A hematology consensus agreement on antifungal strategies for neutropenic patients with hematological malignancies and stem cell transplant recipients

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1 Hematological Oncology Hematol Oncol (2012) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: /hon.2031 Review A hematology consensus agreement on antifungal strategies for neutropenic patients with hematological malignancies and stem cell transplant recipients Corrado Girmenia 1 *, Franco Aversa 2, Alessandro Busca 3, Anna Candoni 4, Simone Cesaro 5, Mario Luppi 6, Livio Pagano 7, Giuseppe Rossi 8, Adriano Venditti 9 and Anna Maria Nosari 10 1 Dipartimento di Ematologia, Oncologia, Anatomia Patologica e Medicina Rigenerativa, Azienda Policlinico Umberto I, Rome Italy 2 Sezione di Ematologia e Centro Trapianti Midollo Osseo, Università di Parma, Parma Italy 3 SSCVD Trapianto di Cellule Staminali, Ematologia 2, Ospedale San Giovanni Battista, Torino Italy 4 Clinica Ematologica-Centro trapianti e Terapie Cellulari, Azienda Ospedaliero-Universitaria di Udine, Udine Italy 5 Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona Italy 6 DAI Oncologia, Ematologia e Malattie Apparato Respiratorio, Cattedra e UO-C di Ematologia, Azienda Ospedaliera Universitaria. Policlinico, Università Modena e Reggio Emilia, Modena Italy 7 Istituto di Ematologia, Università Cattolica del Sacro Cuore, Rome Italy 8 S.C. Ematologia e Dipartimento Oncologia Medica Spedali Civili, Brescia Italy 9 Ematologia, Fondazione Policlinico Tor Vergata, Rome Italy 10 Divisione di Ematologia e Centro Trapianti Midollo Ospedale Niguarda Ca Granda, Milan, Italy *Correspondence to: Corrado Girmenia, MD, Dipartimento di Ematologia, Oncologia, Anatomia Patologica e Medicina Rigenerativa, Azienda Policlinico Umberto I, Via Benevento 6, 00161, Rome, Italy. girmenia@bce.uniroma1.it Received 10 May 2012 Revised 5 September 2012 Accepted 7 September 2012 Abstract In the attempt to establish key therapy definitions and provide shared approaches to invasive fungal diseases in neutropenic patients, trials of empiric, preeemptive and targeted antifungal therapy (EAT, PAT and TAT) were reviewed, and a Consensus Development Conference Project was convened. The Expert-Panel concurred that all antifungal treatments, including EAT, should always follow an adequate diagnostic strategy and that the standard definition of PAT may be misleading: being PAT guided by the results of a diagnostic work-up, it should better be termed diagnostic-driven antifungal therapy (DDAT). The Expert-Panel agreed that radiological findings alone are insufficient for the choice of a TAT and that the identification of the etiologic pathogen is needed. The Consensus Agreement proceeded identifying which clinical and microbiological findings were sufficient to start a DDAT and which were not. Finally, an algorithm to rationalize the choice of antifungal drugs on the basis of clinical manifestations, antifungal prophylaxis, instrumental and laboratory findings was drawn up. Copyright 2012 John Wiley & Sons, Ltd. Keywords: empiric antifungal therapy; pre-emptive antifungal therapy; targeted antifungal therapy; hematological malignancies; stem cell transplant Introduction Antifungal strategies represent a challenging issue in neutropenic patients with hematological diseases (HemD) submitted to chemotherapy or stem cell transplant (SCT). Criteria are available to orientate in choice of antifungal drugs and treatment timing for empiric antifungal therapy (EAT) of febrile neutropenia and targeted antifungal therapy (TAT) of documented invasive fungal diseases (IFDs), whereas the definition of pre-emptive antifungal therapy (PAT) is still debated. International guidelines, although recommending EAT as the standard of care for high-risk neutropenia, recognize that PAT may be an alternative to EAT even though several items of information are still pending: consensus on the optimal indicator to PAT (clinical or radiological signs or a serum biomarker), the biomarker to be used (antigen or PCR), timing (before or after onset of clinical signs) and the most appropriate antifungal agent [1,2]. In the attempt to establish key therapy definitions and provide shared diagnostic and therapeutic approaches, a Consensus Development Conference Project was convened. After reviewing reports of EAT, PAT and TAT in HemD and SCT patients, the panel of experts reached consensus on a multidisciplinary strategy, which is described in the present paper. Design and methods Literature review strategy Full-paper articles on EAT, PAT and TAT in HemD and SCT patients were searched on PubMed for relevant English language publications since 1990 through June 2011 by using the Medical Subjects Heading term empiric antifungal therapy, OR pre-emptive antifungal therapy, OR presumptive antifungal therapy, OR treatment of invasive aspergillosis, OR treatment of invasive candidosis, AND haematological malignancies, OR stem cell transplant, OR neutropenia. Also, the terms galactomannan, fungal protein chain reaction and Copyright 2012 John Wiley & Sons, Ltd.

