What are the guideline sources, guidelines and references for Invasive aspergillosis ?
Guideline sources The following summarized guidelines for the evaluation and management of invasive aspergillosis are prepared by our editorial team based on guidelines from the American Society of Transplantation (AST 2019), the European Confederation of Medical Mycology (ECMM/ERS/ESCMID 2018), the Infectious Diseases Society of America (IDSA 2016), and the American Thoracic Society (ATS 2011). 1 2 3 4 Guidelines 1. Diagnostic investigations Nucleic acid testing: Insufficient evidence to support the routine use of blood-based PCR testing for the diagnosis of invasive aspergillosis. Obtain PCR testing for the diagnosis of invasive aspergillosis in selected patients on a case-by- case basis. Take into account the methodologies and performance characteristics of the specific https://web.pathway.md/diseases/reccWG7cLvPaIwOY7 1/4 6/24/23, 2:34 PM Invasive aspergillosis Pathway assay and interpret results accordingly. Interpret the results of PCR testing in conjunction with other diagnostic tests and the clinical context. B Galactomannan and beta-D-glucan: As per ESCMID 2018 guidelines: Obtain serial screening for invasive aspergillosis with serum galactomannan in patients with prolonged neutropenia and in allogeneic stem cell transplant recipients during the early engraftment phase. B Set an optical density index cut-off of 0.5 for serum samples in hematological patients in the absence of mold-active prophylaxis. A Consider obtaining (1-3)- -D-glucan for the diagnosis of invasive aspergillosis. C As per IDSA 2016 guidelines, obtain serum and BAL galactomannan as an accurate marker for the diagnosis of invasive aspergillosis in adult and pediatric patients with hematologic malignancy or HSCT. A Show 3 more Antibody testing: do not obtain antibody detection tests for the diagnosis of invasive aspergillosis. D Fluorescent dye tests: consider using fluorescent dyes (such as Calcofluor White or Blancophor ) due to their increased sensitivity, rapid turnaround time, and broad applicability, recognizing that they are not specific for Aspergillus. B Species identification: Obtain species identification to the complex level for clinically relevant isolates from patients requiring antifungal treatment, and for epidemiological purposes. B Obtain species identification to the complex level for all clinically significant isolates in clinical laboratories. B Antifungal susceptibility testing: As per ESCMID 2018 guidelines, obtain antifungal susceptibility testing of Aspergillus isolates in patients with invasive disease, with the exception of azole-naive patients in regions with no resistance found in contemporary surveillance programs, and regularly for epidemiological purposes including 100 isolates. Obtain antifungal susceptibility testing especially in patients unresponsive to antifungal treatment and in patients clinically suspected of having an azole- resistant pathogen. B Show 4 more As per IDSA 2016 guidelines: Do not obtain routine antifungal susceptibility testing in patients recovered during initial infection. D Obtain antifungal susceptibility testing of Aspergillus isolates using a reference method in patients with suspected azole-resistant isolates or in patients unresponsive to antifungal agents, or for epidemiological purposes. B Computed tomography: As per ESCMID 2018 guidelines: https://web.pathway.md/diseases/reccWG7cLvPaIwOY7 2/4 6/24/23, 2:34 PM Invasive aspergillosis Pathway Obtain thin-section chest CT (multidetector CT, multislice CT, spiral CT, HRCT) at an optimized dose (according to the ALARA principle) as first-line imaging in patients at risk for invasive aspergillosis presenting with fever of unknown origin or clinical symptoms of lower respiratory tract infection remaining febrile despite broad-spectrum antibacterial treatment. B Consider obtaining pulmonary CT in the early diagnosis of invasive aspergillosis to elicit vessel occlusion at the level of a suspicious fungal lesion, and obtain it in case of hemoptysis. B As per IDSA 2016 guidelines: Obtain chest CT in patients with clinically suspected invasive pulmonary aspergillosis regardless of CXR results. A Do not use routine contrast during chest CT in patients with suspected