Invasive fungal infections in hematologic diseases: evidence, challenges, and clinical practice

Patients with acute leukemia, particularly those undergoing allogeneic hematopoietic stem cell transplantation, are at a high risk of contracting invasive fungal infections (IFIs). These IFIs substantially increase morbidity and mortality. Over the past decade, the paradigm of IFI management has shifted markedly, with an increased emphasis on prevention and treatment. Expanded use of antifungal agents and advances in novel therapies have prolonged survival in patients with hematologic malignancies. This progress also allows subsequent lines of chemotherapy to be administered while maintaining antifungal therapy once IFIs are controlled. However, these shifts have introduced new challenges, including a rising incidence of breakthrough infections despite prophylaxis, the emergence of infections caused by rare fungi, and growing concerns regarding azole resistance. Although Aspergillus species remain the predominant pathogens, infections by uncommon molds and yeasts are increasingly encountered. This phenomenon complicates the diagnosis and necessitates diagnostic tools beyond galactomannan testing alone. Integration of novel biomarkers and antifungal susceptibility testing is essential for timely and accurate diagnosis. Current guidelines provide relatively well-defined recommendations for the definitive management of invasive aspergillosis, candidiasis, and mucormycosis. Individualized care and multidisciplinary collaboration are essential to optimize patient outcomes. In addition to prevention, diagnosis, and treatment, a deeper understanding of host immunity and its interactions with IFIs is critical for improving patient outcomes and guiding the next generation of management strategies.