Guidelines Summary
The Infectious Diseases Society of America (IDSA) published practice guidelines on the management of aspergillosis and recommended using the same antifungal agents for treatment of aspergillosis in children as are used in adults. However, the guidelines added that dosing of many of these agents may be different for children. The authors also note that although voriconazole is only approved by the US Food and Drug Administration for children aged 12 yr and older, it is the cornerstone of aspergillosis treatment in children of all ages. [17, 18]
The guidelines also include the following recommendations [17, 18] :
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Submit tissue and fluid specimens for histopathologic, cytologic, and culture examination to diagnose invasive aspergillosis. However, molecular techniques, such as DNA sequencing, should be used to identify Aspergillus species in cases that involve either isolates with atypical growth or concern for resistance.
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If invasive pulmonary aspergillosis (IPA) is suspected, the guidelines recommend performing computed tomography scanning of the chest, regardless of chest radiography findings. Bronchoscopy with bronchoalveolar lavage is also recommended in such cases, unless significant comorbidities (eg, bleeding or severe hypoxemia) preclude it.
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Detection of galactomannan (a component of the Aspergillus cell wall) in serum or bronchoalveolar lavage fluid is recommended as an accurate marker for the diagnosis of invasive aspergillosis in adults and children, when used in certain patient subpopulations, such as hematopoietic stem cell transplant recipients or patients with hematologic malignancies.
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Serum assays for (1 → 3)-β-D-glucan are recommended for diagnosing invasive aspergillosis in high-risk patients (hematologic malignancy, allogeneic hematopoietic stem cell transplant), but are not specific for Aspergillus.
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If IPA is suspected, antifungal therapy should be initiated while diagnostic evaluation is ongoing. Voriconazole is recommended for primary treatment of IPA, although combination therapy with voriconazole and echinocandin may be warranted for some high-risk patients.
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Antifungal therapy for IPA should continue for at least 6-12 wk. Antifungal prophylaxis should also be instituted for patients with prolonged neutropenia who are at high risk for invasive aspergillosis. Prophylactic regimens with posaconazole, voriconazole, and/or micafungin are considered to be most effective.
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Amphotericin B (AmB) deoxycholate and its lipid derivatives are appropriate options for initial and salvage therapy of Aspergillus infections when voriconazole cannot be administered. However, AmB deoxycholate should be reserved for use in resource-limited settings in which no alternative agents are available. Lipid formulations of AmB should be considered in settings in which azoles are contraindicated or not tolerated.
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Aerosolized formulations of AmB may be considered as prophylaxis in patients with prolonged neutropenia (patients receiving induction/reinduction therapy for acute leukemia and allogeneic HSCT recipients following conditioning or during treatment of graft-vs-host disease [GVHD]) and in lung transplant recipients.
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Echinocandins are effective in salvage therapy (either alone or in combination) against invasive aspergillosis, but they are not recommended for routine use as monotherapy for the primary treatment of invasive aspergillosis.
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Triazoles are preferred agents for treatment and prevention of invasive aspergillosis in most patients.
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Surgery for aspergillosis should be considered for localized disease that is easily accessible to debridement (eg, invasive fungal sinusitis or localized cutaneous disease).
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The guidelines recommend that both surgery and either systemic voriconazole or a lipid formulation of AmB be used in invasive Aspergillus fungal sinusitis, but surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus. Enlargement of the sinus ostomy may be needed to improve drainage and prevent recurrence.
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Recommend prophylaxis with posaconazole, voriconazole, and/or micafungin during prolonged neutropenia for those who are at high risk for invasive aspergillosis.
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The guidelines do not recommend routine testing for antifungal susceptibility testing. Instead, it should be reserved for cases in which infection with an azole-resistant isolate is suspected, or in which a patient is unresponsive to antifungal agents.
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Suggest a follow-up chest CT scan to assess the response of IPA to treatment after a minimum of 2 wk of treatment; earlier assessment is indicated if the patient clinically deteriorates. When a nodule is close to a large vessel, more frequent monitoring may be required.