2 C Girmenia et al. beta-d-glucan were used for the search. Reference lists of articles identified by the search were also reviewed for inclusion of additional relevant reports. Study selection, categorization and data extraction were performed by one reviewer (C. G.) and submitted to the independent evaluation of the other panelists. Only prospective clinical trials in which the antifungal therapy was administered according to a predefined strategy were considered. The following data were extracted from each eligible publication, as available: type of study; study methodology; underlying disease or clinical condition of the population; definition of, and indication for antifungal therapy; and details of diagnostic strategy. The consensus process The consensus group was formed by 10 Italian experts belonging to the main scientific association who deal with IFD in HemD and SCT patients, that is, Gruppo Italiano Malattie EMatologiche dell Adulto, Gruppo Italiano Trapianto di Midollo Osseo, Associazione Italiana Ematologia ed Oncologia Pediatrica, Invasive Fungal Infections Cooperative Group of the European Organization for Research and Treatment of Cancer and Sorveglianza Epidemiologica delle Infezioni Fungine nelle Emopatie Maligne group. These participants have collectively published in international journals at least 200 manuscripts relating to the diagnosis and treatment of IFD in HemD and SCT patients, and most of them have had experience in guidelines process within the GITMO and the European Conference on Infections in Leukemia. Using a Delphi process [3] with the criterion of clinical relevance, the Expert-Panel search generated relevant key issues using which were addressed in the consensus process. Four consensus meetings of the Expert-Panel were held in Milan, Italy, to reach a definitive consensus on the key issues. One member of the Expert-Panel, who was elected to be the consensus writer, provided a summary of the content of each meeting for the other members. In the first meeting, the Expert-Panel discussed the literature review data and evidence in support of the key issues. In each of the next three meetings, each panelist commented on the key issues and the content of the previous encounter, and provided a personal interpretation of the data. The other panelists scored his or her agreement with the speaker s statements and provided suggestions for rephrasing. The nominal group technique was used [4]. Participants were first asked to comment in round-robin fashion on their preliminary votes and then to propose a new vote. If an 80% consensus on the statement was not achieved, choices were discussed and a second vote was taken. If an 80% consensus was still not reached, the issue was declared still open, and the differences of opinion were reported in detail and commented. Considering that this consensus referred to literature review and to the personal opinion of the authors, not considering unpublished data, an ethic committee approval was not necessary Results Review of the literature Out of total 37 articles of EAT of febrile neutropenia initially retrieved, only 12 papers completely fulfilled eligibility being prospective clinical trials with a predefined indication for empiric use of the antifungal drug [5 18]. A total of 29 trials of diagnostic strategies of IFDs in HemD or SCT patients were reviewed, but only 11 of them were finally considered being the predefined diagnostic approach finalized to a PAT [18 28]. Out of 34 trials of TAT of IFDs, studies of salvage therapy and trials of primary therapy of invasive candidiasis, which included only a minority of HemD or SCT patients, were excluded from the analysis, and only four prospective trials of primary therapy of invasive aspergillosis (IA), mainly including HemD and SCT patients, were finally considered [29 32]. Studies of empiric antifungal therapy In the last 25 years, several prospective trials compared amphotericin B deoxycholate with new antifungal drugs as EAT or investigated the feasibility of diagnostic strategies while maintaining an EAT approach (Table 1) [7 18]. The EAT starting time ranged from 3 to 7 days after the onset of fever and in some