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TABLE OF CONTENTS

Get Your Questions Answered!

We hope you enjoyed this content. Do you have any questions for Dr Arrieta or Dr Thompson? Please provide your question using the link below, and we will post the answer on this page in a timely manner.

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Here is an update from the first set of questions through February 2026.

Questions and Answers: Prepared January 2026

Questions and Answers: Prepared January 2026

 

Question: What’s on the horizon for pediatric IFIs?

Dr Arrieta: There are emerging antifungal agents in development that need to be evaluated in pediatrics soon. Enrollment can be challenging for these studies, as was seen with the European refazungin study.1 We are working to get a rezafungin study in pediatrics up and running in the United States. Fosmanogepix is currently being studied in adults.2,3 We need to bring it to pediatrics. Similarly, olorofim has the potential to be useful in emerging mold infections, specifically Lomentospora prolificans.4

Improved diagnostic techniques are urgently needed, such as next-generation sequencing in tissues, body fluids, and blood, as well as PCR testing in blood.

 Question: What advice can you give to parents about avoiding fungal exposures in the home?

Dr Arrieta: This is particularly difficult, since data are not abundant. We tell them to avoid demolition sites, wildfires, and decaying live matter (eg, decaying foods [bread, fruit], some condiments that are decayed food [pepper], and gardening). We also caution against certain recreational activities (motocross, mountain biking, particularly in the desert). Home ventilation modification is difficult and expensive to accomplish. I’m not sure if there is any benefit from HEPA filters at home, and they are expensive.

Dr Thompson: I agree. It’s difficult because the guidance is not particularly evidence-based. We tell them to avoid outdoor activities with high soil content (gardening, mulching, etc). We also advise them against inhaled cannabis (which usually means being near an adult, since this is a pediatric focus).

 Question:  Dr Arrieta, as you mentioned, many pediatric patients develop invasive mold infections during intensive cancer therapy. We are often asked by the patient’s oncologist when it will be okay to resume the next cycle of chemotherapy. Sometimes everyone feels hesitant about that, but then we’re also balancing the risk of cancer progression or relapse, which can be quite high. Do you have a framework in your practice for deciding when it would be appropriate to resume chemotherapy, or when to recommend using less intensive cancer treatment regimens? Thank you.

Dr Arrieta: Again, this is a very difficult question. Most IFIs occur during periods of intense chemotherapy for hematological malignancies. The decision has to be discussed between oncologists and ID.

In cases of ALL, the disease risk stratification is important (low, average, or high), and the marrow residual disease (MRD) at the end of induction needs to be contemplated. Also, it’s important to consider which mold is present and how extensive the disease is. For Aspergillus, particularly if it can be surgically debulked, we may allow chemotherapy to resume as initially planned after documentation of improved or stable disease.  Patients with low-risk disease, or average-risk disease with good MRD, could be started on blinatumomab for 28 days, buying time for antifungal agents to do their job. For high-risk patients or MRD > 1%, chemotherapy may have to be continued.

AML is a different story; these patients need to receive their chemo. This could be delayed while trying to control the disease with antifungal agents and surgery. Mucor is different story—every effort should be made to proceed with surgical debulking, and chemo should be delayed as long as possible, but IMI with Mucor and AML is a bad combination,

 Question: Regarding risk factors for invasive mold infection, recent epidemiologic studies have shown an association between wildfire exposure and burden of systemic fungal infections at a population-level.5 These associations are most apparent for endemic mycoses and are still being studied. Are you aware of any research on how wildfires may impact burden of opportunistic fungal diseases in immunocompromised persons? Do you think that clinicians should be counseling immunocompromised patients to take additional precautions related to wildfire smoke exposure? Thank you.

Dr Arrieta: Burnt material is not likely to be a problem, but the winds that fuel the fire are very likely to mobilize large quantities of spores and hyphae (eg, Coccidioides). George, do you have practical advice on this?

Dr Thompson: We generally tell patients that if the air quality is poor (from fires), the air most likely contains molds, and they should wear an N95 mask.

