Managing invasive fungal disease: empirical vs pre-emptive

In this video, Dr Varun Mehra will discuss whether a pre-emptive or empirical approach is better when managing invasive fungal disease.

As discussed in previous steps, most diagnostic tests fall into two categories: Culture or direct methods (e.g. microscopy which is available in most labs) and non-direct methods (e.g. molecular methods such as ELISA assays).

An empirical approach to managing fungal diseases involves treating patients with a persistent fever, no specific signs or symptoms, and treating on suspicion only. A pre-emptive approach, on the other hand, requires you to wait for specific signs and symptoms or diagnostics to be positive before treating these patients.

In a study comparing empirical and pre-emptive antifungal strategies in high-risk neutropenic patients, results showed the overall survival rate to be very similar but there was an increased risk of fungal disease when taking a pre-emptive approach. The evidence from this study was one of the main reasons why empirical approaches are favoured in most centres, with the fear that if an empirical approach was not used, there would be a risk of missing out on patients and causing additional morbidities.

Which strategy to use depends on a careful balance between ‘Odds of controlling the infection’ and the ‘Burden of the infection’. Early diagnosis for a pre-emptive approach will always be the best strategy, but this requires strong, reliable, sensitive and specific diagnostic tests. As opposed to an empirical approach, where you would need to treat on suspicion only without waiting for diagnostics but risking increased toxicity and potentially overtreating patients.

If you would like to read more on this subject, take a look at the Cordonnier et al 2009 paper on empirical and pre-emptive antifungal therapy for high-risk, febrile, neutropenic patients.