Management of extrapulmonary aspergillosis

  • The recommended treatment for central nervous system aspergilllosis is voriconazole; lipid formulations of AmB should be used only in patients who are intolerant or refractory to voriconazole.
  • Aspergillus endophthalmitis should be treated with systemic oral or intravenous voriconazole plus intravitreal voriconazole or intravitreal AmB deoxycholate.
  • Invasive Aspergillus fungal sinusitis should be treated with both surgery and either systemic voriconazole or a lipid formulation of AmB.
  • Aspergillus endocarditis should be treated with early surgical intervention and antifungal therapy.
  • Aspergillus osteomyelitis and arthritis should be treated with voriconazole and, where feasible, surgery.
  • Patients with cutaneous aspergillosis should be evaluated for a primary focus of infection and treated with voriconazole. If aspergillosis is in burns or massive soft tissue wounds, surgical debridement is also recommended.
  • Aspergillus peritonitis should be treated with prompt peritoneal dialysis catheter removal and systemic antifungal therapy with voriconazole.
  • Esophageal, gastrointestinal, and hepatic aspergillosis should be treated with voriconazole and surgical consultation.
  • Noninvasive Aspergilllus otititis externa can be treated through mechanical cleansing of the external auditory canal followed by topical antifungals or boric acid. IA of the ear should be treated with a prolonged course of systemic voriconazole and surgery.
  • Aspergillus keratitis should be treated with topical natamycin 5% ophthalmic suspension or topical voriconazole.
  • For non-transplant patients, Aspergillus bronchitis should be treated with oral itraconazole or voriconazole with TDM.

Prophylaxis of invasive aspergillosis

  • Patients who are at high risk for IA should undergo prophylaxis with posaconazole, voriconazole, and/or micafungin during prolonged neutropenia.
  • For lung transplant patients, antifungal prophylaxis should include either a systemic triazole or an inhaled AmB product for 3 to 4 months after lung transplant.
  • For non-lung solid organ transplant patients, prophylactic strategies should be based on the institutional epidemiology of infection and assessment of individual risk factors.

Management of breakthrough infection

  • Breakthrough aspergillosis should be managed through an individualized approach that considers the rapidity and severity of infection as well as local epidemiology.
  • Empiric antifungal therapy is recommended for high-risk patients with prolonged neutropenia who are febrile despite broad-spectrum antibiotic therapy.

Chronic and saprophytic syndromes of Aspergillus

  • Chronic cavitary pulmonary aspergillosis (CCPA) can be diagnosed if it meets the following criteria: 3 months of chronic pulmonary symptoms, chronic illness, or progressive radiographic abnormalities with cavitation, pleural thickening, pericavitary infiltrates, and sometimes a fungal ball; Aspergillus IgG antibody elevated or other microbiological data; and no or minimal immunocompromise.
  • Patients with CCPA without pulmonary symptoms, weight loss, or significant fatigue can be observed and followed up after 3 to 6 months.
  • Patients with CCPA with either pulmonary or general symptoms or progressive loss of lung function or radiographic progression should be treated with antifungal therapy for at least 6 months.
  • Asymptomatic patients with a single Aspergillus fungal ball of the lung (aspergilloma) should continue to be observed.
  • Patients with aspergillomas who are symptomatic should have it resected.

Allergic syndromes of Aspergillus

  • Symptomatic asthmatic patients with allergic bronchopulmonary aspergillosis should be treated with oral itraconazole therapy with TDM.
  • Patients with allergic fungal rhinosinusitis caused by Aspergillus species should undergo polypectomy and sinus washout. The use of topical nasal steroids and oral antifungal therapy are also recommended.

The complete guidelines are available in Clinical Infectious Diseases. These guidelines are meant to replace the 2008 guidelines for Aspergillus.

Reference

  1. Patterson TF, Thompson GR III, Denning DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. Published Jun 29, 2016; doi:10.1093/cid/ciw329 [Epub ahead of print]