Diagnosis and Management of Aspergillosis

Publication Date: July 25, 2016
Last Updated: December 16, 2022

Epidemiology and Risk Factors

Hospitalized allogeneic HSCT recipients should be placed in a protected environment to reduce mold exposure. ( S , L)
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These precautions can be reasonably applied to other highly immunocompromised patients at increased risk for invasive aspergillosis (IA), such as patients receiving induction/re-induction regimens for acute leukemia. ( S , L)
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In hospitals in which a protected environment is not available, the IDSA recommends admission to a private room, no connection to construction sites, and not allowing plants or cut flowers to be brought into the patient’s room. ( S , L)
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The IDSA recommends reasonable precautions to reduce mold exposure among outpatients at high risk for IA, including avoidance of gardening, spreading mulch (compost) or close exposure to construction or renovation. ( S , L)
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Leukemia and transplant centers should perform regular surveillance of cases of invasive mold infection. An increase in incidence over baseline or the occurrence of invasive mold infections in patients who are not at high risk for such infections should prompt evaluation for a hospital source. ( S , L)
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Prophylaxis

The IDSA recommends prophylaxis with posaconazole, ( S , H)
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voriconazole, ( S , M)
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micafungin ( W , L)
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during prolonged neutropenia for those who are at high risk for IA. ( S , H)
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Prophylaxis with caspofungin is also probably effective. ( W , L)
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Prophylaxis with itraconazole is effective, but therapy may be limited by absorption and tolerability. ( S , M)
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Triazoles should not be co-administered with other agents known to have potentially toxic levels with concurrent triazole co-administration (such as vinca alkaloids, and others). ( S , M)
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Graft vs. Host Disease (GVHD)

The IDSA recommends prophylaxis with posaconazole for allogeneic HSCT recipients with GVHD who are at high risk for IA. ( S , H)
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Prophylaxis with other mold-active azoles is also effective. Voriconazole is commonly used for prophylaxis against IA in high risk patients but did not show improved survival in clinical trials. ( S , M)
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Prophylaxis with itraconazole is limited by tolerability and absorption. ( S , H)
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The IDSA recommends continuation of antifungal prophylaxis throughout the duration of immunosuppression in patients with chronic immunosuppression associated with GVHD therapies, such as lymphocyte depleting agents or tumor necrosis factor-α [TNF-α] inhibition, for refractory GVHD). ( S , H)
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Lung Transplant

The IDSA recommends antifungal prophylaxis with either a systemic triazole such as voriconazole or itraconazole or an inhaled amphotericin B (AmB) product for 3–4 months after lung transplant. ( S , M)
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Systemic voriconazole or itraconazole is suggested over inhaled amphotericin B for lung transplant recipients with mold colonization pre- or post-lung transplantation, mold infections found in explanted lungs, fungal infections in the sinus, and single lung transplant recipients. ( W , L)
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The IDSA recommends reinitiating antifungal prophylaxis for lung transplant recipients receiving immunosuppression augmentation with either thymoglobulin, alemtuzumab, or high dose corticosteroids. ( S , M)
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Non-lung Solid Organ Transplant

The IDSA recommends prophylactic strategies in solid organ transplant recipients based on the institutional epidemiology of infection and assessment of individual risk factors. ( S , L)
  • Prospective trials are lacking to address the need for routine anti-Aspergillus prophylaxis other than for lung transplant recipients.
  • Individual risk factors have been identified in cardiac (pre-transplant colonization, reoperation, cytomegalovirus [CMV] infection, renal dysfunction, institutional outbreak), liver (fulminant hepatic failure, reoperation, retransplantation or renal failure), and other organs with institutional outbreaks or prolonged or high-dose corticosteroid use. In such patients, the optimal duration of prophylaxis is not known.
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Diagnosis

