Drew J. Winston

A Controlled Trial of Fluconazole to Prevent Fungal Infections in Patients Undergoing Bone Marrow Transplantation

BACKGROUND AND METHODS Superficial and systemic fungal infections are a major problem among severely immunocompromised patients who undergo bone marrow transplantation. We performed a double-blind, randomized, multicenter trial in which patients receiving bone marrow transplants were randomly assigned to receive placebo or fluconazole (400 mg daily). Fluconazole or placebo was administered prophylactically from the start of the conditioning regimen until the neutrophil count returned to 1000 per microliter, toxicity was suspected, or a systemic fungal infection was suspected or proved. RESULTS By the end of the treatment period, 67.2 percent of the 177 patients assigned to placebo had a positive fungal culture of specimens from any site, as compared with 29.6 percent of the 179 patients assigned to fluconazole. Among these, superficial infections were diagnosed in 33.3 percent of the patients receiving placebo and in 8.4 percent of the patients receiving fluconazole (P less than 0.001). Systemic fungal infections occurred in 28 patients who received placebo as compared with 5 who received fluconazole (15.8 percent vs. 2.8 percent, P less than 0.001). Fluconazole prevented infection with all strains of candida except Candida krusei. Fluconazole was well tolerated, although patients who received it had a higher mean increase in alanine aminotransferase levels than patients who received placebo. Although there was no significant difference in overall mortality between the groups, fewer deaths were ascribed to acute systemic fungal infections in the group receiving fluconazole than in the group receiving placebo (1 of 179 vs. 10 of 177, P less than 0.001). CONCLUSIONS Prophylactic administration of fluconazole to recipients of bone marrow transplants reduces the incidence of both systemic and superficial fungal infections.

Voriconazole Compared with Liposomal Amphotericin B for Empirical Antifungal Therapy in Patients with Neutropenia and Persistent Fever

BACKGROUND Patients with neutropenia and persistent fever are often treated empirically with amphotericin B or liposomal amphotericin B to prevent invasive fungal infections. Antifungal triazoles offer a potentially safer and effective alternative. METHODS In a randomized, international, multicenter trial, we compared voriconazole, a new second-generation triazole, with liposomal amphotericin B for empirical antifungal therapy. RESULTS A total of 837 patients (415 assigned to voriconazole and 422 to liposomal amphotericin B) were evaluated for success of treatment. The overall success rates were 26.0 percent with voriconazole and 30.6 percent with liposomal amphotericin B (95 percent confidence interval for the difference, -10.6 to 1.6 percentage points); these rates were independent of the administration of antifungal prophylaxis or the use of colony-stimulating factors. There were fewer documented breakthrough fungal infections in patients treated with voriconazole than in those treated with liposomal amphotericin B (8 [1.9 percent] vs. 21 [5.0 percent], P=0.02). The voriconazole group had fewer cases of severe infusion-related reactions (P<0.01) and of nephrotoxicity (P<0.001). The incidence of hepatotoxicity was similar in the two groups. Patients receiving voriconazole had more episodes of transient visual changes than those receiving liposomal amphotericin B (22 percent vs. 1 percent, P<0.001) and more hallucinations (4.3 percent vs. 0.5 percent, P<0.001). Parenteral voriconazole was changed to the oral formulation in 22 percent of the voriconazole group, with a reduction in the mean duration of hospitalization by one day in all patients (P=0.17) but by two days in patients at high risk (P=0.03). CONCLUSIONS Voriconazole is a suitable alternative to amphotericin B preparations for empirical antifungal therapy in patients with neutropenia and persistent fever.

Infectious complications of human bone marrow transplantation.

