January 1, 2008

IDSA Publishes Updated Guidelines on Aspergillus

New IDSA guidelines on the treatment of Aspergillus have been published in the February 1 issue of Clinical Infectious Diseases, now available online.

The new guidelines replace the previous practice guidelines that were published in 2000. The objective of the new guidelines is to summarize the current evidence for treatment of three different forms of aspergillosis, including invasive, chronic (and saprophytic), and allergic. They also introduce major new anti-fungal agents, including extended spectrum triazoles (such as voriconazole and posaconazole) and echinocandins, a new drug class with anti-Aspergillus activity. 

Similar to the previous practice guidelines, the new set places emphasis on early diagnosis, treatment, and prevention of the different forms of invasive aspergillosis, which include invasive pulmonary, sinus, disseminated and several types of single-organ.

Early detection is vital since aspergillus species have emerged as an important cause of life-threatening infections in patients with compromised immune systems, particularly those with prolonged neutropenia, advanced HIV infection, or those who have undergone allogeneic hematopoietic stem cell or lung transplantation.

As part of its emphasis on the importance of early diagnosis and therapy, the guidelines consider the role of galactomannan and beta-glucan as surrogate markers for early diagnosis, as well as the use of therapeutic drug monitoring (especially for triazoles) and potential for drug toxicity in patients with progressive infection.

Since 2000, new clinical data has been published to support the updated treatment recommendations for Aspergillus, including:

  • A global comparative clinical trial establishing voriconazole as the recommended primary therapy of invasive aspergillosis in most patients
  • A comparison of data establishing the efficacy and safety of liposomal amphotericin B as an alternative agent in some patients
  • Echinocandins being used as salvage therapy
  • Posaconazole prophylaxis being used for prevention of invasive aspergillosis in high-risk patients

In the absence of a well-controlled prospective clinical trial, routine administration of combination therapy is not recommended, but in the setting of salvage therapy, an additional anti-fungal agent might be added to current therapy.  Combination anti-fungal drugs from different classes other than the initial regimen may also be used.  It was also concluded that because of poorer outcomes and increased toxicity, the role of amphotericin B deoxycholate is reduced to resource-limited settings where other agents are not available.

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