Until molecular tools are more widely used in clinical laboratories, the IDSA recommends that tissue and fluid specimens be submitted in adequate quantities for simultaneous histopathologic/cytologic and culture examination. In the case of isolates with atypical growth or concerns for resistance, species identification by molecular methods should be employed. ( S , H)
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As research in the area continues, the IDSA recommends that clinicians choosing to use polymerase chain reaction (PCR) assays employ them carefully in the management of individual patients on a case-by-case basis. Clinicians should be aware of the methodologies and performance characteristics of the specific assay used, and interpret results accordingly. When PCR assays are used, results should be considered in conjunction with other diagnostic tests and the clinical context. ( S , M)
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Galactomannan (GM) and (1→3)-β-D-glucan

Serum and bronchoalveolar lavage (BAL) GM is recommended as an accurate marker for the diagnosis of IA in adult and pediatric patients when used in certain patient subpopulations (hematologic malignancy, HSCT). ( S , H)
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GM is NOT recommended for routine blood screening in patients receiving mold-active antifungal therapy or prophylaxis but can be applied to bronchoscopy specimens from those patients. ( S , H)
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GM is NOT recommended for screening in solid organ transplant recipients or patients with chronic granulomatous disease (CGD). ( S , H)
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Serum assays for (1→3)-β-D-glucan are recommended for diagnosing IA in high risk patients (hematologic malignancy, allogeneic HSCT), but are NOT specific for Aspergillus. ( S , M)
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Radiographic Diagnosis

The IDSA recommends performing a chest computed tomographic (CT) scan whenever there is a clinical suspicion of invasive pulmonary aspergillosis (IPA) regardless of chest radiograph results. ( S , H)
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Routine use of contrast during a chest CT scan for a suspicion of IPA is NOT recommended. ( S , M)
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Contrast is recommended when a nodule or a mass is close to a large vessel. ( S , M)
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The IDSA suggests a follow-up chest CT-scan to assess the response of IPA to treatment after a minimum of two weeks of treatment; earlier assessment is indicated if the patient clinically deteriorates. ( W , L)
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Bronchoscopy

The IDSA recommends performing a bronchoscopy with BAL in patients with a suspicion of IPA. ( S , M)
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Significant comorbidities such as severe hypoxemia, bleeding, and platelet transfusion-refractory thrombocytopenia may preclude BAL. (, )
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The yield of BAL is low for peripheral nodular lesions, so that percutaneous or endobronchial lung biopsy should be considered. (, )
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The IDSA recommends the use of a standardized BAL procedure and sending the BAL sample for routine culture and cytology as well as non-culture-based methods (e.g., GM). ( S , M)
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Treatment

Antifungal Agents for Aspergillosis

Amphotericin B (AmB)

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. ( S , M)
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Aerosolized formulations of AmB may be considered as prophylaxis in patients with prolonged neutropenia (patients receiving induction/re-induction therapy for acute leukemia and allogeneic HSCT recipients following conditioning or during treatment of GVHD) and in lung transplant recipients. ( W , L)
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Echinocandins

Echinocandins are effective in salvage therapy (either alone or in combination) against IA, but the IDSA does not recommend their routine use as monotherapy for the primary treatment of IA. ( S , M)
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Triazoles

Triazoles are preferred agents for treatment and prevention of IA in most patients. ( S , H)
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For patients receiving triazole-based therapy for IA, prolonged azole prophylaxis, or other therapies for which drug interactions with azoles are anticipated, the IDSA recommends therapeutic drug monitoring (TDM) once the steady state has been reached. ( S , M)
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A moderate amount of data for itraconazole, voriconazole, and posaconazole suspension suggests this approach may be valuable in enhancing therapeutic efficacy, in evaluating therapeutic failures attributable to suboptimal drug exposures, and to minimize toxicities potentially attributable to the azoles. ( S , M)
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Further studies are needed to address whether TDM is helpful or necessary with the extended release or intravenous formulations of posaconazole or for isavuconazole. (, )
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Clinicians should obtain serum trough drug levels for azole antifungal agents (itraconazole, voriconazole, posaconazole, and possibly isavuconazole) and for potentially interacting drugs such as cyclosporine, tacrolimus, and sirolimus (and other CYP450 3A4 substrates such as tyrosine kinase inhibitors) to optimize therapeutic efficacy and to avoid potential toxicities of both groups of agents. ( S , M)
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Combination Therapy

