Empiric or Pre-Emptive Antifungal Therapy High-Risk
ÎEmpirical antifungal therapy and investigation for invasive fungal infections should be considered for patients with persistent or recurrent fever after 4-7 days of antibiotics and whose overall duration of neutropenia is expected to be > 7 days (A-I).
Data are insufficient to recommend a specific empirical antifungal agent for a patient already on anti-mold prophylaxis, but switching to a different class of anti-mold antifungal given intravenously should be considered (B-III).
ÎPre-emptive antifungal management is acceptable as an alternative to empirical antifungal therapy in a subset of high-risk neutropenic patients.
Those who remain febrile after 4-7 days of broad-spectrum antibiotics but are clinically stable, have no clinical or chest and sinus CT scan signs of fungal infection, have negative serologic assays for evidence of invasive fungal infection, and no recovery of fungi such as Candida or Aspergillus from any body site, may have antifungal agents withheld (B-II). Antifungal therapy should be instituted if any of these indicators of possible invasive fungal infection are identified.
Low-Risk
ÎIn low-risk patients, the risk of invasive fungal infections is low so that routine use of empirical antifungal therapy is
Antifungal Prophylaxis High-Risk
ÎProphylaxis against infections is recommended in patient
groups in whom the risk of invasive candidal infections is substantial, such as allogeneic hematopoietic stem cell transplant (HSCT) recipients or those undergoing intensive remission-induction or salvage-induction chemotherapy for acute leukemia (A-I).
Fluconazole, itraconazole, posaconazole, voriconazole, caspofungin or micafungin are all acceptable alternatives.
ÎProphylaxis against invasive infections with posaconazole
should be considered for selected patients 13 years and older who are undergoing intensive chemotherapy for acute myeloid leukemia/ myelodysplastic syndrome (AML/MDS) in whom the risk of invasive aspergillosis without prophylaxis is substantial (B-I).
ÎProphylaxis against infection in pre-engraftment allogeneic or autologous transplant recipients has been shown
to be efficacious. However, a mold-active agent is recommended in patients with prior invasive aspergillosis (A-III), anticipated prolonged neutropenic periods of at least 2 weeks (C-III), or a prolonged period of neutropenia immediately prior to HSCT (C-III).
5 recommended (A-III).
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