Infectious Complications in Hematology

Post-induction aplasia for acute myeloid leukemia (AML)/myelodysplastic syndromes (MDS) is a period at highrisk for invasive fungal disease (IFD). Invasive aspergillosis (IA) remains the commonest cause of IFD and crude mortality remains considerable at 33-47%. For patients surviving IFDs, delays or modifications to curative chemotherapy may compromise long-term prognosis. Poor clinical outcomes coupled with diagnostic uncertainty underlies the rationale for antifungal prophylaxis, the efficacy of which in preventing IFD and improving short-term survival has best been demonstrated for posaconazole in AML/MDS patients receiving remission-induction chemotherapy. Despite recognition of the high health and economic burden of IFD, non-selective broad-spectrum prophylaxis has raised concerns about expenditure, overtreatment and emergent drug-resistance as only a subset of AML patients develop IFD. Currently, a more targeted use of prophylaxis is hampered by limited knowledge of local fungal epidemiology and an evolving but incomplete understanding of patientlevel risk. Over ten years, we have continuously given antifungal prophylaxis in AML/MDS patients undergoing intensive chemotherapy characterized by use of fluconazole, itraconazole, voriconazole and posaconazole. We retrospectively reviewed the relative effectiveness and safety of azole antifungal prophylaxis with particular attention to the newer triazoles compared to fluconazole/itraconazole.