studies also patients with recurring fever after initial defervescence were considered eligible. No protocol for any multicentre, controlled EAT trial, comparing the efficacy and safety of two antifungal drugs, established a common diagnostic approach [7 15]. In other prospective studies where a predefined diagnostic work-up failed to identify the cause of fever, persisting fever remained an indication to EAT [16 18]. In particular, in the study by Barnes et al. [18], EAT after 4 days of persisting fever was reserved to patients not receiving an antifungal prophylaxis, whereas patients under effective antifungal prophylaxis were not empirically treated but received a PAT on the basis of the results of the diagnostic work-up. Studies of pre-emptive antifungal therapy Overall, out of 11 prospective studies of PAT in neutropenic patients considered for the analysis [18 28], eight of them have been published since 2009 [18,22 28]. Seven studies prospectively evaluated the feasibility of PAT [18 24], and four randomly compared PAT with EAT [25 28] (Table 2). Fungal markers included the galactomannan assay in six studies [18,20,21,23,25,28], the beta-d-glucan assay in one [21] and PCR in four [18,19,26,27], whereas in two studies, no fungal marker was used in the pre-emptive strategy [22,24]. In three studies, fungal colonization was also monitored [20,23,25]. Imaging techniques included chest X-ray in only five studies [18,20,21,24,25], whereas pulmonary computed tomography scan, with other imaging tests when indicated, was used in all reports [18 28]. The timing and use of diagnostic tools differed whether the diagnostic strategy was surveillance driven or clinically driven. In surveillancedriven approaches, used in five studies [20,21,26 28], fungal antigens or PCR assays were performed periodically along

3 Antifungal therapy in neutropenic patients Table 1. Indication for empiric antifungal therapy (EAT) of febrile neutropenia in large clinical trials First author (reference), type of study Indication for EAT during neutropenia Diagnostics strategy Malik et al. [7], randomized clinical trial of EAT: fluconazole vs deoxycholate-amphotericin B White et al. [8], randomized clinical trial of EAT: deoxycholate-amphotericin B vs amphotericin B colloidal dispersion Walsh et al. [9], randomized clinical trial of EAT: deoxycholate-amphotericin B vs liposomal amphotericin B Walsh et al. [10], randomized clinical trial of EAT: liposomal amphotericin B vs voriconazole Walsh et al. [11], randomized clinical trial of EAT: liposomal amphotericin B vs caspofungin Winston et al. [12], randomized clinical trial of EAT: fluconazole vs deoxycholate-amphotericin B Wingard et al. [13], randomized clinical trial of EAT: liposomal amphotericin B vs amphotericin B lipid complex Boogaerts et al. [14], randomized clinical trial of EAT: itraconazole vs deoxycholate-amphotericin B Maertens et al. [15], randomized clinical trial of EAT: liposomal amphotericin B vs caspofungin Penack et al. [16], prospective feasibility study of EAT with not specified antifungal drug Armenian et al. [17], prospective feasibility study of, EAT with voriconazole Barnes et al. [18], prospective feasibility study of EAT with liposomal amphotericin B or voriconazole, in patients not receiving effective antifungal prophylaxis At least 7 days of persisting fever No predefined diagnostic approach At least 3 days of persisting or recurrent fever No predefined diagnostic approach At least 5 days of persisting fever No predefined diagnostic approach At least 4 days of persisting fever No predefined diagnostic approach At least 4 days of persisting fever No predefined diagnostic approach At least 4 days of persisting or recurrent fever No predefined diagnostic approach At least 3 days of persisting fever No predefined diagnostic approach At least 7 days of persisting fever No predefined diagnostic approach At least 4 days of persisting fever No predefined diagnostic approach At least 4 days of persisting or recurrent fever Predefined diagnostic work-up: weekly surveillance cultures for fungal organisms; GM 2/w starting from onset of neutropenia; chest CT and/or chest X-ray at onset of