title: Consensus guidelines for the use of empiric and diagnostic-driven antifungal treatment strategies in haematological malignancy, 2014.
abstract: Invasive fungal disease (IFD) causes significant morbidity and mortality in patients undergoing allogeneic haemopoietic stem cell transplantation or chemotherapy for haematological malignancy. Much of these adverse outcomes are due to the limited ability of traditional diagnostic tests (i.e. culture and histology) to make an early and accurate diagnosis. As persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients despite broad-spectrum antibiotics have been associated with the development of IFD, most centres have traditionally administered empiric antifungal therapy (EAFT) to patients with PFUO. However, use of an EAFT strategy has not been shown to have an overall survival benefit and is associated with excessive antifungal therapy use. As a result, the focus has shifted to developing more sensitive and specific diagnostic tests for early and more targeted antifungal treatment. These tests, including the galactomannan enzyme-linked immunosorbent assay and Aspergillus polymerase chain reaction (PCR), have enabled the development of diagnostic-driven antifungal treatment (DDAT) strategies, which have been shown to be safe and feasible, reducing antifungal usage. In addition, the development of effective antifungal prophylactic strategies has changed the landscape in terms of the incidence and types of IFD that clinicians have encountered. In this review, we examine the current role of EAFT and provide up-to-date data on the newer diagnostic tests and algorithms available for use in EAFT and DDAT strategies, within the context of patient risk and type of antifungal prophylaxis used.
authors.affiliation: Department of Infectious Diseases, Alfred Health and Monash University, Prahran, Victoria; Department of Clinical Haematology, Alfred Health, Prahran, Victoria.
authors.forename: C O
authors.initials: CO
authors.lastname: Morrissey
authors.forename: N M
authors.initials: NM
authors.lastname: Gilroy
authors.forename: N
authors.initials: N
authors.lastname: Macesic
authors.forename: P
authors.initials: P
authors.lastname: Walker
authors.forename: M
authors.initials: M
authors.lastname: Ananda-Rajah
authors.forename: M
authors.initials: M
authors.lastname: May
authors.forename: C H
authors.initials: CH
authors.lastname: Heath
authors.forename: A
authors.initials: A
authors.lastname: Grigg
authors.forename: P G
authors.initials: PG
authors.lastname: Bardy
authors.forename: J
authors.initials: J
authors.lastname: Kwan
authors.forename: S W
authors.initials: SW
authors.lastname: Kirsa
authors.forename: M
authors.initials: M
authors.lastname: Slavin
authors.forename: T
authors.initials: T
authors.lastname: Gottlieb
authors.forename: S
authors.initials: S
authors.lastname: Chen
mesh_terms: D000465:Algorithms; D000935:Antifungal Agents / Q000627:therapeutic use; D001228:Aspergillosis / Q000517:prevention & control*; D002177:Candidiasis / Q000517:prevention & control*; D032921:Consensus; D016638:Critical Illness; D004334:Drug Administration Schedule; D019317:Evidence-Based Medicine; D005335:Fever of Unknown Origin / Q000188:drug therapy / Q000382:microbiology*; D019337:Hematologic Neoplasms / Q000150:complications / Q000276:immunology* / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D016867:Immunocompromised Host; D016133:Polymerase Chain Reaction; D017410:Practice Guidelines as Topic; D065129:Pre-Exposure Prophylaxis
chemical_list: D000935:Antifungal Agents
keywords: diagnostic-driven antifungal treatment; empiric antifungal therapy; haematological malignancy; invasive fungal disease; persistent or recurrent fevers of unknown origin