{"entity":{"id":"antifungal-prophylaxis-in-haematology","kind":"protocol","name":"Antifungal prophylaxis for people at high risk of invasive fungal infection","aka":["mould-active prophylaxis","mold-active prophylaxis","posaconazole prophylaxis","primary antifungal prophylaxis","azole prophylaxis","invasive aspergillosis prevention"],"tldr":"People on the most intensive leukaemia treatment, or a stem cell transplant from a donor, are at risk of serious mould infections in the lungs. Most are offered a preventive antifungal medicine, usually posaconazole, while their immunity is lowest. Other cancer treatments usually do not need one. These drugs interact with many medicines, so the pharmacist checks every combination.","summary":"Give systemic antifungal prophylaxis only to groups at high risk of invasive fungal disease, and make it mould-active. In children (POGO 2020, endorsed by COG; the 2026 update maintains these): strong recommendations for AML expected to cause profound and prolonged neutropenia (high quality) and for allogeneic HSCT pre-engraftment and during systemic immunosuppression for GVHD (moderate); consider it in newly diagnosed or relapsed ALL at high risk (weak, low); do not use it routinely in low-risk ALL or in most lymphomas and solid tumours (strong); not routinely in autologous HSCT (weak). If warranted, use a mould-active agent (strong, high), an echinocandin or a mould-active azole (strong, moderate), and not amphotericin routinely (strong, low). In adults, ECIL-10 (2025) grades posaconazole A-I during remission induction for AML and MDS, gives isavuconazole, micafungin and caspofungin B-II, does not indicate prophylaxis in ALL, Hodgkin lymphoma, myeloma or autologous HSCT, endorses mould-active prophylaxis for high-risk CAR-T recipients, and now counts children with ALL aged 12 or older or with insufficient treatment response as high risk. Mould-active azoles are not recommended with vincristine (D-II). ASCO/IDSA (2018) recommend antifungal prophylaxis for patients expected to have profound, protracted neutropenia.","asOf":"2026-11-11","links":[],"tags":["protocol","antimicrobial-prophylaxis","antifungal","paediatric"],"related":["paediatric-fever-and-neutropenia","antibacterial-prophylaxis-in-neutropenia","neutropenic-precautions-and-daily-life","vincristine","venetoclax"],"cancers":["aml","all-leukemia","childhood-cancers"],"sections":["supportive-care"],"technologies":["allogeneic-hsct","autologous-stem-cell-transplant","car-t"],"targets":[],"drugs":[],"companies":["childrens-oncology-group"],"institutions":["asco"],"pathways":[],"terms":["neutropenia","lymphoma-tx-pjp-and-infection-prophylaxis"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"simple":"Very strong leukaemia treatment and donor stem cell transplants can let moulds cause lung infections. A preventive antifungal medicine is often given during that time. It can clash with other medicines, so the team checks them.","domain":"infection-prevention","setting":{"who":["doctor","pharmacist","nurse","patient-or-carer"],"where":["ward","outpatient-clinic","home"]},"population":"Adults and children with haematological cancers, and recipients of allogeneic or autologous haematopoietic cell transplant or CAR-T cells (ECIL-10 covers adults and children with haematological malignancies; POGO covers children with cancer and HSCT recipients). Most people with solid tumours or lymphoma are low risk and are not covered by a prophylaxis recommendation.","trigger":"Treatment is planned that is expected to cause profound and prolonged neutropenia, or an allogeneic transplant, or systemic immunosuppression for graft-versus-host disease.","steps":[{"action":"Before each phase, decide whether the person is at high risk of invasive fungal disease, by disease, treatment and expected neutropenia","why":"The benefit of prophylaxis grows with the risk; in low-risk people side effects, cost and drug interactions outweigh it.","source":"paed-afp-2020","quote":"Do not routinely administer systemic antifungal prophylaxis to children and adolescents with cancer at low risk for IFD, such as most pediatric patients with lymphomas and solid tumors (Evidence quality: moderate; Strength of recommendation: strong).","grade":"Evidence quality: moderate; Strength of recommendation: strong"},{"action":"Give antifungal prophylaxis to children and adolescents having AML treatment expected to cause profound and prolonged neutropenia","why":"Children with AML are at high risk of fungal infection, and prophylaxis reduced it most in those at highest risk.","source":"paed-afp-2020","quote":"Administer systemic antifungal prophylaxis to children and adolescents receiving treatment of acute myeloid leukemia that is expected to result in profound and prolonged neutropenia (Evidence quality: high; Strength of recommendation: strong).","grade":"Evidence quality: high; Strength of recommendation: strong"},{"action":"Give it