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Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation

Bone Marrow Transplantation volume 60, pages 1092–1101 (2025)Cite this article

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Abstract

With the aim to reduce the incidence of invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the ECIL group recommends the use of drugs active against molds such as posaconazole instead of fluconazole in high-risk (HR) IFI patients. But data to support this recommendation are poor. The aim of this monocentric study was to compare retrospectively the use of fluconazole (n = 96) vs. posaconazole (n = 63), as primary antifungal prophylaxis within the first 90 days (D) post-transplant in a cohort of patients at HR-IFI (n = 159). HR-IFI was defined by the use of an alternative donor, post-transplant cyclophosphamide and/or sequential conditioning regimen, and/or an active disease at transplant or a previous allo-HSCT. Incidences of D90, 6-month, 1-year and 2-year CI of IFI as well as D90 primary prophylaxis failure (IFI resulting in the initiation of a curative antifungal therapy or a permanent discontinuation of the prophylaxis for toxicity) were similar between both groups. However, the number of probable/proven IFI that occurred between D0 and D90 was the double in the fluco group (9 vs. 4). Also, no proven IFI (vs. 4) or mucormycoses (vs. 1) or IFI related death (vs. 4) occurred in the posa group in the first 90 days. Posaconazole thus appears to be a good option to prevent IFI after allo-HSCT in patients at HR-IFI.

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Fig. 1: Study flowchart.
Fig. 2: Outcome according to IFI status (probable or proven IFI vs. no probable or proven IFI).
Fig. 3: Posaconazole Cmin distribution at first and second assessment.

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Data availability

Individual data used to generate these results are available upon personal request. Please contact the corresponding author.

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Acknowledgements

The authors wish to thank all investigators and data managers for their dedicated patient care. Medical writing for this manuscript was assisted by MPIYP (MC Béné), Paris, France.

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  1. Hématologie Clinique, CHU Hôtel Dieu, Nantes, France

    Valentin Letailleur, Maxime Jullien, Alice Garnier, Pierre Peterlin, Sophie Vantyghem, Aude-Marie Fourmont, Thierry Guillaume, Patrice Chevallier & Amandine Le Bourgeois

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Contributions

A.L.B and V.L designed, performed, coordinated the research, analyzed, interpreted the data, and wrote the manuscript. M.J performed the statistical analyses. A.G, P.P, S.V, A-M.F, T.G, P.C contributed data and commented on the manuscript.

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Correspondence to Amandine Le Bourgeois.

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The authors declare no competing interests.

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All methods were performed in accordance with the relevant guidelines and regulations. Ethics committee was not requested for this study because the design was a retrospective comparison of two antifungal prophylaxis strategies for allo-HSCT recipients at two different periods of time. No experimental drug was given and antifungal strategies were supported by ECIL guidelines that have evolved over the years. However, all patients provided informed consent for collection of their personal data.

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Letailleur, V., Jullien, M., Garnier, A. et al. Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 60, 1092–1101 (2025). https://doi.org/10.1038/s41409-025-02589-z

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