Treatment of Fungal Lung Infections

Invasive Aspergillosis

Voriconazole is the primary treatment of choice with superior efficacy and better survival rates compared to amphotericin B, with dosing at 6 mg/kg IV every 12 hours for 1 day, followed by 4 mg/kg IV every 12 hours or 200 mg oral twice daily, and treatment should continue until resolution of clinical and radiographic manifestations, with a minimum duration of 6-12 weeks 1, 2
Alternative first-line options when voriconazole cannot be used include liposomal amphotericin B at 3-5 mg/kg/day IV and isavuconazole with comparable efficacy to voriconazole 1, 2
For chronic cavitary pulmonary aspergillosis, oral itraconazole or voriconazole is recommended 3, 1
For aspergilloma, surgical resection may be indicated in certain circumstances, and antifungal therapy is generally not required if asymptomatic 3, 4

Liposomal amphotericin B at ≥5 mg/kg/day IV is the preferred treatment, and surgical resection of infected tissue is mandatory when feasible 1, 3, 4
For CNS involvement, high-dose L-AmB is recommended 3

For pulmonary cryptococcosis in immunocompetent patients with isolated pulmonary disease, fluconazole 200-400 mg/day for 6-12 months is recommended, while for immunocompromised patients, treatment as disseminated infection is advised 5
For pulmonary cryptococcoma, observation if serum antigen is negative, or fluconazole 200-400 mg/day is suggested 5
For disseminated/CNS cryptococcosis, amphotericin B deoxycholate plus 5-flucytosine for 2 weeks, followed by fluconazole for 8-10 weeks, or alternative liposomal amphotericin B for 6-10 weeks is recommended 3, 5

Voriconazole is first-line therapy, with dosing at 6 mg/kg IV every 12 hours for 2 doses, then 4 mg/kg IV every 12 hours or 200 mg oral twice daily, and itraconazole 200 mg twice daily is an effective alternative 6
Treatment duration is a minimum of 6-12 weeks, longer in immunocompromised patients 6

Serial clinical evaluation of symptoms and signs, regular radiographic imaging with CT scans, and for aspergillosis, serial serum galactomannan tests can be used to monitor response 1, 2
Therapeutic drug monitoring for azole antifungals, especially in cases of treatment failure, is recommended 1

Surgical intervention may be necessary alongside medical therapy for pulmonary lesions near great vessels or pericardium, invasion of chest wall from contiguous pulmonary lesion, and persistent hemoptysis from a cavitary lesion 3, 6
Reversal of immunosuppression, if feasible, is crucial for favorable outcomes in invasive fungal infections 3
Aspergillus terreus is clinically resistant to amphotericin B, requiring therapy with azoles 1
In areas with high prevalence of azole-resistant A. fumigatus, liposomal amphotericin B may be preferred as first-line treatment 1