Presenter: Cory Schulz, DNP, AGACNP-BC, Nurse Practitioner, Johns Hopkins Hospital, Baltimore, MD
Co-Authors: Jenica Patel, PharmD, BCPS, Johns Hopkins Hospital, Baltimore, MD; Matthew Newman, PharmD, BCOP, Johns Hopkins Hospital, Baltimore, MD
BACKGROUND: Patients with hematologic malignancies have an increased risk for invasive fungal infections (IFIs). Primary antifungal prophylaxis with triazoles or a parenteral echinocandin, such as micafungin, is recommended.1-3 Triazoles are typically preferred because of decreased rates of IFI.4,5 However, because of drug–drug interactions, financial barriers, and/or the adverse effects of triazoles, micafungin is used often in clinical practice for select patients.
OBJECTIVES: The primary objective was to determine the rates of IFIs amongst patients with hematologic malignancies who received micafungin for primary antifungal prophylaxis. The secondary objectives included identifying pertinent patient characteristics and describing micafungin dosing patterns.
METHOD: This was an Institutional Review Board–approved, single-center, retrospective analysis of adult patients with hematologic malignancies who were receiving micafungin for antifungal prophylaxis at a large academic medical center from September 2017 to September 2020. The European Conference on Infections in Leukemia (ECIL) criteria were used to categorize and classify the patients to determine the incidence of IFI. Adult patients (aged ≥18 years) were included if they were receiving treatment for a hematologic malignancy and if they were receiving micafungin as the primary antifungal prophylaxis. Patients were excluded if they had a nonhematologic malignancy, received <4 doses of micafungin, or were receiving micafungin for empiric treatment.
RESULTS: A total of 433 patients were reviewed, and 163 patients met the study inclusion criteria. Of the patients selected, 132 (81%) did not have an IFI, 10 (6.1%) had a proven IFI, 3 (1.8%) had a possible IFI, and 18 (11%) had a possible IFI according to the ECIL criteria. The primary oncologic diagnoses observed were acute myeloid leukemia (57%) and acute lymphoid leukemia (21%). Patients received intensive regimens (N = 48; 30%), nonintensive regimens (N = 84; 53%), bone marrow transplant (N = 12; 8%), ATRA and arsenic (N = 8; 5%), and all immunotherapies (N = 8; 5%). For patient host factors, 125 (78%) patients had neutropenia, 22 (14%) were recipients of an allogeneic stem-cell transplant, and 8 (5%) were receiving immunosuppressants. For clinical features, 31 (19%) patients had lower respiratory tract infections, 3 (2%) had sinonasal infections, and no patients had reported tracheobronchitis or central nervous system infections. Most patients received micafungin 100 mg daily for prophylaxis (N = 123; 77%). Alternative micafungin dosing regimens included 100 mg to 150 mg 2 or 3 times weekly.
CONCLUSION: The use of micafungin as antifungal prophylaxis can be an alternative treatment for patients who are not ideal candidates to receive triazole antifungals.
Supported by funding from Johns Hopkins Hospital.
- Taplitz R, Kennedy E, Bow E, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018;36:3043-3054.
- Teh BW, Yeoh DK, Haeusler GM, et al. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2021. Intern Med J. 2021;51:67-88.
- Wang J, Zhou M, Xu J, et al. Comparison of antifungal prophylaxis drugs in patients with hematological disease or undergoing hematopoietic stem cell transplantation: a systematic review and network meta-analysis. JAMA Netw Open. 2020;3(10):e2017652.
- Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs. fluconazole or itraconazole prophylaxis in patients with neutropenia. N Engl J Med. 2007;356:348-359.
- Wong TY, Loo YS, Veettil SK, et al. Efficacy and safety of posaconazole for the prevention of invasive fungal infections in immunocompromised patients: a systematic review with meta-analysis and trial sequential analysis. Sci Rep. 2020;10(1):14575.
- Agarwal SK, DiNardo CD, Potluri J, et al. Management of venetoclax-posaconazole interaction in acute myeloid leukemia patients: evaluation of dose adjustments. Clin Ther. 2017;39:359-367.
- Neofytos D, Huang Y-T, Cheng K, et al. Safety and efficacy of intermittent intravenous administration of high-dose micafungin. Clin Infect Dis. 2015;61(suppl 6):S652-S661.
- Bochennek K, Balan A, Müller-Scholden L, et al. Micafungin twice weekly as antifungal prophylaxis in paediatric patients at high risk for invasive fungal disease. J Antimicrob Chemother. 2015;70:1527-1530.
- De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) consensus group. Clin Infect Dis. 2008;46:1813-1821.