Antifungal prophylaxis for severely neutropenic chemotherapy recipients

Abstract

BACKGROUND The overall clinical efficacy of the azoles antifungal agents and low‐dose intravenous amphotericin B for antifungal chemoprophylaxis in patients with malignant disease who have severe neutropenia remains unclear. METHODS Randomized‐controlled trials of azoles (fluconazole, itraconazole, ketoconazole, and miconazole) or intravenous amphotericin B formulations compared with placebo/no treatment or polyene‐based controls in severely neutropenic chemotherapy recipients were evaluated using meta‐analytical techniques. RESULTS Thirty‐eight trials that included 7014 patients (study agents, 3515 patients; control patients, 3499 patients) were analyzed. Overall, there were reductions in the use of parenteral antifungal therapy (prophylaxis success: odds ratio [OR], 0.57; 95% confidence interval [95% CI], 0.48–0.68; relative risk reduction [RRR], 19%; number requiring treatment for this outcome [NNT], 10 patients), superficial fungal infection (OR, 0.29; 95% CI, 0.20–0.43; RRR, 61%; NNT, 12 patients), invasive fungal infection (OR, 0.44; 95% CI, 0.35–0.55; RRR, 56%; NNT, 22 patients), and fungal infection‐related mortality (OR, 0.58; 95% CI, 0.41–0.82; RRR, 47%; NNT, 52 patients). Invasive aspergillosis was unaffected (OR, 1.03; 95% CI, 0.62–1.44). Although overall mortality was not reduced (OR, 0.87; 95% CI, 0.74–1.03), subgroup analyses showed reduced mortality in studies of patients who had prolonged neutropenia (OR, 0.72; 95% CI, 0.55–0.95) or who underwent hematopoietic stem cell transplantation (HSCT) (OR, 0.77; 95% CI, 0.59–0.99). The multivariate metaregression analyses identified HSCT, prolonged neutropenia, acute leukemia with prolonged neutropenia, and higher azole dose as predictors of treatment effect. CONCLUSIONS Antifungal prophylaxis reduced morbidity, as evidenced by reductions in the use of parenteral antifungal therapy, superficial fungal infection, and invasive fungal infection, as well as reducing fungal infection‐related mortality. These effects were most pronounced in patients with malignant disease who had prolonged neutropenia and HSCT recipients. Cancer 2002;94:3230–46. © 2002 American Cancer Society. DOI 10.1002/cncr.10610