Treatment of IFD in patients with A-Leuk
| Disease . | Drug of choice . | Alternative . | Comment . |
|---|---|---|---|
| Candidemia | Echinocandin: anidulafungin, caspofungin, or micafungin | Fluconazole or L-AMB (3 mg/kg per day) | Anidulafungin (200-mg loading dose, then 100 mg/d) or caspofungin (70-mg loading dose, then 50 mg/d) or micafungin (100 mg/d). |
| Switch to oral agent after a few days when conditions are met. | |||
| Response criteria: clinical findings, blood cultures, CRP. | |||
| DOT: 2 wk. If persistent candidemia, rule out endovascular infection (septic thrombophlebitis, endocarditis); remove central venous catheters; and consider switching to another drug class if no response after the above measures. Continue treatment of 2 wk after resolution of clinical findings and normal CRP. | |||
| Chronic disseminated candidiasis | L-AMB (3 mg/kg per day) | Echinocandin or fluconazole | Switch to oral agent after a few days when conditions are met. |
| Immune modulation: consider oral corticosteroids (0.5 mg/kg of prednisone) if symptoms persist despite optimal antifungal therapy.100 | |||
| Response criteria: clinical findings, CRP, and s-BDG (if elevated at baseline). Persistence of radiologic lesions is not, by itself, indicative of active infection. | |||
| DOT: continuous throughout consolidation to prevent possible reactivation. | |||
| Aspergillosis | Voriconazole53 IV (loading 6 mg/kg every 12 h × 2, then 4 mg/kg every 12 h) | L-AMB (3 mg/kg per day) | Switch to oral voriconazole after a few days when conditions are met. |
| Immune modulation: | |||
| Decrease dose of immunosuppressive agents, particularly corticosteroids. | |||
| Consider G-CSF and G-CSF-elicited granulocyte transfusions if neutrophil recovery is not expected within 3-4 d. | |||
| Consider corticosteroids (prednisone 2 mg/kg per day for 2-3 d if early respiratory failure from PIRIS.9 | |||
| Response criteria: clinical findings, s-GMI ± s-BDG if elevated at baseline, CRP. | |||
| Radiologic findings may be misleading (e,. PIRIS9 ) and lag behind response. | |||
| DOT: until recovery from neutropenia, immunosuppression, resolution of clinical findings, and normalization of CRP and s-GMI ± s-BDG (if elevated at baseline). | |||
| Fusariosis | L-AMB (3 mg/kg per day) or voriconazole IV at same dose schedule as for aspergillosis | ABLC (5 mg/kg per day) | Consider adding second agent (voriconazole) if no response after 3-4 d. |
| Switch to oral voriconazole when conditions are met. The role of antifungal susceptibility tests in guiding therapy is not known. | |||
| Immune modulation: same as for aspergillosis. | |||
| Response criteria: blood cultures; otherwise, same as for aspergillosis. | |||
| DOT: same as for aspergillosis. | |||
| Mucormycosis | L-AMB (5 mg/kg per day) | ABLC (5 mg/kg per day or posaconazole IV (loading 300 mg twice a day on day 1, then 300 mg/d) | Surgical debridement and control of acidosis if present. |
| Switch to oral posaconazole when conditions are met, provided the organism is susceptible to the drug. | |||
| Delayed-release tablets: loading dose 300 mg orally twice a day on day 1, then 300 mg/d | |||
| Oral suspension: 200 mg orally three times a day. | |||
| Immune modulation: same as for fusariosis. | |||
| Response criteria: clinical findings, CRP. | |||
| DOT: until recovery from neutropenia, immunosuppression, resolution of clinical findings, and normalization of CRP. |
| Disease . | Drug of choice . | Alternative . | Comment . |
|---|---|---|---|
| Candidemia | Echinocandin: anidulafungin, caspofungin, or micafungin | Fluconazole or L-AMB (3 mg/kg per day) | Anidulafungin (200-mg loading dose, then 100 mg/d) or caspofungin (70-mg loading dose, then 50 mg/d) or micafungin (100 mg/d). |
| Switch to oral agent after a few days when conditions are met. | |||
| Response criteria: clinical findings, blood cultures, CRP. | |||
| DOT: 2 wk. If persistent candidemia, rule out endovascular infection (septic thrombophlebitis, endocarditis); remove central venous catheters; and consider switching to another drug class if no response after the above measures. Continue treatment of 2 wk after resolution of clinical findings and normal CRP. | |||
| Chronic disseminated candidiasis | L-AMB (3 mg/kg per day) | Echinocandin or fluconazole | Switch to oral agent after a few days when conditions are met. |
| Immune modulation: consider oral corticosteroids (0.5 mg/kg of prednisone) if symptoms persist despite optimal antifungal therapy.100 | |||
| Response criteria: clinical findings, CRP, and s-BDG (if elevated at baseline). Persistence of radiologic lesions is not, by itself, indicative of active infection. | |||
| DOT: continuous throughout consolidation to prevent possible reactivation. | |||
| Aspergillosis | Voriconazole53 IV (loading 6 mg/kg every 12 h × 2, then 4 mg/kg every 12 h) | L-AMB (3 mg/kg per day) | Switch to oral voriconazole after a few days when conditions are met. |
| Immune modulation: | |||
| Decrease dose of immunosuppressive agents, particularly corticosteroids. | |||
| Consider G-CSF and G-CSF-elicited granulocyte transfusions if neutrophil recovery is not expected within 3-4 d. | |||
| Consider corticosteroids (prednisone 2 mg/kg per day for 2-3 d if early respiratory failure from PIRIS.9 | |||
| Response criteria: clinical findings, s-GMI ± s-BDG if elevated at baseline, CRP. | |||
| Radiologic findings may be misleading (e,. PIRIS9 ) and lag behind response. | |||
| DOT: until recovery from neutropenia, immunosuppression, resolution of clinical findings, and normalization of CRP and s-GMI ± s-BDG (if elevated at baseline). | |||
| Fusariosis | L-AMB (3 mg/kg per day) or voriconazole IV at same dose schedule as for aspergillosis | ABLC (5 mg/kg per day) | Consider adding second agent (voriconazole) if no response after 3-4 d. |
| Switch to oral voriconazole when conditions are met. The role of antifungal susceptibility tests in guiding therapy is not known. | |||
| Immune modulation: same as for aspergillosis. | |||
| Response criteria: blood cultures; otherwise, same as for aspergillosis. | |||
| DOT: same as for aspergillosis. | |||
| Mucormycosis | L-AMB (5 mg/kg per day) | ABLC (5 mg/kg per day or posaconazole IV (loading 300 mg twice a day on day 1, then 300 mg/d) | Surgical debridement and control of acidosis if present. |
| Switch to oral posaconazole when conditions are met, provided the organism is susceptible to the drug. | |||
| Delayed-release tablets: loading dose 300 mg orally twice a day on day 1, then 300 mg/d | |||
| Oral suspension: 200 mg orally three times a day. | |||
| Immune modulation: same as for fusariosis. | |||
| Response criteria: clinical findings, CRP. | |||
| DOT: until recovery from neutropenia, immunosuppression, resolution of clinical findings, and normalization of CRP. |
The DOT should be individualized. Switching to oral therapy requires good treatment adherence and intact gut function. Except for hematogenous candidiasis, secondary prophylaxis is required if additional chemotherapy is planned. ABLC, amphotericin B lipid complex.