title: Triggers for driving treatment of at-risk patients with invasive fungal disease.
abstract: Timing of treatment for invasive fungal disease (IFD) is critical for making appropriate clinical decisions. Historically, many centres have treated at-risk patients prior to disease detection to try to prevent fungal colonization or in response to antibiotic-resistant fever. Many studies have indicated that a diagnostic-driven approach, using radiological tests and biomarkers to guide treatment decisions, may be a more clinically relevant and cost-effective approach. The Invasive Fungal Infections Cooperative Group of the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) defined host clinical and mycological criteria for proven, probable and possible classes of IFD, to aid diagnosis. However, some patients at risk of IFD do not meet EORTC/MSG criteria and have been termed Groups B (patients with persistent unexplained febrile neutropenia) and C (patients with non-definitive signs of IFD) in a study by Maertens et al. (Haematologica 2012; 97: 325-7). Consequently, we considered the most appropriate triggers (clinical or radiological signs or biomarkers) for treatment of all patient groups, especially the unclassified B and C groups, based on our clinical experience. For Group C patients, additional diagnostic testing is recommended before a decision to treat, including repeat galactomannan tests, radiological scans and analysis of bronchoalveolar lavage fluid. Triggers for stopping antifungal treatment were considered to include resolution of all clinical signs and symptoms. For Group B patients, it was concluded that better definition of risk factors predisposing patients to fungal infection and the use of more sensitive diagnostic tests are required to aid treatment decisions and improve clinical outcomes.
authors.affiliation: Department of Hemato-oncology, National Cancer Institute and Comenius University, Bratislava, Slovakia.
authors.forename: Lubos
authors.initials: L
authors.lastname: Drgona
authors.forename: Anca
authors.initials: A
authors.lastname: Colita
authors.forename: Nikolay
authors.initials: N
authors.lastname: Klimko
authors.forename: Galia
authors.initials: G
authors.lastname: Rahav
authors.forename: Mehmet A
authors.initials: MA
authors.lastname: Ozcan
authors.forename: J Peter
authors.initials: JP
authors.lastname: Donnelly
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use*; D003955:Diagnostic Tests, Routine / Q000379:methods; D005335:Fever of Unknown Origin / Q000175:diagnosis* / Q000188:drug therapy*; D019337:Hematologic Neoplasms / Q000150:complications* / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects; D006801:Humans; D016867:Immunocompromised Host; D009181:Mycoses / Q000175:diagnosis* / Q000188:drug therapy*; D014184:Transplantation, Homologous / Q000009:adverse effects
chemical_list: D000935:Antifungal Agents
keywords: diagnostic-driven therapy; galactomannan test; immunocompromised patients; radiological triggers