Wait and see or rush and switch? New questions for the management of patients with febrile neutropenia receiving antifungal prophylaxis.

Infections are a major threat for patients with haematological malignancies after intensive myelosuppressive chemotherapy. The severity and extent of neutropenia are considered a major risk factor for infections in these patients. Antibacterial treatment for patients with febrile neutropenia was standardised in the late 1990s with no further significant improvements within the last decade. Major progress in febrile neutropenia has come from the advent of new antifungals since the late 1990s. Lipid-based amphotericin B, third-generation azoles and the introduction of echinocandins allow a safer and effective treatment of invasive fungal infections. The mortality rate of invasive fungal infection is as high as 30-100% and a definitive diagnosis by culture may take too long. Thus, early diagnosis and early initiation of antifungal therapy remain important for the reduction of mortality rates. In the last two decades, randomised trials on prophylaxis and empirical therapy of invasive fungal infections were undertaken. Both primary prophylaxis and empirical therapy of invasive fungal infection proved effective. However, important questions remain unanswered. This article points out the clinicians view on unmet needs for patients with suspected invasive fungal infections after a decade of well-designed randomised trials for prevention of invasive fungal infections. Should we wait and see what happens in febrile neutropenic patients on antifungal prophylaxis or under empirical treatment or should we rush and switch antifungal treatment?