Combinations of polyenes or azoles with echinocandins suggest additive or synergistic effects in some pre-clinical studies. ( W , L)
  • However, variable test designs and conflicting results of preclinical and in vitro testing have led to uncertainty as to how to interpret the findings.
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Susceptibility Testing

Routine antifungal susceptibility testing of isolates recovered during initial infection is NOT recommended. ( S , M)
  • Antifungal susceptibility testing of Aspergillus isolates using a reference method is reserved for patients suspected to have an azole resistant isolate, who are unresponsive to antifungal agents, or for epidemiological purposes.
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Recommended Therapy for Invasive Disease

Invasive Pulmonary Aspergillosis (IPA)

The IDSA recommends primary treatment with voriconazole. ( S , H)
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Early initiation of antifungal therapy in patients with strongly suspected IPA is warranted while a diagnostic evaluation is conducted. ( S , H)
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Alternative therapies include liposomal AmB, ( S , M)
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isavuconazole, ( S , M)
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or other lipid formulations of AmB. ( W , L)
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Combination antifungal therapy with voriconazole and an echinocandin may be considered in select patients with documented IPA. ( W , M)
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Primary therapy with an echinocandin is NOT recommended. ( S , M)
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Echinocandins (micafungin or caspofungin) can be used in settings in which azole and polyene antifungals are contraindicated. ( W , M)
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The IDSA recommends that treatment of IPA be continued for a minimum of 6–12 weeks, largely dependent on the degree and duration of immunosuppression, site of disease, and evidence of disease improvement. ( S , L)
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For patients with successfully treated IPA who require subsequent immunosuppression, secondary prophylaxis should be initiated to prevent recurrence. ( S , M)
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Invasive Aspergillosis (IA)

Reducing doses of, or eliminating altogether, immunosuppressive agents, when feasible, is advised as a component of anti-Aspergillus therapy. ( S , L)
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Colony stimulating factors (CSFs) may be considered in neutropenic patients with diagnosed or suspected IA. ( W , L)
  • There is insufficient evidence regarding the value of G-CSF versus GM-CSF in this setting.
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Granulocyte transfusions can be considered for neutropenic patients with IA that is refractory or are unlikely to respond to standard therapy, and for an anticipated duration of more than one week. ( W , L)
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Recombinant interferon-γ is recommended as prophylaxis in CGD patients. ( S , H)
Its benefit as adjunctive therapy for IA is unknown.
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Surgery for aspergillosis should be considered for localized disease that is easily accessible to debridement (e.g., invasive fungal sinusitis or localized cutaneous disease). ( S , L)
  • The benefit for IA in other settings such as in the treatment of endocarditis, osteomyelitis or focal central nervous system (CNS) disease appears rational.
  • Other indications are less clear and require consideration of the patient’s immune status, co-morbidities, confirmation of a single focus, and the risks of surgery.
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IA is not an absolute contraindication to additional chemotherapy or HSCT ( S , M)
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Decisions about when to proceed with additional chemotherapy or HSCT following the diagnosis of aspergillosis should involve both Infectious Diseases specialists and Hematologists/Oncologists.

These decisions must consider the risk of progressive aspergillosis during periods of subsequent anti-neoplastic treatment versus the risk of death from the underlying malignancy if this treatment is delayed. ( S , L)
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Refractory or Progressive Disease

The IDSA recommends an individualized approach that takes into consideration the rapidity, severity, extent of infection and patient co-morbidities, and excludes the emergence of a new pathogen. ( S , L)
  • The general strategies for salvage therapy typically include:
    • changing the class of antifungal
    • tapering or reversal of underlying immunosuppression when feasible
    • surgical resection of necrotic lesions in selected cases.
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In the context of salvage therapy, an additional antifungal agent may be added to current therapy, or combination antifungal drugs from different classes other than those in the initial regimen may be used ( W , M)
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In patients currently receiving an antifungal and exhibiting an adverse event attributable to this agent, the IDSA recommends changing to an alternative class of antifungal, or the use of an alternative agent with a non-overlapping side-effect profile. ( S , L)
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For salvage therapy, agents include lipid formulations of AmB, micafungin, caspofungin, posaconazole or itraconazole. The use of a triazole as salvage therapy should take into account prior antifungal therapy, host factors, pharmacokinetic considerations, and possible antifungal resistance. ( S , M)
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Biomarkers to Assess Response