to children having an allogeneic transplant before engraftment, and during systemic immunosuppression for graft-versus-host disease","why":"These are two separate periods of high fungal risk; in transplant recipients prophylaxis also lowered deaths from fungal infection.","source":"paed-afp-2020","quote":"Administer systemic antifungal prophylaxis to children and adolescents undergoing allogeneic HSCT pre-engraftment and to those receiving systemic immunosuppression for the treatment of graft-versus-host disease (GVHD; Evidence quality: moderate; Strength of recommendation: strong).","grade":"Evidence quality: moderate; Strength of recommendation: strong"},{"action":"Consider it for children with ALL at high risk, including those aged 12 or older and those with an insufficient response to induction","why":"Risk in ALL varies by protocol and phase; a large European trial found older children and poor responders were at higher risk, and ECIL now recommends prophylaxis for them.","source":"ecil-10","quote":"Consequently, older children (≥ 12 years) with ALL and those with insufficient treatment response are identified as being at elevated risk for IFD and are now recommended to receive antifungal prophylaxis."},{"action":"In adults with AML or high-risk MDS having remission induction chemotherapy, give mould-active prophylaxis, with posaconazole the best-supported choice","why":"Posaconazole is the only agent ECIL grades A-I in this setting; isavuconazole, micafungin and caspofungin are B-II alternatives.","source":"ecil-10","quote":"Regarding acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) patients undergoing remission induction chemotherapy, a B-II grading has been assigned to isavuconazole, micafungin, and caspofungin, based on non-randomized studies that have shown efficacy in preventing invasive fungal diseases (IFD).","grade":"posaconazole A-I; isavuconazole, micafungin, caspofungin B-II"},{"action":"When prophylaxis is warranted, use a mould-active drug: an echinocandin or a mould-active azole, not routine amphotericin","why":"Compared with fluconazole, mould-active drugs reduced fungal infection and deaths from it; amphotericin was no better than fluconazole and caused more side effects.","source":"paed-afp-2020","quote":"In choosing a mold-active agent, administer an echinocandin or a mold-active azole (Evidence quality: moderate; Strength of recommendation: strong).","grade":"Evidence quality: moderate; Strength of recommendation: strong"},{"action":"Do not give voriconazole or posaconazole with vincristine; consider isavuconazole with caution or another option","why":"These azoles slow the breakdown of vincristine and can cause severe nerve damage.","source":"ecil-10","quote":"Antifungal prophylaxis with a mold-active triazole, such as voriconazole or posaconazole, is not recommended because of interactions which could increase the toxicity of vincristine (D-II).","grade":"D-II"},{"action":"Check every other medicine for interactions before starting an azole, including venetoclax and other targeted drugs","why":"Azoles raise the levels of many drugs; in its section on chronic lymphocytic leukaemia, ECIL says that with venetoclax prophylaxis should be avoided or used cautiously, adjusting the venetoclax dose and monitoring antifungal levels.","source":"ecil-10","quote":"In the case of co-administration of venetoclax, antifungal prophylaxis should be avoided or used cautiously because of drug-drug interactions (i.e. adjustment of venetoclax dosing is needed with therapeutic drug monitoring of the antifungal agent)"},{"action":"Do not give routine antifungal prophylaxis for autologous transplant, ALL in adults, Hodgkin lymphoma or myeloma","why":"The risk of fungal infection in these groups is too low for prophylaxis to help; ECIL suggests fluconazole against Candida in the neutropenic phase of autologous transplant (B-III).","source":"ecil-10","quote":"Prophylaxis is not indicated in patients treated for myeloproliferative neoplasms (NPM), acute lymphoid leukemia (ALL), and Hodgkin lymphoma (HL)."},{"action":"For CAR-T recipients, give mould-active prophylaxis to those at high risk and anti-yeast prophylaxis to those at low risk","why":"Fungal infections after CD19 CAR-T run at 1 to 15%, higher with cytokine release syndrome and the steroids used to treat it.","source":"ecil-10","quote":"The expert panel proposes to endorse the use of anti-mold prophylaxis in high-risk patients during pre-infusion and post-infusion, while in low-risk patients, anti-yeast prophylaxis can be recommended (B-II).","grade":"B-II"},{"action":"In children, give prophylaxis during observed or expected severe neutropenia, and in allogeneic transplant during immunosuppression for GVHD","why":"These are the periods of highest risk; no trial has compared start and stop rules.","source":"paed-afp-2020","quote":"If systemic antifungal prophylaxis is warranted, consider administration