Treatment of Invasive Aspergillosis with Bowel Wall Thickening

Introduction to Management

The American College of Physicians recommends initiating voriconazole immediately as first-line systemic antifungal therapy, performing urgent surgical debridement of necrotic bowel tissue, and reducing immunosuppression if feasible, as this triad represents the cornerstone of management for gastrointestinal invasive aspergillosis 1, 2, 3

The Infectious Diseases Society of America suggests that voriconazole is the standard of care for invasive aspergillosis regardless of anatomic location, demonstrating superior survival compared to amphotericin B (71% vs 58% at 12 weeks) in the pivotal randomized trial 2, 3
The loading dose of voriconazole 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 for a minimum of 7 days, and then transition to oral 200 mg twice daily once clinically stable 2, 3

The Society of Critical Care Medicine recommends urgent surgical exploration with resection of necrotic bowel as mandatory in gastrointestinal invasive aspergillosis presenting with bowel wall thickening and necrosis 1
The combination of surgical debridement and antifungal therapy improves survival (64% with endoscopic sinus surgery in rhinosinusitis studies, principle applies to all invasive aspergillosis sites) 1

The European Society of Clinical Microbiology and Infectious Diseases states that positive serum galactomannan has 80-100% sensitivity and 90-100% specificity in neutropenic patients, with a positive predictive value of 88% when both PCR and galactomannan are positive 1, 5, 6
The negative predictive value is >90% for excluding invasive aspergillosis 5, 6

The American Society of Transplantation recommends reducing or discontinuing immunosuppressive medications when medically feasible, as this is the third essential pillar of treatment alongside antifungals and surgery 1, 4

The International Immunocompromised Host Society suggests serial galactomannan testing every 3-4 days initially, then twice weekly, with a progressive decrease in galactomannan optical density index during the first 2 weeks predicting satisfactory response 5, 6, 7
Regular CT scans should be performed to assess lesion resolution 2, 4

The European Respiratory Society notes that hematologic malignancy, recent chemotherapy, recent bone marrow transplant, neutropenia at diagnosis, and renal/hepatic failure are associated with worse survival 1

The Infectious Diseases Society of America recommends liposomal amphotericin B formulations, echinocandins (caspofungin or micafungin), or itraconazole as alternative azole for salvage therapy if initial voriconazole therapy fails or is not tolerated 2, 4