Infections are an almost inevitable complication of human bone marrow transplantation and account for the majority of deaths in transplant recipients. Even prior to the initiation of the transplantation procedure, patients may present with infections complicating previously unsuccessful chemotherapy for hematological malignancy or aplastic anemia. Nevertheless, these pre-transplantation infections should not exclude the possibility of bone marrow transplantation if they can be successfully controlled with specific antimicrobial therapy and necessary adjunctive measures. The immediate post-transplantation period prior to engraftment is characterized by severe marrow aplasia that results from high-dose chemotherapy and total-body irradiation. Infections are primarily septicemias and localized processes caused by bacteria and fungi and their incidence increases as the intensity of immunosuppression is escalated. The high mortality associated with bacterial septicemia makes early, empirical antibacterial therapy mandatory. However, the reduction in mortality from bacterial infection resulting from such an aggressive approach may be offset by a higher mortality from invasive fungal infection, especially in patients with prior fungal colonization and undergoing prolonged conditioning therapy. Thus, until more specific and sensitive tests for the diagnosis of invasive fungal infection become available, empirical intravenous amphotericin should be considered in patients who are persistently febrile and deteriorate clinically in the face of appropriate antibacterial therapy. Interstitial pneumonia associated with severe GVHD is the major infectious complication after successful marrow engraftment and is the most significant barrier to long-term survival. Trimethoprim-sulfamethoxazole is effective prophylaxis against interstitial pneumonia due to Pneumocystis carinii, but one half of the patients still develop a pneumonitis either associated with CMV or of unknown etiology. Mortality from interstitial pneumonia is related to prior radiation therapy while survival is associated with a four-fold rise in CMV CF antibody titer. The latter observation supports the need to investigate passive immunization with CMV antibody as a means of preventing some interstitial pneumonias. Despite the progress made in many areas of human bone marrow transplantation, the majority of graft recipients still die of infectious complications. Thus, new approaches to the management of infections in transplant recipients are urgently needed. Better-tolerated oral nonabsorbable antibiotics, laminar-air-flow rooms, granulocyte transfusions, and chemotherapy and immunotherapy for CMV are among the prophylactic and therapeutic measures that must be critically evaluated in well-controlled, prospective studies. Continued assessment of the infectious complications of bone marrow transplantation is a critical aspect of any ongoing transplant program, not just a research goal...

Intravenous and Oral Itraconazole versus Intravenous and Oral Fluconazole for Long-Term Antifungal Prophylaxis in Allogeneic Hematopoietic Stem-Cell Transplant Recipients: A Multicenter, Randomized Trial

