1;40 Suppl 6:S392-400
references.pmid: 15809925
references.citation: Postgrad Med J. 2009 Nov;85(1009):573-81
references.pmid: 19892892
references.citation: Bone Marrow Transplant. 2007 May;39(10):631-5
references.pmid: 17384656
references.citation: Clin Infect Dis. 2002 Mar 1;34(5):563-71
references.pmid: 11807679
references.citation: Am J Med. 1991 Aug;91(2):137-41
references.pmid: 1867239
references.citation: J Clin Microbiol. 2005 Apr;43(4):1818-28
references.pmid: 15815003
references.citation: Clin Infect Dis. 2001 Jul 15;33(2):177-86
references.pmid: 11418877
references.citation: Blood. 2005 Oct 15;106(8):2641-5
references.pmid: 15998833
references.citation: N Engl J Med. 1997 Jul 24;337(4):254-9
references.pmid: 9227932
references.citation: Clin Infect Dis. 1996 Nov;23(5):964-72
references.pmid: 8922787
references.citation: Clin Infect Dis. 2007 Oct 1;45(7):883-93
references.pmid: 17806055
references.citation: Clin Infect Dis. 2004 Apr 15;38(8):1119-27
references.pmid: 15095217
references.citation: Antimicrob Agents Chemother. 2007 Jan;51(1):137-43
references.pmid: 17088483
references.citation: Bone Marrow Transplant. 2010 Jul;45(7):1227-33
references.pmid: 20062093
references.citation: Crit Care Med. 2006 Mar;34(3):730-7
references.pmid: 16505659
references.citation: Am J Med. 2001 Nov;111(7):528-34
references.pmid: 11705428
references.citation: Eur J Clin Microbiol Infect Dis. 2002 Dec;21(12):892-6
references.pmid: 12525928
references.citation: J Infect Dis. 2000 Jul;182(1):274-82
references.pmid: 10882607
references.citation: Clin Infect Dis. 1995 Aug;21(2):361-9
references.pmid: 8562745
references.citation: J Chemother. 2009 Apr;21(2):211-4
references.pmid: 19423476
references.citation: N Engl J Med. 2004 Feb 26;350(9):950-2
references.pmid: 14985500
references.citation: Semin Hematol. 2007 Jan;44(1):15-23
references.pmid: 17198843
references.citation: Clin Infect Dis. 2009 Apr 15;48(8):1042-51
references.pmid: 19281327
references.citation: Clin Infect Dis. 2008 Jan 15;46(2):201-11
references.pmid: 18171251
references.citation: J Clin Oncol. 2001 Jan 1;19(1):253-9
references.pmid: 11134220
references.citation: Lancet. 2005 Oct 22-28;366(9495):1435-42
references.pmid: 16243088
references.citation: Haematologica. 2006 Aug;91(8):1068-75
references.pmid: 16885047
references.citation: J Antimicrob Chemother. 1991 Oct;28 Suppl B:73-82
references.pmid: 1778894
references.citation: Antimicrob Agents Chemother. 2005 Sep;49(9):3640-5
references.pmid: 16127033
references.citation: Med Mycol. 2006 Sep 1;44(Supplement_1):S315-S318
references.pmid: 30408923
references.citation: Ann Hematol. 2008 Nov;87(11):863-76
references.pmid: 18629501
references.citation: Clin Infect Dis. 2006 Jun 15;42(12):1726-34
references.pmid: 16705579
references.citation: N Engl J Med. 1999 Mar 11;340(10):764-71
references.pmid: 10072411
references.citation: Surg Neurol. 2008 Jul;70(1):87-91
references.pmid: 18313733
references.citation: Antimicrob Agents Chemother. 2002 Jun;46(6):1773-80
references.pmid: 12019089
references.citation: Am J Med. 1998 Mar;104(3):238-45
references.pmid: 9552086
references.citation: Antimicrob Agents Chemother. 2006 May;50(5):1881-3
references.pmid: 16641468
references.citation: Br J Haematol. 1994 Apr;86(4):754-60
references.pmid: 7918068
references.citation: Mycoses. 2011 Oct;54 Suppl 3:12-21
references.pmid: 21995658
references.citation: J Antimicrob Chemother. 2004 Aug;54(2):575-7
references.pmid: 15231763
references.citation: Clin Infect Dis. 2008 Jun 1;46(11):1733-7
references.pmid: 18419427
references.citation: Transpl Infect Dis. 2012 Apr;14(2):184-7
references.pmid: 22093149
references.citation: J Pediatr Hematol Oncol. 2012 May;34(4):e161-3
references.pmid: 22258349
references.citation: Clin Infect Dis. 1995 Oct;21(4):994-6
references.pmid: 8645855
references.citation: Clin Infect Dis. 2007 May 15;44(10):1289-97
references.pmid: 17443465
references.citation: Lancet. 2004 May 29;363(9423):1764-7
