From the Guidelines
Treatment of Aspergillus in sputum is not always necessary and depends on the clinical context, with voriconazole being the first-line therapy for invasive aspergillosis. The decision to treat Aspergillus in sputum should be based on the presence of signs of invasive disease, allergic bronchopulmonary aspergillosis (ABPA), or chronic pulmonary aspergillosis, rather than treating based on isolation alone 1. Not all Aspergillus found in sputum requires treatment, as it may represent colonization rather than infection, especially in patients with underlying lung disease.
Key Considerations
- Treatment is indicated when there are signs of invasive disease, ABPA, or chronic pulmonary aspergillosis
- Voriconazole is the first-line therapy for invasive aspergillosis, typically administered at a dose of 6mg/kg IV twice daily on day 1, then 4mg/kg twice daily, transitioning to oral 200-300mg twice daily for at least 6-12 weeks 1
- Alternative options include isavuconazole, posaconazole, or liposomal amphotericin B
- For ABPA, treatment involves corticosteroids (prednisone 0.5mg/kg/day, tapered over months) and possibly antifungals
- For chronic forms, long-term azole therapy may be needed
Diagnosis and Monitoring
- Before starting treatment, confirm the diagnosis with clinical, radiological, and possibly bronchoscopic findings, as unnecessary antifungal therapy carries risks of side effects and resistance development
- Monitoring liver function and drug levels during treatment is essential due to potential toxicity and drug interactions 1
- Serial clinical evaluation of all symptoms and signs, as well as performance of radiographic imaging, usually with CT, at regular intervals, is recommended 1
Evidence-Based Recommendations
- The Infectious Diseases Society of America recommends voriconazole as the primary treatment for invasive aspergillosis in most patients (A-I) 1
- Liposomal amphotericin B may be considered as alternative primary therapy in some patients (A-I) 1
- Salvage therapy options include liposomal amphotericin B, posaconazole, itraconazole, caspofungin, or micafungin (B-II) 1
From the FDA Drug Label
The study also included patients with solid organ transplantation, solid tumors, and AIDS. The patients were mainly treated for definite or probable IA of the lungs. Diagnosis of definite or probable IA was made according to criteria modified from those established by the National Institute of Allergy and Infectious Diseases Mycoses Study Group/European Organisation for Research and Treatment of Cancer (NIAID MSG/EORTC) The answer to whether to treat aspergillus in the sputum is yes, as the drug labels discuss the treatment of invasive aspergillosis, including lung infections, with voriconazole and amphotericin B 2 3.
- Key points:
- Voriconazole was used to treat definite or probable invasive aspergillosis (IA) of the lungs.
- Amphotericin B is indicated for potentially life-threatening fungal infections, including aspergillosis.
- Treatment of aspergillus in the sputum is implied as part of the treatment for invasive aspergillosis.
From the Research
Treatment of Aspergillus in Sputum
- Aspergillus spp. can cause a range of pulmonary disorders, and treatment is primarily with antifungal agents 4
- The choice of antifungal agent depends on the specific species of Aspergillus and the patient's underlying condition
- Voriconazole, posaconazole, and caspofungin are commonly used antifungal agents for the treatment of invasive aspergillosis 5, 6, 7
- Posaconazole is recommended for prophylaxis against aspergillosis in patients with certain underlying conditions, such as acute myelogenous leukemia or myelodysplastic syndrome 7
- Combination therapy with a mold-active triazole plus an echinocandin may be considered for patients with proven or probable invasive pulmonary aspergillosis, although the evidence is of low quality 8
Antifungal Agents
- Voriconazole, posaconazole, and itraconazole are triazole antifungal agents with activity against Aspergillus spp. 5, 6
- Caspofungin is an echinocandin antifungal agent with activity against Aspergillus spp. 5, 7
- Amphotericin B is a polyene antifungal agent with activity against Aspergillus spp., but it has a higher MIC against some species 5
Treatment Guidelines
- The American Thoracic Society has published clinical practice guidelines for the treatment of invasive pulmonary aspergillosis and preventive and empirical therapy for invasive candidiasis in adult pulmonary and critical care patients 8
- The guidelines recommend either initial combination therapy with a mold-active triazole plus an echinocandin or initial mold-active triazole monotherapy for patients with proven or probable invasive pulmonary aspergillosis, based on low-quality evidence 8