In this episode, I’ll discuss empiric posaconazole to prevent influenza-associated pulmonary aspergillosis.
Critically ill patients who develop influenza-induced acute respiratory distress syndrome (ARDS) sometimes go on to experience secondary fungal infections such as influenza-associated pulmonary aspergillosis (IAPA). To evaluate the impact of empiric antifungal therapy on the development of IAPA, a group of authors published a multicenter observational study in Clinical Infectious Diseases.
Consecutive ICU patients from 9 centers with influenza-associated ARDS were analyzed. The authors compared patients receiving empirical antifungal treatment with those who did not, focusing on 30-day IAPA incidence as the primary outcome and survival as the secondary outcome.
Out of 172 patients, about one-third received empiric antifungal therapy which was almost always posaconazole. IAPA was diagnosed in 24 patients, with a median onset of 2 days after ICU admission. The incidence of IAPA was 20% in the non-treatment group and 7% in the empirical treatment group. This difference was statistically significant with a hazard ratio of 0.21 in favor of receiving empiric antifungal treatment. Unfortunately, for the secondary outcome of survival, there was no difference found between groups in terms of 30-day ICU survival.
The authors concluded:
In ICU patients with influenza ARDS, empirical antifungal treatment was associated with significantly reduced IAPA incidence, but this did not translate into improved survival. Randomized controlled trials are warranted to evaluate the efficacy and safety of patients’ specific empirical antifungal treatment with regard to IAPA incidence and outcomes.
While the prevention of fungal infection is great, a strategy that reduces more clinically meaningful outcomes like mortality remains elusive for this patient population. In addition to empiric therapy, some researchers have also studied pre-emptive therapy where antifungals are started before cultures are available based on biomarkers, but this too has yet to show an impact on mortality rates. Until then, whether to give patients with influenza induced ARDS empiric antifungal therapy will remain an individual provider-based decision.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
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