Shifting paradigms in antifungal prophylaxis and their effects on candidemia outcomes in hematological malignancies: A 14-year experience from a single tertiary center

Abstract

Evolving antifungal prophylaxis approaches have reshaped candidemia patterns and outcomes in hematological malignancy (HM) patients. This study aimed to evaluate temporal changes in candidemia incidence, species distribution, and factors associated with mortality in relation to prophylaxis practices. Adult HM patients with candidemia between 2009 and 2023 were included. Clinical and microbiological data were analyzed, and candidemia rates were compared across different prophylaxis periods. Sixty-six patients were identified, with acute myeloid leukemia (AML) being the most common underlying malignancy (40.9%). Non-albicans Candida species predominated, especially C. krusei and C. tropicalis. In AML patients, candidemia incidence significantly decreased over time (beta = -0.694, p = 0.004), with the lowest rates observed during the extended-release posaconazole tablet era (2016-2023). However, 30-day mortality remained high (53%) and unchanged across periods. Multivariate analysis identified C. tropicalis and total parenteral nutrition as independent risk factors for 30-day mortality (OR: 4.3 and 4.6, p < 0.05), while antifungal prophylaxis was protective (OR: 0.07, p = 0.017). In patients with AML, posaconazole prophylaxis, particularly in the extended-release tablet formulation, significantly reduced the incidence of candidemia. However, overall 30-day mortality rates remained high, with C. tropicalis being a major contributor. Thus, individualized prophylaxis and treatment strategies are crucial for improving outcomes.