What is the treatment for Aspergillus sydowii infections?

Treatment of Aspergillus sydowii Infections

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

Primary Treatment Options

• Voriconazole is the drug of choice for initial therapy of invasive aspergillosis, including Aspergillus sydowii, 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 1, 2
• Voriconazole has demonstrated significantly better response rates (52.8% vs 31.6%) and improved survival compared to amphotericin B in the treatment of invasive aspergillosis 3
• Therapeutic drug monitoring should be considered for voriconazole to ensure adequate serum levels, particularly in cases of treatment failure 1

Alternative Treatment Options

• Liposomal amphotericin B (L-AMB) at 3-5 mg/kg/day IV can be considered as alternative primary therapy in patients who cannot tolerate voriconazole 1, 2
• Isavuconazole is another alternative first-line agent that can be considered for treatment of invasive aspergillosis 1, 4
• Itraconazole (200 mg IV every 12 hours for 2 days, then 200 mg daily IV or 200 mg PO twice daily) can be used as an alternative therapy 2

Salvage Therapy Options

• For patients who fail primary therapy or cannot tolerate initial treatment, the following options are recommended:
  • Lipid formulations of amphotericin B (LFAB) 1, 2
  • Caspofungin (70 mg loading dose on day 1, followed by 50 mg daily IV) 2
  • Micafungin (100-150 mg/day IV) 2, 5
  • Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization) 2, 1

Duration of Treatment

• Treatment should continue for a minimum of 6-12 weeks 1, 4
• Therapy should be continued until resolution or stabilization of all clinical and radiographic manifestations 2
• For immunosuppressed patients, treatment should continue until immunosuppression is reversed, if feasible 2

Special Considerations

• The site of infection (pulmonary, sinus, CNS, etc.) may influence treatment approach and duration 2
• For CNS aspergillosis, voriconazole is particularly recommended due to its ability to penetrate the blood-brain barrier 2, 6
• Combination therapy is not routinely recommended for primary treatment but may be considered for salvage therapy in refractory cases 1, 6
• Surgical intervention may be necessary in certain cases, particularly for endocardial lesions, aspergilloma, or localized cutaneous infections 2

Treatment Monitoring

• Regular clinical and radiographic assessments should be performed to evaluate treatment response 1
• For voriconazole, be aware of potential visual disturbances (occurring in approximately 30-45% of patients), which are typically transient 7, 3
• Monitor for drug interactions, particularly with azoles, which have significant potential for interactions with other medications 5

Pitfalls and Caveats

• Amphotericin B deoxycholate is associated with significant nephrotoxicity and infusion-related adverse events and should be avoided when other options are available 2, 6
• Drug-drug interactions are common with azoles and require careful medication review before initiating therapy 5
• Therapeutic drug monitoring is essential for voriconazole due to its variable pharmacokinetics and narrow therapeutic window 1
• Some Aspergillus species (like A. terreus) may be resistant to amphotericin B, necessitating azole therapy 1