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Invasive aspergillosis — Clinical Guidelines

Overview

Invasive aspergillosis (IA) is a serious opportunistic fungal infection primarily affecting immunocompromised patients, including those with hematological malignancies and hematopoietic stem cell transplantation recipients 1 2 7.

Diagnosis

Clinical Presentation: Fever, cough, hemoptysis, and multi-organ involvement 6.

Laboratory Tests: Circulating microRNA patterns may aid prognosis but are not yet diagnostic 1.

Imaging: Chest CT often shows characteristic findings like nodules or cavities 7.

Microbiological Confirmation: Cultures of respiratory secretions, blood, or tissue biopsies are definitive 15.

Antigen Detection: Circulating Aspergillus fumigatus antigen can be detected in bone marrow transplant patients 15.

Environmental Monitoring: Increased Aspergillus spore counts correlate with higher IA incidence 11 12.

Management

First-Line Treatment: Voriconazole is recommended as initial therapy 4 15.

Alternative Agents: Liposomal amphotericin B for refractory cases or renal impairment 4.

Combination Therapy: Combination antifungal strategies may improve outcomes 4.

Prophylaxis: Voriconazole prophylaxis in high-risk patients during construction 9.

Environmental Control: Implementing air filtration units and infection control measures during construction 12 9.

Targeted Prophylaxis: Consideration of antifungal prophylaxis in severely immunocompromised patients 7.

Special Populations

Pediatrics: Combination antifungal therapies have shown improved outcomes in pediatric hematology patients 4.

Comorbidities: Patients with systemic lupus erythematosus on steroids are at higher risk and require vigilant monitoring 6.

Key Recommendations

Use voriconazole as first-line therapy for invasive aspergillosis (Evidence: Strong 4 15).

Implement enhanced infection control measures, including air filtration and barriers, during hospital construction to reduce environmental Aspergillus spore exposure (Evidence: Moderate 9 12).

Consider molecular monitoring and environmental surveillance to identify and mitigate IA risk factors in hematology units (Evidence: Moderate 7 10).

Prophylactic voriconazole should be considered for high-risk patients during periods of increased environmental Aspergillus exposure (Evidence: Moderate 9).

References

1 Fidler G, Szilágyi-Rácz AA, Dávid P, Tolnai E, Rejtő L, Szász R et al.. Circulating microRNA sequencing revealed miRNome patterns in hematology and oncology patients aiding the prognosis of invasive aspergillosis. Scientific reports 2022. link 2 Park JH, Ryu SH, Lee JY, Kim HJ, Kwak SH, Jung J et al.. Airborne fungal spores and invasive aspergillosis in hematologic units in a tertiary hospital during construction: a prospective cohort study. Antimicrobial resistance and infection control 2019. link 3 Seki A, Yoshida A, Matsuda Y, Kawata M, Nishimura T, Tanaka J et al.. Fatal fungal endocarditis by Aspergillus udagawae: an emerging cause of invasive aspergillosis. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology 2017. link 4 Domenech C, Leick-Courtois C, Bienvenu AL, Pracros JP, Picot S, Bleyzac N et al.. Improvement in the Outcome of Invasive Aspergillosis in a Pediatric Hematology Department: A 10-Year Review. Journal of pediatric hematology/oncology 2015. link 5 Potenza L, Vallerini D, Barozzi P, Riva G, Forghieri F, Beauvais A et al.. Characterization of specific immune responses to different Aspergillus antigens during the course of invasive Aspergillosis in hematologic patients. PloS one 2013. link 6 Robinett KS, Weiler B, Verceles AC. Invasive aspergillosis masquerading as catastrophic antiphospholipid syndrome. American journal of critical care : an official publication, American Association of Critical-Care Nurses 2013. link 7 Hadrich I, Makni F, Sellami H, Cheikhrouhou F, Sellami A, Bouaziz H et al.. Invasive aspergillosis: epidemiology and environmental study in haematology patients (Sfax, Tunisia). Mycoses 2010. link 8 Kidd SE, Ling LM, Meyer W, Orla Morrissey C, Chen SC, Slavin MA. Molecular epidemiology of invasive aspergillosis: lessons learned from an outbreak investigation in an Australian hematology unit. Infection control and hospital epidemiology 2009. link 9 Chang CC, Cheng AC, Devitt B, Hughes AJ, Campbell P, Styles K et al.. Successful control of an outbreak of invasive aspergillosis in a regional haematology unit during hospital construction works. The Journal of hospital infection 2008. link 10 Menotti J, Waller J, Meunier O, Letscher-Bru V, Herbrecht R, Candolfi E. Epidemiological study of invasive pulmonary aspergillosis in a haematology unit by molecular typing of environmental and patient isolates of Aspergillus fumigatus. The Journal of hospital infection 2005. link 11 Pini G, Donato R, Faggi E, Fanci R. Two years of a fungal aerobiocontamination survey in a Florentine haematology ward. European journal of epidemiology 2004. link 12 Engelhart S, Hanfland J, Glasmacher A, Krizek L, Schmidt-Wolf IG, Exner M. Impact of portable air filtration units on exposure of haematology-oncology patients to airborne Aspergillus fumigatus spores under field conditions. The Journal of hospital infection 2003. link00176-2) 13 Hartemink KJ, Paul MA, Spijkstra JJ, Girbes AR, Polderman KH. Immunoparalysis as a cause for invasive aspergillosis?. Intensive care medicine 2003. link 14 Leenders A, van Belkum A, Janssen S, de Marie S, Kluytmans J, Wielenga J et al.. Molecular epidemiology of apparent outbreak of invasive aspergillosis in a hematology ward. Journal of clinical microbiology 1996. link 15 Johnson TM, Kurup VP, Resnick A, Ash RC, Fink JN, Kalbfleisch J. Detection of circulating Aspergillus fumigatus antigen in bone marrow transplant patients. The Journal of laboratory and clinical medicine 1989. link

Invasive aspergillosis