Context Fungal infections after allogeneic hematopoietic stem-cell transplantation are a serious problem. Current prophylactic regimens are limited by toxicity and the emergence of resistant infections. Contribution This open-label randomized trial of 140 patients undergoing stem-cell transplantation found that prophylaxis with itraconazole for 100 days after transplantation prevented more invasive fungal infections than did prophylaxis with fluconazole (absolute difference, 16 percentage points [95% CI, 29 to 5 percentage points]). More fungal pathogens were resistant to fluconazole. Nausea, vomiting, diarrhea, and abdominal pain were more common in patients receiving itraconazole. Implications Itraconazole is better than fluconazole for preventing invasive fungal infections in allogeneic stem-cell transplant recipients but causes more gastrointestinal side effects. The Editors Fungal infections have become an increasing cause of morbidity and death after allogeneic hematopoietic stem-cell transplantation. Indeed, with better prevention of cytomegalovirus disease, invasive fungal infections are now the leading cause of death from infection at many transplantation centers (1, 2). Consequently, antifungal agents are often used for prophylaxis in allogeneic hematopoietic stem-cell transplant recipients. An amphotericin B formulation or fluconazole has been most commonly used (3-11). Each of these agents, however, has substantial limitations for prophylaxis. The amphotericin B formulations are limited by toxicity, and the lipid preparations of amphotericin B can be expensive. Furthermore, the prophylactic efficacy of standard amphotericin B and the newer lipid formulations of amphotericin has not been consistently demonstrated in randomized, controlled trials (1, 5-11). Routine use of fluconazole for prophylaxis has been associated with the emergence of fluconazole-resistant Candida infections (12-14). Fluconazole also lacks reliable activity against Aspergillus species, which have now become the primary cause of invasive fungal infection at many transplantation centers (15, 16). Itraconazole is an azole antifungal agent that may overcome some of the limitations of fluconazole and the amphotericin B formulations as prophylactic agents in allogeneic hematopoietic stem-cell transplant recipients. Itraconazole has excellent in vitro activity against many opportunistic fungi that are resistant to fluconazole, including Aspergillus and some Candida species (17, 18). Itraconazole is less toxic than the amphotericin B formulations. It is now available in an oral hydroxypropyl--cyclodextrin solution as well as an intravenous formulation. Compared with itraconazole capsules, itraconazole oral solution is much better absorbed and has been used successfully for antifungal prophylaxis in neutropenic patients who had not received an allogeneic hematopoietic stem-cell transplant (19-21). Intravenous itraconazole is the only azole approved for empirical antifungal therapy in febrile neutropenic patients (22). We performed a randomized trial to compare intravenous and oral itraconazole with intravenous and oral fluconazole for prevention of fungal infections in allogeneic hematopoietic stem-cell transplant recipients. Methods Patients Patients of either sex who were 13 years of age or older and undergoing allogeneic hematopoietic stem-cell transplantation were eligible for the study if they had no history of an invasive yeast or mold infection within 8 weeks before initiation of therapy with the study drug. Because of the paucity of efficacy and safety data on the use of intravenous and oral itraconazole in children at the time this study was initiated, patients younger than 13 years of age were excluded. Patients with liver enzyme values greater than five times the upper limit of normal, a bilirubin level greater than 85.5 mol/L (5.0 mg/dL), an allergy to imidazoles or azoles, or a body temperature greater than 38.0 C within 48 hours of starting therapy with the study drug were also excluded. Similarly, patients who had received a previous bone marrow or peripheral stem-cell transplant and patients requiring concomitant therapy with drugs (rifampin, rifabutin, phenobarbital, phenytoin, carbamazepine, midazolam, triazolam, cisapride, terfenadine, or astemizole) having potential interactions with azole antifungal agents were not eligible for the study. Women were required to have a negative result on a pregnancy test. Informed consent was obtained from each patient or appropriate relative in a manner approved by the institutional review board at each study center. Study Drugs and Design Eligible patients were randomly assigned to receive prophylaxis with either itraconazole or fluconazole. We used blocked randomization, which was done in a 1:1 ratio and stratified by study center. The randomization process was performed by the pharmacy department at each study site. The study design was open label because blinding of intravenous and oral itraconazole against intravenous and oral fluconazole was technologically impossible at the time the study was conducted. Prophylaxis with each study medication was started on the first day after transplantation. Because a previous trial had shown both a reduction in fungal infections and improved survival when prophylactic fluconazole was used for 75 days after transplantation (4), use of the study drug was continued until day 100 after transplantation. Patients randomly assigned to receive itraconazole were initially given intravenous itraconazole at a loading dose of 200 mg every 12 hours for 2 days, followed by 200 mg every 24 hours for 12 days. Patients were then switched to oral itraconazole solution at a dose of 200 mg every 12 hours until day 100 after transplantation. Similarly, patients randomly assigned to receive fluconazole were initially given intravenous fluconazole at a dose of 400 mg once daily for 14 days and were then switched to oral fluconazole tablets at a dose of 400 mg once daily until day 100 after transplantation. If patients could not take or tolerate oral medications, they resumed prophylaxis with the intravenous form of the study drug. The dose of itraconazole was not adjusted in patients with renal failure. However, if the serum creatinine level increased to greater than 354 mol/L (4.0 mg/dL) during treatment with intravenous itraconazole, patients were changed to itraconazole oral solution because of the prolonged elimination rate of intravenous hydroxypropyl--cyclodextrin with severe renal impairment. The daily dose of fluconazole was decreased by 50% for a creatinine clearance of 0.33 to 0.84 mL/s (20 to 50 mL/min) and by 75% for a creatinine clearance of less than 0.33 mL/s (20 mL/min). After transplantation, prophylaxis with the study drug was discontinued if an invasive fungal infection was documented, a serious adverse event definitely related to the study drug occurred, or the patient died. Patients with a documented superficial fungal infection could be treated with a topical antifungal agent while continuing prophylaxis with the study drug. Use of the study drug was temporarily discontinued when empirical therapy with amphotericin B was administered for suspected but undocumented fungal infection. After the empirical amphotericin B therapy was stopped, prophylaxis with the study drug was resumed. Transplantation Regimen Investigators at each study center were allowed to use the preparative regimens of chemoradiation therapy and the immunosuppressive agents for prophylaxis and treatment of graft-versus-host disease that were considered standard practice at their institutions. Similarly, each study center used its own standard agents to prevent and treat bacterial and viral infections. The criteria used to diagnose and grade graft-versus-host disease have been previously published (23, 24). Laboratory Procedures We obtained complete blood counts with differential leukocyte count and platelet count, blood urea nitrogen levels, serum creatinine and electrolyte determinations, urinalyses, and liver function studies (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin levels) at study entry, at least once weekly during the study, and within 3 days of completion of prophylaxis with the study drug. Serum cyclosporine levels, measured by using high-pressure liquid chromatography, were also monitored during the study (25). In patients receiving itraconazole, trough plasma levels of itraconazole and its active metabolite, hydroxy-itraconazole, were measured by using high-performance liquid chromatography on days 3 and 7 of the study and then once every 1 or 2 weeks thereafter (26). We obtained cultures of the blood and other suspected sites of fungal infection whenever a patients clinical condition suggested the possibility of infection. Chest radiography, computed tomography, bronchoscopy, and biopsies were also done when clinically indicated to diagnose fungal infection. We determined minimum inhibitory concentrations (MICs) of itraconazole and fluconazole for yeast and filamentous fungi isolated from patients with documented fungal infections to evaluate the possible emergence of resistant organisms. Antifungal susceptibility testing was performed by a central reference laboratory according to guidelines of the National Committee for Clinical Laboratory Standards (27, 28). Definitions of Fungal Infection Superficial fungal infections were diagnosed by the isolation of a fungus from the skin, oropharynx, gastrointestinal tract, or vagina in association with signs of inflammation, ulcerations, plaques, exudates, or other manifestations of infection not explainable by other pathogens. Invasive fungal infections were diagnosed by using criteria published by the National Institutes of Health Mycoses Study Group and the European Organization for Research and Treatment of Cancer (29). The diagnosis of invasive fungal infection

