What are the recommended tests and treatment for suspected Aspergillus infection?

Recommended Tests and Treatment for Suspected Aspergillus Infection

For suspected Aspergillus infection, serum galactomannan testing and PCR from the site of infection are the recommended diagnostic tests, while voriconazole is the first-line treatment for invasive aspergillosis. 1, 2

Diagnostic Tests for Aspergillus Infection

Initial Testing

• If aspergillosis is suspected, serum galactomannan testing is recommended (especially in immunocompromised patients) 1
• Blood or serum Aspergillus PCR testing is strongly recommended for patients with severe immunocompromise, such as those with hematological malignancy or transplant recipients 1
• Cultures, imaging, and other diagnostic tests should be performed to help identify the fungal infection 1

Bronchoscopy and Respiratory Specimens

• Bronchoscopy with bronchoalveolar lavage (BAL) is strongly recommended in patients with suspected invasive aspergillosis 1, 3
• BAL samples should be sent for routine culture, cytology, and galactomannan testing 1
• BAL galactomannan has higher sensitivity (85-91%) compared to serum galactomannan for diagnosis of chronic pulmonary aspergillosis 1
• PCR from the site of infection (e.g., BAL, CSF, tissue samples) is superior to blood PCR, particularly in patients receiving antifungal prophylaxis or therapy 4

Serological Testing

• Aspergillus IgG antibody testing is a key diagnostic feature for chronic pulmonary aspergillosis with high sensitivity (>90%) 1
• (1→3)-β-D-glucan serum assays are recommended for diagnosing invasive aspergillosis in high-risk patients but are not specific for Aspergillus 1

Imaging Studies

• Chest CT scan is strongly recommended whenever there is clinical suspicion for invasive pulmonary aspergillosis, regardless of chest radiograph results 1
• Contrast is recommended when a nodule or mass is close to a large vessel 1

Treatment of Aspergillus Infection

First-line Treatment

• Voriconazole is the preferred first-line agent for treatment of invasive aspergillosis 1, 2
• For adults, the loading dose is 6 mg/kg IV every 12 hours for the first 24 hours, followed by a maintenance dose of 4 mg/kg IV every 12 hours or 200 mg oral every 12 hours 2
• Treatment should be continued for a minimum of 6-12 weeks, depending on the degree and duration of immunosuppression 5

Alternative Treatment Options

• Liposomal amphotericin B is recommended as an alternative first-line agent if voriconazole cannot be tolerated or is contraindicated 1, 5
• Isavuconazole is another alternative with strong recommendation 5
• Echinocandins (micafungin or caspofungin) should not be used as primary therapy but can be used when azole and polyene antifungals are contraindicated 5

Treatment Based on Type of Aspergillosis

• For chronic cavitary pulmonary aspergillosis (CCPA), oral itraconazole and voriconazole are the preferred oral antifungal agents, with treatment for at least 6 months 1
• For simple aspergilloma, surgical excision is the treatment of choice if technically feasible and if the patient can tolerate the procedure 3
• For hemoptysis due to aspergilloma, management options include oral tranexamic acid, bronchial artery embolization, or antifungal therapy 1, 3

Prophylaxis

• Antifungal prophylaxis is not routinely recommended unless a patient has a previous history of fungal infections, prolonged neutropenia, or has recently received prolonged treatment with high-dose corticosteroids 1
• If prophylaxis is needed, fluconazole is recommended; itraconazole and voriconazole may also be considered 1

Monitoring and Follow-up

• Follow-up chest CT scan is recommended to assess response to treatment after a minimum of 2 weeks of therapy 1, 3
• Therapeutic drug monitoring is strongly recommended for patients receiving triazole-based therapy to enhance efficacy and minimize toxicity 1, 5
• For patients with progressive disease, long-term or even lifelong antifungal therapy may be required 1, 3

Common Pitfalls to Avoid

• Delaying antifungal therapy while awaiting diagnostic confirmation can worsen outcomes in high-risk patients 5
• Using echinocandins as primary therapy is not recommended due to inferior efficacy compared to voriconazole 5
• Failing to monitor drug levels for azole antifungals can lead to suboptimal treatment outcomes or toxicity 5
• Routine monitoring with β-glucan or galactomannan tests is not recommended in patients without suspected infection 1