What is the treatment for Aspergillus Niger infection?

Treatment of Aspergillus Niger Infection

Voriconazole is the first-line treatment for invasive Aspergillus niger infections due to its superior efficacy and survival outcomes compared to other antifungal agents. 1, 2, 3

Primary Treatment Options

• Voriconazole should be administered with a loading dose of 6 mg/kg IV every 12 hours for 1 day, followed by a maintenance dose of 4 mg/kg IV every 12 hours or 200 mg oral twice daily 2, 4
• For patients who cannot tolerate voriconazole, liposomal amphotericin B (L-AMB) at 3-5 mg/kg/day IV can be considered as alternative primary therapy 1, 2
• Treatment should continue for a minimum of 6-12 weeks, with ongoing therapy in immunosuppressed patients until lesions have resolved 2

Treatment Based on Type of Infection

Invasive Pulmonary Aspergillosis

• Voriconazole is the preferred agent with significantly better outcomes than amphotericin B (52.8% vs 31.6% success rate) 3
• Surgical intervention may be necessary for massive hemoptysis or lesions close to great vessels 1
• Therapeutic drug monitoring should be performed for voriconazole to ensure adequate serum levels, especially in cases with poor response 5, 2

Cutaneous Aspergillosis

• Voriconazole is recommended as systemic therapy, along with evaluation for a primary focus of infection 1
• For burns or massive soft tissue wounds, surgical debridement is essential in addition to antifungal therapy 1

Aspergillus Peritonitis

• Prompt peritoneal dialysis catheter removal accompanied by systemic antifungal therapy with voriconazole is recommended 1

Esophageal, Gastrointestinal, and Hepatic Aspergillosis

• Voriconazole is recommended along with surgical consultation to prevent complications of hemorrhage, perforation, obstruction, or infarction 1
• For hepatic aspergillosis, voriconazole or a lipid formulation of amphotericin B is recommended as initial therapy 1

Renal Aspergillosis

• Combined medical and urologic management is recommended 1
• Obstruction of ureters should be managed with decompression if possible and local instillation of amphotericin B deoxycholate 1
• Parenchymal disease is best treated with voriconazole 1

Ear Infections

• For noninvasive Aspergillus otitis externa (otomycosis), thorough mechanical cleansing of the external auditory canal followed by topical antifungals or boric acid is recommended 1, 6
• For invasive aspergillosis of the ear, a prolonged course of systemic voriconazole, usually combined with surgery, is recommended 1, 6

Aspergillus Keratitis

• Topical natamycin 5% ophthalmic suspension or topical voriconazole is recommended 1
• Systemic therapy may be beneficial in management of aspergillus endophthalmitis 1

Salvage Therapy Options

• For patients who fail primary therapy or cannot tolerate initial treatment, options include:
  • Lipid formulations of amphotericin B 2
  • Itraconazole 2
  • Echinocandins (caspofungin, micafungin) 2
• Combination therapy is not routinely recommended for primary treatment but may be considered for salvage therapy 2, 7

Special Considerations for A. niger

• A. niger can produce calcium oxalate crystals in infected tissues, which can be a diagnostic clue even in the absence of visible fungal elements 5
• While A. niger is less commonly considered a cause of invasive aspergillosis compared to A. fumigatus and A. flavus, it can cause serious infections, particularly in immunocompromised hosts 5, 8
• A. niger has varying minimum inhibitory concentrations to triazoles, but voriconazole remains the preferred treatment 8
• Patient outcomes with A. niger infections appear to be more favorable compared to other Aspergillus species 8

Common Pitfalls to Avoid

• Delaying treatment while awaiting definitive diagnosis can worsen outcomes; empiric therapy should be initiated based on clinical suspicion in high-risk patients 1
• Inadequate drug monitoring may lead to treatment failure; voriconazole levels should be monitored, especially in cases with poor response 5, 2
• Failing to address the underlying immunosuppression when possible (reducing steroids, improving neutrophil counts) 9
• For otomycosis, failing to thoroughly clean the ear canal before applying medications can prevent treatment from reaching infected areas 6