Characterization of Antifungal Prophylaxis and Breakthrough Fungal Infections within a Pediatric Allogeneic Hematopoietic Cell Transplant Population

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Abstract Corresponding Author Lauren Prack, PharmD, Department of Pharmacy, Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie Building Room 180, Baltimore, MD 21287, USA, (419) 681-3830, lprack1@jh.edu Funding No funding to report. Conflict(s) of Interest Lauren Prack, no conflict; Alice Hsu, no conflict; Blair Nuoffer, no conflict; Cambree Fillis, no conflict; Erica Prochaska, no conflict Background Invasive fungal infections (IFI) cause significant morbidity and mortality in pediatric allogeneic hematopoietic cell transplantation (allo-HCT). Most candidal infections occur prior to engraftment while invasive mold infections occur after, particularly with profound/prolonged neutropenia, graft versus host disease, and exposure to high dose corticosteroids. Prior to 2023, The Johns Hopkins Children’s Centers standard prophylaxis post-allo-HCT included fluconazole. After 2023, mold-active prophylaxis was provided to “high-risk” patients. Our study aimed to evaluate pediatric allo-HCT recipients during the first-year post-transplant to compare the incidence of IFIs between prophylactic strategies. The primary objective is to define rates of IFI based on antifungal prophylactic agent received. The secondary objective is to analyze current therapeutic drug monitoring practices in allo-HCT recipients receiving mold-active prophylaxis. Methods We conducted a retrospective cohort study from 2017-2025 of allo-HCT recipients