The Iranian National Guideline for Invasive Fungal Infections (IFI) in Hematology–Oncology: An Expert Consensus Report

Abstract

Invasive fungal infections are a leading cause of death in patients with hematological malignancies and those receiving bone marrow transplants. Although standard guidelines exist globally, their direct application in Iran is not always possible due to differences in the types of common fungi and limited diagnostic and therapeutic facilities. To address this challenge, a national committee of experts in the field was formed to carefully review internationally recognized protocols published up to 2024 and solicit opinions from selected experts across the country to develop the first national guideline specifically for prophylaxis. To ensure methodological rigor, the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework and Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were utilized. The resulting consensus established a localized risk-stratification model identifying acute myeloid leukemia (AML), myelodysplastic syndromes (MDS), and active graft-versus-host disease (GVHD) patients as high-risk, recommending posaconazole as the primary standard. Notably, the guideline advises against routine azole use in acute lymphoblastic leukemia (ALL) to prevent neurotoxicity. Furthermore, a resource-tiered framework was developed for centers with varying diagnostic capabilities. The result of this effort was to present a tiered and local model that provides a practical solution for both well-equipped and limited facilities. The existence of this national guideline creates a major advantage in that treatment approaches are unified and standardized across the country. By eliminating discretionary decisions, this document helps to better manage medication use and ultimately improve patient outcomes, regardless of the city in which they are treated or the facilities they are treated at.