Treatment for invasive aspergillosis using the diagnostic-driven approach with voriconazole that includes galactomannan testing was associated with better outcomes when compared with empiric therapy with a non-voriconazole-containing regimen, and was equivalent in outcome to empiric therapy with voriconazole in patients with hematologic malignancy, according to data published in BMC Infectious Diseases.

Medical records from 342 patients with hematologic malignancy with diagnosed or probable invasive aspergillosis who had received at least 7 days of diagnostic-driven approach with voriconazole, empiric therapy with a non-voriconazole-containing regimen, or empiric therapy with voriconazole were reviewed. The response to therapy, both clinical and radiographic; all-cause mortality; and infectious aspergillosis-attributable mortality were assessed and multivariate analysis was used to identify factors predictive of favorable outcomes.

Localized/sinus invasive aspergillosis vs disseminated/pulmonary invasive aspergillosis (P <.0001), not receiving white blood cell transfusion (P <.01), and diagnostic-driven approach with voriconazole vs empiric therapy with voriconazole (P <.0001) were all predictive of a favorable response. Researchers demonstrated that invasive disease had a hazard ratio of 3.3 (95% CI, 1.5-7.2) times more associated with overall mortality compared with localized invasive aspergillosis. Having undergone stem cell transplantation within 1 year before invasive aspergillosis was also associated with a lower mortality rate (HR0.60; 95% 0.41-0.88; P =.008). In addition, empiric therapy without voriconazole was 18.8-fold more likely to be associated with mortality compared with patients who received the diagnostic-driven approach treatment with voriconazole (P <.0001).

This study was limited in that it was retrospective in nature and conducted at a single medical center. Further, in comparison with the other 2 groups, the sample size for the diagnostic-driven approach with the voriconazole group was small, and the study investigators could not account for the status of the malignant disease at the time of diagnosis, whether it was remission vs relapse or refractory disease, the intensity of graft vs host disease, or any comorbidities and coinfections. Despite these limitations, the study authors concluded that “the [diagnostic-driven approach] could reduce the use of unnecessary antifungals with a superior to equivalent outcome.”

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According to the study authors, this could lead to a more rational use of available antifungals and reduce costs and adverse events associated with the widespread use of empirical treatments. In addition, researchers believe this targeted and diagnostic-driven approach could be useful in improving the care of this high-risk patient group.

Reference

Dib RW, Hachem RY, Chaftari AM, Ghaly F, Jiang Y, Raad I. Treating invasive aspergillosis in patients with hematologic malignancy: diagnostic driven approach versus empiric therapies. BMC Infect Dis. 2018;18:656.