Haematological malignancies

In one randomised controlled trial (RCT) comparing different treatment modalities, itraconazole (oral solution) was compared with fluconazole for antifungal prophylaxis.7 Adults with haematological malignancies receiving chemotherapy or bone marrow transplants were randomly allocated itraconazole solution, 5 mg/kg/day, or fluconazole suspension, 100 mg, from before the onset of neutropenia until neutrophil recovery or suspected fungal infection. More proven systemic fungal infections occurred with fluconazole (four Aspergillus, one C. tropicalis and C. krusei) than with itraconazole (one C. albicans) and more of these were fatal (four versus none). Significantly more cases of proven aspergillosis occurred with fluconazole than with itraconazole (six versus none).7

In a non-randomised Bulgarian study, 69 patients with haematological malignancies and neutrophil count below 1 x 109/litre received oral fluconazole, 150 mg every other day. The incidence of mycotic infections was lower in the patients on antifungal prophylaxis compared with patients who received no prophylaxis. Most of the clinically and/or microbiologically verified infections were superficial oropharyngeal (61%) or oesophageal infections (22%), or single cases of skin, genital or rectal infections. C. albicans was isolated in 85% of the cases.8

An RCT compared fluconazole, 400 mg/day, with placebo in patients after bone-marrow transplantation treated for up to 75 days. Systemic fungal infections were found in 10 (7%) of 152 fluconazole-treated patients and in 26 (18%) of 148 placebo-treated patients (P= 0-004). No C. albicans infections occurred in fluconazole recipients, compared with 18 in placebo recipients (P<0-001) and no significant increase in infection with Candida species other than C. albicans. Fluconazole also significantly reduced the incidence of superficial fungal infections (P<0-001), fungal colonisation (P= 0-037) and empiric amphotericin B use (P= 0-005). Fluconazole recipients were more likely to survive: 31 of them died up to day 110 after transplantation, compared with 52 among the placebo recipients (P= 0-004).9 Fluconazole toxicity was well manageable.

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