Serial monitoring of serum GM can be used in the appropriate patient subpopulations (hematologic malignancy, HSCT) who have an elevated GM at baseline to monitor disease progression, therapeutic response, and predict outcome. ( S , M)
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(1→3)-β-D-glucan has not been extensively studied in IA to predict outcome ( W , L)
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Pediatric Aspergillosis

Treatment of aspergillosis in children uses the same recommended therapies as in adult patients. However, the dosing is different and for some antifungals is unknown ( S , H)
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Transplant and Nontransplant Recipients

Saprophytic forms of tracheobronchial aspergillosis (TBA) do NOT require antifungal treatment except for symptomatic or immunosuppressed patients. (, )
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Treatment includes bronchoscopic removal of mucoid impaction. (, )
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Mold-active triazole agents are recommended for immunocompromised patients in whom the possibility of invasive disease cannot be eliminated. ( S , M)
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Bronchocentric granulomatosis is treated in the same fashion as allergic bronchopulmonary aspergillosis. (ABPA) ( S , L)
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Invasive forms of TBA are treated with a mold-active triazole or intravenous lipid formulations of AmB. ( S , L)
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The IDSA also recommends minimization or reversal of underlying immunosuppression when feasible, and bronchoscopic debridement of airway lesions in selected cases. ( S , L)
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In lung transplant recipients, the IDSA recommends treatment with a systemic anti-mold antifungal for TBA, including saprophytic forms. The IDSA also recommends adjunctive inhaled AmB in the setting of TBA associated with anastomotic endobronchial ischemia or ischemic reperfusion injury due to airway ischemia associated with lung transplantation. ( S , M)
  • Duration of antifungal therapy is at least 3 months or until TBA is completely resolved, whichever is longer.
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Extrapulmonary Aspergillosis

CNS

The IDSA recommends voriconazole as primary therapy for CNS aspergillosis. ( S , M)
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Lipid formulations of AmB are reserved for those intolerant or refractory to voriconazole. ( S , M)
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Endophthalmitis

The IDSA recommends that Aspergillus endophthalmitis be treated with systemic oral or intravenous voriconazole plus intravitreal voriconazole or intravitreal AmB deoxycholate. ( S , M)
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Keratitis

The IDSA recommends that clinicians treat Aspergillus keratitis with topical natamycin 5% ophthalmic suspension or topical voriconazole. ( S , M)
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Paranasal Sinuses

The IDSA recommends that both surgery and either systemic voriconazole or a lipid formulation of AmB be used in invasive Aspergillus fungal sinusitis but that surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus. ( S , M)
  • Enlargement of the sinus ostomy may be needed to improve drainage and prevent recurrence.
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Endocarditis, Pericarditis, and Myocarditis

In Aspergillus endocarditis, the IDSA recommends early surgical intervention combined with antifungal therapy in attempts to prevent embolic complications and valvular decompensation. ( S , M)
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Voriconazole or a lipid formulation of AmB is recommended as initial therapy. ( S , L)
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Following surgical replacement of an infected valve, lifelong antifungal therapy should be considered. ( S , L)
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Osteomyelitis and Septic Arthritis

Surgical intervention is recommended, where feasible, for management of Aspergillus osteomyelitis and arthritis, combined with voriconazole ( S , M)
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Cutaneous

Since cutaneous lesions may reflect disseminated infection, the IDSA recommends treatment with voriconazole in addition to evaluation for a primary focus of infection. ( S , L)
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In cases of aspergillosis in burns or massive soft tissue wounds, surgical debridement is recommended, in addition to antifungal therapy. ( S , M)
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Peritonitis