Ganciclovir Prophylaxis of Cytomegalovirus Infection and Disease in Allogeneic Bone Marrow Transplant Recipients: Results of a Placebo-Controlled, Double-Blind Trial

Cytomegalovirus (CMV) infection is a frequent cause of morbidity and mortality after allogeneic bone marrow transplantation [1, 2]. Approximately 50% of all allogeneic transplant recipients develop CMV infection, which is more common in CMV-seropositive patients [1]. Some patients with CMV infection are asymptomatic, but many develop pneumonia, gastroenteritis, fever and wasting, or hepatitis. In a recent review of CMV infection at several transplant centers, the average incidence of CMV pneumonia in allogeneic transplants was 15%, and the mortality was 80% to 90% [1]. Treatment of CMV pneumonia with antiviral agents or intravenous immunoglobulin has generally been ineffective [1], although the combination of ganciclovir and immunoglobulin has been reported to increase survival to 50% to 60% at some centers [3-5]. Attempts to prevent CMV infection and disease in bone marrow transplant recipients have produced mixed results. In CMV-seronegative patients, most CMV infections can be prevented by the use of CMV-seronegative blood products [6]. Prophylactic intravenous immunoglobulin also modifies the severity of CMV infection in CMV-seronegative patients and decreases the risk for acute graft-versus-host disease (GVHD) and interstitial pneumonia [7, 8]. On the other hand, effective prophylaxis for CMV reactivation and pneumonia in patients who are CMV-seropositive at the time of transplantation has not been clearly established. Previous trials of prophylactic vidarabine, human leukocyte interferon, and low-dose acyclovir showed no clinically significant effect [1]. In a nonrandomized, controlled trial, high doses of prophylactic acyclovir were associated with a decreased incidence of CMV infection and CMV disease [9]. However, the incidence of CMV infection and CMV-related pneumonia was 59% and 19%, respectively, despite the high doses of acyclovir. The efficacy of CMV immune plasma or immunoglobulin in CMV-seropositive patients is also uncertain [7, 10, 11]. Ganciclovir, an acyclic nucleoside analog of guanosine, has recently become available for treatment of CMV infection in immunocompromised patients [12]. In vitro, ganciclovir is approximately 50 times more active than acyclovir against CMV isolates [13]. Thus, we initiated a placebo-controlled, double-blind, randomized trial of prophylactic ganciclovir in CMV-seropositive allogeneic bone marrow transplants. Methods From May 1987 to August 1990, patients hospitalized at the UCLA Center for the Health Sciences were enrolled in the study if they met the following criteria: undergoing allogeneic bone marrow transplantation for hematologic malignancy or aplastic anemia; 12 years of age or older; seropositive for CMV antibody; and no evidence of pneumonia or other CMV clinical syndrome. Informed consent approved by the UCLA Human Subject Protection Committee was obtained from each patient. Patients undergoing a second bone marrow transplant were excluded. Only three patients meeting the eligibility criteria and subsequently approached for consent refused to participate in the study. Transplant Procedure Details on conditioning therapy before transplantation and clinical management after transplantation have been reported previously [14-16]. Patients were given high-dose chemotherapy alone or with radiation therapy followed by intravenous infusion of bone marrow from a related or unrelated donor. Cyclosporine alone or in combination with methotrexate, corticosteroids, T-cell depletion, or immunotoxin (Xomazyme-CD5; Xoma Corporation, Berkeley, California) was used to prevent GVHD. Patients who developed GVHD were evaluated by standard criteria and treated with either corticosteroids alone or corticosteroids plus immunotoxin [14-16]. Trimethoprim-sulfamethoxazole was administered to all patients between the seventh and second days before transplantation and then for 2 consecutive days of each week between day 40 and day 150 after transplantation to prevent Pneumocystis carinii pneumonia [1]. Neither prophylactic acyclovir nor intravenous immunoglobulin was used. All patients received unscreened blood products that were not tested for CMV antibody. Study Drugs Patients were randomly assigned in a double-blind fashion to receive ganciclovir or placebo through a central intravenous catheter. The ganciclovir was given at a dosage of 2.5 mg per kg body weight every 8 hours intravenously, starting on the day that pretransplant conditioning therapy was initiated (usually day 7 before transplant) and continuing until the day before the bone marrow infusion. After transplantation, when the neutrophil count reached 1.0 109/L, the ganciclovir was resumed at a dosage of 6 mg/kg once per day, Monday through Friday, and continued until day 120 after transplant. The dosage was adjusted in patients with renal failure. For patients whose neutrophil count fell below 1.0 109/L while receiving the study drug, prophylaxis was temporarily discontinued. When the neutrophil