Initial Treatment for BAL Galactomannan Positive Patients
For patients with a positive bronchoalveolar lavage (BAL) galactomannan result indicating probable invasive aspergillosis, voriconazole is the recommended first-line treatment. 1
First-Line Treatment Options
Primary Recommendation: Voriconazole
- Voriconazole has demonstrated superior efficacy compared to amphotericin B deoxycholate, with significantly better survival rates (71% vs 58% at 12 weeks) and successful outcomes (53% vs 32%) 1, 2
- Dosing regimen:
Alternative First-Line Option: Liposomal Amphotericin B (L-AMB)
- Consider in patients who cannot tolerate voriconazole or have contraindications 1
- Recommended dose: 3 mg/kg/day IV 1
- Higher doses (10 mg/kg/day) have shown similar efficacy but greater toxicity 1
Emerging Alternative: Isavuconazole
- Recent guidelines support isavuconazole as an alternative first-line agent 1
- Has shown comparable efficacy to voriconazole with potentially better tolerability 4
Treatment Considerations
Patient-Specific Factors
- For seriously ill patients, parenteral formulation of voriconazole is strongly recommended 1
- Early initiation of antifungal therapy is critical while diagnostic evaluation continues 1
- Visual disturbances are common with voriconazole (occurring in approximately 30-45% of patients) but are typically transient 2, 5
Treatment Duration
- Minimum treatment duration: 6-12 weeks 1
- For immunosuppressed patients: continue therapy throughout the period of immunosuppression and until lesions have resolved 1
- Long-term therapy is facilitated by the availability of oral voriconazole in stable patients 1
Monitoring Response to Treatment
- Serial clinical evaluation of symptoms and signs 1
- Regular radiographic imaging with CT at intervals determined by the individual patient's condition 1
- Note that pulmonary infiltrates may increase in volume during the first 7-10 days of therapy, especially during granulocyte recovery 1
- Serial serum galactomannan assays may be useful for monitoring, though this remains investigational 1
- Progressive increase in Aspergillus antigen levels over time signifies a poor prognosis 1
Salvage Therapy Options
If initial therapy fails or is not tolerated, options include:
- Liposomal amphotericin B formulations 1
- Posaconazole (has shown non-inferiority to voriconazole in a recent study) 6
- Echinocandins (caspofungin or micafungin) 1
- Itraconazole 1
Important Caveats
- Resolution of galactomannan antigenemia to normal levels alone is not sufficient for discontinuation of therapy 1
- For patients with successfully treated invasive aspergillosis who will require subsequent immunosuppression, resumption of antifungal therapy can prevent recurrent infection 1
- Without adequate therapy, invasive pulmonary aspergillosis will almost always progress to fatal pneumonia, potentially with dissemination to the CNS or extension to contiguous intrathoracic structures 1