Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

Aspergillosis 169

■If present, have a low threshold for instituting high-dose ampho-

tericin, even in absence of conclusive data.

■Think of involving surgical services early if surgical excision for

biopsy or therapy (brain abscess, sinus disease) may be needed.

General Measures

■General supportive care, reverse neutropenia, dose reduction of cor-

ticosteroids and other immunosuppressives if possible; await bone

marrow recovery

specific therapy

Indications

■Everyone for whom invasive disease is suspected; this is a rapidly

progressive disease with a high mortality even if therapy is initiated

promptly.

Treatment Options

■Medical Therapy:

➣Voriconazole: Has replaced amphotericin as the initial agent of

choice. Start IV, can switch to PO after 7 days if improvement

seen.

➣Amphotericin:

Use at maximally tolerated doses.

Lipid-based formulations of amphotericin may be substituted

if the patient develops nephrotoxicity on therapy, or has base-

line impaired renal function.

➣Itraconazole:

Itraconazole oral therapy may be an option to initiate therapy

if the patient is not ill, for pulmonary disease, or as follow-

up therapy to amphotericin once the progression of disease is

halted.

Itraconazole cyclodextran solution may have increased

bioavailability.

➣Caspofungin:

In the echinocandin class, approved for invasive aspergillosis.

No PO form available. Commonly has been used in salvage

therapy.

➣Other agents:

New triazoles such as posaconazole and ravuconazole may be

effective alternatives for invasive disease.