Prognostic Index for Post-Engraftment Invasive Fungal Disease Validated

Researchers have published the first prognostic index validated in an external cohort to predict the occurrence of post-engraftment invasive fungal disease after allogeneic hematopoietic stem cell transplant in the journal Mycoses.

The aim of the study was to validate a previously established prognostic score for post-engraftment invasive fungal disease, which was obtained from a training cohort of 404 adults who had received an allogeneic hematopoietic stem cell transplant. Researchers included 465 consecutive adult recipients surviving >40 days who engrafted and were discharged without prior invasive fungal disease to assess the 1-year cumulative incidence of post-engraftment invasive fungal disease.

Patients were classified as low- (n=139), intermediate- (n=162), or high-risk (n=174) (35% vs 27% in the training-cohort; P =.03). The cumulative incidence of probable or proven invasive fungal disease in the validation vs training cohort was 8% vs 11% (P =.006). In the training cohort, only voriconazole prophylaxis, 100 mg/12 hours was used. Prophylaxis in the training vs validation cohorts was 65% vs 27%, but 38% also received 200 mg/12 hours in the validation group, and thus this cohort showed a lower cumulative incidence of invasive fungal disease (P =.009). The post-engraftment invasive fungal disease score was validated, showing a cumulative incidence of invasive fungal disease of 3% in low-risk, 6% in intermediate-risk, and 14% in high-risk patients (P <.001).

Study limitations included the fact that both cohorts spanned a long period of time and were retrospectively analyzed. There was also a significant heterogeneity in many critical patient and transplant characteristics, which may have potentially influenced the risk for post-engraftment invasive fungal disease.

Investigators concluded that to their knowledge, “this is the first prognostic index to predict the occurrence of post-engraftment invasive fungal disease validated in an external cohort of recipients [of allogeneic hematopoietic stem cell transplant].” This validated prognostic index may be useful for implementing risk-adapted antifungal prophylactic strategies in this setting. However, the investigators cautioned that, “our prognostic tool should be used only in the setting of post-engraftment patients fulfilling the study inclusion/exclusion criteria.”

Further, the study suggested that a full-dose schedule of oral voriconazole prophylaxis could reduce risks in low- and intermediate-risk patients but not high-risk patients. In this group, optimized prophylactic schedules or more effective therapies need to be considered.

Reference

Rodríguez-Veiga R, Montesinos P, García E, et al. Validation of a multivariable prediction model for post-engraftment invasive fungal disease in 465 adult allogeneic hematopoietic stem cell transplant recipients [published online January 11 2019]. Mycoses. doi:10.1111/myc.12891