title: Recent developments in the management of invasive fungal infections in patients with oncohematological diseases.
abstract: Patients with hematological cancer have a high risk of invasive fungal diseases (IFDs). These infections are mostly life threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly,AspergillusandCandidaspecies are involved. However, other non-Aspergillusmolds are increasingly be identified in cases of documented IFDs. Important risk factors are long lasting granulocytopenia with neutrophil counts below 500/μl for more than 10 days or graft-versus-host disease resulting from allogeneic stem-cell transplantation. For definite diagnosis of IFD, various diagnostic tools have to be applied, including conventional mycological culture and nonconventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. In the last few years, various laboratory methods, like theAspergillusGM immunoassay (AspergillusGM EIA), 1,3-ß-D-glucan (BG) assay or polymerase chain reaction (PCR) techniques have been developed for better diagnosis. Since no single indirect test, including radiological methods, provides the definite diagnosis of an invasive fungal infection, the combination of different diagnostic procedures, which include microbiological cultures, histological, serological and molecular methods like PCR together with the pattern of clinical presentation, may currently be the best strategy for the prompt diagnosis, initiation and monitoring of IFDs. Early start of antifungal therapy is mandatory, but clinical diagnostics often do not provide clear evidence of IFD. Integrated care pathways have been proposed for management and therapy of IFDs with either the diagnostic driven strategy using the preemptive antifungal therapy as opposed to the clinical or empirical driven strategy using the 'traditional' empirical antifungal therapy. Antifungal agents preferentially used for systemic therapy of invasive fungal infections are amphotericin B preparations, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, micafungin, and most recently isavuconazole. Clinical decision making must consider licensing status, local experience and availability, pharmacological and economic aspects.
authors.affiliation: Department of Hematology and Oncology, Paracelsus-Kliniken Osnabrück, Am Natruper Holz 69, 49090 Osnabrück, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Ruhnke
authors.affiliation: Department of Internal Medicine, Division of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Benjamin Franklin, Berlin.
authors.forename: Stefan
authors.initials: S
authors.lastname: Schwartz
keywords: aspergillosis; candidosis; diagnosis; fungal; hematology and oncology; mycosis; treatment; zygomycosis