Diagnostic-driven antifungal therapy in neutropenic patients using the D-index and serial serum galactomannan testing.

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Diagnostic-driven antifungal therapy in neutropenic patients using the D-index and serial serum galactomannan testing.

Braz J Infect Dis. 2016 Jun 6;

Authors: Garnica M, Sinhorelo A, Madeira L, Portugal R, Nucci M

Abstract
INTRODUCTION: Invasive mold disease (IMD) is an important complication of patients with hematologic malignancies, and is associated with high mortality. A diagnostic-driven approach has been an alternative to the classical empiric antifungal therapy. In the present study we tested an algorithm that incorporated risk stratification using the D-index, serial serum galactomannan (s-GMI) and CT-scan to guide the decision to start antifungal therapy in neutropenic patients.
PATIENTS AND METHODS: Between May 2010 and August 2012, patients with acute leukemia in induction remission were prospectively monitored from day 1 of chemotherapy until discharge or death with the D-index and s-GMI. Patients were stratified in low, intermediate and high risk according to the D-index and an extensive workup for IMD was performed in case of positive s-GMI (≥0.5), persistent fever, or the appearance of clinical manifestations suggestive of IMD.
RESULTS: Among 29 patients, 6 (21%), 11 (38%), and 12 (41%) were classified as high, intermediate, and low risk, respectively. Workup for IMD was undertaken in 67%, 73% and 58% (p=0.77) of patients in each risk category, respectively, and antifungal therapy was given to 67%, 54.5%, and 17% (p=0.07). Proven or probable IMD was diagnosed in 67%, 45.5%, and in none (p=0.007) of high, intermediate, and low risk patients, respectively. All patients survived.
CONCLUSION: A risk stratification using D-index was a useful instrument to be incorporated in IMD diagnostic approach, resulting in a more comprehensive antifungal treatment strategy, and to guide an earlier start of treatment in afebrile patients under very high risk.

PMID: 27280789 [PubMed - as supplied by publisher]