Real-World Outcomes of Antifungal Prophylaxis in Adult Acute Lymphoblastic Leukemia Patients: A Multicenter Comparison of the Use of Fluconazole and Micafungin

<b>Background:</b> Adult acute lymphoblastic leukemia (ALL) patients are at increased risk of invasive fungal infections (IFIs) due to intensive therapy and prolonged neutropenia. While pediatric guidelines support administering fluconazole or mold-active agents, the evidence in adults is limited. This study presents the first multicenter retrospective comparison of fluconazole and micafungin use in this setting. <b>Methods:</b> We retrospectively analyzed 336 adult ALL patients from 11 centers in Türkiye (2010-2024) who received fluconazole (<i>n</i> = 230) or micafungin (<i>n</i> = 106) during induction chemotherapy. IFIs were classified according to the EORTC/MSG criteria. <b>Results:</b> The median age was 38.5 years, and 38.7% were female. Proven/probable IFIs occurred in 8.9% of patients, with similar rates between the fluconazole and micafungin groups (8.7% vs. 9.4%; <i>p</i> = 0.82). Multivariate analysis confirmed no significant association between the prophylactic antifungal type and IFI incidence, indicating comparable outcomes across groups. The median prophylaxis duration was longer with fluconazole, while the discontinuation rates, switch patterns, and subsequent antifungal use were comparable. The overall infection rates (~60%) and distribution of bacterial, viral, and polymicrobial infections were similar between the two groups. Prior bacterial infection increased the risk of IFI by 2.7-fold, and IFI-positive patients had longer neutropenia. At the end of induction, the remission, refractory, and mortality rates were similar between groups. The median overall survival was 24 months. <b>Conclusions:</b> Fluconazole and micafungin showed similar efficacy as the primary antifungal prophylaxis treatment in adult ALL patients. Given the limited evidence in adults and the ongoing need to optimize antifungal strategies, prospective randomized trials directly comparing these agents in this population are needed to confirm and expand upon our findings.

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Journal
Journal of Clinical Medicine
Published
2025-10-16
DOI
https://doi.org/10.3390/jcm14207294
Primary Topic
Antifungal resistance and susceptibility
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article
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article

Real-World Outcomes of Antifungal Prophylaxis in Adult Acute Lymphoblastic Leukemia Patients: A Multicenter Comparison of the Use of Fluconazole and Micafungin

Aysun Şentürk Yıkılmaz, Orhan Kemal Yücel, Ozlem Candan, Burak Devecı et al.
Journal of Clinical Medicine
Antifungal resistance and susceptibility
article

Real-World Outcomes of Antifungal Prophylaxis in Adult Acute Lymphoblastic Leukemia Patients: A Multicenter Comparison of the Use of Fluconazole and Micafungin

Aysun Şentürk Yıkılmaz, Orhan Kemal Yücel, Ozlem Candan, Burak Devecı, Işık Atagündüz, Tayfur Toptaş, Süreyya Yiğit Kaya, Ünal Ataş, Atakan Tekinalp, Leylagül Kaynar, Erdal Kurtoğlu, Rafiye Çiftçiler, Ozan Salim, Volkan Karakuş, Gülsüm Özet, Ömür Gökmen Sevindik, Selin Küçükyurt, Ahmet Kürşad Güneş, Gülten Korkmaz, Pınar Tığlıoğlu, Utku İltar, Tayfun Elibol, Levent Ündar, Marcela Bilek, Rabin Saba, Tayfun Ustabaş, Hasan Salur
article en

Abstract

<b>Background:</b> Adult acute lymphoblastic leukemia (ALL) patients are at increased risk of invasive fungal infections (IFIs) due to intensive therapy and prolonged neutropenia. While pediatric guidelines support administering fluconazole or mold-active agents, the evidence in adults is limited. This study presents the first multicenter retrospective comparison of fluconazole and micafungin use in this setting. <b>Methods:</b> We retrospectively analyzed 336 adult ALL patients from 11 centers in Türkiye (2010-2024) who received fluconazole (<i>n</i> = 230) or micafungin (<i>n</i> = 106) during induction chemotherapy. IFIs were classified according to the EORTC/MSG criteria. <b>Results:</b> The median age was 38.5 years, and 38.7% were female. Proven/probable IFIs occurred in 8.9% of patients, with similar rates between the fluconazole and micafungin groups (8.7% vs. 9.4%; <i>p</i> = 0.82). Multivariate analysis confirmed no significant association between the prophylactic antifungal type and IFI incidence, indicating comparable outcomes across groups. The median prophylaxis duration was longer with fluconazole, while the discontinuation rates, switch patterns, and subsequent antifungal use were comparable. The overall infection rates (~60%) and distribution of bacterial, viral, and polymicrobial infections were similar between the two groups. Prior bacterial infection increased the risk of IFI by 2.7-fold, and IFI-positive patients had longer neutropenia. At the end of induction, the remission, refractory, and mortality rates were similar between groups. The median overall survival was 24 months. <b>Conclusions:</b> Fluconazole and micafungin showed similar efficacy as the primary antifungal prophylaxis treatment in adult ALL patients. Given the limited evidence in adults and the ongoing need to optimize antifungal strategies, prospective randomized trials directly comparing these agents in this population are needed to confirm and expand upon our findings.

Journal of Clinical MedicineVol. 14(20)
Selçuk University (TR), Bilkent University (TR), Akdeniz University (TR), Istanbul Medipol University (TR), Memorial Ankara Hospital (TR), Antalya Bilim University (TR), Necmettin Erbakan University (TR), Antalya Eğitim ve Araştırma Hastanesi (TR), Başkent University Hospital (TR), Sağlık Bilimleri Üniversitesi (TR), Denizli Devlet Hastanesi (TR), Istanbul Eye Hospital (TR), Antalya IVF (TR), İstanbul Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi (TR), Istanbul Medeniyet University (TR), Marmara University (TR), University of Health Sciences Antigua (AG)
Openalex Percentile: Top 65%
Antifungal resistance and susceptibility
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