fever and if 5 days persisting or recurrent fever At least 5 days of persisting or recurrent fever Predefined diagnostic work-up: GM 2/w and PCR 1/w starting from onset of neutropenia and during GVHD in allo-sct patients and at onset of fever and until neutropenia recovery in high-risk leukaemia patients; chest CT if 5 days persisting or recurrent fever At least 4 days of persisting fever Predefined diagnostic work-up: GM and PCR 2/w from onset of fever; chest CT if positive fungal marker, or clinically indicated GM, Aspergillus galactomannan; PCR, protein chain reaction; CT, computed tomography; GVHD, graft-versus-host disease; w, weekly. DOI: /hon

4 C Girmenia et al. Table 2. Diagnostic strategy employed in 11 prospective studies of preemptive antifungal therapy in patients with febrile neutropenia First author (reference), type of study Underlying clinical condition Colonization monitoring Fungal marker (criteria of positivity) [strategy of collection and timing] Radiological exams (timing) Lin et al. [19], feasibility CHT No PCR (2 consecutive positive PCR tests) [clinically driven, 2 3/w starting from onset of fever] Maertens et al. [20], feasibility CHT or allo-sct Yes GM (2 consecutive positive GM tests using a cutoff of 0.5 ODI) [surveillance, daily starting from onset of neutropenia] Oshima et al. [21], feasibility Allo-SCT No GM and BDG (2 consecutive positive GM tests using a cutoff of 0.6 ODI; for BDG positivity cutoff not specified) [ surveillance, 1/w starting from onset of neutropenia] Barnes et al. [18], feasibility, PAT in patients receiving effective antifungal prophylaxis CHT or allo-sct No GM and PCR (2 consecutive positive GM tests using a cutoff within 0.5 and 0.7 ODI, or a single positive test of >0.7 ODI; 2 consecutive positive PCR tests) [clinically driven, 2/w starting from onset of fever] Chest CT (if positive fungal marker or clinically indicated) Chest X-ray (surveillance, 1 2/w), chest CT (if positive fungal marker, 5 days persisting or recurrent fever or clinically indicated) Chest X-ray (surveillance,), chest CT (if positive fungal marker, 7 days persisting or recurrent fever or clinically indicated) Chest CT (if positive fungal marker, or clinically indicated) Dignan et al. [22], feasibility Allo-SCT No No Chest CT (if 3 days persisting or recurrent fever or clinically indicated) Chest CT (if 4 days persisting or recurrent fever or clinically indicated) Girmenia et al. [23], feasibility CHT or auto-sct Yes GM (2 consecutive positive GM tests using a cutoff of 0.5 ODI) [clinically driven, 3 consecutive days starting from 4 days persisting or recurrent fever] Aguilar-Guisado et al. [24], feasibility CHT or allo-sct No No Chest CT and/or chest X-ray (if 5 days persisting or recurrent fever or clinically indicated) Cordonnier et al. [25], randomized Chest CT and/or chest X-ray (if positive fungal marker, controlled trial of PAT vs EAT 4 days persisting or recurrent fever or clinically indicated) Hebart et al. [26], randomized controlled trial of PAT vs EAT Blennow et al. [27], randomized controlled trial of PAT vs EAT Tan et al. [28], randomized controlled trial of PAT vs EAT CHT or auto-sct Yes GM (2 consecutive positive GM tests using a cutoff of 1.5 ODI) [clinically driven, 2/w starting from 4 days persisting or recurrent fever] Allo-SCT No PCR (one positive PCR result) [surveillance, 2/w starting from onset of neutropenia] Allo-SCT No PCR (one positive PCR result) [surveillance, 2/w starting from onset of neutropenia] CHT or allo-sct No GM (2 consecutive positive GM using a cutoff of 0.5 ODI, or a single positive GM plus a highly suggestive CT thorax) [surveillance, 2/w starting from onset of neutropenia] Chest CT and/or chest X-ray (if positive fungal marker, 4 days persisting or recurrent fever or clinically indicated) Not specifically defined Chest CT (if positive fungal marker or clinically indicated) PAT, preemptive antifungal therapy; EAT, empiric antifungal therapy; CHT, chemotherapy; SCT, stem cell transplant; allo, allogeneic; auto, autologous; w, weekly; CT, computed tomography; ODI, optical density index; GM, Aspergillus galactomannan; PCR, protein chain reaction; BDG, beta-d-glucan.