 

References

  1. ClinicalTrials.gov. A phase 1, multicentre, open-label study to evaluate the pharmacokinetics, safety, and tolerability of a single IV dose of rezafungin acetate in pediatric subjects from birth to <18 years of age (NCT05534529). ClinicalTrials.gov website. https://clinicaltrials.gov/study/NCT05534529. Accessed February 27, 2026.
  2. Kriegl L, Egger M, Boyer J, Hoenigl M, Krause R. New treatment options for critically important WHO fungal priority pathogens. Clin Microbiol Infect. 2025;31(6):922-930. doi:10.1016/j.cmi.2024.03.006
  3. ClinicalTrials.gov. A phase 3 efficacy and safety study of fosmanogepix for the treatment of adult participants with candidemia and/or invasive candidiasis (NCT05421858). ClinicalTrials.gov website. https://www.clinicaltrials.gov/study/NCT05421858. Accessed January 19, 2026.
  4. Georgacopoulos O, Nunnally N, Law D, Birch M, Berkow EL, Lockhart SR. In vitro activity of the novel antifungal olorofim against Scedosporium and Lomentospora prolificans. Microbiol Spectr. 2023 Feb 14;11(1):e0278922. doi: 10.1128/spectrum.02789-22
  5. Mulliken JS, Hampshire KN, Rappold AG, Fung M, Babik JM, Doernberg SB. Risk of systemic fungal infections after exposure to wildfires: a population-based, retrospective study in California. Lancet Planet Health. 2023;7(5):e381-e386. doi:10.1016/S2542-5196(23)00064-7

 

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Faculty

George R. Thompson, III, MD

Professor of Medicine
University of California, Davis, School of Medicine
Sacramento, California

Dr George Thompson is a Professor of Medicine at the University of California, Davis, School of Medicine (Sacramento, CA) with a joint appointment in the Departments of Medical Microbiology and Immunology, and Internal Medicine, Division of Infectious Diseases. Dr Thompson specializes in the care of patients with invasive fungal infections and his research interests are in fungal epidemiology, pathophysiology, diagnostics, treatments, and outcomes.

Dr Thompson focuses on the fungal diseases caused by Aspergillus, Candida, and Coccidioides spp. These fungi are of both regional and global importance. Aspergillus infections continue to emerge in new patient populations (e.g., COVID-19), Candida spp. are the 4th leading cause of bloodstream infections across the world and carry substantial morbidity and mortality, and coccidioidomycosis affects over 450,000 people per year within the Southwestern United States. Our studies focus on the evaluation of new antifungal agents, the pathophysiologic mechanisms of antifungal therapy, including both the development of resistance and the biologic underpinnings of adverse drug reactions.

Dr Thompson served as the co-chair of the National Academy of Sciences Symposium on Coccidioidomycosis in the fall of 2022, and as an advisor to the World Health Organization (WHO) for fungal priority pathogens. He has additionally served on multiple international guidelines that are highly utilized by clinicians globally. He was formerly the educational chair of the Mycoses Study Group Education Committee (MSGERC) – and was responsible for the development of fungal educational content to practitioners globally and the design of pivotal clinical trials. He is currently the president elect of the MSGERC. He has served on both the CDC and the National Institute of Allergy and Infectious Diseases Special Emphasis Panels as a grant reviewer and on the FDA Antifungal and Coccidioidomycosis Advisory committees. He has also been a congressional consultant for the Valley Fever Task Force, and the Congressional Pasteur and Forward Acts focused on antifungal and antibacterial resistance.

Antonio C. Arrieta, MD

Division Chief
Pediatric Infectious Diseases
Children’s Hospital of Orange County (CHOC)
Orange, California

As a nationally-recognized expert in pediatric infectious disease, Dr. Arrieta specializes in the treatment of serious community-acquired and nosocomial infections and has added expertise in HIV medicine. His main area of research centers on investigating invasive fungal infections and new antifungal agents. He is also investigating the immune response to infections in premature infants. Dr Arrieta is a respected physician leader and currently serves as president of the medical staff as well as Division Chief of Pediatric Infectious Diseases at Children’s Hospital of Orange County (CHOC).

A prolific author, Dr Arrieta has written many poster presentations, articles, and book chapters. He has coauthored more than 50 poster presentations for meetings and conferences including many of the past Interscience Conferences on Antimicrobial Agents and Chemotherapy and Annual Meetings of the European Society for Paediatric Infectious Diseases. His more than 50 articles have been featured in journals including the Pediatric Infectious Disease Journal, the American Journal of Surgery, and the Journal of the American Medical Association. He has written and edited book chapters in the Textbook of Pediatric Infectious Diseases, Pediatric Adolescent Medicine, and Pediatric Hospital Medicine, among others.

Dedicated to clinical excellence, Dr Arrieta is board certified in pediatrics and pediatric infectious diseases. Prior to joining CHOC, Dr Arrieta attended medical school at Universidad Peruana Cayetano Heredia in Lima, Peru. He completed his residency at Southern Illinois University and conducted his fellowship training in pediatric infectious diseases at Miller Children’s and Women’s Hospital in Long Beach and University of California, Irvine.

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