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Invasive aspergillosis before HCT: safe to proceed?

Bone Marrow Transplantation volume 51, pages 346–347 (2016)Cite this article

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Much of what we know about the outcomes of allogeneic hematopoietic cell transplantation (HCT) in patients with pre-transplant invasive aspergillosis (IA) in the pre-voriconazole era stems from the large studies from the Fred Hutchinson Cancer Research Center (FHCRC) in the early 2000s. Marr et al.1 studied 5589 patients who received allogeneic HCTs at FHCRC between 1985 and 1999; the overall 1-year survival after any invasive mold infection was dismal (~20%). Most patients with IA were treated with therapies that were standard at the time: amphotericin B deoxycholate and lipid-formulation amphotericin, although a few received an investigational triazole.1 In another study from that era, Fukuda et al. reported that 45/2319 (1.9%) of patients transplanted at FHCRC between 1992 and 2001 had known pre-transplant IA. Of these, post-transplant IA occurred in 13/45 (29%), and these patients had significantly lower overall survival and higher transplant-related mortality.2 Notably, these studies involved patients transplanted before the availability of the more potent mold-active azoles: voriconazole (approved in Europe and in the United States in 2002), posaconazole (approved in Europe in 2005 and in the United States in 2006) and isavuconazonium (approved in the United States in 2015).

More recent multicenter prospective studies have documented the changing epidemiology of invasive fungal infections after HCT in the current era,3, 4 including the rise of non-Aspergillus mold infections and the improved mortality of invasive aspergillosis in the era of newer antifungal agents. The use of secondary fungal prophylaxis with voriconazole for the first 100–150 days, in patients with known pre-transplant invasive fungal infections, has also led to improved outcomes post HCT.5 Most recently, Marr et al.6 performed a randomized multicenter trial comparing voriconazole alone to voriconazole plus anidulafungin for initial treatment of IA in patients with hematologic malignancies and HCT, and found a survival benefit in the combination therapy group, at least in the subgroup diagnosed on the basis of galactomannan assays.

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  1. Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA

    R K Avery

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Avery, R. Invasive aspergillosis before HCT: safe to proceed?. Bone Marrow Transplant 51, 346–347 (2016). https://doi.org/10.1038/bmt.2015.302

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