5 Antifungal therapy in neutropenic patients the entire period of neutropenia even in the absence of fever or other infectious signs. A clinically driven strategy was applied in the other six studies [18,19,22 25]. It was based on a diagnostic work-up with fungal markers detection, cultures and radiological exams performed only when an underlying IFD was clinically suspected (onset, persistence or relapse of febrile neutropenia and/or other clinical findings). Radiological exams were performed only when an IFD was clinically suspected in all but two studies where patients periodically underwent chest X-ray regardless of fever or other infectious signs [20,21]. No study specifically tested the efficacy of the antifungal agents used, and in only four studies [21,23,24,27], the diagnostic work-up dictated the choice of the antifungal agent and any modifications to therapy. These experiences, although offering a precious contribution to the progress of a modern approach to febrile neutropenia, may suffer of a difficult feasibility in the clinical practice. The study by Maertens et al. [20] represents a milestone of the PAT in HemD and SCT patients; however, it might be difficult to perform in standard resource centres the intensive surveillance and diagnostic approach employed (daily serum galactomannan, once or twice weekly surveillance chest X-ray, bronchoscopy with lavage as a common practice). The trial by Cordonnier et al. [25] is the largest until now reported, which randomly compared a PAT strategy with an EAT strategy. However, in this study, the duration of fever before start of PAT (13 median days, range 6 17 days) underlines the difficulties in adopting a uniform and timely diagnostic approach able to guide an early and safe therapeutic intervention. Finally, the experience by Girmenia et al. [23], although demonstrating the feasibility of a selective and inexpensive clinically driven diagnostic antifungal approach in highrisk neutropenic patients, imply the availability of timely reports by dedicated microbiological and radiological services. In summary, all these experiences provide important information for the implementation of a pre-emptive strategy in HemD and SCT patients, but the choice and the timing of the diagnostic tools should be adapted to the local resources. Studies of targeted antifungal therapy The four multicenter studies of first-line TAT of IA have been conducted mainly in HemD and SCT patients [29 32]. Herbrecht et al. randomly compared voriconazole and amphotericin B deoxycholate before the European Organization for Research and Treatment of Cancer- Mycoses Study Group (EORTC-MSG) definitions had been published [29,33]. Proven (definite) IA included also cases documented by specific radiologic findings and isolation of Aspergillus from respiratory tract (later defined as probable IA by EORTC-MSG). Computed tomography findings such as nodules with halo-sign or cavitary lesions in the absence of microbiological criteria were considered probable pulmonary aspergillosis (later defined as possible IFD by EORTC-MSG). The other three studies [30 32] adopted the 2002 EORTC-MSG definitions [33]. However, the study by Cornely et al. [32] (the AMBILOAD trial), in which standard (3 mg/kg) doses of liposomal AmB were compared with high (10 mg/kg) doses, also enclosed in the group of probable IA infections documented by specific radiological findings (nodules with halo-sign and cavitary lesions) but without microbiological documentation (cases of possible IFD according to the EORTC-MSG definitions). On the contrary, two EORTC open-label, non-comparative, multicentre studies of caspofungin therapy in HemD and SCT patients, respectively, strictly employed the EORTC- MSG definitions, and cases not fulfilling at least a definition of probable IA were excluded from the efficacy analysis [31,32]. Substantial discrepancies in the definitions of proven/probable IA make a comparative assessment of these studies impossible. This point of view is confirmed by the re-evaluation of the data of the AMBILOAD trial by the same authors [34] using the EORTC/MSG 2008 criteria for the definition of IA [35]. By excluding the cases of IA originally classified as probable invasive mould disease and categorized as possible IFD using 2008 criteria, the favourable response at the end of treatment decreased from 56% to 40%, and from 48% to 42% in the patients who received standard doses and high doses of liposomal amphotericin B, respectively. Consensus process results Key issues Key issues for the present consensus review process were as follows: 1. definition of EAT, PAT and TAT in neutropenic patients; 2. PAT indications and diagnostic strategies; and 3. selecting the antifungal agent for PAT. Definition of EAT, PAT and TAT (a) EAT has been defined as an antifungal treatment given to neutropenic patients affected by fever of unknown origin which does not respond to broad spectrum antibacterials. EAT was started after 3 7 days persistent or recurrent fever. Expert-Panel comments: Considering that in neutropenic patients with persistent fever a precise identification of the infective agent with a prompt intervention is advisable, the Expert-Panel agreed that EAT cannot be a remedy of an inadequate diagnostic strategy and remarked that a work-up including cultures, fungal markers, and imaging exams should be always performed. As early intervention may impact with the outcome [36 38], the Expert-Panel concurred with most studies in whom 3 4 days of persistent fever was an appropriate time to start EAT. However, this starting time of the EAT is not mandatory and may be delayed based on the clinical assessment of the patient during each febrile neutropenia episode. (b) PAT has been defined as an antifungal treatment in neutropenic patients, with or without fever, and clinical and/or microbiological findings suspected to be related to an IFD but insufficient to satisfy the criteria of proven/probable IFD [35]. Expert-Panel comments: The Expert-Panel agreed that, although conventionally used, the term PAT may be DOI: /hon

