SECONDARY ANTIFUNGAL PROPHYLAXIS INALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANT: THE NIGUARDA HOSPITAL EXPERIENCE
(Abstract release date: 05/19/16)
EHA Library. Ferrari S. 06/09/16; 133074; E1525
Dr. Silvia Ferrari
Contributions
Contributions
Abstract
Abstract: E1525
Type: Eposter Presentation
Background
As allogeneic hematopoietic SCT (HSCT) is the only curative treatment for the majority of acute leukemia patients (pts), clinicians encounter the therapeutic dilemma of balancing cytotoxic therapy and HSCT with the risk of invasive mold infections (IMIs) relapse-related morbidity and death. Use of effective, less toxic antifungals and routine early chest CT implementation, leading to prompt intensive antifungal therapy, improved responses and survival. These developments have increased the interest regarding the efficacy of secondary antifungal prophylaxis (SAP), but data are limited.
Aims
The aim of the study was to evaluate the IMI relapse rate and associated mortality rate after allogeneic HSCT in a cohort of pts with hematological malignancies. We assessed the HSCT outcome of pts with a history of IFI and the efficacy of SAP.
Methods
We retrospectively collected data of pts with IFI treated at Niguarda bone marrow transplant center between 2004 and 2016. Among the 322 HSCT recipients we identified 36 pts, median age 49 yrs (range 16-67), with a history of IFI. The underlying malignancies were AML (26), ALL (8), myelodysplastic syndrome (2). Hematologic disease status at transplant was CR (26), PR (6) and refractory disease (4). Conditioning regimens were myeloablative in 22 pts and reduced-intensity conditioning in 14.
Results
The IFI diagnosis according to the EORTC/MSG criteria was proven, probable and possible in 6 (2 A.fumigatus, 1 A.terreus, 1 Absidia Corymbifera and 2 Mucor), 5 and 25 pts, respectively. Sites of involvement included lung (31), sinuses (3), central nervous system (1) and breastbone (1). The median duration of antifungal treatment before SCT was 110 days (10-360) and the IFI status at transplantation was CR, PR (defined as presence of residual pulmonary localizations at CT scan but no symptoms) and active in 18, 16 and 2 pts, respectively. During the peritransplant period 31 pts received SAP with liposomal amphotericin (Amb), 1 pt received both Amb and Posaconazole, 2 pts Voriconazole, 2 pts Caspofungin. After engraftment 12 pts (1 active IFI, 5 PR and 6 CR) continued antifungal therapy: 6 received Voriconazole, 1 Posaconazole, 5 Amb for a median period of a month; 3 of Amb pts continued prophylaxis with Posaconazole (2) and Voriconazole (1) up to ciclosporine suspension. By day +100, IFI progression occurred in only 1 pt with active hematologic disease and proven aspergillosis who rapidly died. No fungal recurrence was present in the other pts, also in presence of CMV reactivation (15 pts). We observed 16 cases of aGVHD (12 with possible, 1 with probable and 3 with proven IFI) and 18 cases of cGVHD, treated with steroid therapy (median duration 17 months, 1-80). Among GVHD pts only one had a possible IFI reactivation (20 months from HSCT) in absence of SAP. With a median follow-up of 37 months (1–118) 20 pts died due to leukemia relapse (10), bacterial infections (6), GVHD/transplant toxicities (3), IFI (1).
Conclusion
In our experience (1 IFI-related death and 1 possible late IFI reactivation) with a correct SAP, prior IFI may no longer be considered a contraindication for allo-SCT. However, new data are needed to guide the use of SAP and to improve the cost-effectiveness of treatment. Determination of appropriate time to discontinue SAP is one of the many areas where more data are needed. Prolonged fungal pre-transplant therapy, aiming to achieve a clinically undetectable state of infection, followed by SAP during transplant may allow the SCT with reduced fungal reactivation.
Session topic: E-poster
Keyword(s): Allogeneic hematopoietic stem cell transplant, Fungal infection, Prophylaxis
Type: Eposter Presentation
Background
As allogeneic hematopoietic SCT (HSCT) is the only curative treatment for the majority of acute leukemia patients (pts), clinicians encounter the therapeutic dilemma of balancing cytotoxic therapy and HSCT with the risk of invasive mold infections (IMIs) relapse-related morbidity and death. Use of effective, less toxic antifungals and routine early chest CT implementation, leading to prompt intensive antifungal therapy, improved responses and survival. These developments have increased the interest regarding the efficacy of secondary antifungal prophylaxis (SAP), but data are limited.
Aims
The aim of the study was to evaluate the IMI relapse rate and associated mortality rate after allogeneic HSCT in a cohort of pts with hematological malignancies. We assessed the HSCT outcome of pts with a history of IFI and the efficacy of SAP.
