Antifungal treatment duration in hematology patients with invasive mold infections: an untold story

Abstract

Abstract Background Limited data exist on when and how to stop antifungal treatment (AFT) in immunocompromised patients with invasive mold infections (IMI). Methods This is a retrospective multi-center study on adult patients with acute myelogenous leukemia (AML) and proven/probable IMI (01.01.2010-31.12.2022) in three University Hospitals. The primary objective was to describe AFT duration and adaptation. Secondary objectives were to investigate the reasons for AFT adjustments and prolongation. Results Seventy-one patients with 73 IMI were identified; 51 (71.8%) had an allogeneic hematopoietic cell transplant (HCT). Most infections were invasive aspergillosis (IA, 49/71, 69%), followed by mucormycosis (12, 16.9%), and other IMI (12, 16.9%); there were two mixed infections. Treatment duration was 227 days (IQR:115.5-348.5). There was no difference in AFT duration between patients with IA and non-IA IMI (P:0.85) or by center (P:0.92). Treatment was longer in patients with an allogeneic HCT versus not (P:0.004). Sixteen (22.5%) patients had no therapy modifications. In 55 (77.5%) patients 2 (median; IQR:1-3; range:1,8) changes were observed. There were 182 reasons leading to 165 changes, associated with clinical efficacy (82/182, 44.5%), toxicity (47, 25.8%), and logistical reasons (22, 12.1%); no reason was documented in 32 (18.8%) changes. AFT was continued beyond day-90/day-180 in 59 (83%)/39 (54.9%) patients, respectively, mostly due to persistence of immunosuppression. Conclusions AFT in AML patients with IMI is longer than recommended by guidelines and frequently associated with treatment adjustments due to variable reasons. More data and better guidance are required to optimize AFT duration and secondary prophylaxis administration according to immunosuppression.