6 C Girmenia et al. misleading. Traditionally, a preemptive therapy is considered a treatment of a high risk patient with laboratory signs not diagnostic for but predictive of a possibly incoming disease (i.e. raising or abnormal value of cytomegalovirus antigenemia or DNAemia in SCT is not diagnostic but only predictive of viral disease). On the contrary, the so called PAT is a treatment guided by some clinical signs and/or radiological imaging or microbiological results of the diagnostic work-up which may be suggestive for an already established IFD. In view of the above considerations, the Expert-Panel agreed that PAT may be better defined as a diagnostic driven antifungal therapy (DDAT) of a suspected IFD. (c) TAT has been defined as the treatment of a proven/ probable IFD in accordance with EORTC-MSG criteria, with specific clinical and microbiological evidence to orientate the choice of the antifungal agent. Expert-Panel comments: Some TAT clinical trials included patients with radiological findings suggesting IA but without microbiological evidence. These cases of possible IFD according to EORTC-MSG definitions were upgraded to probable invasive aspergillosis [29,30]. The Expert- Panel agreed that, since radiological criteria of IFD are not pathogen specific, TAT cannot be guided by radiological findings only. Efforts should concentrate on identifying the pathogen and an appropriate targeting drug. According to these considerations, the treatment of patients based on computed tomography imaging suggestive of IFD should be defined as PAT. PAT indications and diagnostic strategies (a) The following microbiological tools have been used in clinical trials of PAT: - galactomannan from serum or respiratory specimens (bronchoalveolar lavage and sputum); - serum beta-d-glucan; - molecular detection (PCR) of fungi; and - isolation of filamentous fungi from non-sterile body sites, such as the respiratory tract. Expert-Panel comments: Expert-Panel agreed that in neutropenic patients a positive galactomannan test should be evaluated as an early marker of occult infection which should prompt further diagnostic work-up. Various cutoff criteria have been used (Table 2). The Expert-Panel agreed that at least two consecutive samples with an index 0.5 or one sample with an index >0.7 should be considered as significant. Considering that false positive results may occur, in absence of other clinical and radiological findings, positive serum galactomannan test is not a mandatory indication to start an antifungal therapy. Detection of galactomannan from respiratory specimens is a precious microbiological tool considering its high sensitivity and specificity [39,40]. An index 1 has been considered the galactomannan cutoff value for bronchoalveolar lavage in several studies, but it has recently been redefined and approved for 0.5 by the FDA [41]. Expert-Panel agreed that blood beta-d-glucan and PCR detection alone cannot be accepted as indicators for starting PAT. Although beta-d-glucan serum detection has been included as a marker for probable IFDs in the revised EORTC-MSG definitions [38], its diagnostic role has not been properly assessed in HemD and SCT patients. With regard to PCR assay, until standardized and validated test is available, its role in PAT remains uncertain [38]. The type of pathogen which is isolated from non-sterile body sites, even in absence of specific clinical signs of IFD, will determine decision-making. If Aspergillus, Zygomycetes, Fusarium, and Scedosporium species are found from the respiratory tract but also from the intestinal tract, being they potential invasive pathogens, a PAT may be considered. More caution should be used when other filamentous fungi such as Penicillium, Alternaria, Paecilomyces and Cladosporium species are found because they are common colonizers rarely involved in invasive infections [42]; in such cases a PAT should be guided by clinical findings potentially associated to and IFD more than by the microbiological results. Yeasts are usually considered colonizers when isolated from non sterile body sites. Nevertheless, the isolation of some strains, such as Trichosporon species, Geotrichum capitatum and Candida tropicalis, due to their frequent association with deep seated infections, may be considered as an indication for a strict clinical monitoring and a specific antifungal treatment [43,44]. (b) The following clinical findings have been used in trials of PAT: - all clinical signs of possible IFD according to EORTC-MSG; - any new pulmonary infiltrate not responding to antibacterial therapy; - any clinical and/or radiological extra-pulmonary sign (sino-nasal, cutaneous, cerebral, hepato-splenic and intestinal) suggesting IFD but not satisfying EORTC-MSG criteria; - oral mucositis; - diarrhoea; and - septic shock. Expert-Panel comments: In patients with persistent febrile neutropenia any clinical and radiological evidence of tissue infection, although not specific for an IFD, may be an indication to administer PAT. Oral mucositis and diarrhoea in absence of other signs of gastrointestinal infection, such as thickening of the bowel wall, are not an indication for PAT, considering also that they represent common non-infectious complications of chemotherapy. The Expert- Panel panel agreed that septic shock does not represent a specific finding of an IFD, however, in patients who are not receiving antifungal prophylaxis the possibility of an underlying candidemia should be considered. (c) Diagnostic strategies used in clinical trials of PAT The timing and use of diagnostic strategies in the PAT studies differed whether they were surveillance driven or clinically driven, as detailed earlier. Expert-Panel comments: The choice of a diagnostic strategy depends on the infectious risk of the patient.

