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Preemptive antifungal treatment demonstrates comparable survival rates to empirical therapy
Preemptive antifungal therapy yielded a 95.1% survival rate in neutropenic patients with hematological malignances who remained febrile despite broad-spectrum antibacterial treatment.
Researchers compared empirical antifungal treatment with preemptive treatment in 293 patients. They defined empirical treatment as antifungal treatment of patients with persistent or recurring fever. They wrote that preemptive treatment was conducted in patients who had clinical, imaging or galactomannan-antigen-assay evidence suggesting fungal disease.
The average duration of neutropenia was 18 days. Neutropenia was defined as neutrophil counts less than 500 cells/mm3.
Amphotericin B deoxycholate at 1 mg/kg/day or liposomal amphotericin 3 mg/kg/day were first-line therapies.
The primary outcome was defined as the number of patients alive at 14 days after recovery from neutropenia.
The survival rate was 97.3% with empirical treatment and 95.1% with preemptive treatment, representing a lower 95% CI difference in mortality of –5.9%.
Of 143 patients who received preemptive treatment, 13 had probable or proven invasive fungal infections; among 150 patients receiving empirical treatment, four had probably or proven invasive fungal infections (P<.05). Twelve of 73 patients in the preemptive treatment arm and three of 78 patients in the empirical treatment arm were infected during induction therapy (P<.01).
Catherine Cordonnier, MD, of the hematology department at the Henri Mondor Teaching Hospital, was involved in the research. “The issue is that we now have noninvasive procedures, especially galactomanna and, eventually, computed tomography scan, which were not available at the time the empirical strategy was implemented,” she told Infectious Disease News. “By restricting the indications of antifungals of such high-risk patients, we wanted first to be sure that the preemptive strategy did not impair the survival chances of the patient during neutropenia. The trial provides a clear answer to that question. We can now go further in next trials on questions about incidence of fungal infection as primary objective.”
Cordonnier C. Clin Infect Dis. 2009;48:1042-1051.