ANTIFUNGAL PROPHYLAXIS IN BONE-MARROW TRANSPLANT

The benefits of fungal prophylaxis with fluconazole in BMT patients appear to outweigh the risks of a possible increase in colonization and infection by C. krusei or T. glabrata. Disseminated fungal infections caused by C. tropicalis and C. albicans have a 38.8% mortality rate, and these infections may be prevented by the prophylactic use of fluconazole. C krusei and T. glabrata infections generally do not contribute to increased mortality, and most patients infected by these organisms recover after appropriate antifungal therapy. The use of amphotericin B as prophylaxis may have some efficacy. One retrospective study found low-dose amphotericin B therapy to be effective in preventing Candida infections, but results from a placebo- controlled, randomized prospective trial with 0.1 mg/kg/d failed to support this claim. Low-dose amphotericin B prophylaxis (0.1-0.25 mg/kg/d) shows promise against aspergillosis, an opportunistic infection associated with high morbidity and mortality. The literature suggests the possible value of using oral or intravenous fluconazole 200-400 mg/d or intravenous amphotericin B 0.1-0.25 mg/kg/d as antifungal prophylaxis in patients after autologous or allogeneic BMT. Many questions remain unanswered, however. These studies described the potential decrease in morbidity and mortality of BMT patients with the use of either fluconazole or amphotericin B, but it is not known whether all patients after BMT or only those at high risk of fungal infection may benefit from prophylaxis. Optimal dosing of either antifungal agent has not been defined in the studies. Clinicians should be aware of the possible increase in colonization by less pathogenic fungal species, such as C. krusei and T. glabrata, when prescribing fluconazole prophylaxis. Patients with fungal infection require more intense monitoring for signs of disseminated infections. Early and appropriate treatment may prevent mortality.