The IDSA recommends prompt peritoneal dialysis catheter removal accompanied by systemic antifungal therapy with voriconazole. ( S , L)
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Esophageal, Gastrointestinal, and Hepatic

The IDSA suggests voriconazole and surgical consultation in attempts to prevent complications of hemorrhage, perforation, obstruction or infarction. ( W , L)
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The IDSA suggests antifungal therapy with voriconazole or a lipid formulation of AmB as initial therapy for hepatic aspergillosis. ( W , L)
  • For extrahepatic or perihepatic biliary obstruction, or localized lesions that are refractory to medical therapy, surgical intervention should be considered.
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Renal

The IDSA suggests a combined approach of medical and urologic management for renal aspergillosis. ( W , L)
  • Obstruction of one or both ureters should be managed with decompression if possible and local instillation of AmB deoxycholate.
  • Parenchymal disease is best treated with voriconazole.
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Ear Infections

Noninvasive Aspergillus otitis externa, also called otomycosis, is treated by thorough mechanical cleansing of the external auditory canal followed by topical antifungals or boric acid. ( S , M)
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The IDSA recommends that clinicians treat IA of the ear with a prolonged course of systemic voriconazole, usually combined with surgery. ( S , L)
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Bronchitis in the Non-transplant Population

The IDSA suggests the diagnosis of Aspergillus bronchitis in non-transplant patients be confirmed by detection of Aspergillus spp. in respiratory secretions, usually sputum, with both PCR and GM on respiratory samples being much more sensitive than culture. ( W , L)
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The IDSA suggests treatment with oral itraconazole or voriconazole with therapeutic drug monitoring. ( W , L)
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Breakthrough Infection

The IDSA suggests an individualized approach that takes into consideration the rapidity and severity of infection and local epidemiology. ( W , M)
  • As principles, the IDSA recommends an aggressive and prompt attempt to establish a specific diagnosis with bronchoscopy and/or CT-guided biopsy for peripheral lung lesions.
  • Documentation of serum azole levels should be verified if TDM is available for patients receiving mold-active triazoles.
  • Antifungal therapy should be empirically changed to an alternative class of antifungal with Aspergillus activity.
  • Other considerations include reduction of underlying immunosuppression, if feasible, and susceptibility testing of any Aspergillus isolates recovered from the patient.
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Empirical and Pre-emptive Strategies

Empirical antifungal therapy is recommended for high-risk patients with prolonged neutropenia who remain persistently febrile despite broad-spectrum antibiotic therapy. ( S , H)
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Antifungal options include a lipid formulation of AmB, ( S , H)
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an echinocandin (caspofungin or micafungin), ( S , H)
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or voriconazole. ( S , M)
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Empirical antifungal therapy is recommended for high-risk patients with prolonged neutropenia who remain persistently febrile despite broad-spectrum antibiotic therapy. ( S , H)
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Empirical antifungal therapy is NOT recommended for patients who are anticipated to have short durations of neutropenia (duration of neutropenia <10 days), unless other findings indicate a suspected invasive fungal infection. ( S , M)
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The use of serum or BAL fungal biomarkers such as GM or (1→3)-β-D-glucan to guide antifungal therapy in asymptomatic or febrile high risk patients (often referred to as pre-emptive or biomarker-driven antifungal therapy) can reduce unnecessary antifungal therapy. ( S , M)
  • The pre-emptive approach can result in more documented cases of IA without compromise in survival and can be used as an alternative to empirical antifungal therapy.
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Early initiation of antifungal therapy in patients with strongly suspected IPA is warranted while a diagnostic evaluation is conducted. ( S , M)
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Management of suspected or documented breakthrough IPA in the context of mold-active azole prophylaxis or empirical suppressive therapy is not defined by clinical trial data, but a switch to another drug class is suggested. ( W , L)
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In lung transplant recipients not on anti-mold prophylaxis, the IDSA suggests pre-emptive therapy with an anti-mold antifungal for asymptomatic patients with Aspergillus colonization of the airways within 6 months of lung transplantation or within 3 months of receiving immunosuppression augmentation for rejection. ( W , M)
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Six months after lung transplantation and in the absence of recent immunosuppression augmentation for rejection, it may be prudent to withhold antifungal therapy for Aspergillus airway colonization (i.e., Aspergillus respiratory cultures in the absence of clinical features that suggest disease, such as compatible symptoms, or bronchoscopic, histopathologic and/or radiographic findings). ( W , L)
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Chronic and Saprophytic Syndromes

