Network meta-analysis of triazole, polyene, and echinocandin antifungal agents in invasive fungal infection prophylaxis in patients with hematological malignancies

Abstract

Background and aim Triazole, polyene, and echinocandin antifungal agents are extensively used to treat invasive fungal infections (IFIs); however, the optimal prophylaxis option is not clear. This study aimed to determine the optimal agent against IFIs for patients with hematological malignancies. Methods Randomized controlled trials (RCTs) comparing the effectiveness of triazole, polyene, and echinocandin antifungal agents with each other or placebo for IFIs in patients with hematological malignancies were searched. This Bayesian network meta-analysis was performed for all agents. Results The network meta-analyses showed that all triazoles, amphotericin B, and caspofungin, but not micafungin, reduced IFIs. Posaconazole was superior to fluconazole [odds ratio (OR), 0.30; 95% credible interval (CrI), 0.12–0.60], itraconazole (OR, 0.40; 95% CrI, 0.15–0.85), and amphotericin B (OR, 4.97; 95% CrI, 1.73–11.35). It also reduced all-cause mortality compared with fluconazole (OR, 0.35; 95% CrI, 0.08–0.96) and itraconazole (OR, 0.33; 95% CrI, 0.07–0.94), and reduced the risk of adverse events compared with fluconazole (OR, 0.02; 95% CrI, 0.00–0.03), itraconazole (OR, 0.01; 95% CrI, 0.00–0.02), posaconazole (OR, 0.02; 95% CrI, 0.00–0.03), voriconazole (OR, 0.005; 95% CrI, 0.00 to 0.01), amphotericin B (OR, 0.004; 95% CrI, 0.00–0.01), and caspofungin (OR, 0.05; 95% CrI, 0.00–0.42) despite no significant difference in the need for empirical treatment and the proportion of successful treatment. Conclusions Posaconazole might be an optimal prophylaxis agent because it reduced IFIs, all-cause mortality, and adverse events, despite no difference in the need for empirical treatment and the proportion of successful treatment.