‘Uncertainties’ in Detecting, Treating Invasive Aspergillosis

SAN DIEGO—With a survival rate of only 5%, invasive aspergillosis remains a devastating problem that is difficult to prevent, tricky to diagnose, and complicated to treat, according to presenters at a symposium aptly named “Uncertainties in Invasive Aspergillosis,” held at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy.

Prevention (see article below) is especially important, given that there has been little progress in diagnostic strategies, said Paul Verweij, MD, PhD, of University Hospital, Nijmegen, The Netherlands. “Making an accurate diagnosis requires a combination of different elements, such as culture, radiology, and serology,” Dr. Verweij noted.

Management in the face of uncertainty means treating early, but the costs, he warned, are high. “Markers such as pulmonary infiltrates and high temperature are neither very specific nor very sensitive,” he said, “so many patients are treated unnecessarily, with added expense, toxicity, and possible development of drug resistance.”

ELISA Reactivity Test

Dr. Verweij recommended use of the ELISA reactivity test, which is commercially available outside the United States. He noted that studies using ELISA will be performed in the United States sometime this year.

Once a diagnosis is made, the conventional “gold standard” treatment is amphotericin B, said Thomas J. Walsh, MD, of the National Cancer Institute. Lipid formulations of amphotericin B “are filling a critical previously unmet need,” he said. A double-blind randomized controlled trial in immunocompromised patients showed an equivalent therapeutic response for conventional amphotericin B and a lipid formulation, but the lipid formulation showed superior safety, with significantly reduced nephrotoxicity.

Azoles are also making their way into treatment of invasive aspergillosis. David Denning, MD, of North Manchester General Hospital, Manchester, England, said that itraconazole (Sporanox) “is probably as good as amphotericin B as primary therapy, even in highly immunocom-promised patients.” Itraconazole is generally given orally in large doses, at least 400 mg daily.

Surgery, too, may be indicated, although, thoracic surgeon, Alain Bernard, MD, of Hôpital du Bocage, Dijon, France, said that available studies are poor.

Lesions Near the Lung

Dr. Bernard noted that surgery may be indicated when a residual aspergillosis lesion is near the lung, sinus, or brain. To prevent massive hemoptysis, he added, pulmonary resection is indicated when an aspergillosis lesion is localized near a pulmonary artery before bone marrow recovery.