International journal of antimicrobial agents · 2026
Comparative efficacy and safety of antifungal prophylactic agents in allogeneic hematopoietic stem cell transplantation: A systematic review and network meta-analysis.
СтатьяСистематический обзорNetwork Meta-AnalysisСравнительное исследованиеНазвание и аннотация: Перевод в очереди
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Li Xinyi, Shao Ruonan, Zhang Tingting, Fan Yuping, Chen Xin, Feng Sizhou
Аннотация
BACKGROUND: Invasive fungal infections remain a major cause of morbidity and mortality among allogeneic hematopoietic stem cell transplantation recipients. There is still limited high-quality comparative evidence for antifungal agents.
METHODS: We conducted a systematic review and network meta-analysis of randomized controlled trials and observational studies (PROSPERO: CRD420251270033), with databases search updated to September 2025. A prespecified assumption-based proportional imputation method was applied to estimate outcomes in mixed populations. Relative risks (RRs) were synthesized using a frequentist random-effects model, and treatments were ranked using surface under the cumulative ranking curve (SUCRA).
RESULTS: Thirty-two studies were selected, including 10 006 hematopoietic stem cell transplantation recipients. Across randomized controlled trials, posaconazole (RR, 0.19; 95% confidence interval, 0.08-0.44) and voriconazole (RR, 0.20; 95% confidence interval, 0.09-0.42) demonstrated the strongest efficacy against invasive fungal infections compared with placebo. Posaconazole ranked first for preventing invasive aspergillosis (SUCRA, 77.1%) and fungus-related mortality (SUCRA, 91.9%), while micafungin had the lowest discontinuation risk (SUCRA, 95.5%). Observational data favoured posaconazole tablets (SUCRA, 90.3%) over suspension (SUCRA, 75.2%). Isavuconazole showed lower hepatotoxicity-related discontinuation (5.3% vs. 22.9%; P = 0.0002), though these findings are based on limited cases. Trials implementing therapeutic drug monitoring showed a non-significant trend towards improved efficacy.
CONCLUSIONS: Posaconazole and voriconazole demonstrate strong efficacy. Posaconazole tablets offer a favourable balance between benefit and risk. However, the potential safety benefits of isavuconazole warrant further evidence accumulation.
METHODS: We conducted a systematic review and network meta-analysis of randomized controlled trials and observational studies (PROSPERO: CRD420251270033), with databases search updated to September 2025. A prespecified assumption-based proportional imputation method was applied to estimate outcomes in mixed populations. Relative risks (RRs) were synthesized using a frequentist random-effects model, and treatments were ranked using surface under the cumulative ranking curve (SUCRA).
RESULTS: Thirty-two studies were selected, including 10 006 hematopoietic stem cell transplantation recipients. Across randomized controlled trials, posaconazole (RR, 0.19; 95% confidence interval, 0.08-0.44) and voriconazole (RR, 0.20; 95% confidence interval, 0.09-0.42) demonstrated the strongest efficacy against invasive fungal infections compared with placebo. Posaconazole ranked first for preventing invasive aspergillosis (SUCRA, 77.1%) and fungus-related mortality (SUCRA, 91.9%), while micafungin had the lowest discontinuation risk (SUCRA, 95.5%). Observational data favoured posaconazole tablets (SUCRA, 90.3%) over suspension (SUCRA, 75.2%). Isavuconazole showed lower hepatotoxicity-related discontinuation (5.3% vs. 22.9%; P = 0.0002), though these findings are based on limited cases. Trials implementing therapeutic drug monitoring showed a non-significant trend towards improved efficacy.
CONCLUSIONS: Posaconazole and voriconazole demonstrate strong efficacy. Posaconazole tablets offer a favourable balance between benefit and risk. However, the potential safety benefits of isavuconazole warrant further evidence accumulation.