Intravenous and Oral Itraconazole Versus Intravenous and Oral Fluconazole for Long-Term Antifungal Prophylaxis in Allogeneic Hematopoietic Stem-Cell Transplant Recipients

A Multicenter, Randomized Trial

Drew J. Winston, Richard Maziarz, Pranatharthi H. Chandrasekar, Hillard M. Lazarus, Mitchell Goldman, Jeffrey L. Blumer, Gerhard J. Leitz, Mary C. Territo

Research output: Contribution to journalArticle

325 Citations (Scopus)

Abstract

Background: Allogeneic hematopoietic stem-cell transplant recipients often receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole and toxicity with amphotericin B, alternative prophylactic regimens have become necessary. Objective: To compare the efficacy and safety of intravenous and oral itraconazole with the efficacy and safety of intravenous and oral fluconazole for long-term prophylaxis of fungal infections. Design: Open-label, multicenter, randomized trial. Setting: Five transplantation centers in the United States. Patients: 140 patients undergoing allogeneic hematopoietic stem-cell transplantation. Intervention: Itraconazole (200 mg intravenously every 12 hours for 2 days followed by 200 mg intravenously every 24 hours or a 200-mg oral solution every 12 hours) or fluconazole (400 mg intravenously or orally every 24 hours) from day 1 until day 100 after transplantation. Measurements: Proven invasive or superficial fungal infection, drug-related side effects, mortality from fungal infection, and overall mortality. Results: Proven invasive fungal infections occurred in 6 of 71 itraconazole recipients (9%) and in 17 of 67 fluconazole recipients (25%) during the first 180 days after transplantation (difference, -16 percentage points [95% CI, -29.2 to -4.7 percentage points]; P = 0.01). Superficial fungal infections occurred in 3 of 71 itraconazole recipients (4%) and in 2 of 67 fluconazole recipients (3%). In a multivariable analysis using factors known to affect the risk for invasive fungal infection after hematopoietic stem-cell transplantation, prophylaxis with itraconazole was still associated with fewer invasive fungal infections (odds ratio, 0.300 [CI, 0.111 to 0.814]; P = 0.02) caused by either yeasts or molds. More fungal pathogens were found to be resistant to fluconazole than to itraconazole. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea, or abdominal pain) in patients given itraconazole (24% vs. 9%; difference, 15 percentage points [CI, 2.9 to 27.0 percentage points]; P= 0.02), both itraconazole and fluconazole were well tolerated. The overall mortality rate was similar in each group (32 of 71 patients in the itraconazole group [45%] vs. 28 of 67 patients in the fluconazole group [42%]; difference, 3 percentage points [CI, -13.2 to 19.8 percentage points]; P > 0.2), but fewer deaths were related to fungal infection in patients given itraconazole (6 of 71 [9%]) than in patients given fluconazole (12 of 67 [18%]) (difference, 9 percentage points [CI, -20.6 to 1.8 percentage points]; P= 0.13). Conclusion: Itraconazole is more effective than fluconazole for long-term prophylaxis of invasive fungal infections after allogeneic hematopoietic stem-cell transplantation. Except for gastrointestinal side effects, itraconazole is well tolerated.

Original languageEnglish (US)
JournalAnnals of Internal Medicine
Volume138
Issue number9
StatePublished - May 6 2003
Externally publishedYes

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Itraconazole
Fluconazole
Hematopoietic Stem Cells
Multicenter Studies
Transplants
Mycoses
Hematopoietic Stem Cell Transplantation
Transplantation
Amphotericin B
Mortality
Transplant Recipients
Safety
Drug-Related Side Effects and Adverse Reactions
Nausea
Abdominal Pain
Statistical Factor Analysis
Vomiting
Diarrhea
Fungi
Yeasts

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Intravenous and Oral Itraconazole Versus Intravenous and Oral Fluconazole for Long-Term Antifungal Prophylaxis in Allogeneic Hematopoietic Stem-Cell Transplant Recipients : A Multicenter, Randomized Trial. / Winston, Drew J.; Maziarz, Richard; Chandrasekar, Pranatharthi H.; Lazarus, Hillard M.; Goldman, Mitchell; Blumer, Jeffrey L.; Leitz, Gerhard J.; Territo, Mary C.

In: Annals of Internal Medicine, Vol. 138, No. 9, 06.05.2003.

