Antifungal Prophylaxis in Haematology

Invasive fungal diseases are a source of significant morbidity and mortality in patients with haematological malignancies, particularly those with prolonged and severe neutropenia. In view of the poor prognosis associated with tardy treatment initiation, antifungal prophylaxis has become increasingly popular. Until recently, fluconazole – a drug with no Aspergillus activity – and itraconazole, which has absorption-associated problems and is often poorly tolerated, used to be the preferred choices for antifungal prophylaxis. Clinical trials have now assessed the prophylactic use of posaconazole, a new-generation triazole with broad spectrum antifungal activity against Candida, Aspergillus and Fusarium spp., as well as the Zygomycetes. Results have further strengthened the evidence base for antifungal prophylaxis, showing a significant reduction of invasive fungal diseases and significantly improved overall survival in patients with acute myelogenous leukaemia and myelodysplastic syndrome. Moreover, improved attributable survival in patients with severe graft versus host disease on immunosuppressive therapy was documented. For patients undergoing allogeneic haematopoietic stem cell transplantation, fluconazole prophylaxis is still considered current standard. Considering the extended spectrum of posaconazole and its good tolerability, it seems warranted to replace fluconazole by posaconazole for this indication.