Invasive Aspergillosis Treatment Guidelines

Primary Treatment Options

The Infectious Diseases Society of America recommends voriconazole as the first-line treatment for invasive aspergillosis due to its superior efficacy and survival outcomes compared to other antifungal agents, with strong evidence supporting its use (A-I level recommendation) 1, 4, 5
The dosing regimen for voriconazole includes 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 5, 6, 3
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, with an A-I recommendation 1, 3

Lipid formulations of amphotericin B (LFAB) are recommended as salvage therapy options for patients who fail primary therapy or cannot tolerate initial treatment, with an A-II recommendation 1, 8
Itraconazole is also recommended as a salvage therapy option, with a B-II recommendation 1, 6
Caspofungin and micafungin are recommended as salvage therapy options, with a B-II recommendation 1, 6, 8

The treatment approach algorithm involves confirming diagnosis while initiating therapy, starting primary therapy with voriconazole or isavuconazole, monitoring response through clinical evaluation and radiographic imaging, and adjusting therapy if inadequate response 1, 3, 5, 7
Adjusting therapy may involve changing to a different drug class or considering combination therapy in refractory cases, with a B-II recommendation 1, 9

Treatment should continue for a minimum of 6-12 weeks, with ongoing therapy in immunosuppressed patients until lesions have resolved 3, 5, 7

Aspergillus terreus is clinically resistant to amphotericin B, necessitating azole therapy, with an A-I recommendation 1, 10
Therapeutic drug monitoring should be considered for azoles, particularly in cases of treatment failure, with a B-II recommendation 9
Combination therapy is not routinely recommended for primary treatment but may be considered for salvage therapy, with a B-II recommendation 3, 9