Fungal infections in patients with neutropenia - Challenges in prophylaxisand treatment

Fungal infections are a leading cause of mortality in patients with neutrop enia. Candidiasis and aspergillosis account for most invasive fungal infect ions. General prophylactic measures include strict hygiene and environmental meas ures. Haemopoietic growth factors shorten the duration of neutropenia and t hus may reduce the incidence of fungal infections. Fluconazole is appropria te for antifungal prophylaxis and should be offered to patients with prolon ged neutropenia, such as high-risk patients with leukaemia undergoing remis sion induction or consolidation therapy and high-risk stem cell transplant recipients. Empirical antifungal therapy is mandatory in patients with persistent febri le neutropenia who fail to respond to broad-spectrum antibacterials. Intrav enous amphotericin B at a daily dose of 0.6 to 1 mg/kg is preferred wheneve r aspergillosis cannot be ruled out. Lipid formulations of amphotericin B h ave demonstrated similar efficacy and are much better tolerated. Fluconazole is the best choice for acute candidiasis in stable patients; am photericin B should be used in patients with unstable disease. Use of fluco nazole is restricted by the existence of resistant strains (Candida krusei and, to a lesser extent, C. glabrata). Amphotericin B still remains the gold standard for invasive aspergillosis. Lipid formulations of amphotericin B are effective in aspergillosis and bec ause they are less nephrotoxic are indicated in patients with poor renal fu nction. Itraconazole is an alternative in patients who have good intestinal function and are able to eat. Mucormycosis, trichosporonosis, fusariosis and cryptococcosis are less comm on but require specific management. New antifungal agents, especially new azoles, are under development. Their broad in vitro spectrum and preliminary clinical results are premising.