Reply to Wong et al

TO THE EDITOR—We read with great interest the letter by Wong et al regarding our recently published article, “Evaluation of the Practice of Antifungal Prophylaxis Use in Patients With Newly Diagnosed Acute Myeloid Leukemia: Results From the SEIFEM 2010-B Registry” [1, 2]. Wong et al treated a large number of patients with acute myeloid leukemia (AML) with posaconazole prophylaxis during induction chemotherapy or during salvage chemotherapy and observed a very low incidence of invasive mold diseases (IMD); 93 courses in 90 patients (63 induction and 30 salvage), with only 1 case of probable IMD (1.1%) during salvage chemotherapy. Their results confirm the good efficacy in a real-life pattern of antifungal prophylaxis with posaconazole, not only for patients with AML in induction chemotherapy phase but also for patients in salvage treatment. We recently confirmed the efficacy of posaconazole prophylaxis in our multicentric cohort [2]. In fact, we continued our real-life follow-up of AML patients treated prophylactically with posaconazole until April 2012 in the 33 centers that participated in the survey. Of 510 patients with AML who received posaconazole prophylaxis, only 28 (5.7%) presented a proven/probable invasive fungal infection (IFI; 5 proven candidemia, 1 Pneumocystsis jirovecii pneumonia, and 22 proven/probable aspergillosis). This is a very low number, but not as low as that observed by Wong et al. In fact, if we consider only mold infections, the incidence was 4.3% (22/510) [3]. Furthermore, of these 510 AML patients, 127 needed follow-up with systemic antifungal treatment (26%); in a majority of patients, this was an empirical approach. Consequently, this means that approximately 100 patients presented with a possible IFI. The overall attributable mortality due to the IFIs in our series was 1% (only 5 patients: 2 for candidemia and 2 for aspergillosis), which is very low. Regarding the efficacy of salvage treatment for AML patients, we have no data because the drug is not licensed in Italy for this approach. We must also note another delicate but not insignificant point in this type of patient. Considering the economic impact of the posaconazole prophylaxis, the use of this high-cost drug for antifungal prophylaxis during salvage chemotherapy should be limited to those patients for whom a new, complete remission, not only transitory improvement, is a real possibility.