Expert Perspectives: Management of Acute Myeloid Leukemia - Episode 2

Infection Prophylaxis in Acute Myeloid Leukemia

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Ruben A. Mesa, MD, FACP, moderates this discussion with Rafael Bejar, MD, PhD; Elias Jabbour, MD; and Rami Komrokji, MD. These experts in hematology and oncology discuss the pathways involved in leukemic transformation, risk-adjusted approaches to treatment, and supportive care in acute myeloid leukemia.

In this segment, Ruben A. Mesa, MD, FACP; Rafael Bejar, MD, PhD; Elias Jabbour, MD; and Rami Komrokji, MD, review infection prophylaxis treatment strategies that help prevent the development of infection in immunocompromised patients with acute myeloid leukemia (AML).

Guidelines provided by the National Comprehensive Cancer Network (NCCN) and Infectious Disease Society of America (IDSA) are useful resources for managing infection prevention and neutropenic fever, says Rafael Bejar, MD, PhD, adding that it is also important for the entire treatment team to have experience treating these disorders. This involves starting antibiotics on time and the ability to recognize patients who might be ill and require additional attention.

MD Anderson Cancer Center employs quinolone agents for bacterial coverage, valacyclovir for viral coverage, and azoles for antifungal coverage, says Elias Jabbour, MD.

Ongoing phase 2 studies assessing the prophylactic use of posaconazole or voriconazole may help determine selection of which azole antifungal may be more effective in this setting. Assessing the toxicity profile can also dictate use, notes Rami Komrokji, MD, explaining that posaconazole may cause less transaminitis than voriconazole.

The costs of these agents to the patient must also be taken into consideration, adds Jabbour. Patients who are unable to afford $500 or $1000 in monthly copays can be given fluconazole since antifungal coverage is imperative, although prevention data is clear that posaconazole and voriconazole are superior to fluconazole. It is disappointing to have clearly effective therapies and be limited in this way, comments Ruben A. Mesa, MD, FACP.

Length of prophylactic therapy partly depends on what is coming next in the patient’s future, explains Bejar, but recovery of counts is a good point to assess where a patient may be.

Due to the challenge of diagnosing an invasive fungal infection, treatment, many times, is for a presumptive infection, states Komrokji, because diagnostic imaging, such as bronchoscopy, is sometimes not feasible in patients who are immunocompromised and neutropenic. These patients do not exhibit classical features of infection, making it critical to be able to identify patients at high risk for fungal infections.

Many patients with AML rely on allogeneic transplant as a key part of their salvage or cure. Nothing can derail that process more effectively than an invasive fungal infection, leading to patients losing their opportunity for some treatment options because of a severe infection, says Mesa.