What is the initial treatment for a patient with ground glass infiltrates and a positive Fungitell (Fungal antigen) test?

From the Guidelines

The initial treatment for a patient with ground glass infiltrates and a positive Fungitell test should be voriconazole (strong recommendation; high-quality evidence) 1. This recommendation is based on the 2016 update by the Infectious Diseases Society of America, which suggests primary treatment with voriconazole for patients with suspected invasive aspergillosis (IA) 1. The positive Fungitell test indicates the presence of (1→3)-β-D-glucan, a component of many fungal cell walls, suggesting an invasive fungal infection. Ground glass infiltrates on imaging are consistent with fungal pneumonia, particularly due to Aspergillus species. Some key points to consider when treating a patient with ground glass infiltrates and a positive Fungitell test include:

• Early initiation of antifungal therapy is warranted while a diagnostic evaluation is conducted 1
• Alternative therapies include liposomal AmB, isavuconazole, or other lipid formulations of AmB 1
• Combination antifungal therapy with voriconazole and an echinocandin may be considered in select patients with documented IA 1
• Treatment of IA should 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 1 Additional diagnostic tests should be pursued concurrently, including fungal cultures, galactomannan assay, and possibly bronchoscopy with bronchoalveolar lavage. Once the specific pathogen is identified, therapy may be tailored accordingly. For instance, if Aspergillus is confirmed, voriconazole would remain the preferred agent (6 mg/kg IV twice daily for two doses, then 4 mg/kg IV twice daily, with transition to oral therapy when appropriate) 1.

From the FDA Drug Label

In a clinical study of IA, the median duration of intravenous voriconazole therapy was 10 days (range 2 to 85 days). In clinical trials, patients with candidemia received 3 mg/kg intravenous infusion every 12 hours as primary therapy, while patients with other deep tissue Candida infections received 4 mg/kg every 12 hours as salvage therapy. Infection Loading dose Maintenance Dose Intravenous infusion Intravenous infusion Oral Invasive Aspergillosis 6 mg/kg 12 hours for the first 24 hours 4 mg/kg every 12 hours 200 mg every 12 hours

The initial treatment for a patient with ground glass infiltrates and a positive Fungitell (Fungal antigen) test is Voriconazole.

• The recommended dosing regimen for Invasive Aspergillosis is a loading dose of 6 mg/kg every 12 hours for the first 24 hours, followed by a maintenance dose of 4 mg/kg every 12 hours.
• The treatment should be initiated with an intravenous infusion regimen and may be switched to an oral regimen after significant clinical improvement.
• The duration of therapy should be based on the severity of the patient's underlying disease, recovery from immunosuppression, and clinical response 2.

From the Research

Initial Treatment for Ground Glass Infiltrates with Positive Fungitell

The initial treatment for a patient with ground glass infiltrates and a positive Fungitell (Fungal antigen) test is typically an antifungal medication.

• The choice of antifungal medication depends on various factors, including the severity of the infection, the patient's underlying medical conditions, and the specific type of fungus suspected or identified 3, 4.
• Voriconazole is a broad-spectrum triazole that has been shown to be effective against a range of fungal infections, including those caused by Aspergillus species 3, 4.
• Liposomal amphotericin B is another option for treating invasive fungal infections, particularly in patients who are immunocompromised or have severe infections 5, 6.
• A study comparing voriconazole with liposomal amphotericin B for empirical antifungal therapy in patients with neutropenia and persistent fever found that voriconazole was a suitable alternative to amphotericin B preparations, with fewer cases of severe infusion-related reactions and nephrotoxicity 7.

Antifungal Medication Options

Some antifungal medication options for treating ground glass infiltrates with positive Fungitell include:

• Voriconazole: a broad-spectrum triazole with activity against Aspergillus species and other fungi 3, 4
• Liposomal amphotericin B: a formulation of amphotericin B that reduces toxicity and allows for higher doses to be given 5, 6
• Other antifungal medications, such as posaconazole and caspofungin, may also be considered depending on the specific clinical scenario and the patient's individual needs 4

Considerations for Treatment

When selecting an antifungal medication, considerations include:

• The severity of the infection and the patient's underlying medical conditions
• The specific type of fungus suspected or identified
• The potential for drug interactions and adverse effects
• The need for combination antifungal therapy in selected patients with invasive fungal infections 4