Aspergillus_Guideline.ZIP

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Now, I know we should not make light of any IDSA Guidelines, far from it. This latest, the Aspergillus Guideline [1], like others before, is a thoughtful document which reviews the newest information and reflects expert authoritative thinking on the subject. It also is a hefty 60 pages long, as seems to become the norm for these documents nowadays.

Hey, no problem for my electronic bookshelf – bring ‘em on!  As I think about it, every bug causing infection will eventually get its own guideline.  Soon, there will be no longer be a need for monographs or textbooks, Aspergillus Guideline IDSAinstead we will have a ‘living library’ of thousands of guideline pages. Mandell’s will be replaced by a Guideline Encyclopedia Universalis Infectiologica.

Who can keep up with this? What the busy clinician really needs is something more succinct. The poor fellow who would so much like to stay current but simply cannot cope (he just read 3 versions of hepatitis C guidelines in rapid succession!) should get a break.

We would like to offer a succinct version in this blog, highlighting core messages and new recommendations. Nothing else, just the key points.  Call it the Cliff Notes for ID Guidelines or the Quick Take-Aways for the busy ID doc, below the abridged Aspergillus Guideline, unabashedly condensed.  Just don’t call it Aspergillus for DUMMIES, please.

Here is our zipped version:

  1. Keep exposure of high-risk patients to molds low and perform surveillance checks
  2. Galactomannan testing on serum or BAL is useful for diagnostics and f/u
  3. Chest CT is useful for diagnosis and f/u
  4. 1st line treatment of invasive aspergillosis (IA) is voriconazole, with liposomal AMB or isavuconazole as 2nd line agents
  5. Prophylaxis of invasive aspergillosis IA should be with voriconazole or posaconazole
  6. Check trough levels at steady state, esp. for voriconazole
  7. For azoles with a propensity for DDI, monitor therapeutic levels of concomitant therapies (tacrolimus, cyclosporine, TKIs)
  8. Routine antifungal susceptibility testing is not advisable

If this sounds a bit anticlimactic, you are correct. Since the last aspergillus guidelines in 2008, there has been significant progress overall, with small steps here and there but we had no major breakthroughs. We are missing a new class of antifungals that would change the field like the candins did for candidiasis. The candins have yet to prove efficacy in aspergillosis in a convincing study. Besides the arrival of a new azole (isavuconazole), only the diagnostics have brought some improvement in care and advanced the field.

The full guidelines contain a lot more, of course. They also address pediatric IA, the approach to non-responders, extrapulmonary aspergillosis and controversies (candins for IA, febrile neutropenia). There is also a section on allergic pulmonary aspergillosis. For that rare case of aspergillus ophthalmitis, I trust you will refer to the newest Guidance and other source documents for advice when the time comes and you are confronted with such a case.

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Abbreviations:
TKI        tyrosine kinase inhibitor
DDI       drug-drug interactions
IA          invasive aspergillosis
TDM      therapeutic drug monitoring

Reference:
[1] T Patterson. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases Advance Access published June 29, 2016

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