An Approach to Suspected Invasive Fungal Infection in Patients with Hematologic Malignancy and HCT Recipients with Persistent Neutropenic Fever Despite Mold-Active Prophylaxis

Abstract

This review offers an approach to managing suspected invasive fungal infection (IFI) in a febrile neutropenic patient with hematologic malignancy or hematopoietic cell transplantation (HCT) while on mold-active prophylaxis. We take into consideration host characteristics, new diagnostic tools, and available therapeutics. Despite use of anti-Aspergillus prophylactic agents, invasive aspergillosis is the most commonly reported IFI breaking through common prophylactic agents including the newest azole, isavuconazole. While more fungal diagnostic modalities are available, how to best incorporate them in the work-up of IFI remains unclear, while sensitivity of any particular fungal biomarker or molecular test is low. In a febrile neutropenic patient with hematologic malignancy or HCT and suspected IFI, consider particularly invasive aspergillosis, regardless of the mold-active prophylactic agent. Early diagnosis and intervention are especially important to a favorable outcome; treatment is directed based on the suspected IFI syndrome and suspected organism. Switching azoles, consideration of combination therapy, and reducing immunosuppression are proposed strategies for the management of breakthrough IFI, while surgical debridement remains crucial for Mucormycoses. More study is needed into the optimal antifungal approach in these clinical scenarios. Meanwhile, therapeutic drug monitoring and attention to drug-drug interactions are encouraged.