Introduction: Antifungal prophylaxis (AF) during neutropenia following SCT is recommended, especially in allo-SCT, however it is associated with adverse events, drug interactions or high prices. Except when needed secondary AF, we use environmental protection (HEPA air and water filters) and only start antifungal treatment at the 1st peak of fever during the neutropenic phase of autologous (auto-SCT) or allogeneic (allo-SCT) transplant. We evaluate retrospectively the incidence of fungal infections (IFI) during the early phase and compare the real cost of our procedure with the hypothetical cost if we had used posaconazole (200 mg/8h po), voriconazole (200 mg/12h iv) or micafungin (100 mg/24h iv), started at the beginning of conditioning or started the infusion day.
Materials (or patients) and methods: 215 patients allo-SCT (88 MRD, 67 MUD, 60 MmD) and 130 auto-SCT were evaluated. Median age was 49 years (allo-SCT) and 58 years (auto-SCT). The main underlying disease was acute leukemia/MDS (133). BM in 158 patients was the main stem cell source in allo-SCT. Efficacy was assesed evaluating the development of probable or proven IFI according with the EORTC-2008 criteria during the first 60 days post-SCT, the type of microorganism, the cause of death and autopsy diagnosis. We compared the efficacy, with that reported in the literature. To assess the cost of our procedure (Group V1), we evaluated the days on the protected environment room, the days of hospitalization and the type and days of antifungal tretment. The hypothetical cost of the standard prophylaxis was calculated in each patient based on the beginning of the conditioning regimen (Groups CPos, CVor, CMic) or the day of infusion (Groups TPos, TVor and TMic) to outpatient. Cost/day of HEPA and water filters was 3.4 €. Drug costs were calculated based on our local prices. Differences were calculated with the paired two-sample t-test.
Results: Two proven (C.parapsilosis and Alternaria sp.) and 3 probable (2 Aspergillus and 1 Mucor) IFI were diagnosed during the early phase (incidence 1.45%). At day +60, 16 patients had died, 2 of them because of fungal infection (1 Aspergillus and 1 Mucor). Another fungal infection was detected in 1 of the 8 autopsies made (Cumulative incidence 1.5%). Median duration of conditioning regimen, hospitalization and isoation in the protrected room was 6 days, 25 days and 24 days respectively. 47 patients (14%) did not need any treatment. Patients were treated only with fluconazole (91) or with an echinocandin (59) and 68 patients with fluconazole followed by echinocandin. The mean cost of Group V1 was 1851 €, statistically different (p <0.001) when it was compared with Groups CVor (7936 €), TVor (6400€), CMic (10974 €) and TMic (8850 €). We did not find differences in costs when the Group V1 was compared with posaconazole (CPos 2666 € and TPos 2150 €, p=0.066 and p=0.973 respectively).
Conclusion: We present a different schedule for the prevention of IFI during the neutropenic period of SCT with the same efficacy as reported by Cornely (2007), Wingard (2010), Van Burik (2004), and lower cost than voriconazole or micafungin in primary prohylaxis. Although we did not observe differences with the posaconazole group, we did not include in the analysis several factors (mucositis, hepatic impairment, fungal suspiction) that can modify its continued use.
Disclosure of Interest: L. Yañez Conflict with: Gilead, MSD and Pfizer Speaker´s bureau. Gilead, MSD, Pfizer and Astellas advisory m., N. Fernandez: None Declared, A. Bermudez: None Declared, A. Insunza: None Declared, C. Richard: None Declared, E. Conde: None Declared
Full conference title:
- EBMT 41st (2015)