Adaptation of clinical guidelines to develop a risk-based
algorithm for antifungal prophylaxis
Development of an evidence-based algorithm for antifungal prophylaxis,
including broader coverage prophylaxis, was initially prompted by a
relatively high incidence of IMI noted in specific leukemia patient
populations treated prior to 2016 compared with reported frequencies of
IMI in the published literature. Prior to 2016, routine antifungal
prophylaxis was employed for a limited population of children diagnosed
with high-risk hematologic malignancies. For example, all children
diagnosed with AML were prescribed fluconazole, but there was
inconsistent practice for prescribing prophylaxis to children with
relapsed disease or in other high risk groups. If antifungal prophylaxis
was strongly recommended on a particular clinical trial, such
prophylaxis was given to all patients treated according to that regimen,
regardless of their enrollment to the research study. In 2015, we
established a multidisciplinary team of TCH Cancer and Hematology Center
Leukemia team providers, clinical pharmacy specialists, and members of
the TCH Infectious Diseases team to identify and address factors that
may be contributing to excess IMI in children with hematologic
malignancies. The team reviewed incident cases in patients with
oncologic diagnoses, and hospital-wide patterns of mycoses epidemiology.
Available evidence-based guidelines were reviewed, considering specific
at-risk populations and perceived intensity of chemotherapy treatment,
prior to reaching a consensus for a risk-based algorithm and flow chart
(Figure 1 ). This clinical resource was finalized and
implemented in January of 2016, an effort that included delivery of
section-wide education to TCH Cancer and Hematology Center faculty and
fellows.
Change in IMI frequency pre and post-implementation of an
antifungal risk-based algorithm
Implementation of an evidence-based, risk-adapted algorithm for
antifungal prophylaxis reduced the frequency of IMI in patients with
hematologic malignancies by 40%, from 4.8% to 2.9%. The decrease in
IMI incidence was most pronounced among patients with AML, likely due to
a change in practice that broadened antifungal coverage to include molds
(Table 2 ).