7 Antifungal therapy in neutropenic patients Patients with acute myeloid leukemia during induction chemotherapy and allo-sct recipients should be considered at high risk of IFDs. Both surveillance-driven and clinically-driven antifungal strategies are advised in SCT patients during the engraftment period and during steroid treatment of GVHD when a sub-clinical onset of infection may occur. A microbiological marker (preferably galactomannan according to the literature evidence) should be monitored for the entire period at risk to guarantee early detection of certain IFDs. Positive surveillance marker, persistent fever or other clinical signs should then trigger a clinically-driven diagnostic approach. The Expert-Panel did not reach complete consensus regarding the strategy to be used in acute myeloid leukemia patients undergoing chemotherapy. Half of the panellists stated that the low probability of documenting an IFD in afebrile and asymptomatic neutropenic patients does not justify a surveillance strategy [23,45]. They advised using a clinically-driven antifungal approach in acute myeloid leukemia patients with prolonged/recurrent fever [23]. Patients with acute myeloid leukemia during consolidation chemotherapy, acute lymphoid leukemia or other lymphoproliferative diseases undergoing intensive chemotherapy, aplastic anemia or myelodysplastic syndromes leading to chronic neutropenia, autologous SCT recipients, allo-sct recipients after engraftment without GVHD should be considered at standard risk of IFD. In these cases, a clinically-driven antifungal diagnostic strategy without microbiological surveillance is advised. Choice of antifungal drugs for PAT No specific indication in the choice of antifungal drugs derives from the published clinical trials of PAT. The Expert- Panel advised antifungal agents according to the clinical presentation. (a) Any pulmonary infiltrate or sino-nasal infection with negative cultural and non-cultural microbiological exams: microbiologically undetected infections possibly caused by various fungi including Zygomycetes may be suspected in these cases; therefore, a lipid amphotericin B formulation should be used. Liposomal amphotericin B is preferable, given its high-grade recommendation in Aspergillus therapy guidelines and its activity against Zygomycetes [1,2]. (b) Pulmonary infiltrate, sino-nasal infection not fulfilling EORTC-MSG criteria and positive galactomannan and/or Aspergillus spp. culture isolation: As IA is strongly suspected, voriconazole should be used or alternatively liposomal amphotericin B [1,2]. (c) Persisting febrile neutropenia and only serum galactomannan positivity: As a deep-seated occult IA may be suspected, voriconazole should be used or alternatively liposomal AmB while continuing in the diagnostic efforts. (d) Neutropenic enterocolitis: As yeasts, and less frequently moulds, may be involved in the pathogenesis of this severe complication of chemotherapy, intravenous fluconazole, an echinocandin or a lipid formulation of amphotericin B, may be used [46]. Microbiological exams, ongoing triazole prophylaxis, renal or liver function, or electrolytic abnormalities will address the choice. (e) Central nervous system involvement with negative microbiological tests: Given its wide-spectrum activity including the anti-zygomycetes action, a lipid amphotericin B formulation should be used. It may be associated with other antifungals to take advantage of diverse pharmacokinetic properties and the potential additive effect against Aspergillus infections [47]. Diagnostic and therapeutic strategies in patients receiving triazoles prophylaxis Aspergillus-active prophylaxis with a triazole (usually posaconazole, but also voriconazole or itraconazole) is a practice that is widespread in the units taking care of acute myeloid leukaemia and allogeneic SCT patients. Such antifungal prophylaxis may interfere with diagnostic and therapeutic strategies. In particular, possible impaired sensitivity of the galactomannan assay in patients on antifungal therapy should be considered [48]; furthermore, the choice of antifungal drugs in patients with a documented or suspected IFD while receiving triazole prophylaxis represents a challenging issue. Expert-Panel comments: Published randomized clinical trials and post marketing real life experiences on posaconazole prophylaxis in neutropenic and SCT patients showed that most of cases of breakthrough IA were diagnosed thank to galactomannan detection from serum or bronchoalveolar lavage [49 52]. Assuming that a breakthrough IA may be related to a reduced gastrointestinal absorption with subtherapeutic serum concentrations of posaconazole, a normal production and spread of galactomannan by the fungal pathogen in these cases seems to be likely. However, the Expert- Panel