Preliminary report of fungemia in hematological malignancies from seifem-2015 survey

Background: In the era of mold active azoles prophylaxis, the incidence of invasive fungal infections has varied. Aims: We evaluated characteristics and outcome of patients (pts) with fungal bloodstream infections (FBSI) during treatment of hematological malignancies (HMs) on a retrospective/prospective study. Methods: We gathered all consecutive documented FBSI diagnosed between January 2011 and December 2015 in 29 Italian Hematology Departments (both adults and pediatrics), referring to SEIFEM (Sorveglianza Epidemiologica Infezioni Fungine Emopatie Maligne). Results: We collected 198 cases: M/F 116/82, median age 55 y. o. (range 3- 88). FBSI were detected in 82 AML pts (41.4%), 53 (26.8%) NHL, 24 (12.1%) ALL, 14 (7.1%) MM, 13 (6.5%) MDS, 4 (2.1%) MPN, 5 (2.5%) CLL and 3 (1.5%) HL. Regarding the underlying malignancies' treatment at FBSI onset, 64 pts (35.3%) experienced the first cycle of chemotherapy, 55 pts (43.9%) salvage treatment for refractory/relapsed HMs, 21 pts (20.7%) subsequent treatment after complete or partial remission; 58 pts (29.3%) underwent HSCT (16 autologous and 42 allogeneic). Central venous catheter had been placed in 182 pts (92%), urinary catheter in 75 pts (37.8%) and nasogastric tube in 8 pts (4%); 76 pts (38.3%) were supported with parenteral nutrition. Among 114 (57.6%) neutropenic pts at FBSI diagnosis (neutrophils count <500/mmc), 45 (39.5%) recovered at the end of observation period, (median duration of neutropenia 13 days, range 1-100). Use of steroids was reported in 105 pts (53%), with a median duration of 12 days (range 3-106). In 43 pts (21.7%) a skin, oral and/or rectal fungal colonization was detected. FBSI was most frequently caused by yeasts: 158 (79.8%) Candida spp. (49 albicans and 109 non albicans), 10 (5.1%) Geotrichum, 5 (2.5%) Trichosporon, 6 (3%) Rhodotorula, 4 (2%) Saprochaeta and 1 (0.5%) Blastoschizomyces. Molds have been detected rarely: 12 (6%) Fusarium, 1 each (0.5%) Scedosporium and Mucor. Antifungal prophylaxis was administered in 121 pts: 11 received only topic antifungals. In 101 pts systemic antifungals were administered as follow: 38 (37.6%) posaconazole, 38 (37.6%) fluconazole, 8 (7.9%) itraconazole, 6 (5.9%) liposomal amphotericin B (L-AmB), 8 (7.9%) echinocandins (6 caspofungin and 2 micafungin), 3 (3%) voriconazole. The median duration of prophylaxis was 15 days (range 4-120). The residual 86 pts (43.5%) did not received any antifungals. In 20 pts (10%) no systemic antifungal therapy was administered: 14 of them experienced early mortality. The residual 178 pts were treated as follow: 89 (44.9%) echinocandins (77 caspofungin, 6 anidulafungin, 6 micafungin), 50 (25.2%) L-AmB, 31 (15.5%) azoles (20 fluconazole, 1 posaconazole, 7 voriconazole, 3 itraconazole) and 9 (4.4%) combo therapy (4 posa+L-AmB, 4 caspo+L-AmB, 1 vori+caspo). The median duration on treatment was 12 days (range 2-180). At 30 days from FBSI diagnosis 81 pts (40.9%) were dead: 37 (18.6%) from fungal infection, 19 (9.6%) from HMs, 11 (5.5%) from other causes; in 14 pts (7.1%) we cannot discriminate the cause of death (FBSI vs HMs). Of note, 33 dead pts (16.6%) received no antifungal prophylaxis and 6 (3%) received neither prophylaxis or therapy. Summary/Conclusions: Our study confirms the rarity of FBSI in hematological pts. The most frequently identified strains are Candida spp, especially non albicans, yet molds are identified not so rarely, i.e. Fusarium spp. Although the wider use of broad spectrum azoles prophylaxis and the early institution of antifungal therapy, overall mortality in this setting is still high.