While antifungal prophylaxis can effectively prevent invasive fungal infections in patients with hematologic diseases, there is no consensus on which prophylactic agents provide the greatest benefit for different patient populations. In a meta-analysis recently published in JAMA Network Open, a team of researchers found that among antifungal prophylactic agents, posaconazole may be the best option for patients with acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS), while voriconazole may be the best option for patients undergoing hematopoietic stem cell transplantation (HSCT). In this interview with i3 Health, Yuan Wan, MD, PhD, the study's principal investigator, discusses the significance of these findings and shares advice for the optimal management of invasive fungal infections in patients with hematologic malignancies.
What are some of the most challenging aspects of preventing and managing invasive fungal infections in patients with hematologic diseases?
Yuan Wan, MD, PhD: High potential for tissue invasion and dissemination and high mortality rates are hallmarks of invasive fungal infections. Assessment of drug efficacy is difficult, and the inconsistent response between in vitro and in vivo evaluation makes it even more difficult. Further challenges include delays in diagnosis, the status of immune suppression, and the multiple interrelated factors influencing clinical outcomes, such as pharmacokinetic and pharmacodynamic parameters.
Can you comment on the significance of your findings regarding antifungal prophylactic agents for patients with hematologic diseases?
Dr. Wan: Our findings will help experts to update guidelines on antifungal prophylaxis for hematological malignancies such as acute AML and for recipients of allogeneic HSCT. The need for primary prophylaxis for these patient groups is clear. Our key recommendations are that voriconazole could be the best option for patients undergoing HSCT, but posaconazole could be the best option for patients with AML or MDS.
While we strongly recommend posaconazole for all patients with AML or MDS, there is poor evidence regarding using it for prophylaxis in patients undergoing HSCT, especially allogeneic transplant. Hence, randomized controlled large-scale multicenter clinical trials are required to further assess whether voriconazole is more effective than posaconazole in patients undergoing allogeneic HSCT.
Do you have any words of advice for members of the cancer care team managing invasive fungal infections in patients with hematologic malignancies?
Dr. Wan: Three aspects must be emphasized in managing invasive fungal infections in this patient population: infection risk prediction; the evidence of biomarkers, including galactomannan, 1,3-β-D-glucan, and polymerase chain reaction (PCR) assays for aspergillus spp; and the utilization of early diagnostic and therapeutic strategies such as prophylaxis, empirical therapy, and targeted therapy.
About Dr. Wan
Yuan Wan, MD, PhD, is an Assistant Professor of Biomedical Engineering at Binghamton University in New York, where he also serves as Principal Investigator for the Pq Laboratory of Micro/Nano BiomeDx. His research interests include translational medicine, diagnostic technologies, targeted drug delivery, separation and detection of disease-related biomolecules, the design of microfluidic devices, and the utilization of nanobiotechnology for disease prevention and treatment. Dr. Wan has authored or coauthored numerous publications in peer-reviewed journals, including Nature Biomedical Engineering, Annals of Oncology, and Cancer Research.
For More Information
Wang J, Zhou M, Xu JY, et al (2020). Comparison of antifungal prophylaxis drugs in patients with hematological disease or undergoing hematopoietic stem cell transplantation. JAMA Netw Open, 3(10):e2017652. DOI:10.1001/jamanetworkopen.2020.17652
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.