agreed that, although galactomannan assay remains the most useful microbiological diagnostic tool of IA also during prophylaxis with triazoles, negative results of the galactomannan assay should be considered with caution and, when possible, antigen detection should be also performed in bronchoalveolar lavage. In patients with a breakthrough IFD during prophylaxis with a triazole, treatment with a different class of antifungalsa lipid formulation of amphotericin B for a breakthrough aspergillosis and an echinocandin for a breakthrough candidiasis- should be preferred. However, failure of prophylaxis may be due not only to an impaired microbiological activity but also to pharmacokinetic problems related to reduced absorption or increased metabolism of the drug. In these cases therapeutic drug monitoring may be used as a decision-making tool [53,54]. Conclusions Management of IFDs continues to be a challenging issue in HemD and SCT neutropenic patients. A schematic definition of the different antifungal strategies in this population is detailed in Figure 1. The present Consensus Agreement concurred that EAT continues to be a standard in the management of DOI: /hon

8 C Girmenia et al. Figure 1. Antifungal strategies in neutropenic patients febrile neutropenia, but it cannot be an alternative to trying to make a diagnosis. The experts underlined that the standard definition of PAT may be misleading and observed that, being PAT a strategy guided by the results of a diagnostic work-up, it should better be termed DDAT. As regards TAT, the Expert-Panel agreed that radiological findings alone, although specific, are insufficient and that efforts should focus on identifying the pathogen. The Consensus Agreement proceeded with diagnostic indications for DDAT, identifying which clinical and microbiological findings were sufficient to start it and which were not. As any tailored strategy is determined by the type of patient and the specific risk of IFD, the Expert- Panel stratified patients according to risk categories. Surveillance-driven and clinically driven antifungal strategies were advised for high-risk patients, whereas only a clinically driven antifungal diagnostic strategy was advised for those at standard risk. Any diagnostic-driven strategy should be adapted to the resources of each hematologic centre. Finally, the Expert-Panel drew up an algorithm to rationalize the choice of antifungal drugs on the basis of clinical manifestations, antifungal prophylaxis, instrumental and laboratory findings. Conflict of interest All authors provided substantial contributions to conception and design, acquisition of evidence, and analysis and interpretation of data, in particular during panel meetings. All authors also participated in drafting the article and revising it critically, and gave final approval of the version to be published. C. G. and A. M. N. were responsible for the project s design and analysis of results. C. G., F. A. and G. R. were responsible for manuscript preparation. All the authors critically revised the final version of the paper. C. G. has received honoraria from Gilead Sciences, Schering-Plough, Astellas Pharma, Merck and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Schering-Plough, Merck and Pfizer Pharmaceuticals. F. A. has received honoraria from Gilead Sciences, Schering-Plough, Merck, Cephalon and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Schering- Plough, Merck, Cephalon and Pfizer Pharmaceuticals. A. B. has received honoraria from Gilead Sciences, Schering-Plough and Merck. He has been speaker for Gilead Sciences, Schering-Plough, Merck, Pfizer Pharmaceuticals, Astellas Pharma, Cephalon and Novartis. A. C. has received honoraria from Gilead Sciences, Schering-Plough, Merck, and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Schering-Plough, Merck and Pfizer Pharmaceuticals. S. C. has received honoraria as speaker for Gilead Sciences and Pfizer Pharmaceuticals. M. L. received research funds from Merck Sharp & Dohme and Gilead Sciences. He serves in the advisory boards of Merck Sharp & Dohme and Gilead Sciences and received honoraria from these two pharmaceutical industries, and from Pfizer, Schering-Plough and Nanogen. He has applied for a European patent regarding clinical applications of the ELISpot assay for the diagnosis of Aspergillus infection [PCT: WO2008/075395A3, EP , IT2007/ ]. L. P. has received honoraria from Gilead Sciences, Schering-Plough, Astellas Pharma, Merck and Pfizer Pharmaceuticals. He has been a speaker for Gilead Sciences, Schering-Plough, Merck and Pfizer Pharmaceuticals. G. R. has received honoraria and participated in the advisory boards of Gilead Sciences, Merck and Cephalon. A. V. has received honoraria from Gilead Sciences.

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