Low rates of antifungal prophylaxis in patients high risk for fungal infections

Submitted by MeganB on 8 November 2018

Immunosuppressed patients, such as transplant recipients or those undergoing chemotherapy, are at high risk for invasive fungal infections (IFIs). As IFIs are associated with very high mortality rates, several professional guidelines recommend the prescription of prophylactic antifungals for such high-risk patients. Many antifungal drugs are not very effective when used for prophylactic purposes, yet trials have shown that posaconazole may be clinically superior to other triazoles for this use; the translation of research findings into clinical practice and the implementation of resulting guidelines is not well executed however. A recent paper by Rao Fu, Jake Gundrum and Anita Sung has collected data from across the US in a retrospective study of the use of antifungal medication, particularly posaconazole, and the associated trends and clinical outcomes of patients.

Fu et al.  searched the Premier Healthcare Database to identify high-risk patients discharged between January 2007 and March 2016, and the details of their treatment.  There were 4 immunocompromising conditions that they used to identify patients at high risk of IFIs: acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), those undergoing hematopoietic stem cell transplantation (HSCT) and those with graft-vs-host disease (GVHD). Among these cohorts, they found that between 33% and 94% (with a mean average of 57%) of patients did not receive any of the selected antifungal medications, and posaconazole was prescribed to <10% of patients overall. Interestingly antifungal prophylaxis was given more frequently to patients by teaching hospitals, and teaching hospitals also prescribed posaconazole to AML and MDS patients more frequently than non-teaching hospitals. This may be due to greater knowledge, receptivity, and/or availability of tools for the administration of antifungal prophylaxis, although it could just be that teaching hospitals contain a higher proportion of patients high-risk for IFIs.

This paper highlights the significant, wide-spread underuse of antifungal prophylaxis, despite guidelines recommending their prescription to high-risk patients. The authors recommend further research into determining why antifungals are so under-prescribed and the development of methods to improve adherence to clinical guidelines.