Pediatric Aspergillosis Treatment & Management

  • Author: Vandana Batra, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Dec 6, 2011
 

Medical Care

Aspergillosis treatment is based on the disease manifestation, which includes invasive disease in an immunocompromised host or allergic disease that includes allergic bronchopulmonary aspergillosis (ABPA) and colonizing syndromes (eg, aspergilloma, otomycosis) in an immunocompetent host.

  • When invasive aspergillosis (IA) is strongly suspected in an immunocompromised patient, empiric treatment with antifungal medications is the consensus therapy. Suspicion may be based on the clinical course of the illness, isolation of the fungus from the pulmonary and/or nasopharyngeal secretions, and failure to respond to initial antibacterial treatment. If a patient with profound neutropenia does not respond to broad spectrum antibiotics within 5-7 days, empiric treatment for invasive aspergillosis with antifungals is indicated.
  • Voriconazole has now become the drug of choice for invasive aspergillosis. This is due to the increased efficacy and significantly less toxicity compared to amphotericin B.
  • Caspofungin is a newer antifungal agent that is effective against invasive aspergillosis but more pediatric studies are needed prior to its widespread use. Currently caspofungin has been approved for use as salvage therapy for invasive aspergillosis that does not respond to existing antifungals.
    • Treatment duration has not been well defined and is based on the clinical response and the tolerance to the drug. Continue therapy 4-12 weeks or longer.
    • Itraconazole is used as prophylaxis in some cancer centers for immunocompromised patients.
  • ABPA exacerbations are treated with corticosteroids.[6]
    • The desired goal is to reduce serum immunoglobulin E (IgE) levels to a range consistent with levels obtained from patients with asthma (without ABPA) living in the same geographic area. Reinstitution of corticosteroid therapy may be required if the serum IgE levels rise to twice this level or higher.
    • Immediately obtain IgE levels after corticosteroid therapy.
  • For asthma exacerbation, as indicated, administer other agents, such as beta-adrenergic agonists, high-dosage inhaled corticosteroids, and, possibly, nedocromil or theophylline.
  • Administer prednisone as a single morning dose for 2 weeks and then convert to an alternate-day dosage for 3 months.
  • Systemic antifungal therapy is not indicated for ABPA.
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Surgical Care

  • Invasive aspergillosis requires surgical care in the following situations:
    • In invasive pulmonary aspergillosis, resection of the fungal lesion is indicated when the lesion in localized, and or if disease is likely to cause perforation of the pulmonary artery with consequent hemoptysis.
    • In immunocompromised patients, resection and surgical reduction of the Aspergillus mass is indicated before myeloablative procedures.
    • In patients with osteomyelitis, surgical intervention, including thorough debridement, may help chronic invasive sinusitis and cutaneous lesions.
  • Surgical care is recommended in patients with aspergilloma only when severe hemoptysis occurs.
    • Resection is the mainstay therapy for patients with adequately functioning lungs, although bronchial artery embolization may be considered for patients who are not candidates for resectional surgery.
    • Systemic antifungal therapy is not indicated in patients with nonallergic colonization.
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Contributor Information and Disclosures
Author

Vandana Batra, MD  Fellow, Department of Pediatric Hematology Oncology, Children's Hospital of Philadelphia

Vandana Batra, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Basim Asmar, MD  Director, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan; Professor, Department of Pediatrics, Wayne State University School of Medicine

Basim Asmar, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Jocelyn Y Ang, MD  Assistant Professor, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan and Wayne State University

Jocelyn Y Ang, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Itzhak Brook, MD, MSc  Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

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