ASH: Wide Variability Observed in Antifungal Use for Pediatric AML

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ATLANTA—Wide variability across U.S. children's hospitals in antifungal use for pediatric acute myeloid leukemia (AML) does not appear to correlate with induction case fatality rates, according to a study presented during the 54th American Society of Hematology Annual Meeting and Exposition.

More studies are needed, however, to define the ideal approach for this population, noted Marko Kavcic, MD, of the Division of Oncology, The Children's Hospital of Philadelphia, PA, and colleagues.

While consistency exists in chemotherapy protocols for pediatric acute AML, “there is a lack of consensus for supportive care therapies,” leading to significant variation in practice, Dr. Kavcic noted. This extends to treatment for invasive fungal infections, a major cause of treatment-related morbidity and mortality in this patient population.

The investigators used the Pediatric Health Information System administrative database to establish a cohort of children treated for de novo AML between January 1999 and March 2010 at freestanding U.S. children's hospitals. The study cohort included children <19 years of age receiving chemotherapy for new onset AML.

Patients were included if they were assigned an ICD-9 discharge diagnosis code for myeloid or unspecified leukemia and if their daily pharmaceutical billing data supported receipt of an ADE induction regimen (cytarabine, daunorubicin, and etoposide with or without gemtuzumab ozogamicin). They defined the induction period from start of the first to initiation of the third course of chemotherapy.

They identified 931 patients from 38 children's hospitals; overall, induction case fatality rate was 3.8%.

Variation in antifungal use was defined for 28 institutions caring for at least 15 patients with AML.  Antifungal use exposure varied widely across institutions. Median exposure was 836 per 1,000 hospital days (range, 384-958 per 1,000 hospital days). Azoles such as fluconazole, voriconazole, posaconazole, and itraconazole were most commonly used (591 per 1,000 hospital days) followed by amphotericin products (120 per 1,000 hospital days) and the echinocandins caspofungin, micafungin, anidulafungin (60 per 1,000 hospital days).

After adjusting for demographic characteristics and frequency of severe hospital days—defined as the need for intensive care resources such as intubation, mechanical ventilation, or vasopressors—variation in antifungal use persisted across institutions, ranging from 393 to 946 per 1,000 hospital days.

Induction case fatality rates also varied by institution, ranging from 0% to 11%, but did not correlate with antifungal use (Spearman's rho=0.28, P=0.15).

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