The diagnosis of CCPA requires: ( S , M)
  • 3 months of chronic pulmonary symptoms or chronic illness or progressive radiographic abnormalities, with cavitation, pleural thickening, peri-cavitary infiltrates and sometimes a fungal ball
  • Aspergillus IgG antibody elevated or other microbiological data (The Aspergillus IgG antibody test is the most sensitive microbiological test.)
  • No or minimal immunocompromise, usually with one or more underlying pulmonary disorders.
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The IDSA suggests an individualized approach that takes into consideration the rapidity and severity of infection and local epidemiology ( W , M)
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Chronic Cavitary Pulmonary Aspergillosis (CCPA)

The diagnosis of CCPA requires: ( S , M)
  • 3 months of chronic pulmonary symptoms or chronic illness or progressive radiographic abnormalities, with cavitation, pleural thickening, peri-cavitary infiltrates and sometimes a fungal ball
  • Aspergillus IgG antibody elevated or other microbiological data (The Aspergillus IgG antibody test is the most sensitive microbiological test.)
  • No or minimal immunocompromise, usually with one or more underlying pulmonary disorders.
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Note: Sputum Aspergillus PCR testing is more sensitive than culture. ( W , M)
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Patients with CCPA without pulmonary symptoms, weight loss or significant fatigue, and those without major impairment of pulmonary function or gradual loss of pulmonary function may be observed without antifungal therapy and followed every 3–6 months. ( W , L)
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Patients with CCPA and either pulmonary or general symptoms or progressive loss of lung function or radiographic progression should be treated with a minimum of 6 months of antifungal therapy. ( S , L)
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Oral itraconazole and voriconazole are the preferred oral antifungal agents. ( S , H)
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Posaconazole is a useful third-line agent for those with adverse events or clinical failure. ( S , M)
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Hemoptysis may be managed with oral tranexamic acid, ( W , L)
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bronchial artery embolization ( S , M)
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antifungal therapy to prevent recurrence. ( S , L)
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Patients failing these measures may require surgical resection. ( W , M)
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In those who fail therapy, who develop triazole resistance and/or have adverse events,

intravenous micafungin, ( W , L)
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caspofungin, ( W , L)
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amphotericin B ( W , L)
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yield some responses.
  • Treatment may need to be prolonged.
Surgical resection is an option for some patients with localized disease unresponsive to medical therapy, including those with pan-azole resistant A. fumigatus infection or persistent hemoptysis despite bronchial artery embolization. ( S , M)
  • The outcomes from surgery are less favorable than those with single aspergilloma, and a careful risk assessment prior to surgical intervention is required.
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In those with progressive disease, long term, even life-long, antifungal therapy may be required to control disease, ( W , L)
with continual monitoring for toxicity and resistance.
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Aspergilloma

Asymptomatic patients with a single aspergilloma and no progression of the cavity size over 6–24 months should continue to be observed. ( S , M)
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Patients with symptoms, especially significant hemoptysis, with a single aspergilloma, should have it resected, assuming that there are no contraindications. ( S , M)
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Peri/post-operative antifungal therapy is not routinely required, but if the risk of surgical spillage of the aspergilloma is moderate (related to location and morphology of the cavity) antifungal therapy with voriconazole (or another mold-active azole) or an echinocandin is suggested to prevent Aspergillus empyema. ( W , L)
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Allergic Syndromes

