Antifungal therapy in hematopoietic stem cell transplant recipients

Abstract

Invasive fungal infections (IFI) represent a major hindrance to the success of hematopoietic stem cell transplantation (HSCT), contributing substantially to morbidity and infection-related  mortality.During the most recent years several reports indicate an overall increase of IFI among hematologic patients, in particular invasive aspergillosis, that may be explained, at least partially, by the fact that diagnoses only suspected in the past, are now more easily established due to the application of serum biomarkers and  early use of  CT scan. Along with new diagnostic options, comes the recent development of novel antifungal agents that expanded the spectrum of activity over traditional treatments contributing to the successful management of fungal diseases.When introduced in 1959, Amphotericin B deoxycholate (d-AmB) was a life-saving drug, and the clinical experience over 50 years has proven that this compound is effective although toxic. Given the superior safety profile, lipid formulations of AmB have now replaced d-AmB in many circumstances. Similarly, echinocandins have  been investigated as initial therapy for IA in several clinical trials including  HSCT recipients, although the results were moderately disappointing leading to a lower grade of recommendation in the majority of published guidelines. Azoles represent the backbone of therapy for treating immunocompromised patients with IFI, including voriconazole and the new comer isavuconazole; in addition, large studies support the use of mold-active azoles, namely voriconazole and posaconazole,  as antifungal prophylaxis in HSCT recipients.Aim of present review is to summarize the clinical application of antifungal agents most commonly employed in the treatment of IFI.