What are the treatment options for common fungal infections of the lung?

Treatment Options for Common Fungal Infections of the Lung

For common fungal lung infections, voriconazole is the first-line treatment for invasive aspergillosis, liposomal amphotericin B is preferred for mucormycosis, and specific antifungals are indicated for other fungal pathogens based on identification and patient factors. 1, 2

Invasive Aspergillosis

• Voriconazole is the primary treatment of choice with superior efficacy and better survival rates (71% vs 58% at 12 weeks) compared to amphotericin B 1, 2

  • Dosing: 6 mg/kg IV every 12 hours for 1 day (loading), followed by 4 mg/kg IV every 12 hours or 200 mg oral twice daily 2, 3
  • Treatment should continue until resolution of clinical and radiographic manifestations, with a minimum duration of 6-12 weeks 2

• Alternative first-line options when voriconazole cannot be used:

  • Liposomal amphotericin B (L-AmB) at 3-5 mg/kg/day IV 1, 2
  • Isavuconazole with comparable efficacy to voriconazole 1, 2

• For chronic cavitary pulmonary aspergillosis:

  • Oral itraconazole or voriconazole is recommended 4, 1

• For aspergilloma:

  • Surgical resection may be indicated in certain circumstances 4
  • Antifungal therapy is generally not required if asymptomatic 4

Mucormycosis (Zygomycosis)

• Liposomal amphotericin B at ≥5 mg/kg/day IV is the preferred treatment 1
• Surgical resection of infected tissue is mandatory when feasible 4
• For CNS involvement, high-dose L-AmB is recommended 4

Cryptococcosis

• For pulmonary cryptococcosis:

  • In immunocompetent patients with isolated pulmonary disease: fluconazole 200-400 mg/day for 6-12 months 4
  • For immunocompromised patients: treat as disseminated infection 4
  • For pulmonary cryptococcoma: observation if serum antigen is negative, or fluconazole 200-400 mg/day 4

• For disseminated/CNS cryptococcosis:

  • Amphotericin B deoxycholate plus 5-flucytosine for 2 weeks, followed by fluconazole for 8-10 weeks 4
  • Alternative: liposomal amphotericin B for 6-10 weeks 4

Dematiaceous Fungi

• Voriconazole is first-line therapy (6 mg/kg IV every 12 hours for 2 doses, then 4 mg/kg IV every 12 hours or 200 mg oral twice daily) 5
• Itraconazole 200 mg twice daily is an effective alternative 5
• Treatment duration minimum 6-12 weeks, longer in immunocompromised patients 5

Monitoring Response to Treatment

• Serial clinical evaluation of symptoms and signs 1, 2
• Regular radiographic imaging with CT scans 1, 2
• For aspergillosis, serial serum galactomannan tests can be used to monitor response 1, 2
• Therapeutic drug monitoring for azole antifungals, especially in cases of treatment failure 1

Special Considerations

• Surgical intervention may be necessary alongside medical therapy for:

  • Pulmonary lesions near great vessels or pericardium 4, 5
  • Invasion of chest wall from contiguous pulmonary lesion 4
  • Persistent hemoptysis from a cavitary lesion 4, 5

• Reversal of immunosuppression, if feasible, is crucial for favorable outcomes in invasive fungal infections 4

• Candida isolated from the lower respiratory tract rarely represents true infection and requires histopathologic evidence to confirm diagnosis before treatment 4

• Aspergillus terreus is clinically resistant to amphotericin B, requiring therapy with azoles 1

• In areas with high prevalence of azole-resistant A. fumigatus, liposomal amphotericin B may be preferred as first-line treatment 1

• Drug interactions must be carefully monitored, particularly between voriconazole and anticonvulsants 4, 6

• Nephrotoxic medications should be used with caution when administering amphotericin B formulations 6