count returned to a level greater than 1.0 109/L, the ganciclovir was restarted at a dosage of 6 mg/kg once per day on Monday, Wednesday, and Friday. If a patient developed documented interstitial pneumonia, gastrointestinal disease, or other clinical syndromes related to CMV, the primary physician could remove the patient from the study and treat the patient with ganciclovir. Laboratory Procedures The cytomegalovirus serologic status of patients and bone marrow donors was determined by latex agglutination (CMV SCAN; Becton Dickinson, Cockeysville, Maryland). After transplantation, serologic studies for CMV antibody were done every 2 to 4 weeks on all patients by both complement-fixation and enzyme-linked immunosorbent assay (ELISA) (CMV ELISA-IgG; Pharmacia Diagnostics, Fairfield, New Jersey). Viral cultures of throat, urine, and buffy coat were obtained from marrow transplant recipients before entry into the study and then once a week. Whenever appropriate, viral cultures of suspicious lesions, bronchoalveolar lavage, biopsy material, and autopsy tissue were performed. Tissue cultures were initially screened for viral antigen by immunofluorescence using monoclonal antibodies to viral proteins and then observed for 4 weeks to detect characteristic cytopathic effects. Bronchoalveolar lavage and biopsy material were also examined histologically for typical viral inclusions and immunohistochemically by indirect immunofluorescence using murine monoclonal antibodies to early and late CMV proteins. Complete blood counts and tests for serum creatinine, electrolytes, and liver function were done before, during, and after the study period to assess patients for treatment-related side effects. Diagnosis of Cytomegalovirus Infection and Disease Cytomegalovirus infection was diagnosed by isolation of CMV from a culture obtained from any site, a fourfold or greater increase in the CMV antibody titer on complement fixation, an increase in the CMV ELISA measurement to 1.1 units or greater, or the presence of typical CMV inclusion bodies in a tissue specimen. Interstitial pneumonia was diagnosed by tachypnea, hypoxemia, fever, and interstitial pulmonary infiltrates on a chest roentgenogram not explainable by other obvious causes. Cultures, histologic examination, and immunochemical staining of bronchoalveolar lavage or lung biopsy were done to determine the cause of interstitial pneumonia. Similarly, cultures, histologic examination, and immunochemical staining of an endoscopic biopsy of the gastrointestinal tract or a biopsy of the liver in a patient with associated symptoms and signs were used to diagnose CMV disease of the gastrointestinal tract and liver. The wasting syndrome related to CMV was defined as fever, anorexia, and weight loss not explainable by other causes in a patient with culture or serologic evidence of CMV infection. Statistical Analysis The Fisher exact test was used to compare differences in proportions. The Student t-test was used to compare means. Univariate comparisons of times to specific events were performed by the method of Kaplan and Meier and analyzed by the log-rank test. Confidence intervals (CIs) for 95% of differences are given where appropriate. Results Patient Characteristics One hundred thirty patients were enrolled in the study. However, 45 patients (20 placebo patients, 25 ganciclovir patients) were considered nonevaluable and were excluded from the efficacy analysis. Reasons for nonevaluability were as follows: early death within 9 to 34 days after the transplant (24 patients), marrow graft failure preventing administration of the study drug after transplant (9 patients), withdrawal of patient from the study (10 patients), and inadvertent enrollment of a patient undergoing a second transplant (2 patients). Fifteen placebo patients and 18 ganciclovir patients were not evaluable due to either early death or graft failure. Eight of the 45 patients removed from the study subsequently developed CMV infection (asymptomatic CMV excretion in five patients, fever and wasting in one patient, and pneumonia in two patients). The one patient with a CMV wasting syndrome and one of the two patients with pneumonia were initially randomized to receive ganciclovir. The other patient with CMV pneumonia was randomized to receive placebo. None of these patients received study drug after the transplant, and none was taking study drug when CMV disease developed. All determinations of evaluability were done blindly without knowledge of the patients treatment assignment and before the study code was broken. The characteristics of the 85 evaluable patients are summarized in Table 1. Forty-five patients received placebo, and 40 patients were given ganciclovir. The two groups of patients were similar in terms of age, sex, underlying disease, marrow source, GVHD prophylaxis, and the marrow donors CMV serologic status. More patients in the ganciclovir group received HLA-mismatched marrow (95% CI, 29% to 2%; P = 0.04) and

Intravenous immune globulin for prevention of cytomegalovirus infection and interstitial pneumonia after bone marrow transplantation.

