Red Flags
- Severely immunocompromised host (prolonged neutropenia, allogeneic HSCT, SOT, high-dose steroids) with new pulmonary infiltrate, sinusitis, or CNS lesion — empiric mould-active therapy pending workup[1]
- Cavitary pulmonary infiltrate with halo/air-crescent sign on CT in immunocompromised — invasive pulmonary aspergillosis[1]
- Massive haemoptysis from a known aspergilloma — interventional radiology embolisation; surgical resection if recurrent[1]
- ABPA flare in asthma or cystic fibrosis (rising IgE, new infiltrates, mucous plugging, eosinophilia) — corticosteroids ± antifungal[2]
First-line treatment
Interventions
- Source control and surgical resection[1]For aspergilloma with significant haemoptysis or refractory invasive disease in resectable foci; combined with systemic antifungal
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Voriconazole[1] | Triazole antifungal | Loading 6 mg/kg IV q12h × 2 doses, then 4 mg/kg IV q12h or 200 mg PO BD; therapeutic drug monitoring (target trough 1–5.5 mg/L) | 9 mg/kg IV q12h loading then 8 mg/kg q12h | Primary therapy for invasive aspergillosis (pulmonary, sinus, CNS); monitor LFTs and visual side effects |
| Isavuconazole[1] | Triazole antifungal | Loading 200 mg PO/IV q8h × 6 doses, then 200 mg once daily | — | Alternative first-line; non-inferior to voriconazole, fewer drug interactions, no QTc prolongation, easier administration |
| Liposomal amphotericin B[1] | Polyene antifungal | 3–5 mg/kg IV once daily | 3–5 mg/kg IV once daily | Salvage or primary when triazoles contraindicated (drug interaction, refractory disease) |
| Caspofungin or anidulafungin[1] | Echinocandin | Caspofungin 70 mg loading then 50 mg IV daily | — | Salvage therapy or in combination for refractory disease; not for primary monotherapy |
| Posaconazole[1] | Triazole (prophylaxis) | 300 mg PO BD × 1 day, then 300 mg daily (delayed-release tablet) | — | Prophylaxis in high-risk neutropenic patients (AML induction, GVHD) |
| Prednisolone (oral) for ABPA[2] | Glucocorticoid | 0.5 mg/kg/day for 2 weeks then taper over 8–12 weeks | — | ABPA acute exacerbation; itraconazole 200 mg BD as steroid-sparing add-on |
Voriconazole[1]
Triazole antifungal
- Adult
- Loading 6 mg/kg IV q12h × 2 doses, then 4 mg/kg IV q12h or 200 mg PO BD; therapeutic drug monitoring (target trough 1–5.5 mg/L)
- Paediatric
- 9 mg/kg IV q12h loading then 8 mg/kg q12h
Primary therapy for invasive aspergillosis (pulmonary, sinus, CNS); monitor LFTs and visual side effects
Isavuconazole[1]
Triazole antifungal
- Adult
- Loading 200 mg PO/IV q8h × 6 doses, then 200 mg once daily
- Paediatric
- —
Alternative first-line; non-inferior to voriconazole, fewer drug interactions, no QTc prolongation, easier administration
Liposomal amphotericin B[1]
Polyene antifungal
- Adult
- 3–5 mg/kg IV once daily
- Paediatric
- 3–5 mg/kg IV once daily
Salvage or primary when triazoles contraindicated (drug interaction, refractory disease)
Caspofungin or anidulafungin[1]
Echinocandin
- Adult
- Caspofungin 70 mg loading then 50 mg IV daily
- Paediatric
- —
Salvage therapy or in combination for refractory disease; not for primary monotherapy
Posaconazole[1]
Triazole (prophylaxis)
- Adult
- 300 mg PO BD × 1 day, then 300 mg daily (delayed-release tablet)
- Paediatric
- —
Prophylaxis in high-risk neutropenic patients (AML induction, GVHD)
Prednisolone (oral) for ABPA[2]
Glucocorticoid
- Adult
- 0.5 mg/kg/day for 2 weeks then taper over 8–12 weeks
- Paediatric
- —
ABPA acute exacerbation; itraconazole 200 mg BD as steroid-sparing add-on
Safety-net
- Take voriconazole or isavuconazole exactly as prescribed; missing doses risks treatment failure and resistance[1]
- On voriconazole, expect transient visual disturbances (light flashes, blurring) — usually subside; report sustained changes[1]
- If you have ABPA, monitor for asthma flare or new haemoptysis — same-day medical review[2]
Referral criteria
- Suspected invasive aspergillosis in immunocompromised hostInfectious diseases and clinical microbiology same-day[1]
- Massive haemoptysis from aspergillomaInterventional radiology for embolisation; thoracic surgery for resection[1]
- Refractory or progressive aspergillosis on first-line triazoleInfectious diseases for salvage regimen and TDM review[1]
- ABPA in asthma/CF with frequent exacerbationsPulmonology for combined steroid-antifungal management[2]
Clinical summary
Diagnosis and treatment of invasive aspergillosis (pulmonary, sinus, CNS, disseminated) and chronic forms; isavuconazole and voriconazole as first-line.
References
- 1.IDSA 2016 Clinical Practice Guideline Update for the Diagnosis and Management of Aspergillosis (current; 2024 ISHAM update for ABPA) (2016)
- 2.Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. European Respiratory Journal (2024)