references.pmid: 15172774
references.citation: Antimicrob Agents Chemother. 2006 Feb;50(2):658-66
references.pmid: 16436724
references.citation: Antimicrob Agents Chemother. 1997 Sep;41(9):1944-8
references.pmid: 9303390
references.citation: Transpl Infect Dis. 2009 Feb;11(1):89-93
references.pmid: 18983417
references.citation: Infect Dis Clin North Am. 2003 Mar;17(1):159-91, ix
references.pmid: 12751265
references.citation: Eur Radiol. 1997;7(3):316-9
references.pmid: 9087348
references.citation: Clin Infect Dis. 2005 Sep 1;41(5):634-53
references.pmid: 16080086
references.citation: Br J Haematol. 1998 Oct;103(1):205-12
references.pmid: 9792309
references.citation: Clin Infect Dis. 2010 Jul 15;51(2):225-32
references.pmid: 20536366
references.citation: Mycoses. 2011 Jul;54(4):279-310
references.pmid: 21672038
references.citation: Bone Marrow Transplant. 2004 Mar;33(5):543-8
references.pmid: 14730342
references.citation: Antimicrob Agents Chemother. 2011 Jul;55(7):3491-7
references.pmid: 21518846
references.citation: Drug Metab Dispos. 2004 Feb;32(2):267-71
references.pmid: 14744950
references.citation: Med Mycol. 2009 Jun;47(4):359-70
references.pmid: 19031336
references.citation: BMC Infect Dis. 2010 Jun 22;10:182
references.pmid: 20569436
references.citation: Mycoses. 2007 May;50(3):205-9
references.pmid: 17472618
references.citation: Clin Infect Dis. 2008 Jul 1;47(1):123-30
references.pmid: 18505387
references.citation: Clin Infect Dis. 2004 Sep 15;39(6):797-802
references.pmid: 15472810
references.citation: Clin Infect Dis. 2006 Apr 1;42(7):e61-5
references.pmid: 16511748
references.citation: Crit Care Med. 2008 Nov;36(11):2967-72
references.pmid: 18824910
references.citation: Infect Control Hosp Epidemiol. 2002 Sep;23(9):542-5
references.pmid: 12269454
references.citation: Scand J Infect Dis. 2007;39(1):87-90
references.pmid: 17366022
references.citation: Clin Infect Dis. 2006 Aug 15;43(4):e29-38
references.pmid: 16838223
references.citation: Clin Infect Dis. 2006 Mar 15;42(6):753-7
references.pmid: 16477548
references.citation: Br J Haematol. 2005 Oct;131(2):201-7
references.pmid: 16197450
references.citation: Antimicrob Agents Chemother. 2011 Dec;55(12):5798-803
references.pmid: 21911573
references.citation: J Infect. 2010 May;60(5):331-7
references.pmid: 20138081
references.citation: Clin Infect Dis. 2010 Feb 1;50(3):338-44
references.pmid: 20038244
references.citation: J Antimicrob Chemother. 2009 Dec;64(6):1274-81
references.pmid: 19841031
references.citation: Cancer. 1995 Dec 1;76(11):2357-62
references.pmid: 8635043
references.citation: Br J Haematol. 2011 Nov;155(3):318-27
references.pmid: 21880032
references.citation: Curr Opin Infect Dis. 2006 Aug;19(4):365-70
references.pmid: 16804385
references.citation: Transfusion. 2002 Nov;42(11):1414-21
references.pmid: 12421213
references.citation: Mycoses. 2007;50 Suppl 1:24-37
references.pmid: 17394607
references.citation: Pediatr Infect Dis J. 2005 Apr;24(4):375-7
references.pmid: 15818301
references.citation: Clin Infect Dis. 2008 Mar 1;46(5):696-702
references.pmid: 18230039
references.citation: Respiration. 2007;74(6):663-73
references.pmid: 17622755
references.citation: Clin Infect Dis. 2005 Sep 15;41 Suppl 6:S389-93
references.pmid: 16108005
references.citation: Clin Microbiol Infect. 2012 Feb;18(2):189-94
references.pmid: 21729194
references.citation: Clin Infect Dis. 2003 May 1;36(9):1122-31
references.pmid: 12715306
references.citation: J Chemother. 2009 Feb;21(1):108-9
references.pmid: 19297284
references.citation: Chest. 2004 Dec;126(6):1783-8
references.pmid: 15596674
references.citation: Eur J Haematol. 2010 May;84(5):441-7
references.pmid: 20059528
references.citation: Antimicrob Agents Chemother. 2011 Oct;55(10):4782-8
references.pmid: 21768513
references.citation: Antimicrob Agents Chemother. 2002 Jan;46(1):160-5
references.pmid: 11751127
references.citation: Clin Infect Dis. 2006 May 15;42(10):1398-403
references.pmid: 16619151