Introduction
Although many and novel antifungal agents are in use, invasive fungal infections (IFI) continue to cause high morbidity and mortality rates in pediatric hematologic malignancy patients.1,2Successful treatment of IFI is required to ensure the survival of this population. Currently, there are four classes (azoles, polyenes, pyrimidine analogues, and echinocandins) of drugs used in the treatment of IFI in children.3 Appropriate use of existing antifungals in this vulnerable population is important for the treatment of IFI.2 However, safety and efficacy data including antifungal activity, pharmacokinetic properties, and toxicity of the antifungal agents in children still needs to be supported by trials.3,4 Monotherapy is often preferred for the treatment of fungal infections in pediatric patients.4In some serious fungal infections where monotherapy is insufficient, the combination of antifungals remains on the agenda as a potential treatment strategy.5 Because serious fungal infections need to be cured during the treatment of primary diseases, children with hematologic malignancies are the group of patients in whom combination regimens are frequently considered and tried to be applied.4,5
Antifungal combination therapies are used in hematologic malignancy patients considering potential gains such as preventing resistance problems, increasing treatment efficacy and reducing side effects.5,6 Combined antifungal therapy (CAT) is not a new notion, it is even used effectively in the treatment of some well-defined infections.7 Unfortunately, the role of combination regimens in the treatment of IFI in patients with hematologic malignancies remains controversial.8Despite insufficient evidence, there are pre-clinical studies indicating that combination regimens are effective in fungal infections difficult to treat.9-11 However, these studies could not be transferred to the clinical practice, and quite few data are available for clinical use. The limited data on this treatment prescription, with almost no prospective studies and more limited data in pediatric patients, are obtained as a result of clinical experience.6,8,12-15 The combinations of four groups of antifugal agents, acting through different molecular pathways and different cellular targets, is shaped to the preference and priority of clinicians as there is no definitive accepted recommendation.8,9 In the absence of sufficient evidence and suggestions; this study was aimed to demostrate experience data on the use of CAT in pediatric patients with haematological malignancies with IFI, including the results of efficacy and toxicity.