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Invasive aspergillosis

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of invasive aspergillosis are prepared by our editorial team based on guidelines from the American Society of Transplantation (AST 2019), the European Confederation of Medical Mycology (ECMM/ERS/ESCMID 2018), the Infectious Diseases Society of America (IDSA 2016), and the American Thoracic Society (ATS 2011). ...
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Diagnostic investigations

Nucleic acid testing
As per IDSA 2016 guidelines:
Insufficient evidence to support the routine use of blood-based PCR testing for the diagnosis of invasive aspergillosis.
Obtain PCR testing for the diagnosis of invasive aspergillosis in selected patients on a case-by-case basis. Take into account the methodologies and performance characteristics of the specific assay and interpret results accordingly. Interpret the results of PCR testing in conjunction with other diagnostic tests and the clinical context.
B
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  • Galactomannan and beta-D-glucan

  • Antibody testing

  • Fluorescent dye tests

  • Species identification

  • Antifungal susceptibility testing

  • CT

Diagnostic procedures

Diagnostic bronchoscopy
As per IDSA 2016 guidelines:
Perform bronchoscopy with bronchoalveolar lavage in patients with suspected invasive pulmonary aspergillosis. Do not perform bronchoalveolar lavage in patients with significant comorbidities, such as severe hypoxemia, bleeding, or platelet transfusion-refractory thrombocytopenia.
B
Perform a standardized bronchoalveolar lavage procedure and send the sample for routine culture, cytology, and non-culture-based methods (such as galactomannan).
B

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  • Bronchoalveolar lavage

  • Lung biopsy

  • Histopathology

Medical management

General principles: as per ECMM/ERS/ESCMID 2018 guidelines, initiate antifungal therapy in all patients at risk considered by the responsible clinician as having invasive aspergillosis.
B

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  • Azoles

  • Amphotericin B

  • Echinocandins

  • Combination therapy

  • Immunomodulators

  • Therapeutic drug monitoring

Surgical interventions

Indications for surgery
As per IDSA 2016 guidelines:
Consider performing surgery in patients with localized invasive aspergillosis easily accessible to debridement (such as invasive fungal sinusitis or localized cutaneous disease).
B
Consider performing surgery in patients with invasive aspergillosis of other locations, such as aspergillosis of the focal CNS and Aspergillus endocarditis or osteomyelitis.

Specific circumstances

Pediatric patients: as per ECMM/ERS/ESCMID 2018 guidelines, initiate voriconazole as the first-line agent for the treatment of invasive aspergillosis in all pediatric patients except neonates.
B
consider initiating liposomal amphotericin B instead of voriconazole in areas or institutions with a high prevalence of azole resistance.
B
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  • Solid organ transplant recipients (prophylaxis, general principles)

  • Solid organ transplant recipients (prophylaxis, lung transplant)

  • Patients with GvHD

  • Patients awaiting chemotherapy or HSCT

  • Patients treated for acute myeloid leukemia and HSCT recipients

  • Patients with Aspergillus bronchitis

  • Patients with invasive pulmonary aspergillosis

  • Patients with chronic pulmonary aspergillosis

  • Patients with tracheobronchial aspergillosis

  • Patients with allergic bronchopulmonary aspergillosis

  • Patients with hypersensitivity pneumonitis

  • Patients with allergic fungal rhinosinusitis

  • Patients with invasive aspergillosis of paranasal sinuses

  • Patients with Aspergillus ear infections

  • Patients with CNS aspergillosis

  • Patients with gastrointestinal aspergillosis

  • Patients with cardiac aspergillosis

  • Patients with renal aspergillosis

  • Patients with Aspergillus osteomyelitis and septic arthritis

  • Patients with cutaneous aspergillosis

  • Patients with Aspergillus keratitis

  • Patients with Aspergillus endophthalmitis

  • Patients with aspergilloma

Preventative measures

Antifungal prophylaxis: as per IDSA 2016 guidelines, administer the following agents for prophylaxis in patients with prolonged neutropenia at high risk for invasive aspergillosis:
posaconazole
A
voriconazole
B
micafungin.
B
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  • Infection control

Follow-up and surveillance

Assessment of treatment response: as per IDSA 2016 guidelines, consider obtaining a follow-up chest CT to assess the response of invasive pulmonary aspergillosis to treatment after a minimum of 2 weeks of treatment. Obtain earlier assessment if the patient clinically deteriorates. Consider obtaining a more frequent monitoring if the nodule is close to a large vessel.
C
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  • Management of refractory disease

  • Management of breakthrough aspergillosis