Methods
We retrospectively collected data of pts with IFI treated at Niguarda bone marrow transplant center between 2004 and 2016. Among the 322 HSCT recipients we identified 36 pts, median age 49 yrs (range 16-67), with a history of IFI. The underlying malignancies were AML (26), ALL (8), myelodysplastic syndrome (2). Hematologic disease status at transplant was CR (26), PR (6) and refractory disease (4). Conditioning regimens were myeloablative in 22 pts and reduced-intensity conditioning in 14.
Results
The IFI diagnosis according to the EORTC/MSG criteria was proven, probable and possible in 6 (2 A.fumigatus, 1 A.terreus, 1 Absidia Corymbifera and 2 Mucor), 5 and 25 pts, respectively. Sites of involvement included lung (31), sinuses (3), central nervous system (1) and breastbone (1). The median duration of antifungal treatment before SCT was 110 days (10-360) and the IFI status at transplantation was CR, PR (defined as presence of residual pulmonary localizations at CT scan but no symptoms) and active in 18, 16 and 2 pts, respectively. During the peritransplant period 31 pts received SAP with liposomal amphotericin (Amb), 1 pt received both Amb and Posaconazole, 2 pts Voriconazole, 2 pts Caspofungin. After engraftment 12 pts (1 active IFI, 5 PR and 6 CR) continued antifungal therapy: 6 received Voriconazole, 1 Posaconazole, 5 Amb for a median period of a month; 3 of Amb pts continued prophylaxis with Posaconazole (2) and Voriconazole (1) up to ciclosporine suspension. By day +100, IFI progression occurred in only 1 pt with active hematologic disease and proven aspergillosis who rapidly died. No fungal recurrence was present in the other pts, also in presence of CMV reactivation (15 pts). We observed 16 cases of aGVHD (12 with possible, 1 with probable and 3 with proven IFI) and 18 cases of cGVHD, treated with steroid therapy (median duration 17 months, 1-80). Among GVHD pts only one had a possible IFI reactivation (20 months from HSCT) in absence of SAP. With a median follow-up of 37 months (1–118) 20 pts died due to leukemia relapse (10), bacterial infections (6), GVHD/transplant toxicities (3), IFI (1).
Conclusion
In our experience (1 IFI-related death and 1 possible late IFI reactivation) with a correct SAP, prior IFI may no longer be considered a contraindication for allo-SCT. However, new data are needed to guide the use of SAP and to improve the cost-effectiveness of treatment. Determination of appropriate time to discontinue SAP is one of the many areas where more data are needed. Prolonged fungal pre-transplant therapy, aiming to achieve a clinically undetectable state of infection, followed by SAP during transplant may allow the SCT with reduced fungal reactivation.
Session topic: E-poster
Keyword(s): Allogeneic hematopoietic stem cell transplant, Fungal infection, Prophylaxis
Abstract: E1525
Type: Eposter Presentation
Background
As allogeneic hematopoietic SCT (HSCT) is the only curative treatment for the majority of acute leukemia patients (pts), clinicians encounter the therapeutic dilemma of balancing cytotoxic therapy and HSCT with the risk of invasive mold infections (IMIs) relapse-related morbidity and death. Use of effective, less toxic antifungals and routine early chest CT implementation, leading to prompt intensive antifungal therapy, improved responses and survival. These developments have increased the interest regarding the efficacy of secondary antifungal prophylaxis (SAP), but data are limited.
Aims
The aim of the study was to evaluate the IMI relapse rate and associated mortality rate after allogeneic HSCT in a cohort of pts with hematological malignancies. We assessed the HSCT outcome of pts with a history of IFI and the efficacy of SAP.
Methods
We retrospectively collected data of pts with IFI treated at Niguarda bone marrow transplant center between 2004 and 2016. Among the 322 HSCT recipients we identified 36 pts, median age 49 yrs (range 16-67), with a history of IFI. The underlying malignancies were AML (26), ALL (8), myelodysplastic syndrome (2). Hematologic disease status at transplant was CR (26), PR (6) and refractory disease (4). Conditioning regimens were myeloablative in 22 pts and reduced-intensity conditioning in 14.
Results
The IFI diagnosis according to the EORTC/MSG criteria was proven, probable and possible in 6 (2 A.fumigatus, 1 A.terreus, 1 Absidia Corymbifera and 2 Mucor), 5 and 25 pts, respectively. Sites of involvement included lung (31), sinuses (3), central nervous system (1) and breastbone (1). The median duration of antifungal treatment before SCT was 110 days (10-360) and the IFI status at transplantation was CR, PR (defined as presence of residual pulmonary localizations at CT scan but no symptoms) and active in 18, 16 and 2 pts, respectively. During the peritransplant period 31 pts received SAP with liposomal amphotericin (Amb), 1 pt received both Amb and Posaconazole, 2 pts Voriconazole, 2 pts Caspofungin. After engraftment 12 pts (1 active IFI, 5 PR and 6 CR) continued antifungal therapy: 6 received Voriconazole, 1 Posaconazole, 5 Amb for a median period of a month; 3 of Amb pts continued prophylaxis with Posaconazole (2) and Voriconazole (1) up to ciclosporine suspension. By day +100, IFI progression occurred in only 1 pt with active hematologic disease and proven aspergillosis who rapidly died. No fungal recurrence was present in the other pts, also in presence of CMV reactivation (15 pts). We observed 16 cases of aGVHD (12 with possible, 1 with probable and 3 with proven IFI) and 18 cases of cGVHD, treated with steroid therapy (median duration 17 months, 1-80). Among GVHD pts only one had a possible IFI reactivation (20 months from HSCT) in absence of SAP. With a median follow-up of 37 months (1–118) 20 pts died due to leukemia relapse (10), bacterial infections (6), GVHD/transplant toxicities (3), IFI (1).
