Treatment of invasive fungal infections in cancer patients—updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

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Abstract

The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient’s risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.

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Most cited references 177

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Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america.

John R. Perfect, William E. Dismukes, Francoise Dromer … (2010)

Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.

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Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America.

Thomas Walsh, Elias Anaissie, David W. Denning … (2008)

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2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours.

M S Aapro, J Bohlius, D A Cameron … (2011)

Chemotherapy-induced neutropenia is a major risk factor for infection-related morbidity and mortality and also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact the success of treatment, particularly when treatment intent is either curative or to prolong survival. In Europe, prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim (including approved biosimilars), lenograstim or pegfilgrastim is available to reduce the risk of chemotherapy-induced neutropenia. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. The need for generally applicable, European-focused guidelines led to the formation of a European Guidelines Working Party by the European Organisation for Research and Treatment of Cancer (EORTC) and the publication in 2006 of guidelines for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. A new systematic literature review has been undertaken to ensure that recommendations are current and provide guidance on clinical practice in Europe. We recommend that patient-related adverse risk factors, such as elderly age (≥65 years) and neutrophil count be evaluated in the overall assessment of FN risk before administering each cycle of chemotherapy. It is important that after a previous episode of FN, patients receive prophylactic administration of G-CSF in subsequent cycles. We provide an expanded list of common chemotherapy regimens considered to have a high (≥20%) or intermediate (10-20%) risk of FN. Prophylactic G-CSF continues to be recommended in patients receiving a chemotherapy regimen with high risk of FN. When using a chemotherapy regimen associated with FN in 10-20% of patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Clinical evidence shows that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications where indicated. Filgrastim biosimilars are also approved for use in Europe. While other forms of G-CSF, including biosimilars, are administered by a course of daily injections, pegfilgrastim allows once-per-cycle administration. Choice of formulation remains a matter for individual clinical judgement. Evidence from multiple low level studies derived from audit data and clinical practice suggests that some patients receive suboptimal daily G-CSFs; the use of pegfilgrastim may avoid this problem. Copyright © 2010 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

: +49-69-95334617 , +49-69-95334637 , smousset@gmx.net

Journal

Journal ID (nlm-ta): Ann Hematol

Journal ID (iso-abbrev): Ann. Hematol

Title: Annals of Hematology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0939-5555

ISSN (Electronic): 1432-0584

Publication date (Electronic): 12 September 2013

Publication date PMC-release: 12 September 2013

Publication date (Print): 2014

Volume: 93

Pages: 13-32

Affiliations

[ ]Interdisziplinäres Zentrum für Palliativmedizin, Agaplesion Markus Krankenhaus, Wilhelm Epstein-Straße 4, 60431 Frankfurt, Germany

[ ]III. Medizinische Klinik, Hämatologie und Internistische Onkologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany

[ ]Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080 Würzburg, Germany

[ ]Abt. Onkologie und Hämatologie, Med. Klinik u. Poliklinik II, Campus Charité Mitte, Charité Universitätsmedizin, Charitéplatz 1, 10117 Berlin, Germany

[ ]Department I of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany

[ ]Med. Klinik V, Universität Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany

[ ]Medizinische Klinik C, Ferdinand-Sauerbruch-Strasse, Ernst-Moritz-Arndt-Universität, 17487 Greifswald, Germany

[ ]Klinik für Innere Medizin I, Westpfalz-Klinikum Kaiserslautern, Hellmut-Hartert-Str. 1, 67655 Kaiserslautern, Germany

[ ]Department of Hematology and Oncology, Georg-August-University Göttingen, Göttingen, Germany

[ ]Department Hematology and Oncology, University of Munich, Marchionistrasse 15, 81377 Munich, Germany

[ ]Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074 Aachen, Germany

[ ]Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany

[ ]Department of Hematology/Oncology, University of Munich, Campus Großhadern, Munich, Germany

[ ]HELIOS Clinic Berlin Buch, Clinic for Hematology, Oncology and Tumorimmunology, Schwanebecker Chaussee 50, 13175 Berlin, Germany

[ ]Department of Internal Medicine A, Hematology/Oncology, University of Muenster, Muenster, Germany

[ ]II. Medizinische Klinik, Klinikum Passau, Innstraße 76, 94032 Passau, Germany

[ ]Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080 Würzburg, Germany

[ ]Department of Oncology, University Hospital Halle, Ernst-Grube-Str. 40, 06120 Halle, Germany

[ ]Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Charlottenstrasse 72, 14467 Potsdam, Germany

[ ]ONKOLOGIKUM, Frankfurt am Museumsufer, Schaubstraße 16, 60596 Frankfurt, Germany

Article

Publisher ID: 1867

DOI: 10.1007/s00277-013-1867-1

PMC ID: 3889633

PubMed ID: 24026426

SO-VID: 956a8e47-e534-45f0-927f-fc3ece06159c

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Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

History

Date received : 14 May 2013

Date accepted : 29 July 2013

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ScienceOpen disciplines: Hematology

Keywords: antifungal agents,aspergillosis,invasive candidiasis,mycoses,hematologic malignancies

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ScienceOpen disciplines: Hematology

Keywords: antifungal agents, aspergillosis, invasive candidiasis, mycoses, hematologic malignancies

Treatment of invasive fungal infections in cancer patients—updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

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Hematology and Oncology Discovery

Most cited references 177

Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america.

Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America.

2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours.

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