Different risk factors have been associated with a high risk of developing invasive fungal infection in haematological neoplasias (Prentice et al. Br J Haematol 2000; 110:273-284). Treatment with liposomal amphotericin B at different doses (1-5 mg/kg/day) has been tried successfully with febrile neutropenic patients, but no standardised procedures are available for other intermediate risk groups. Forty-six acquired febrile episodes in the absence of neutropenia have been studied, the fever being of undocumented source and treated with AmBisome at a dosage of 1 mg/kg/day `(Table 1). Table 1. Characteristics of febrile episodes Acute Myeloblastic Leukaemia Acute Lymphoblastic Leukaemia Lymphoma/E. Hodgkin CLL, HCL and other chronic lymphoproliferative syndromes Multiple Myeloma 1 factor 7 2 4 5 2 >1 factor 3 10 6 4 3 Total 10 12 10 9 5 Risk factors (Prentice et al. 2000): Lymphopenia 500/mm3 if antibiotics use, Corticosteroids maintained, Purine analogue, Candida colonisation >1 site. The mean duration of treatment was 8.6 days (2-21), suspended when the patient remained apyretic for 1 week, with no microbiological evidence of fungal infection. Anti-fungal prophylaxis was reinstated usually with another azole. Results Sixty-one per cent of patients obtained febrile response, the rate being similar to our historic control in febrile neutropenic patients (63% vs. 58%, p=ns). Different individual factors, such as previous treatment with itraconazole, base pathology (acute leukaemia vs. the rest) or having >1 risk factor of fungal infection do not appear to be associated with significant differences in the febrile response rate, but there is an association with a greater probability of febrile relapse, which is produced more frequently and earlier in the group of patients with >1 factor (34% vs. 8%). Discussion Our experience suggests that empiric treatment with low doses of liposomal amphotericin B proves to be effective in the majority of undocumented febrile syndromes affecting patients with non-neutropenic haematological neoplasias with risk factors of invasive fungal infection, with similar response rates to the neutropenics. It is likely that new strategies of secondary prophylaxis will be developed with the intention of reducing the high rates of febrile relapse in the group of patients with several risk factors. However, more extensive studies are required to confirm both hypotheses.
Full conference title:
American Society of Hematology 45th Annual Meeting
- ASH 45th (2003)