Improved Outcome of Patients with Invasive Pulmonary Fungal Infection Complicated by Respiratory Failure Due to the Use of New Antimycotis Agens and Early Tracheostomy after Allogeneic Transplantation.

Abstract

The mortality rate associated with respiratory failure due to invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (HSCT) is exceedingly high. Here we compared in a retrospective analysis the influence of the antimycotic agents and early tracheostomy on the outcome of patients (pts) with required artificial respiration (AV) due to pulmonary IFI. The first cohort presented pts, who were treated at our center before the new antimycotic agents became available. This cohort consisted 16 pts from 236 consecutive allogeneic transplant recipients (median age 38 years [range 22–59], 88% had a leukemic disorder) died during or soon after weaning from AV (median survival: 64 days). The mean weaning time was 16 days, only one patient could be tracheotomized. In contrast to this, within a second cohort of 24 pts from 279 consecutive allogeneic transplant recipients, who required AV after the introduction of the new antimycotic agents 9 (38 %) pts could be brought back to spontaneous breathing. The median survival of these pts was 370 days. The weaning time was 24 days, 67% of those pts underwent tracheotomy within ten days after initiation of AV. There were no differences between the two cohorts regarding the underlying diseases, engraftment time or the ratio of myeloablative and reduced intensity conditioning regimens. However, the cohort of pts who were transplanted during the era of new antimycotic agents had a higher median age (43 years, range 20–65, not significantly) and included more mismatched and unrelated grafts with a higher incidence of GVHD grade II-IV (79% vs. 69%). To date, four of those pts are still alive and well (mean survival 463 days, range 240 to 732). We propose that our observations reflect an improved management of these pts nowadays mainly due to the use of new antimycotics and more effective antifungal treatment approaches, as well as the advantages of early tracheostomy may contribute to better outcomes in the treatment of respiratory failure due to pulmonary IFI following allogeneic HSCT.