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This guideline has been written to assist specialists in the prophylaxis and management of invasive fungal infection in children being treated for haematological malignancies.
This guideline should be used by specialists caring for children with haematological malignancies and at risk of invasive fungal infections.
Invasive fungal infections (IFI) are an important cause of morbidity and mortality in patients with haematological malignancies, in particular those with prolonged and severe neutropenia. Treatment of invasive fungal infection with antifungal medicines is complicated in haemato-oncology patients due to the need for other potentially nephrotoxic or hepatotoxic medicines e.g. aminoglycosides, ciclosporin, tacrolimus and concomitant or potential nephrotoxic/hepatotoxic chemotherapy regimens.
See the 'related guidelines' section at the bottom of this guideline
3.1 The diagnosis and management of fungal disease will be directed by the Consultant/Associate Specialist or a senior member of the medical team.
3.2 The Medical/Nursing team will be responsible for monitoring & investigation.
4.1 Blood culture bottles
4.2 Bacteriology swabs
4.3 Universal container
4.4 Stool sample container
5.1 High Risk Group:
Patients with the following risk factors are at high risk of developing IFI:
It is imperative that patients are regularly assessed for clinical features of IFI i.e:
5.3 Monitoring of Renal Function:
Many antifungal medicines are nephrotoxic or hepatotoxic. Monitor serum creatinine daily and LFTs regularly during treatment.
All haemopoietic stem cell transplant (HSCT) patients are commenced on IV Ambisome on the day of admission. It is prescribed on Mondays, Wednesdays and Fridays (dose: 2mg/kg/day).
When engraftment is established and there are no signs of IFI Ambisome will be substituted with oral itraconazole or posaconazole. Discuss with HSCT consultant or HSCT associate specialist prior to commencing anti-fungal prophylaxis. For doses see YBMT-CLIN-006 SOP.
If not tolerating oral medicines or high risk for IFI:
If documented allergy to Ambisome:
5.5 Empirical/Possible IFI Therapy:
Patients eligible for empirical therapy should either:
|POSSIBLE INVASIVE INFECTION|
|At least 1 host criterion|
|EITHER 1 microbiological criterion|
|OR 1 major OR 2 minor clinical criteria|
Ambisome 3mg/kg/day (doses can be increased to 10mg/kg/day) in proven infections.
If allergic to Ambisome or impaired renal function:
Caspofungin: 70mg/m2 on D1, then 50mg/m2 once daily
5.6 Proven/Probable IFI Therapy:
|PROBABLE INVASIVE INFECTION|
|At least 1 host criterion|
|AND 1 microbiological criterion|
|AND 1 major OR 2 minor clinical criteria|
Treatment drugs and doses as for empirical therapy (see section 5.5)
Voriconazole (by intravenous infusion):
N.B: For individuals with evidence of intracerebral infection intravenous voriconazole is the drug of choice due to excellent penetration of the blood brain barrier
5.7 Alternative Agents:
Posaconazole can be used to treat invasive aspergillosis which is unresponsive to Ambisome, or in patients intolerant to Ambisome, voriconazole or fluconazole (see YMBT-CLIN-0006 SOP for dosing and side-effects).
5.8 Additional Agents:
The addition of the following agents to antifungal therapy can be considered depending on the patients’ clinical condition.
G-CSF - Lenograstim 5mcg/kg equivalent dose, can be doubled to 10mcg/kg equivalent dose if required.
6.1 This SOP will be reviewed every two years.
6.2 Identify how the procedure/process within the SOP will be audited
For further information contact:
Haemopoietic Stem Cell Transplant Team
Ext: 81880 / 81879 / 89304
Last reviewed: 01 March 2015
Next review: 01 March 2017
Author(s): Dr A M Ewins
Approved By: Clinical Effectiveness