The effects of high doses of polyvalent intravenous immune globulin given for prophylaxis of cytomegalovirus infection and interstitial pneumonia in recipients of allogeneic marrow transplants were evaluated in a randomized controlled trial. Both symptomatic cytomegalovirus infection (21% compared with 46%, p = 0.03) and interstitial pneumonia (18% compared with 46%, p = 0.02) occurred less frequently in the recipients of intravenous immune globulin than in control patients. Prophylactic intravenous immune globulin was also associated with a lower incidence of graft-versus-host disease (34% in recipients compared with 65% in controls, p = 0.01), but its reduction in rates of interstitial pneumonia was independent of graft-versus-host disease and occurred in both patients with and without graft-versus-host disease. The high doses of immune globulin were well tolerated. Prophylactic intravenous immune globulin can modify the severity of cytomegalovirus infection and prevent interstitial pneumonia and possibly graft-versus-host disease in patients having allogeneic marrow transplantation.

Prophylactic fluconazole in liver transplant recipients. A randomized, double-blind, placebo-controlled trial.

Because of the relatively high incidence and severity of fungal infections (1), prophylaxis with antifungal drugs is frequently used in recipients of certain solid organ transplants. Oral prophylaxis with such agents as nystatin, clotrimazole, and amphotericin B and intravenous prophylaxis with low doses of amphotericin B have produced inconsistent results, and their beneficial effects remain largely unproved (1). Consequently, no approach for prevention of fungal infections in solid organ transplant recipients has been uniformly accepted or recommended. The triazole antifungal drug fluconazole was found to be safe and effective for preventing superficial and invasive Candida infection in recipients of bone marrow transplants (2, 3). The exact role of fluconazole in solid organ transplant recipients and other surgical patients, however, has not been clearly established. Therefore, we performed a double-blind, placebo-controlled trial of prophylactic fluconazole in patients undergoing solid organ transplantation. Liver transplant recipients were chosen for the trial because they have the highest incidence of fungal infection among solid organ transplant recipients (1, 4). Methods Patients Patients were eligible for the study if they were undergoing orthotopic liver transplantation, were 13 years of age or older, had no clinical evidence of fungal infection at study entry, had received no systemic antifungal therapy in the 2 weeks before randomization, and were not allergic to imidazole or azole antifungal agents. Women were required to have a negative result on a pregnancy test. Informed consent was obtained from patients or their relatives in a manner approved by the University of California, Los Angeles (UCLA), Human Subject Protection Committee. Transplantation Procedures The surgical procedures and post-transplantation management used in liver transplant recipients at the UCLA Medical Center have previously been published (5, 6). Baseline immunosuppression therapy usually consisted of cyclosporine, azathioprine, and corticosteroids. Acute rejection documented by liver biopsy was treated with boluses of intravenous corticosteroids. Episodes of rejection refractory to corticosteroids were treated with OKT3. Immediately before transplantation, patients received oral neomycin and erythromycin for decontamination of the gastrointestinal tract. Perioperative intravenous antibacterial prophylaxis was given for 24 hours and consisted of ampicillin-sulbactam alone, vancomycin with ceftizoxime, or an aminoglycoside (for patients who were allergic to penicillin). During surgery, the abdominal cavity was irrigated with a solution of 25 mg of amphotericin B in 1000 mL of sterile water. Nystatin and oral antibiotics were not used for bowel decontamination to prevent infection after transplantation. Antiviral prophylaxis consisted of 100 days of intravenous ganciclovir or high doses of acyclovir (6, 7). Twice-weekly trimethoprim-sulfamethoxazole or pentamidine once every 2 weeks (for patients who were allergic to sulfa drugs) was used for Pneumocystis carinii prophylaxis. Study Drugs and Design In a double-blind fashion, eligible patients were randomly assigned to receive prophylactic fluconazole or placebo. A 1:1 computer-generated randomization schedule was used. Fluconazole or placebo was started preoperatively on the day of surgery; patients in the treatment group received 400 mg of fluconazole as a single daily dose. The study drug was initially administered intravenously over a period of 1 hour. After transplantation, fluconazole was given by mouth as four 100-mg capsules when patients were able to receive oral medications. The daily dose of fluconazole was decreased by 50% for a creatinine clearance of 20 to 50 mL/min and by 75% for a creatinine clearance less than 20 mL/min. The intravenous placebo was normal saline (0.9% sodium chloride). Placebo capsules consisted of lactose, corn starch, and magnesium stearate. Because most fungal infections occur in the first 2 to 3 months after liver transplantation (1, 4, 6), prophylaxis with the study drug was continued for 10 weeks after transplantation. If the patient required another transplantation during the study period, prophylaxis was given for an additional 10 weeks from the date of the repeated procedure. Prophylaxis was discontinued if a documented