invasive pulmonary aspergillosis. Administer contrast when a nodule or a mass is close to a large vessel. D 2. Diagnostic procedures Diagnostic bronchoscopy: Perform bronchoscopy with BAL in patients with suspected invasive pulmonary aspergillosis. Do not perform BAL in patients with significant comorbidities, such as severe hypoxemia, bleeding, or platelet transfusion-refractory thrombocytopenia. B Perform a standardized BAL procedure and send the sample for routine culture, cytology, and non-culture-based methods (such as galactomannan). B Brochoalveolar lavage: consider performing early BAL, guided by CT findings. B Show 2 more Lung biopsy: as per IDSA 2016 guidelines, consider performing percutaneous or endobronchial lung biopsy in patients with peripheral nodular lesions. B Histopathology: As per ESCMID 2018 guidelines, obtain molecular detection of fungi on hyphal positive biopsy samples. B As per IDSA 2016 guidelines, send tissue and fluid specimens in adequate quantities for simultaneous histopathologic/cytologic and culture examination. Use molecular methods in case of atypical growth or concerns for resistance. A 3. Medical management General principles: As per ESCMID 2018 guidelines, initiate antifungal therapy in all patients at risk considered by the responsible clinician as having invasive aspergillosis. B As per ATS 2011 guidelines, reverse immune suppression, such as neutropenia, if possible, for successful treatment. https://web.pathway.md/diseases/reccWG7cLvPaIwOY7 3/4 6/24/23, 2:34 PM Invasive aspergillosis Pathway Azoles: As per ESCMID 2018 guidelines, initiate voriconazole or isavuconazole for the treatment of invasive aspergillosis due to species showing high amphotericin B MICs. A Show 2 more As per IDSA 2016 guidelines, initiate triazoles as the preferred agents for the treatment and prevention of invasive aspergillosis in most patients. A As per ATS 2011 guidelines, initiate either IV voriconazole or liposomal amphotericin B in patients with invasive pulmonary aspergillosis. Administer IV voriconazole 6 mg/kg every 12 hours for 1 day, followed by 4 mg/kg every 12 hours until improvement, followed by oral voriconazole 200 mg every 12 hours (preferred) or oral itraconazole 400-600 mg/day until resolution or stabilization of all clinical and radiographic manifestations. A Amphotericin B: As per ESCMID 2018 guidelines, initiate liposomal amphotericin B therapy in patients with voriconazole-resistant infection (MIC > 2 mg/L). B Show 2 more As per IDSA 2016 guidelines: Administer amphotericin B deoxycholate and its lipid derivatives, if voriconazole cannot be administered, for initial and salvage therapy in patients with Aspergillus infections, recognizing that it should be reserved for use in resource-limited settings in which no alternative agents are available. Consider administering lipid formulations of amphotericin B if azoles are contraindicated or not tolerated. B Consider administering aerosolized formulations of amphotericin B for prophylaxis in patients with prolonged neutropenia including: patients receiving induction/reinduction therapy for acute leukemia allogeneic hematopoietic stem cell transplant recipients following conditioning or during treatment of GvHD lung transplant recipients. C As per ATS 2011 guidelines: Initiate either IV voriconazole or liposomal amphotericin B in patients with invasive pulmonary aspergillosis. Administer IV liposomal amphotericin B 3-5 mg/kg/day until improvement, followed by oral voriconazole 200 mg every 12 hours (preferred) or oral itraconazole 400-600 mg/day until resolution or stabilization of all clinical and radiographic manifestation. A Prefer a lipid formulation of amphotericin B to reduce renal toxicity to allow the administration of high doses of amphotericin for a prolonged time. B Echinocandins: do not use echinocandins as monotherapy routinely for primary treatment of patients with invasive aspergillosis, even though they are effective in salvage therapy, either alone or in combination. D Combination therapy: As per ESCMID 2018 guidelines, initiate a combination of voriconazole and an echinocandin or liposomal amphotericin B as first-line therapy in setting with azole resistance rates of > 10%. B https://web.pathway.md/diseases/reccWG7cLvPaIwOY7 4/4