7
Treatment
Î Granulocyte transfusions can be considered for neutropenic patients
with IA that is refractory or are unlikely to respond to standard
therapy, and for an anticipated duration of more than one week (W-L).
Î Recombinant interferon-γ is recommended as prophylaxis in CGD
patients (S-H). Its benefit as adjunctive therapy for IA is unknown.
Î Surgery for aspergillosis should be considered for localized disease
that is easily accessible to debridement (e.g., invasive fungal sinusitis
or localized cutaneous disease) (S-L).
• The benefit for IA in other settings such as in the treatment of endocarditis,
osteomyelitis or focal central nervous system (CNS) disease appears rational.
• Other indications are less clear and require consideration of the patient's immune
status, co-morbidities, confirmation of a single focus, and the risks of surgery.
Î IA is not an absolute contraindication to additional chemotherapy or
HSCT (S-M).
Î Decisions about when to proceed with additional chemotherapy or HSCT
following the diagnosis of aspergillosis should involve both Infectious
Diseases specialists and Hematologists/Oncologists.
These decisions must consider the risk of progressive aspergillosis
during periods of subsequent anti-neoplastic treatment versus the risk of
death from the underlying malignancy if this treatment is delayed (S-L).
Refractory or Progressive Disease
Î The IDSA recommends an individualized approach that takes into
consideration the rapidity, severity, extent of infection and patient
co-morbidities, and excludes the emergence of a new pathogen (S-L).
• The general strategies for salvage therapy typically include:
▶ changing the class of antifungal
▶ tapering or reversal of underlying immunosuppression when feasible
▶ surgical resection of necrotic lesions in selected cases.
Î In the context of salvage therapy, an additional antifungal agent may be
added to current therapy, or combination antifungal drugs from different
classes other than those in the initial regimen may be used (W-M).
Î In patients currently receiving an antifungal and exhibiting an adverse
event attributable to this agent, the IDSA recommends changing to an
alternative class of antifungal, or the use of an alternative agent with a
non-overlapping side-effect profile (S-L).
Î For salvage therapy, agents include lipid formulations of AmB,
micafungin, caspofungin, posaconazole or itraconazole. The use of a
triazole as salvage therapy should take into account prior antifungal
therapy, host factors, pharmacokinetic considerations, and possible
antifungal resistance (S-M).