invasive fungal infection developed, a serious adverse side effect definitely related to the study drug occurred, or the patient was unable to continue in the study because of noncompliance or death. Patients who developed a documented superficial fungal infection could be treated with topical clotrimazole while continuing to receive the study drug. Similarly, treatment with the study drug was continued when empirical therapy with intravenous amphotericin B was administered for suspected but undocumented systemic fungal infection. Laboratory Procedures Complete blood counts, prothrombin times, blood urea nitrogen levels, serum creatinine and electrolyte determinations, and liver function studies (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin levels) were obtained at study entry, twice weekly during the study, and at the end of prophylaxis to assess patients for drug-related side effects. Serum cyclosporine levels determined by high-pressure liquid chromatography were measured 24 to 48 hours after transplantation and at least once per week for the duration of the study (8). Before the study, a serum pregnancy test was done on all women of childbearing age. Patients were examined at least twice weekly for clinical symptoms and signs of adverse effects related to the study drug. Surveillance cultures of the oropharynx, axillae, inguinal skin folds, urine, and stool or perirectal area were done at study entry, once weekly during the study, and at the end of prophylaxis to determine the presence of fungal colonization. Blood cultures for fungus were also performed at study entry. Cultures of blood and other suspected sites of fungal infection were obtained during the study whenever a patients clinical condition suggested the possibility of infection. Definitions of Fungal Colonization and Infection Fungal colonization was defined as the presence of a fungus in one or more surveillance cultures in the absence of any clinical symptoms or signs of infection. Superficial fungal infections were diagnosed by the isolation of a fungus from the skin, oropharynx, vagina, gastrointestinal tract, wounds, or urine in association with signs of inflammation, ulcerations, plaques, or exudates that could not be explained by other pathogens. Invasive fungal infections were diagnosed by the presence of fungus in the blood, pulmonary tissue or secretions, sinuses, peritoneal cavity, or other organ structures in association with symptoms and signs of infection that could not be explained by other pathogens. Data Collection and Statistical Analysis All reviews, classification of infections, and data entry were done blindly before the statistical analyses were performed. Similarly, all side effects or adverse events that occurred during the study were recorded and classified blindly by the investigators as unrelated, possibly related, or probably related to the study drug. All statistical tests were performed as two-tailed tests. The Fisher exact test was used to compare differences in proportion. The equality of two distributions was compared by using the Wilcoxon rank-sum test. Bivariate comparisons of times to specific events were performed by using Kaplan-Meier estimates of survival distributions and the Gehan generalized Wilcoxon test (9). The SAS procedure LIFETEST (SAS Institute, Cary, North Carolina) was used for these comparisons (10). Estimates of relative risk and multivariable analyses were done by using the Cox proportional-hazards model (11). If fungal infection occurred in at least 20% of patients undergoing liver transplantation (estimated incidence), then each study group (placebo and fluconazole) would need to include 102 patients to demonstrate a reduction in proven fungal infection to 7% (power, 0.8; P=0.05). All patients were included in the efficacy analysis (modified intention-to-treat analysis) except 24 patients who did not receive the study drug after transplantation. Role of the Funding Source The study sponsor (Pfizer, Inc., New York, New York) provided both fluconazole and placebo. The study design was developed jointly by Pfizer, Inc., and the authors. The study sponsor also provided clinical research associates and statisticians for the collection and analysis of data. The decision to submit the manuscript for publication was made by the authors. Results Patient Characteristics From May 1992 to September 1993, 291 adults and children were hospitalized for orthotopic liver transplantation at the UCLA Medical Center. Two hundred thirty-nine patients were eligible for the study (Figure 1). Only 3 eligible patients declined to participate. The other 236 patients were randomly assigned to receive placebo or fluconazole. Twenty-four patients (13 placebo recipients and 11 fluconazole recipients) were excluded from analysis after randomization and after receiving a single preoperative dose of the study drug because it was found that they did not meet the inclusion criteria. Reasons for exclusion were cancellation of transplantation because of metastatic tumor (7 cases), inadequate donor organ (6 cases), or severe pulmonary hypertension (1 case); death in the operating room during transplantation (4 cases); pregnancy (1 case); age younger than 13 years (1 case); long-term dialysis (1 case); preoperative blood culture that was positive for Candida glabrata (1 case); and previous enrollment in the study (2 cases). No patients were excluded because of noncompliance with the study medication. Of the 4 patients who died during surgery, 3 were receiving placebo and 1 was receivi

