Tolerability of Daily Micafungin Antifungal Prophylaxis in High Risk Pediatric Patients Undergoing Hematopoietic Cell Transplantation for Non-Malignant Disorders

Invasive fungal infections are a cause of mortality in pediatric allogeneic hematopoietic cell transplantation (allo-HCT) recipients. Prophylaxis with triazoles present a challenge in patients with non-malignant disorders due to pre-HCT risk for organ dysfunction. Micafungin is an echinocandin with activity against Candida and Aspergillus species. Limited toxicity and drug interactions of micafungin make this an attractive option. Limited experience has been reported in pediatric HCT patients with non-malignant disorders. We report our experience with daily micafungin antifungal prophylaxis in pediatric allo-HCT patients with non-malignant disorders. A retrospective descriptive analysis of 28 pediatric patients with a variety of non-malignant disorders undergoing allo-HCT and prophylaxis with micafungin is provided. The median age at allo-HCT was 5 years (range, 0.4-11). No patient had a previous invasive fungal infections, hepatic, or renal dysfunction except for one patient with hepatic fibrosis. Cyclosporine was used for graft-versus-host disease prophylaxis. Table 1 provides a summary of results associated with daily micafungin antifungal prophylaxis. Micafungin was discontinued in one patient due to liver function test abnormalities. A baseline elevation in AST, ALT, and bilirubin was documented in 25%, 39%, and 0% of patients; respectively. There was a two-fold increase in AST, ALT, and bilirubin in 60%, 67%, and 85% of patients during treatment; these decreased on therapy. A similar trend was noted in renal function. Cyclosporine levels did not fluctuate significantly during therapy. Daily micafungin prophylaxis is a well-tolerated method which may prevent fungal infections in pediatric allo-HCT patients with non-malignant disorders. Further study of micafungin prophylaxis to evaluate the efficacy of micafungin in the prevention of fungal infections in pediatric allo-HCT recipients with non-malignant disorders is needed.Table 1Daily Micafungin Antifungal Prophylaxis ResultsObservationsNumber (%) or Median (Range)Total patients28Duration (days)37 (3-94)Average dose - start (mg/kg/day)2.1 (0.8-4.3)AST Baseline elevation7 (25) End elevation7 (25) Increase ≥ 2x baseline17 (61)ALT Baseline elevation11 (39) End elevation10 (36) Increase ≥ 2x baseline19 (68)Total Bilirubin Baseline elevation0 End elevation4 (14) Increase ≥ 2x baseline24 (86)Creatinine Baseline elevation1 (4) End elevation1 (4) Increase ≥ 2x baseline10 (36) Open table in a new tab