The Infectious Diseases Society of America (IDSA) has released updated practice guidelines for the diagnosis and management of aspergillosis, published in Clinical Infectious Diseases.
The guidelines, which emphasize early diagnosis, focus on the 3 major forms of aspergillosis: invasive aspergillosis (IA), chronic (and saprophytic) forms of aspergillosis, and allergic forms of aspergillosis. Particularly, the guidelines focus on IA and its different manifestations, including invasive pulmonary aspergillosis (IPA), Aspergillus sinusitis, disseminated aspergillosis, and single-organ IA.
The recommendations are summarized as follows.
Epidemiology and risk factors for infection
- The at-risk population for aspergillosis includes patients with prolonged neutropenia, allogeneic hematopoietic stem cell transplant (HSCT), solid organ transplant (SOT), inherited/acquired immunodeficiencies, and corticosteroid use.
- Patients who are hospitalized and are highly immunocompromised should be placed in protected environments to reduce mold exposure. If no protected environment is available, patients should be admitted to a private room with no connection to construction sites and no plants or cut flowers.
- Outpatients who are at high risk for IA should avoid gardening, spreading mulch, and close exposure to construction or renovation.
Diagnosis of aspergillosis
- To identify Aspergillus, tissue and fluid specimens should be submitted for simultaneous histopathologic/cytologic and culture examination. For isolates with atypical growth or resistance concerns, identify the species by molecular methods.
- If there is a clinical suspicion for IPA, perform a chest CT scan and a bronchoscopy with bronchoalveolar lavage (BAL).
- Amphotericin B (AmB) deoxycholate and its lipid derivatives are appropriate for initial and salvage therapy of Aspergillus infections when voriconazole cannot be administered.
- Echinocandins are effective for salvage therapy of IA but are not recommended for monotherapy.
- For most patients with IA, triazoles are the preferred agents for both treatment and prevention. Once a steady state has been reached, therapeutic drug monitoring is recommended.
Invasive syndromes of aspergillosis
- The guidelines recommended voriconazole as the primary treatment for IPA. For patients with strongly suspected IPA, antifungal therapy should be initiated while a diagnostic evaluation is being completed.
- Alternative treatments for IPA include liposomal AmB or other lipid formulations of AmB.
- Patients with IPA should be treated for a minimum of 6 to 12 weeks, depending on the degree and duration of immunosuppression, site of disease, and evidence of disease improvement. Patients with successfully treated IPA who need subsequent immunosuppression should undergo secondary prophylaxis to prevent recurrence.
- If possible, reduce or cease immonsuppressive agents as part of anti-Aspergillus therapy.
- For neutropenic patients, colony-stimulating factors may be considered for diagnosed or suspected IA. Granulocyte transfusions can be considered if their IA is refractory or unlikely to respond to standard therapy.
- If aspergillosis is localized and easily accessible for debridement, surgery should be considered.
- If aspergillosis is refractory or progressive, salvage therapy should include these strategies: changing the class of antifungal, tapering or reversing underlying immunosuppression when feasible, and surgical resection of necrotic lesions. Additional antifungals may also be used in addition to current therapy.
- Patients with saprophytic forms of tracheobronchial aspergillosis (TBA) do not require antifungal treatment unless they are symptomatic or immunosuppressed. Treatment should include bronchoscopic removal of mucoid impaction. Invasive forms of TBA should be treated with a mold-active triazole or intravenous lipid forms of AmB.