Abstract

BACKGROUND: The University HealthSystem Consortium (UHC) conducted a benchmarking study to assess members’ compliance with published guidelines for prevention of fungal infections in hematopoietic stem cell transplant (HSCT) recipients.

METHODS: Adult HSCT patients were evaluated by retrospective chart review of cases discharged between 01/01/04 and 06/30/05. Data collected included demographics, use of prophylaxis (px), and outcomes. Patients were classified as high or low risk for fungal infection according to NCCN and CDC guidelines.

RESULTS: Thirteen UHC member hospitals submitted a total of 242 HSCT cases. Patient characteristics and administration of antifungal therapy are shown in Table 1. 57% (137/242) of patients were classified as high risk for fungal infection. Overall, 85% (205/242) of patients received antifungal px. Compliance with national guideline directed antifungal px was 54%. Of patients who did not receive px, 59% (22/37) were high-risk. 32% (7/22) of these patients required empiric antifungal therapy, 29% (2/7) had a confirmed fungal infection and 1 of these patients died. Of patients who received antifungal px, 44% (90/205) were classified as low risk. 6.7% (6/90) went on to require empiric therapy and 2 died. 84.4% of patients had fluconazole as at least one of their prophylactic agents, and 34% of patients received prophylactic antifungals that provided coverage for both Aspergillus and Candida species. 5.4% (13/242) of HSCT recipients died during the target hospitalization. 76.9% (10/13) of these patients were high risk. 61.5% (8/13) had signs/symptoms of a suspected or definitive fungal infection at the time of death (6 were high risk).

CONCLUSION: Most HSCT patients did not receive appropriate fungal px based on current guidelines. Failure represented both under and over utilization of px. Further study is required to explain poor adherence to current guidelines.

Table 1:

Patient Characteristics by Degree of Risk

High Risk (n=137)Low Risk (n=105)
% (n)% (n)
*ABX = broad spectrum antibiotics 
Chemotherapy prior to admission 53.3% (73) 61.9% (65) 
Radiation prior to admission 23.4% (32) 17.1% (18) 
Allogeneic Transplant 75.9% (104) 17.1% (18) 
Cytomegalovirus disease 11.7% (16) 6.7% (7) 
GVHD 15.3% (21) 1.0% (1) 
Mucositis 55.5% (76) 7.6% (8) 
Systemic corticosteroids 63.5% (87) 44.8% (47) 
Fever unresponsive to >4 days of ABX 19.0% (26) 12.4% (13) 
Neutropenia during antifungal therapy 39.4% (54) 27.6% (29) 
History of Aspergillus infection 3.6% (5) 0.0% (0) 
Antifungal therapy:   
Prophylaxis 83.9% (115) 85.7% (90) 
Failed prophylaxis 21.2% (29) 5.7% (6) 
Empiric therapy 25.4% (32) 10.5% (11) 
Definite treatment 6.6% (8) 0.0% (0) 
High Risk (n=137)Low Risk (n=105)
% (n)% (n)
*ABX = broad spectrum antibiotics 
Chemotherapy prior to admission 53.3% (73) 61.9% (65) 
Radiation prior to admission 23.4% (32) 17.1% (18) 
Allogeneic Transplant 75.9% (104) 17.1% (18) 
Cytomegalovirus disease 11.7% (16) 6.7% (7) 
GVHD 15.3% (21) 1.0% (1) 
Mucositis 55.5% (76) 7.6% (8) 
Systemic corticosteroids 63.5% (87) 44.8% (47) 
Fever unresponsive to >4 days of ABX 19.0% (26) 12.4% (13) 
Neutropenia during antifungal therapy 39.4% (54) 27.6% (29) 
History of Aspergillus infection 3.6% (5) 0.0% (0) 
Antifungal therapy:   
Prophylaxis 83.9% (115) 85.7% (90) 
Failed prophylaxis 21.2% (29) 5.7% (6) 
Empiric therapy 25.4% (32) 10.5% (11) 
Definite treatment 6.6% (8) 0.0% (0) 

Disclosure: No relevant conflicts of interest to declare.

Author notes

*

Corresponding author