Pediatric Aspergillosis Treatment & Management

Updated: Jan 24, 2019
  • Author: Vandana Batra, MD; Chief Editor: Russell W Steele, MD  more...
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Treatment

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. [15]

    • 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. [16]

    • 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

See the list below:

  • 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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