Antifungal Use in Pediatric Hematology–Oncology and Bone Marrow Transplantation Units in Greece

BACKGROUND: Invasive fungal disease remains a major cause of morbidity and mortality among children with malignancies and those undergoing hematopoietic stem cell transplantation (HSCT). Real-world data that describe antifungal prescribing practices in pediatric hematology-oncology units are very limited. METHODS: A national prospective observational study from June 2016 through December 2019 in 5 pediatric hematology-oncology units and the single pediatric HSCT unit in Greece was conducted. The first 15 children per month admitted to these units who required initiation of new antifungal agents for prophylaxis or treatment were recorded. Demographics, presence of a central venous line, type of underlying disease, absolute neutrophil count on the first day of antifungal therapy, presence of invasive fungal disease, days of therapy, microbiologic findings and outcomes were recorded. RESULTS: Among 1838 anti-infective courses, 737 (40.1%) involved antifungal agents. Antifungal use was predominantly prophylactic (47.6%) or empiric (50.7%), with targeted therapy accounting for only 1.5%. Prophylaxis was more common in the HSCT unit, whereas empiric therapy predominated in pediatric hematology-oncology units. Fluconazole was the most frequently used prophylactic agent, followed by micafungin and voriconazole. Proven fungemia was uncommon; Candida albicans was the most frequently isolated pathogen. Overall mortality was 1.8%, with slightly higher mortality among patients receiving antifungal therapy. CONCLUSIONS: Antifungal use in pediatric oncology and HSCT settings was extensive and heterogeneous, characterized by heavy reliance on prophylactic and empiric strategies and minimal targeted therapy. These findings support the need for structured antifungal stewardship programs to optimize antifungal exposure while preserving favorable outcomes.