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Treatment
Î In those who fail therapy, who develop triazole resistance and/or have
adverse events, intravenous micafungin (W-L), caspofungin (W-L), or
amphotericin B (W-L) yield some responses.
• Treatment may need to be prolonged.
Î Surgical resection is an option for some patients with localized
disease unresponsive to medical therapy, including those with pan-
azole resistant A. fumigatus infection or persistent hemoptysis despite
bronchial artery embolization (S-M).
• The outcomes from surgery are less favorable than those with single aspergilloma,
and a careful risk assessment prior to surgical intervention is required.
Î In those with progressive disease, long term, even life-long, antifungal
therapy may be required to control disease (W-L), with continual
monitoring for toxicity and resistance.
Aspergilloma
Î Asymptomatic patients with a single aspergilloma and no progression
of the cavity size over 6–24 months should continue to be observed
(S-M).
Î Patients with symptoms, especially significant hemoptysis, with a
single aspergilloma, should have it resected, assuming that there are
no contraindications (S-M).
Î Peri/post-operative antifungal therapy is not routinely required,
but if the risk of surgical spillage of the aspergilloma is moderate
(related to location and morphology of the cavity) antifungal therapy
with voriconazole (or another mold-active azole) or an echinocandin is
suggested to prevent Aspergillus empyema (W-L).
