Emprirical Antifungal Therapy of Persistent Neutropenic Fever After Allogeneic Hematopoietic Stem Cell Transplantation With Caspofungin or Liposomal Amphotericin B

Caspofungin and liposomal amphotericin B (L-ampho B) have shown similar efficacy for the treatment of persistent febrile neutropenia (PFN). Although patients undergoing allogeneic stem cell transplantation (allo-SCT) are at high risk of life-threatening invasive fungal infections (IFI), specific data on the best choice of antifungal agent in this setting are scarce.The aim of the present study was to analyse the efficacy of caspofungin and L-ampho B used as empirical treatment of PFN in two consecutive historical cohorts of patients undergoing allo-SCT at a single institution. Efficacy was evaluated using a five-part composite end point.From 2000 to 2009, we analyzed 134 consecutive patients undergoing allo-SCT who received empirical antifungal therapy for the treatment of PFN: a first cohort of 61 patients treated with L-ampho B (2000-2004) vs a second cohort of 73 patients treated with caspofungin (2005-2009). Most baseline characteristics were comparable between both groups. However, patients in the caspofungin group received more unrelated donor cord blood transplants (63% vs 41%, p = 0.011).Breakthrough fungal infections were observed in 4 (6%) and 11 (15%) patients in the L-ampho B and the caspofungin groups, respectively (p = 0.2). Of all, 13 were due to Aspergillus spp while 1 C. neoformans CNS infection and 1 B. capitatus fungemia were observed in patients receiving caspofungin. Nine additional patients had a baseline fungal infection (4 in the L-ampho B group and 5 in the caspofungin group) and none of them had successful treatment. Resolution of fever during neutropenia was seen in 40 (66%) and 41 (56%) of patients in the L-ampho B and the caspofungin groups, respectively (p = 0.17). There was a trend towards higher premature discontinuation of therapy due to lack of efficacy or toxicity in the caspofungin group (27% vs 13%, p = 0.057). However, more patients survived at least 7 days after completion of therapy in the caspofungin group (92% vs 75%, p = 0.007). The overall success rate defined as the fulfilment of all 5 composite end points was achieved in 28 (46%) and 24 (33%) patients in the L-ampho B and the caspofungin groups, respectively (p = 0.16).L-ampho B and caspofungin were both effective when given as empirical antifungal therapy for the treatment of PFN in patients undergoing allogeneic SCT. Differences between L-ampho B and caspofungin in overall success assessed by the 5-component end point were not statistically significant. Caspofungin and liposomal amphotericin B (L-ampho B) have shown similar efficacy for the treatment of persistent febrile neutropenia (PFN). Although patients undergoing allogeneic stem cell transplantation (allo-SCT) are at high risk of life-threatening invasive fungal infections (IFI), specific data on the best choice of antifungal agent in this setting are scarce. The aim of the present study was to analyse the efficacy of caspofungin and L-ampho B used as empirical treatment of PFN in two consecutive historical cohorts of patients undergoing allo-SCT at a single institution. Efficacy was evaluated using a five-part composite end point. From 2000 to 2009, we analyzed 134 consecutive patients undergoing allo-SCT who received empirical antifungal therapy for the treatment of PFN: a first cohort of 61 patients treated with L-ampho B (2000-2004) vs a second cohort of 73 patients treated with caspofungin (2005-2009). Most baseline characteristics were comparable between both groups. However, patients in the caspofungin group received more unrelated donor cord blood transplants (63% vs 41%, p = 0.011). Breakthrough fungal infections were observed in 4 (6%) and 11 (15%) patients in the L-ampho B and the caspofungin groups, respectively (p = 0.2). Of all, 13 were due to Aspergillus spp while 1 C. neoformans CNS infection and 1 B. capitatus fungemia were observed in patients receiving caspofungin. Nine additional patients had a baseline fungal infection (4 in the L-ampho B group and 5 in the caspofungin group) and none of them had successful treatment. Resolution of fever during neutropenia was seen in 40 (66%) and 41 (56%) of patients in the L-ampho B and the caspofungin groups, respectively (p = 0.17). There was a trend towards higher premature discontinuation of therapy due to lack of efficacy or toxicity in the caspofungin group (27% vs 13%, p = 0.057). However, more patients survived at least 7 days after completion of therapy in the caspofungin group (92% vs 75%, p = 0.007). The overall success rate defined as the fulfilment of all 5 composite end points was achieved in 28 (46%) and 24 (33%) patients in the L-ampho B and the caspofungin groups, respectively (p = 0.16). L-ampho B and caspofungin were both effective when given as empirical antifungal therapy for the treatment of PFN in patients undergoing allogeneic SCT. Differences between L-ampho B and caspofungin in overall success assessed by the 5-component end point were not statistically significant.