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. 2024 Jul 23;11(8):ofae409.
doi: 10.1093/ofid/ofae409. eCollection 2024 Aug.

Impact of Antifungal Prophylaxis Continuation or Discontinuation After Allogeneic Hematopoietic Cell Transplant on the Incidence of Invasive Mold Infection

Justine Abella Ross  1 , Brian Lee  1 , Huiyan Ma  2 , Bernard Tegtmeier  3 , Deepa Nanayakkara  4 , Jana Dickter  4 , Ricardo Spielberger  5 , Eileen Smith  5 , Vinod Pullarkat  5 , Stephen J Forman  5 , Randy Taplitz  6 , Ryotaro Nakamura  5 , Monzr Al Malki  5 , Sanjeet Singh Dadwal  4
Affiliations

Impact of Antifungal Prophylaxis Continuation or Discontinuation After Allogeneic Hematopoietic Cell Transplant on the Incidence of Invasive Mold Infection

Justine Abella Ross et al. Open Forum Infect Dis. .

Abstract

Background: Continuing antifungal prophylaxis (AFPx) to prevent invasive mold infections (IMIs) in recipients of allogeneic hematopoietic cell transplantation (alloHCT) after primary hospital discharge from alloHCT admission varies among transplant centers despite recommendations to continue prophylaxis through day +75. Characteristics driving AFPx prescribing at hospital discharge and outcomes are unknown.

Methods: In this retrospective analysis, we reviewed patients continuing AFPx vs no AFPx at hospital discharge. We included patients with a hospital stay ≥7 days and ≤40 days. We excluded patients with a history of IMI prior to alloHCT, new IMI during admission, or death prior to discharge. Our primary objective was incidence of probable or proven IMI per the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Our secondary objectives were nonrelapse mortality at day +100, overall survival at day +100, and characteristics driving AFPx discontinuation at hospital discharge.

Results: Of the 430 patients identified, 387 met inclusion criteria. At discharge, 56% (217/387) continued AFPx, and 44% (170/387) had no AFPx. At day +100, 3 probable IMI cases occurred in the group with continued AFPx vs 1 probable IMI case in the no-AFPx group (no proven IMI). Univariate analysis showed no difference in cumulative incidence of probable IMI (P = .440), nonrelapse mortality (P = .072), and overall survival (P = .855) between groups. Multivariable logistic regression demonstrated that patients were less likely to continue AFPx if they had a diagnosis other than acute myeloid leukemia, a length of stay ≤30 days, acute graft-vs-host disease grade 0 or 1, and corticosteroid use ≤5 days.

Conclusions: There was no difference in probable IMI at day +100 after alloHCT based on continuing vs discontinuing AFPx at hospital discharge after alloHCT admission supporting a risk-adapted prophylaxis approach.

Keywords: antifungal; hematopoietic; invasive mold infection; prophylaxis; transplant.

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Conflict of interest statement

Potential conflicts of interest. S. J. F. serves as an Science Advisory Board member of Allogene Therapeutics, Lixte Bio Board of Directors, Science Advistory Board, Director, T-Cell Therapeutics Research Laboratories and Hematologic Malignancies Research Institute, City of Hope, Mustang CAR-T cell consultant. R. T. serves as a consultant for Merck and Karius advisory boards. R. N. serves as a consultant for Omeros Corporation, Ono Pharmaceutical, and Pfizer. S. S. D. is a consultant/advisory board member for Merck, Ansun Biopharma, Allovir, Aseptiscope Inc, Takeda, and Karius Research; has received grant support (paid to institution) from Merck, Allovir, Karius, Ansun Biopharma, and F2G; and is on the speakers bureau for Karius, Takeda, and Astellas. All other authors report no potential conflicts.

Figures

Figure 1.
Figure 1.
Study design. alloHCT, allogeneic hematopoietic cell transplantation; D, day.
Figure 2.
Figure 2.
Cumulative incidence of probable invasive mold infections in patients continuing antifungal prophylaxis or not. C-AFPx, continued antifungal prophylaxis; CIF, cumulative incidence function; HR, hazard ratio; N-AFPx, no antifungal prophylaxis; NE, not estimable; pIMI, probable invasive mold infection.
Figure 3.
Figure 3.
Nonrelapsed mortality for patients continuing antifungal prophylaxis or not. C-AFPx, continued antifungal prophylaxis; CIF, cumulative incidence function; HR, hazard ratio; N-AFPx, no antifungal prophylaxis; NE, not estimable; NRM, nonrelapsed mortality.
Figure 4.
Figure 4.
Overall survival for patients continuing antifungal prophylaxis or not. C-AFPx, continued antifungal prophylaxis; HR, hazard ratio; KM, Kaplan-Meier; N-AFPx, no antifungal prophylaxis; NE, not estimable.
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