during periods of observed or expected severe neutropenia.","grade":"Evidence quality: low; Strength of recommendation: weak"}],"bestInClass":{"statement":"Prophylaxis targeted to high-risk groups and mould-active. For children, the POGO guideline (2020, endorsed by COG; its 2026 update keeps the strong recommendations for AML and allogeneic HSCT and for an echinocandin or mould-active azole, and adds good practice statements on drug interactions, infection prevention and local epidemiology). For adults and children with haematological cancers, ECIL-10 (2025): posaconazole A-I during AML and MDS induction, isavuconazole, micafungin and caspofungin B-II, and new recommendations for CAR-T and for older or poorly responding children with ALL. The guidelines differ on ALL: ECIL does not indicate prophylaxis for ALL in general but now recommends it for children aged 12 or older or with insufficient response, while POGO makes a weak recommendation to consider it for high-risk ALL without defining the subgroup. They also differ on choice: POGO puts echinocandins and mould-active azoles side by side (echinocandins where hepatotoxicity matters, azoles where oral dosing matters), while ECIL ranks posaconazole highest in AML induction.","sources":["ecil-10","paed-afp-2020","cog-afp-2020","paed-prophylaxis-2026","asco-idsa-2018"]},"variants":[{"name":"Fluconazole where mould risk is low","differs":"Uses fluconazole, which covers yeasts but not moulds, in units where mould infection is rare, or as part of a strategy with mould-directed diagnostic tests.","evidence":"POGO says fluconazole may be appropriate where the mould risk is sufficiently low; ECIL grades fluconazole B-I in AML only where the incidence of mould infections is low.","sources":["paed-afp-2020","ecil-10"]},{"name":"Echinocandin rather than azole in children","differs":"Uses daily intravenous caspofungin or micafungin rather than an oral azole, accepting the need for intravenous access to avoid azole interactions and liver toxicity.","evidence":"POGO strong recommendation for either class (moderate quality); ECIL-10 raised caspofungin to B-I in children after a randomised trial in paediatric allogeneic HSCT found it as effective as triazoles.","sources":["paed-afp-2020","ecil-10"]},{"name":"Haploidentical transplant with post-transplant cyclophosphamide","differs":"ECIL treats haploidentical allogeneic HSCT with post-transplant cyclophosphamide as low risk for mould infection before engraftment.","evidence":"B-II in the ECIL-10 allogeneic HSCT table.","sources":["ecil-10"]}],"grades":[{"claim":"Prophylaxis in children with AML expected to have profound and prolonged neutropenia","grade":"Evidence quality: high; Strength of recommendation: strong","source":"paed-afp-2020"},{"claim":"Prophylaxis in children having allogeneic HSCT pre-engraftment and during GVHD treatment","grade":"Evidence quality: moderate; Strength of recommendation: strong","source":"paed-afp-2020"},{"claim":"Consider prophylaxis in high-risk ALL in children","grade":"Evidence quality: low; Strength of recommendation: weak","source":"paed-afp-2020","quote":"Consider administering systemic antifungal prophylaxis to children and adolescents with newly diagnosed and relapsed acute lymphoblastic leukemia at high risk for IFD (Evidence quality: low; Strength of recommendation: weak)."},{"claim":"Use a mould-active agent when prophylaxis is warranted","grade":"Evidence quality: high; Strength of recommendation: strong","source":"paed-afp-2020","quote":"If systemic antifungal prophylaxis is warranted, administer a mold-active agent (Evidence quality: high; Strength of recommendation: strong)."},{"claim":"No routine amphotericin prophylaxis","grade":"Evidence quality: low; Strength of recommendation: strong","source":"paed-afp-2020","quote":"Do not use amphotericin routinely as systemic antifungal prophylaxis (Evidence quality: low; Strength of recommendation: strong)."},{"claim":"No routine prophylaxis in children having autologous HSCT","grade":"Evidence quality: low; Strength of recommendation: weak","source":"paed-afp-2020"},{"claim":"Posaconazole tablets during AML and MDS remission induction","grade":"A-I","source":"ecil-10"},{"claim":"Mould-active azoles with vincristine","grade":"D-II","source":"ecil-10"},{"claim":"Caspofungin as mould-active prophylaxis in children","grade":"B-I","source":"ecil-10","quote":"Hence, the caspofungin grade of recommendation has been updated to a B-I."