Allergic Bronchopulmonary Aspergillosis

Elevated Aspergillus IgE and total IgE are recommended to establish the diagnosis and are useful for screening. ( S , H)
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The IDSA suggests treating symptomatic asthmatic patients with bronchiectasis or mucoid impaction, despite oral or inhaled corticosteroid therapy, with oral itraconazole therapy with therapeutic drug monitoring. ( W , L)
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In cystic fibrosis (CF) patients with frequent exacerbations and/or falling FEV1, the IDSA suggests treating with oral itraconazole to minimize corticosteroid use — with therapeutic drug monitoring and consideration of other mold-active azole therapy if therapeutic levels cannot be achieved. ( W , L)
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Allergic Aspergillus Rhinosinusitis

The IDSA recommends establishing the diagnosis of allergic fungal rhinosinusitis (AFRS) in patients with nasal polyposis and thick eosinophilic mucin by visualizing hyphae in mucus, which is supported by a positive anti-Aspergillus IgE serum antibody assay or skin prick test (where available) ( S , M)
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The IDSA recommends polypectomy and sinus washout as the optimal means of symptom control and inducing remission. However, relapse is frequent ( S , M)
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The IDSA recommends the use of topical nasal steroids to reduce symptoms and increase time to relapse, especially if given after surgery ( S , M)
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The IDSA suggests oral antifungal therapy using mold-active triazoles for refractory infection and/or rapidly relapsing disease, although this approach is only partially effective. ( W , L)
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Recommendation Grading

Overview

Title

Diagnosis and Management of Aspergillosis

Authoring Organization

Infectious Diseases Society of America

Endorsing Organization

Pediatric Infectious Diseases Society

Publication Month/Year

July 25, 2016

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Aspergillus species continue to be an important cause of life-threatening infection in immunocompromised patients. This at-risk population is comprised of patients with prolonged neutropenia, allogeneic hematopoietic stem cell transplant (HSCT), solid organ transplant (SOT), inherited or acquired immunodeficiencies, corticosteroid use, and others. This document constitutes the guidelines of the Infectious Diseases Society of America (IDSA) for treatment of aspergillosis and replaces the practice guidelines for Aspergillus published in 2008. Since that publication, clinical studies evaluating new and existing therapies including combination therapy for the management of Aspergillus infection have been conducted and the data on use of non-culture-based biomarkers for diagnosing infection have been expanded. The objective of these guidelines is to summarize the current evidence for treatment of different forms of aspergillosis. This document reviews guidelines for management of the 3 major forms of aspergillosis: invasive aspergillosis (IA); chronic (and saprophytic) forms of aspergillosis; and allergic forms of aspergillosis. Given the clinical importance of IA, emphasis is placed upon the diagnosis, treatment, and prevention of the different forms of IA, including invasive pulmonary aspergillosis (IPA), Aspergillus sinusitis, disseminated aspergillosis, and several types of single-organ IA.

Target Patient Population

Patients with Aspergillosis

PICO Questions

  1. How Can the Most Susceptible Patients Be Protected From Aspergillosis, and Which Patients Are Most Susceptible?

  2. How Can a Diagnosis of Invasive Aspergillosis Be Established?

  3. What Antifungal Agents Are Available for the Treatment and Prophylaxis of Invasive Aspergillosis, Including Pharmacologic Considerations, and What Is the Role for Susceptibility Testing?

  4. What Are the Recommended Treatment Regimens and Adjunctive Treatment Measures for the Various Clinical Presentation of Invasive Aspergillosis?

  5. What Are the Recommended Prophylactic Regimens, Who Should Receive Them, and How Should Breakthrough Infection Be Managed?

  6. When Should Patients Be Treated Empirically?

  7. How Should Chronic Aspergillosis, Allergic Syndromes, or Noninvasive Syndromes Be Managed?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D001228 - Aspergillosis, D055732 - Pulmonary Aspergillosis, D001230 - Aspergillus, D055744 - Invasive Pulmonary Aspergillosis

Keywords

fungal infection, aspergillosis, azoles, invasive aspergillosis, allergic aspergillosis, aspergillus

Source Citation

Patterson TF et al. Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63(4):e1-e60

Methodology

Number of Source Documents
655
Literature Search Start Date
January 1, 2008
Literature Search End Date
December 1, 2014