ESCMID 2026: Steroid-Linked Invasive Fungal Infections After CAR-T: Insights from a National Australian Cohort

Presenter: Gemma Reynolds

This national, multicentre cohort study evaluated the incidence and risk factors for invasive fungal infections (IFI) in adults receiving CD19-directed CAR-T therapy for aggressive lymphoma (2019–2023; follow-up to March 2025). A total of 291 patients (median age 64 years) were included. Seventeen IFIs occurred in 17 patients (5.8% of the cohort; 11% of microbiologically confirmed infections). IFIs developed at a median of 122 days post-infusion (IQR: 25–263), with 29% occurring ≥6 months. Infection rates were significantly higher within the first 30 days compared to later periods (0.14 vs 0.007 per 100 patient-days; IRR=0.05, p=0.003). Common pathogens included pulmonary aspergillosis (47%), Candida bloodstream infections (35%), and Pneumocystis jirovecii (6%). IFIs occurred despite antifungal prophylaxis in 29% of cases, and all were grade ≥3, with three fatalities.

In multivariable competing-risk Cox regression, higher cumulative dexamethasone exposure within 30 days post-infusion was independently associated with IFI risk (HR 1.003, 95% CI: 1.002–1.004; p<0.001). A threshold of 56 mg dexamethasone-equivalent predicted IFI (HR 6.6, 95% CI: 1.6–27.1; AUC 0.71; p=0.015).

Overall, IFIs were infrequent but clinically significant, with early steroid exposure identifying a high-risk subgroup.

ESCMID 2026, 17-21 April, Munich, Germany.