title: Azole-based chemoprophylaxis of invasive fungal infections in paediatric patients with acute leukaemia: an internal audit.
abstract: OBJECTIVE
  Children and adolescents with acute myeloid leukaemia (AML) and recurrent acute leukaemias (RALs) are at high risk of life-threatening invasive fungal infections (IFIs). We analysed implementation, safety and efficacy of a standard operating procedure for oral, azole-based, mould-active antifungal prophylaxis.
  
  
  METHODS
  Patients with AML and RALs aged ≥13 years received 200 mg of posaconazole three times daily and patients aged 2-12 years received 200 mg of voriconazole two times daily from the completion of chemotherapy until haematopoietic recovery. Algorithms for fever or focal findings in all patients with haematological malignancies included blood cultures, high-resolution CT and other appropriate imaging, serial serum galactomannan, invasive diagnostics and pre-emptive therapy with change in class if on antifungal medication.
  
  
  RESULTS
  From 2006 to 2010, 40 patients (0.8-17 years; 21 males) with newly diagnosed AML (n = 31) or RAL (n = 9) were admitted, of whom 36 received a total of 149 courses of chemotherapy (reasons for exclusion: contraindications and early death ≤3 days). Azole prophylaxis was given in 87.2% (n = 130/149) of episodes. Pre-emptive antifungal therapy for pulmonary infiltrates was initiated in 5/36 (13.9%) patients or 6/130 (4.6%) episodes for a duration of 3-22 days. No proven or probable IFIs occurred. Adverse events (AEs) were common but mostly low grade and reversible. Three courses (2.3%) were discontinued due to AEs. In simultaneously admitted new patients with acute lymphatic leukaemia (ALL; n = 101) and paediatric lymphomas (n = 29) not receiving standard antifungal prophylaxis, proven/probable IFIs occurred in 4 patients with ALL (4.0%) and 7/130 patients (5.4%) received pre-emptive therapy.
  
  
  CONCLUSIONS
  Azole-based, mould-active antifungal prophylaxis in high-risk paediatric patients with AML and RALs was satisfactorily implemented, well tolerated and effective. The low rate of IFIs in patients with ALL/lymphoma supports the lack of a general indication for prophylaxis in this population in the presence of a diagnostic and therapeutic algorithm.
authors.affiliation: Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Haematology/Oncology, University Children's Hospital Münster, Federal Republic of Germany.
authors.forename: Sara
authors.initials: S
authors.lastname: Yunus
authors.forename: Stephanie
authors.initials: S
authors.lastname: Pieper
authors.forename: Hedwig
authors.initials: H
authors.lastname: Kolve
authors.forename: Grazyna
authors.initials: G
authors.lastname: Goletz
authors.forename: Heribert
authors.initials: H
authors.lastname: Jürgens
authors.forename: Andreas H
authors.initials: AH
authors.lastname: Groll
mesh_terms: D000293:Adolescent; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018890:Chemoprevention / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007223:Infant; D007938:Leukemia / Q000150:complications*; D008297:Male; D009181:Mycoses / Q000517:prevention & control*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014230:Triazoles / Q000009:adverse effects / Q000627:therapeutic use*; D065819:Voriconazole / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; C101425:posaconazole; D065819:Voriconazole
keywords: cancer; children; mycoses; posaconazole; prevention; voriconazole