Research output: Contribution to journalArticle

Winston, Drew J. ; Maziarz, Richard ; Chandrasekar, Pranatharthi H. ; Lazarus, Hillard M. ; Goldman, Mitchell ; Blumer, Jeffrey L. ; Leitz, Gerhard J. ; Territo, Mary C. / Intravenous and Oral Itraconazole Versus Intravenous and Oral Fluconazole for Long-Term Antifungal Prophylaxis in Allogeneic Hematopoietic Stem-Cell Transplant Recipients : A Multicenter, Randomized Trial. In: Annals of Internal Medicine. 2003 ; Vol. 138, No. 9.
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abstract = "Background: Allogeneic hematopoietic stem-cell transplant recipients often receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole and toxicity with amphotericin B, alternative prophylactic regimens have become necessary. Objective: To compare the efficacy and safety of intravenous and oral itraconazole with the efficacy and safety of intravenous and oral fluconazole for long-term prophylaxis of fungal infections. Design: Open-label, multicenter, randomized trial. Setting: Five transplantation centers in the United States. Patients: 140 patients undergoing allogeneic hematopoietic stem-cell transplantation. Intervention: Itraconazole (200 mg intravenously every 12 hours for 2 days followed by 200 mg intravenously every 24 hours or a 200-mg oral solution every 12 hours) or fluconazole (400 mg intravenously or orally every 24 hours) from day 1 until day 100 after transplantation. Measurements: Proven invasive or superficial fungal infection, drug-related side effects, mortality from fungal infection, and overall mortality. Results: Proven invasive fungal infections occurred in 6 of 71 itraconazole recipients (9{\%}) and in 17 of 67 fluconazole recipients (25{\%}) during the first 180 days after transplantation (difference, -16 percentage points [95{\%} CI, -29.2 to -4.7 percentage points]; P = 0.01). Superficial fungal infections occurred in 3 of 71 itraconazole recipients (4{\%}) and in 2 of 67 fluconazole recipients (3{\%}). In a multivariable analysis using factors known to affect the risk for invasive fungal infection after hematopoietic stem-cell transplantation, prophylaxis with itraconazole was still associated with fewer invasive fungal infections (odds ratio, 0.300 [CI, 0.111 to 0.814]; P = 0.02) caused by either yeasts or molds. More fungal pathogens were found to be resistant to fluconazole than to itraconazole. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea, or abdominal pain) in patients given itraconazole (24{\%} vs. 9{\%}; difference, 15 percentage points [CI, 2.9 to 27.0 percentage points]; P= 0.02), both itraconazole and fluconazole were well tolerated. The overall mortality rate was similar in each group (32 of 71 patients in the itraconazole group [45{\%}] vs. 28 of 67 patients in the fluconazole group [42{\%}]; difference, 3 percentage points [CI, -13.2 to 19.8 percentage points]; P > 0.2), but fewer deaths were related to fungal infection in patients given itraconazole (6 of 71 [9{\%}]) than in patients given fluconazole (12 of 67 [18{\%}]) (difference, 9 percentage points [CI, -20.6 to 1.8 percentage points]; P= 0.13). Conclusion: Itraconazole is more effective than fluconazole for long-term prophylaxis of invasive fungal infections after allogeneic hematopoietic stem-cell transplantation. Except for gastrointestinal side effects, itraconazole is well tolerated.",
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TY - JOUR

T1 - Intravenous and Oral Itraconazole Versus Intravenous and Oral Fluconazole for Long-Term Antifungal Prophylaxis in Allogeneic Hematopoietic Stem-Cell Transplant Recipients

T2 - A Multicenter, Randomized Trial

AU - Winston, Drew J.

AU - Maziarz, Richard

AU - Chandrasekar, Pranatharthi H.

AU - Lazarus, Hillard M.

AU - Goldman, Mitchell

AU - Blumer, Jeffrey L.

AU - Leitz, Gerhard J.

AU - Territo, Mary C.

