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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.
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.
Why: The benefit of prophylaxis grows with the risk; in low-risk people side effects, cost and drug interactions outweigh it.
“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).”
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Evidence quality: moderate; Strength of recommendation: strong
Why: Children with AML are at high risk of fungal infection, and prophylaxis reduced it most in those at highest risk.
“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).”
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Evidence quality: high; Strength of recommendation: strong
Why: These are two separate periods of high fungal risk; in transplant recipients prophylaxis also lowered deaths from fungal infection.
“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).”
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Evidence quality: moderate; Strength of recommendation: strong
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.
“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.”
European Conference on Infections in Leukaemia, Leukemia 2025
Why: Posaconazole is the only agent ECIL grades A-I in this setting; isavuconazole, micafungin and caspofungin are B-II alternatives.
“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).”
European Conference on Infections in Leukaemia, Leukemia 2025 · posaconazole A-I; isavuconazole, micafungin, caspofungin B-II
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.
“In choosing a mold-active agent, administer an echinocandin or a mold-active azole (Evidence quality: moderate; Strength of recommendation: strong).”
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Evidence quality: moderate; Strength of recommendation: strong
Why: These azoles slow the breakdown of vincristine and can cause severe nerve damage.
“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).”
European Conference on Infections in Leukaemia, Leukemia 2025 · D-II
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.
“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)”
European Conference on Infections in Leukaemia, Leukemia 2025
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).
“Prophylaxis is not indicated in patients treated for myeloproliferative neoplasms (NPM), acute lymphoid leukemia (ALL), and Hodgkin lymphoma (HL).”
European Conference on Infections in Leukaemia, Leukemia 2025
Why: Fungal infections after CD19 CAR-T run at 1 to 15%, higher with cytokine release syndrome and the steroids used to treat it.
“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).”
European Conference on Infections in Leukaemia, Leukemia 2025 · B-II
Why: These are the periods of highest risk; no trial has compared start and stop rules.
“If systemic antifungal prophylaxis is warranted, consider administration during periods of observed or expected severe neutropenia.”
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Evidence quality: low; Strength of recommendation: weak
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
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.
European Conference on Infections in Leukaemia, Leukemia 2025 · Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · Children's Oncology Group 2020 · Pediatric Oncology Group of Ontario panel, Journal of Clinical Oncology 2026 · ASCO and IDSA, Journal of Clinical Oncology 2018
Where it 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.
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · European Conference on Infections in Leukaemia, Leukemia 2025
Where it 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.
Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 · European Conference on Infections in Leukaemia, Leukemia 2025
Where it 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.
European Conference on Infections in Leukaemia, Leukemia 2025
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Prophylaxis in children with AML expected to have profound and prolonged neutropenia | Evidence quality: high; Strength of recommendation: strong | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| Prophylaxis in children having allogeneic HSCT pre-engraftment and during GVHD treatment | Evidence quality: moderate; Strength of recommendation: strong | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| Consider prophylaxis in high-risk ALL in children “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).” | Evidence quality: low; Strength of recommendation: weak | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| Use a mould-active agent when prophylaxis is warranted “If systemic antifungal prophylaxis is warranted, administer a mold-active agent (Evidence quality: high; Strength of recommendation: strong).” | Evidence quality: high; Strength of recommendation: strong | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| No routine amphotericin prophylaxis “Do not use amphotericin routinely as systemic antifungal prophylaxis (Evidence quality: low; Strength of recommendation: strong).” | Evidence quality: low; Strength of recommendation: strong | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| No routine prophylaxis in children having autologous HSCT | Evidence quality: low; Strength of recommendation: weak | Pediatric Oncology Group of Ontario panel (Lehrnbecher et al.), Journal of Clinical Oncology 2020 |
| Posaconazole tablets during AML and MDS remission induction | A-I | European Conference on Infections in Leukaemia, Leukemia 2025 |
| Mould-active azoles with vincristine | D-II | European Conference on Infections in Leukaemia, Leukemia 2025 |
| Caspofungin as mould-active prophylaxis in children “Hence, the caspofungin grade of recommendation has been updated to a B-I.” | B-I | European Conference on Infections in Leukaemia, Leukemia 2025 |
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