Cited by 979Antifungal resistance and susceptibilityNeutropenia and Cancer InfectionsFungal Infections and Studies

Voriconazole Compared with Liposomal Amphotericin B for Empirical Antifungal Therapy in Patients with Neutropenia and Persistent Fever

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Walsh, Thomas J., Pappas, Peter, Winston, Drew J., Lazarus, Hillard M., Petersen, Finn, Raffalli, John, Yanovich, Saul, Stiff, Patrick +15 more·2002·New England Journal of Medicine

Abstract

BACKGROUND: Patients with neutropenia and persistent fever are often treated empirically with amphotericin B or liposomal amphotericin B to prevent invasive fungal infections. Antifungal triazoles offer a potentially safer and effective alternative. METHODS: In a randomized, international, multicenter trial, we compared voriconazole, a new second-generation triazole, with liposomal amphotericin B for empirical antifungal therapy. RESULTS: A total of 837 patients (415 assigned to voriconazole and 422 to liposomal amphotericin B) were evaluated for success of treatment. The overall success rates were 26.0 percent with voriconazole and 30.6 percent with liposomal amphotericin B (95 percent confidence interval for the difference, -10.6 to 1.6 percentage points); these rates were independent of the administration of antifungal prophylaxis or the use of colony-stimulating factors. There were fewer documented breakthrough fungal infections in patients treated with voriconazole than in those treated with liposomal amphotericin B (8 [1.9 percent] vs. 21 [5.0 percent], P=0.02). The voriconazole group had fewer cases of severe infusion-related reactions (P<0.01) and of nephrotoxicity (P<0.001). The incidence of hepatotoxicity was similar in the two groups. Patients receiving voriconazole had more episodes of transient visual changes than those receiving liposomal amphotericin B (22 percent vs. 1 percent, P<0.001) and more hallucinations (4.3 percent vs. 0.5 percent, P<0.001). Parenteral voriconazole was changed to the oral formulation in 22 percent of the voriconazole group, with a reduction in the mean duration of hospitalization by one day in all patients (P=0.17) but by two days in patients at high risk (P=0.03). CONCLUSIONS: Voriconazole is a suitable alternative to amphotericin B preparations for empirical antifungal therapy in patients with neutropenia and persistent fever.

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Crossref · 10.1056/nejm200201243460403

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  • Voriconazole has been shown to be active in high-risk patients for prevention of breakthrough fungal infections.

    “Voriconazole has been shown to be active in high-risk patients (e.g., allogeneic bone marrow transplant recipients and individuals with relapsed leukemia) for prevention of breakthrough fungal infections [147].”

    From Guidelines for Treatment of Candidiasis (2004) · cites this paper as [147]

  • Voriconazole is superior to liposomal amphotericin B in the prevention of breakthrough fungal infections in high-risk patients.

    “voriconazole has been shown to be superior to liposomal amphotericin B in the prevention of breakthrough fungal infections in high-risk patients (A-I).”

    From Guidelines for Treatment of Candidiasis (2004) · cites this paper as [155]

  • Voriconazole is superior to liposomal amphotericin B in the prevention of breakthrough fungal infections in high-risk patients.

    “voriconazole has been shown to be superior to liposomal amphotericin B in the prevention of breakthrough fungal infections in high-risk patients (A-I).”

    From Guidelines for Treatment of Candidiasis (2004) · cites this paper as [147]

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Research works printed but not linked: 5

  1. Pannuti C, Gingrich R, Pfaller MA, Kao C, Wenzel RP. Nosocomial pneumonia in patients having bone marrow transplant: attributable mor- tality and risk factors. Cancer 1992;69:2653-62.
  2. Walsh TJ, Lutsar TI, Ghahramani P, et al. Efficacy of safety of vori- conazole (VORI) and the treatment of invasive fungal infection in children. Presented at the 40th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, September 17-20, 2000. abstract.
  3. Ascioglu S, Rex JH, de Pauw B, et al. Analysis of definitions used in clinical research on invasive fungal infections: consensus proposal for new, standardized definitions. Clin Infect Dis (in press).
  4. Herbrecht R , Denning DW, Patterson TF, et al. Open, randomized comparison of voriconazole (VRC) and amphotericin B (AmB) followed by other licensed antifungal therapy of invasive aspergillosis (IA). In: Pro- gram and abstracts of the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, December 16-19, 2001.
  5. Washing- ton, D.C.: American Society for Microbiology (in press). abstract.

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Authors
Walsh, T. J., Pappas, P., Winston, D. J., Lazarus, H. M., Petersen, F., Raffalli, J., Yanovich, S., Stiff, P., Greenberg, R., Donowitz, G., Schuster, M., Reboli, A., Wingard, J., Arndt, C., Reinhardt, J., Hadley, S., Finberg, R., Laverdière, M., Perfect, J., Garber, G., Fioritoni, G., Anaissie, E., & Lee, J.
Affiliations
  • National Institutes of Health (US)
  • University of Alabama at Birmingham (US)
  • University of California, Los Angeles (US)
  • University Hospitals of Cleveland (US)
  • University of Utah (US)
  • New York Medical College (US)
  • Virginia Commonwealth University Medical Center (US)
  • Loyola University Medical Center (US)
  • University of Kentucky (US)
  • University of Virginia (US)
  • National Institute of Allergy and Infectious Diseases (US)
  • Mayo Clinic (US)
  • Beth Israel Deaconess Medical Center (US)
Venue
New England Journal of Medicine
Published
2002-01-24
Volume
346
Issue
4
Pages
225-234
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
OpenAlex
W2029714817
Cited by
979
References
32
Citations by year
2026: 5 · 2025: 7 · 2024: 8 · 2023: 5 · 2022: 14 · 2021: 21 · 2020: 12 · 2019: 21 · 2018: 20 · 2017: 20 · 2016: 20 · 2015: 28 · 2014: 37 · 2013: 38 · 2012: 42
FWCI
55.21
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • VCU Scholars Compass (Virginia Commonwealth University) (submittedVersion)
Funders
  • Pfizer
  • National Institutes of Health (n01ai065296-009)
  • National Institute of Allergy and Infectious Diseases (N01AI65296)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Oncology › Neutropenia and Cancer Infections
  • Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
Keywords
voriconazole, liposomal amphotericin B, empirical antifungal therapy, neutropenia, persistent fever, invasive fungal infections, antifungal prophylaxis, breakthrough fungal infection, infusion reactions, nephrotoxicity, hepatotoxicity, visual disturbances, hallucinations, length of hospital stay
MeSH terms
Adolescent, Adult, Aged, Aged, 80 and over, Amphotericin B, Anti-Bacterial Agents, Antifungal Agents, Child, Chronic Disease, Female, Fever, Humans, Infusions, Intravenous, Male, Middle Aged, Mycoses, Neoplasms, Neutropenia, Prospective Studies, Pyrimidines, Triazoles, Chemical and Drug Induced Liver Injury, Voriconazole

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