PY - 2003/5/6

Y1 - 2003/5/6

N2 - Background: Allogeneic hematopoietic stem-cell transplant recipients often receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole and toxicity with amphotericin B, alternative prophylactic regimens have become necessary. Objective: To compare the efficacy and safety of intravenous and oral itraconazole with the efficacy and safety of intravenous and oral fluconazole for long-term prophylaxis of fungal infections. Design: Open-label, multicenter, randomized trial. Setting: Five transplantation centers in the United States. Patients: 140 patients undergoing allogeneic hematopoietic stem-cell transplantation. Intervention: Itraconazole (200 mg intravenously every 12 hours for 2 days followed by 200 mg intravenously every 24 hours or a 200-mg oral solution every 12 hours) or fluconazole (400 mg intravenously or orally every 24 hours) from day 1 until day 100 after transplantation. Measurements: Proven invasive or superficial fungal infection, drug-related side effects, mortality from fungal infection, and overall mortality. Results: Proven invasive fungal infections occurred in 6 of 71 itraconazole recipients (9%) and in 17 of 67 fluconazole recipients (25%) during the first 180 days after transplantation (difference, -16 percentage points [95% CI, -29.2 to -4.7 percentage points]; P = 0.01). Superficial fungal infections occurred in 3 of 71 itraconazole recipients (4%) and in 2 of 67 fluconazole recipients (3%). In a multivariable analysis using factors known to affect the risk for invasive fungal infection after hematopoietic stem-cell transplantation, prophylaxis with itraconazole was still associated with fewer invasive fungal infections (odds ratio, 0.300 [CI, 0.111 to 0.814]; P = 0.02) caused by either yeasts or molds. More fungal pathogens were found to be resistant to fluconazole than to itraconazole. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea, or abdominal pain) in patients given itraconazole (24% vs. 9%; difference, 15 percentage points [CI, 2.9 to 27.0 percentage points]; P= 0.02), both itraconazole and fluconazole were well tolerated. The overall mortality rate was similar in each group (32 of 71 patients in the itraconazole group [45%] vs. 28 of 67 patients in the fluconazole group [42%]; difference, 3 percentage points [CI, -13.2 to 19.8 percentage points]; P > 0.2), but fewer deaths were related to fungal infection in patients given itraconazole (6 of 71 [9%]) than in patients given fluconazole (12 of 67 [18%]) (difference, 9 percentage points [CI, -20.6 to 1.8 percentage points]; P= 0.13). Conclusion: Itraconazole is more effective than fluconazole for long-term prophylaxis of invasive fungal infections after allogeneic hematopoietic stem-cell transplantation. Except for gastrointestinal side effects, itraconazole is well tolerated.

AB - Background: Allogeneic hematopoietic stem-cell transplant recipients often receive fluconazole or an amphotericin B preparation for antifungal prophylaxis. Because of concerns about fungal resistance with fluconazole and toxicity with amphotericin B, alternative prophylactic regimens have become necessary. Objective: To compare the efficacy and safety of intravenous and oral itraconazole with the efficacy and safety of intravenous and oral fluconazole for long-term prophylaxis of fungal infections. Design: Open-label, multicenter, randomized trial. Setting: Five transplantation centers in the United States. Patients: 140 patients undergoing allogeneic hematopoietic stem-cell transplantation. Intervention: Itraconazole (200 mg intravenously every 12 hours for 2 days followed by 200 mg intravenously every 24 hours or a 200-mg oral solution every 12 hours) or fluconazole (400 mg intravenously or orally every 24 hours) from day 1 until day 100 after transplantation. Measurements: Proven invasive or superficial fungal infection, drug-related side effects, mortality from fungal infection, and overall mortality. Results: Proven invasive fungal infections occurred in 6 of 71 itraconazole recipients (9%) and in 17 of 67 fluconazole recipients (25%) during the first 180 days after transplantation (difference, -16 percentage points [95% CI, -29.2 to -4.7 percentage points]; P = 0.01). Superficial fungal infections occurred in 3 of 71 itraconazole recipients (4%) and in 2 of 67 fluconazole recipients (3%). In a multivariable analysis using factors known to affect the risk for invasive fungal infection after hematopoietic stem-cell transplantation, prophylaxis with itraconazole was still associated with fewer invasive fungal infections (odds ratio, 0.300 [CI, 0.111 to 0.814]; P = 0.02) caused by either yeasts or molds. More fungal pathogens were found to be resistant to fluconazole than to itraconazole. Except for more frequent gastrointestinal side effects (nausea, vomiting, diarrhea, or abdominal pain) in patients given itraconazole (24% vs. 9%; difference, 15 percentage points [CI, 2.9 to 27.0 percentage points]; P= 0.02), both itraconazole and fluconazole were well tolerated. The overall mortality rate was similar in each group (32 of 71 patients in the itraconazole group [45%] vs. 28 of 67 patients in the fluconazole group [42%]; difference, 3 percentage points [CI, -13.2 to 19.8 percentage points]; P > 0.2), but fewer deaths were related to fungal infection in patients given itraconazole (6 of 71 [9%]) than in patients given fluconazole (12 of 67 [18%]) (difference, 9 percentage points [CI, -20.6 to 1.8 percentage points]; P= 0.13). Conclusion: Itraconazole is more effective than fluconazole for long-term prophylaxis of invasive fungal infections after allogeneic hematopoietic stem-cell transplantation. Except for gastrointestinal side effects, itraconazole is well tolerated.

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