}],"sources":[{"key":"ecil-10","label":"Primary antifungal prophylaxis in hematological malignancies. Updated clinical practice guidelines by the European Conference on Infections in Leukemia (ECIL-10)","publisher":"European Conference on Infections in Leukaemia, Leukemia","year":2025,"url":"https://europepmc.org/article/PMC/PMC12208874","doi":"10.1038/s41375-025-02586-7","gradingScheme":"ESCMID system: strength A (strongly supports) to D (supports against); quality I (randomised trial), II (non-randomised, cohort or case-control; index r, t, h, u or a for the source), III (expert opinion); printed as, for example, B-II.","read":"full-text","accessed":"2026-11-11"},{"key":"paed-afp-2020","label":"Clinical Practice Guideline for Systemic Antifungal Prophylaxis in Pediatric Patients With Cancer and Hematopoietic Stem-Cell Transplantation Recipients","publisher":"Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology","year":2020,"url":"https://europepmc.org/article/PMC/PMC7499615","doi":"10.1200/jco.20.00158","gradingScheme":"GRADE: evidence quality high to very low and strength strong or weak, printed in brackets after each recommendation.","read":"full-text","accessed":"2026-11-11"},{"key":"cog-afp-2020","label":"Systemic antifungal prophylaxis in pediatric patients with cancer and HSCT recipients (COG endorsement, version date 31 August 2020)","publisher":"Children's Oncology Group","year":2020,"url":"https://childrensoncologygroup.org/wp-content/uploads/2026/05/COG_SC_Antifungal_Prophylaxis_Guideline_Document_31AUG2020-new-logo.pdf","gradingScheme":"Reprints the source guideline's GRADE strength and quality.","read":"full-text","accessed":"2026-11-11"},{"key":"paed-prophylaxis-2026","label":"Clinical Practice Guideline for Systemic Antibacterial and Antifungal Prophylaxis in Pediatric Patients With Cancer and Hematopoietic Cell Transplant Recipients: 2026 Update","publisher":"Pediatric Oncology Group of Ontario panel, Journal of Clinical Oncology","year":2026,"url":"https://europepmc.org/article/MED/42826360","doi":"10.1200/jco-26-00720","read":"abstract","accessed":"2026-11-11"},{"key":"asco-idsa-2018","label":"Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update","publisher":"ASCO and IDSA, Journal of Clinical Oncology","year":2018,"url":"https://europepmc.org/article/MED/30179565","doi":"10.1200/JCO.18.00374","read":"abstract","accessed":"2026-11-11"}],"upgrades":[],"gaps":["The 2026 paediatric update was read only as an abstract; any change in wording or grade beyond what the abstract states is not reflected here, and the COG page still lists the 2020 endorsement.","ASCO/IDSA 2018 was read only as an abstract; its choice of agent and grades are not given.","Doses and therapeutic drug monitoring targets are in the ECIL-10 tables and the product licences; they are not reproduced here.","ECIL-10 says knowledge of fungal infection with bispecific antibodies is too limited for any recommendation.","Neither guideline defines precisely which children with ALL are at high risk; POGO calls for protocol-specific and phase-specific recommendations."]},"route":"/protocols/antifungal-prophylaxis-in-haematology/","neighbours":{"protocol":[{"id":"antibacterial-prophylaxis-in-neutropenia","kind":"protocol","name":"Antibacterial (fluoroquinolone) prophylaxis during expected severe neutropenia","route":"/protocols/antibacterial-prophylaxis-in-neutropenia/"},{"id":"paediatric-fever-and-neutropenia","kind":"protocol","name":"Fever and neutropenia in children with cancer or after stem cell transplant","route":"/protocols/paediatric-fever-and-neutropenia/"},{"id":"neutropenic-precautions-and-daily-life","kind":"protocol","name":"Protective measures and daily life during neutropenia: hand hygiene, visitors, pets, plants, school and swimming","route":"/protocols/neutropenic-precautions-and-daily-life/"}],"drug":[{"id":"venetoclax","kind":"drug","name":"Venetoclax","route":"/drugs/venetoclax/"},{"id":"vincristine","kind":"drug","name":"Vincristine","route":"/drugs/vincristine/"}],"cancer":[{"id":"all-leukemia","kind":"cancer","name":"Acute lymphoblastic leukaemia","route":"/cancers/all-leukemia/"},{"id":"aml","kind":"cancer","name":"Acute myeloid leukaemia","route":"/cancers/aml/"},{"id":"childhood-cancers","kind":"cancer","name":"Childhood cancers (all types)","route":"/cancers/childhood-cancers/"}],"section":[{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"allogeneic-hsct","kind":"technology","name":"Allogeneic stem cell transplantation","route":"/technologies/allogeneic-hsct/"},{"id":"autologous-stem-cell-transplant","kind":"technology","name":"Autologous stem cell transplant (high-dose therapy)","route":"/technologies/autologous-stem-cell-transplant/"},{"id":"car-t","kind":"technology","name":"CAR-T cell therapy","route":"/technologies/car-t/"}],"company":[{"id":"childrens-oncology-group","kind":"company","name":"Children's Oncology Group (COG)","route":"/companies/childrens-oncology-group/"}],"institution":[{"id":"asco","kind":"institution","name":"American Society of Clinical Oncology (ASCO)","route":"/institutions/asco/"}],"term":[{"id":"lymphoma-tx-pjp-and-infection-prophylaxis","kind":"term","name":"Infection prophylaxis in lymphoma: PJP, herpes, fungal risk and vaccination","route":"/terms/lymphoma-tx-pjp-and-infection-prophylaxis/"},{"id":"neutropenia","kind":"term","name":"Neutropenia","route":"/terms/neutropenia/"}]}}