Prophylaxis

Although recently published guidelines for preventing opportunistic infections in hematopoietic cell transplant recipients do not provide concrete recommendations for antifungal prophylaxis against Aspergillus, prophylaxis should be considered in certain high-risk subgroups with rates of IA exceeding 10%. These groups include: (a) patients with prolonged pre-engraftment periods (e.g., cord-blood transplant recipients), (b) patients with a history of IA prior to transplantation, (c) patients receiving transplants with a high risk of graft-versus-host disease (e.g., haploidentical allogeneic transplant) or infection (e.g., T-cell-depleted transplant), any patient with graft-versus-host disease on high-dose corticosteroid therapy (greater than 1 mg/kg pred-nisone equivalent) with or without antithymocyte globulin or tumor necrosis factor blockade (i.e., infliximab), and (d) any patient transplanted with active cytomegalovirus disease, which is associated with an increased risk of subsequent mold infections due to the immunosuppressive effect of the virus. Posaconazole was shown in two prospective randomized trials to reduce Aspergillus-associated death in patients with acute high-risk leukemia and reduce mold infections in patients with graft-versus-

host disease following hematopoetic stem cell transplantation.35,36 Similar data are

available for voriconazole, but less benefit was observed versus standard fluc-onazole prophylaxis in the hematopoetic stem cell transplant patients. Prophylactic approaches, however, are often highly institution and patient specific.

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