Table 2.
Considerations for performing transplantation in patients with prior IFD
| Type of issue |
|---|
| Host |
| Importance of CR of hematologic malignancy before HSCT |
| Comorbidities, age,* performance status |
| Surgery pre-HSCT for residual necrotic fungal lesions |
| Transplantation |
| Autologous HSCT |
| Allo-HSCT |
| RIC |
| Type of allo-HSCT: source of stem cells and donor relatedness† |
| Duration of preengraftment |
| Severe (grade >2) GVHD (acute/chronic) requiring systemic immunosuppression |
| IFD/diagnosis |
| Documenting response to antifungal therapy pre-HSCT |
| Certainty of IFD diagnosis |
| Diagnosis of IFD relapse post-HSCT |
| Coinfections with bacteria as confounders in lung infection |
| Sensitivity/specificity of biomarkers, CT |
| CMV reactivation as predictor, GC use as risk factor |
| Respiratory viral infection (eg, influenza, RSV) as risk of relapsing fungal pneumonia |
| Disseminated vs single-organ involvement by IFD |
| Issues for specific fungi |
| MDR molds (Mucorales, Fusarium, Scedosporium, others) |
| Endemic fungi |
| MDR Candida (eg, Candida glabrata) |
| Rare opportunistic non-Candida yeasts (eg, Rhodotorula) |
| Antifungal treatment for IFD post-HSCT |
| Antifungals as secondary prophylaxis |
| Toxicity of antifungals in patients with liver GVHD, sinusoidal obstruction syndrome |
| Drug-drug interactions of azoles with |
| HSCT drugs |
| Conditioning regimen |
| Azole TDM |
GC, glucocorticoid; MDR, multidrug resistant; RIC, reduced-intensity conditioning; RSV, respiratory syncytial virus; TDM, therapeutic drug monitoring.
*
Sorror et al.23
†
Source of stem cells: peripheral blood, bone marrow, or cord blood. HLA relatedness: matched related, matched unrelated, mismatched related, or mismatched unrelated.