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624 PART 5: Infectious Disorders

for reasons of intolerance in 36% of itraconazole recipients compared nutritional intake and drug administration. Herpes mucositis, stomati-
to 16% of fluconazole recipients. A meta-analysis of itraconazole effi- tis, or esophagitis may be prevented by prophylactic use of nucleoside
525
cacy for antifungal prophylaxis against invasive fungal infection in 13 analogues such as acyclovir or valacyclovir. Those at risk have a history
randomized controlled trials encompassing 3597 randomized subjects of previous herpetic infection and can be identified by a history of the
demonstrated reductions in the mean relative risks for invasive fungal typical vesicular lesions of herpetic stomatitis or by the identification of
infection overall, invasive yeast infection, and fungal infection-related IgG antibodies against HSV in their sera. Between 60% and 80% of HSV-
mortality in neutropenic cancer patients. The risk for invasive asper- seropositive patients will reactivate during cytotoxic therapy. Patients
523
gillosis was reduced only in trials using the cyclodextrin-based oral or undergoing remission-induction therapy, consolidation therapy, or
intravenous formulations of itraconazole. 523 salvage therapy for acute leukemia and those undergoing bone marrow
Echinocandin antifungal agents may also be useful for prophylaxis in allografting or autografting who are IgG-seropositive for HSV-1 are
high-risk patient populations. A study comparing micafungin to flucon- candidates for acyclovir prophylaxis. 316,531 It is not clear whether oral is
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azole in a heterogeneous group of autologous and allogeneic transplant as effective as intravenous administration in patients receiving regimens
recipients demonstrated a significant reduction in the use of empirical sys- highly toxic to intestinal mucosal surfaces such as high-dose cytarabine
temic antifungal therapy among the micafungin recipients (15% compared or etoposide-containing regimens or BMT conditioning regimens.
to 21%, p = 0.018). The incidence of invasive aspergillosis was 0.2% and Acyclovir in doses of 250 mg/m administered intravenously every 8 to
2
526
1.5% in micafungin and fluconazole recipients, respectively (p = 0.07). 12 hours or oral acyclovir administered in doses of 200 to 400 mg four
to five times daily has prevented HSV mucositis successfully.
316
Opportunistic Yeasts: Yeast infections, primarily Candida spp, colonize Prophylaxis for 1 month or less from initiation of treatment has been
the patient and cause infection by invading damaged integumental associated with recurrences in 58% to 70% of patients after the acyclovir
surfaces. HEPA filtered protected environments play no role in the pre- was discontinued. Accordingly, it has been recommended that pro-
vention of these infections. The use of topical agents such as nystatin or phylaxis be continued for 6 weeks from the beginning of induction or
amphotericin B has had a modest impact on colonization profiles but no conditioning or up to 6 weeks following marrow recovery in BMT recipi-
316
significant impact on the incidence of invasive fungal infection or the ents. Acyclovir doses of 800 mg orally every 12 hours appear to be effective
need to use empirical systemic amphotericin B for suspected invasive fun- for this. Valacyclovir has been shown to be as effective as acyclovir. 433
gal infection. Topical chlorhexidine mouth rinses (0.12% chlorhexidine
digluconate three times daily) have been effective in reducing the mor-
bidity of oropharyngeal candidiasis in a series of marrow allograft recipi-
ents. Further, a reduction in candidemia was also noted, suggesting the KEY REFERENCES
317
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■ ANTIVIRAL PROPHYLAXIS Scand J Infect Dis. 1987;52(suppl):65.
Reactivation of HSV infection is one of the most common causes of oro- • Slavin S, Nagler A, Naparstek E, et al. Nonmyeloablative stem cell
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pharyngeal and esophageal mucositis in patients undergoing remission bone marrow transplantation with lethal cytoreduction for the
induction for leukemia or BMT. This painful complication can impair
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