Conclusion
In our experience (1 IFI-related death and 1 possible late IFI reactivation) with a correct SAP, prior IFI may no longer be considered a contraindication for allo-SCT. However, new data are needed to guide the use of SAP and to improve the cost-effectiveness of treatment. Determination of appropriate time to discontinue SAP is one of the many areas where more data are needed. Prolonged fungal pre-transplant therapy, aiming to achieve a clinically undetectable state of infection, followed by SAP during transplant may allow the SCT with reduced fungal reactivation.
Session topic: E-poster
Keyword(s): Allogeneic hematopoietic stem cell transplant, Fungal infection, Prophylaxis
Type: Eposter Presentation
Background
As allogeneic hematopoietic SCT (HSCT) is the only curative treatment for the majority of acute leukemia patients (pts), clinicians encounter the therapeutic dilemma of balancing cytotoxic therapy and HSCT with the risk of invasive mold infections (IMIs) relapse-related morbidity and death. Use of effective, less toxic antifungals and routine early chest CT implementation, leading to prompt intensive antifungal therapy, improved responses and survival. These developments have increased the interest regarding the efficacy of secondary antifungal prophylaxis (SAP), but data are limited.
Aims
The aim of the study was to evaluate the IMI relapse rate and associated mortality rate after allogeneic HSCT in a cohort of pts with hematological malignancies. We assessed the HSCT outcome of pts with a history of IFI and the efficacy of SAP.
Methods
We retrospectively collected data of pts with IFI treated at Niguarda bone marrow transplant center between 2004 and 2016. Among the 322 HSCT recipients we identified 36 pts, median age 49 yrs (range 16-67), with a history of IFI. The underlying malignancies were AML (26), ALL (8), myelodysplastic syndrome (2). Hematologic disease status at transplant was CR (26), PR (6) and refractory disease (4). Conditioning regimens were myeloablative in 22 pts and reduced-intensity conditioning in 14.
Results
The IFI diagnosis according to the EORTC/MSG criteria was proven, probable and possible in 6 (2 A.fumigatus, 1 A.terreus, 1 Absidia Corymbifera and 2 Mucor), 5 and 25 pts, respectively. Sites of involvement included lung (31), sinuses (3), central nervous system (1) and breastbone (1). The median duration of antifungal treatment before SCT was 110 days (10-360) and the IFI status at transplantation was CR, PR (defined as presence of residual pulmonary localizations at CT scan but no symptoms) and active in 18, 16 and 2 pts, respectively. During the peritransplant period 31 pts received SAP with liposomal amphotericin (Amb), 1 pt received both Amb and Posaconazole, 2 pts Voriconazole, 2 pts Caspofungin. After engraftment 12 pts (1 active IFI, 5 PR and 6 CR) continued antifungal therapy: 6 received Voriconazole, 1 Posaconazole, 5 Amb for a median period of a month; 3 of Amb pts continued prophylaxis with Posaconazole (2) and Voriconazole (1) up to ciclosporine suspension. By day +100, IFI progression occurred in only 1 pt with active hematologic disease and proven aspergillosis who rapidly died. No fungal recurrence was present in the other pts, also in presence of CMV reactivation (15 pts). We observed 16 cases of aGVHD (12 with possible, 1 with probable and 3 with proven IFI) and 18 cases of cGVHD, treated with steroid therapy (median duration 17 months, 1-80). Among GVHD pts only one had a possible IFI reactivation (20 months from HSCT) in absence of SAP. With a median follow-up of 37 months (1–118) 20 pts died due to leukemia relapse (10), bacterial infections (6), GVHD/transplant toxicities (3), IFI (1).
Conclusion
In our experience (1 IFI-related death and 1 possible late IFI reactivation) with a correct SAP, prior IFI may no longer be considered a contraindication for allo-SCT. However, new data are needed to guide the use of SAP and to improve the cost-effectiveness of treatment. Determination of appropriate time to discontinue SAP is one of the many areas where more data are needed. Prolonged fungal pre-transplant therapy, aiming to achieve a clinically undetectable state of infection, followed by SAP during transplant may allow the SCT with reduced fungal reactivation.
Session topic: E-poster
Keyword(s): Allogeneic hematopoietic stem cell transplant, Fungal infection, Prophylaxis
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