CMX001 to Prevent Cytomegalovirus Disease in Hematopoietic-Cell Transplantation

BACKGROUND The use of available antiviral agents for the prevention of cytomegalovirus (CMV) disease is limited by frequent toxic effects and the emergence of resistance. CMX001 has potent in vitro activity against CMV and other double-stranded DNA viruses. We evaluated the safety and anti-CMV activity of CMX001 in patients who had undergone allogeneic hematopoietic-cell transplantation. METHODS From December 2009 through June 2011, a total of 230 patients with data that could be evaluated were enrolled in the study. We randomly assigned these adult CMV-seropositive transplant recipients from 27 centers to oral administration of CMX001 or placebo. Patients were assigned in a 3:1 ratio to five sequential study cohorts according to a dose-escalating, double-blind design. Randomization was stratified according to the presence or absence of acute graft-versus-host disease and CMV DNA in plasma. Patients received the study drug after engraftment for 9 to 11 weeks, until week 13 after transplantation. Polymerase-chain-reaction analysis of CMV DNA in plasma was performed weekly. Patients in whom CMV DNA was detected at a level that required treatment discontinued the study drug and received preemptive treatment against CMV infection. The primary end point was a CMV event, defined as CMV disease or a plasma CMV DNA level greater than 200 copies per milliliter when the study drug was discontinued. The analysis was conducted in the intention-to-treat population. RESULTS The incidence of CMV events was significantly lower among patients who received CMX001 at a dose of 100 mg twice weekly than among patients who received placebo (10% vs. 37%; risk difference, -27 percentage points; 95% confidence interval, -42 to -12; P=0.002). Diarrhea was the most common adverse event in patients receiving CMX001 at doses of 200 mg weekly or higher and was dose-limiting at 200 mg twice weekly. Myelosuppression and nephrotoxicity were not observed. CONCLUSIONS Treatment with oral CMX001 at a dose of 100 mg twice weekly significantly reduced the incidence of CMV events in recipients of hematopoietic-cell transplants. Diarrhea was dose-limiting in this population at a dose of 200 mg twice weekly. (Funded by Chimerix; CMX001-201 ClinicalTrials.gov number, NCT00942305.).

Treatment of Donor Bone Marrow with Monoclonal Anti-T-Cell Antibody and Complement for the Prevention of Graft-Versus-Host Disease: A Prospective, Randomized, Double-Blind Trial

The effects of ex-vivo depletion of T lymphocytes from donor bone marrow using a monoclonal anti-T-cell antibody (CT-2) and complement on the outcome of allogeneic bone marrow transplantation was evaluated in a prospective, randomized, double-blind study of 40 patients with leukemia. Patients receiving T-cell-depleted bone marrow had a lower incidence of acute graft-versus-host disease than control patients (3 of 20 compared with 13 of 20; p = 0.004), and mortality due to acute graft-versus-host disease was reduced. Five patients in the T-cell-depletion group developed graft failure; all control patients had sustained engraftment (p less than 0.05). Clinically apparent relapse of leukemia occurred in 7 patients from the T-cell-depletion group and in 2 controls (p, not significant). Cytogenetic evidence of residual leukemia was also detected in the 5 patients with graft failure without overt relapse. Infections and overall survival were similar in the two groups. The effects of T-cell depletion on engraftment and recurrence of leukemia require further evaluation.

Cytomegalovirus Immune Plasma in Bone Marrow Transplant Recipients

The effects of passive immunization on cytomegalovirus infection and interstitial pneumonia in marrow transplants were evaluated in a randomized, controlled trial. Twenty-four patients received cytomegalovirus immune plasma before and after transplantation, and 24 patients were controls. Although the incidence of cytomegalovirus infection was similar in the control and plasma groups, symptomatic infection (12 of 24 versus five of 24, p = 0.07) and interstitial pneumonia (11 of 24 versus five of 24, p = 0.12) occurred less frequently in the group receiving plasma. Cytomegalovirus infection occurred in 11 of 13 recipients of leukocyte transfusions and in 16 of 35 patients not given leukocyte transfusions (p = 0.02). Among patients not given leukocyte transfusions, the incidence of cytomegalovirus infection was similar in the control and plasma groups, but symptomatic infection (eight of 18 versus one of 17, p = 0.03) and interstitial pneumonia (nine of 18 versus one of 17, p = 0.01) were significantly less in the group receiving plasma. These results suggest that passive immunization modifies cytomegalovirus infection in humans and prevents interstitial pneumonia in marrow transplants especially when leukocyte transfusions are not used.