Download Aspergillosis

Guidelines for Prevention and Treatment of Opportunistic
Infections in HIV-Infected Adults and Adolescents
Aspergillosis Slide Set
Prepared by the AETC National Coordinating Resource Center based on
recommendations from the CDC, National Institutes of Health, and HIV
Medicine Association/Infectious Diseases Society of America
About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is clinicians
involved in the care of patients with HIV.
Users are cautioned that, owing to the rapidly changing
field of HIV care, this information could become out of date
quickly. Finally, it is intended that these slides be used as
prepared, without changes in either content or attribution.
Users are asked to honor this intent.
-AETC National Coordinating Resource Center
http://www.aidsetc.org
www.aidsetc.org
May 2013
2
Aspergillosis






Epidemiology
Clinical Manifestations
Diagnosis
Prevention
Treatment
Considerations in Pregnancy
www.aidsetc.org
May 2013
3
Aspergillosis: Epidemiology
 Caused by Aspergillus fumigatus, occasionally by
other Aspergillus species
 Invasive aspergillosis is rare in HIV-infected
persons
 Risk factors: low CD4 count (<100 cells/µL),
neutropenia, use of corticosteroids, exposure to
broad-spectrum antibiotics, underlying lung
disease
 Less common with widespread use of potent
ART
www.aidsetc.org
May 2013
4
Aspergillosis: Clinical Manifestations
 Respiratory
 Invasive pneumonia: fever, cough, dyspnea, chest
pain, hemoptysis, hypoxemia; on CXR, diffuse, focal, or
cavitary infiltrates, “halo” of low attenuation around a
pulmonary nodule (or “air crescent” on CT)
 Tracheobronchitis: fever, cough, dyspnea, stridor,
wheezing, airway obstruction; tracheal
pseudomembrane (multiple ulcerative or plaque-like
lesions) seen on bronchoscopy
 Other extrapulmonary forms include: sinusitis,
cutaneous disease, osteomyelitis
www.aidsetc.org
May 2013
5
Aspergillosis: Diagnosis
 Definitive diagnosis:
 Histopathology: tissue invasion by septate hyphae, with
positive culture for Aspergillus spp
 Probable diagnosis of invasive pulmonary
disease:
 Isolation of Aspergillus spp from respiratory secretions
or septate hyphae consistent with Aspergillus in
respiratory samples, with typical CT findings
 ELISA test for galactomannan: sensitivity better for BAL
than for serum; high specificity; not well studied in HIV
www.aidsetc.org
May 2013
6
Aspergillosis: Preventing Disease
 Preventing exposure:
 Aspergillus spp are ubiquitous in the environment;
exposure is not avoidable
 Avoid dusty environments to decrease exposure to
spores
 Preventing disease
 No data in HIV-infected persons; currently not
recommended
 Posaconazole effective in patients with certain
hematologic malignancies and neutropenia
www.aidsetc.org
May 2013
7
Aspergillosis: Treatment
 Not systematically evaluated in HIV-infected
patients
 Preferred:
 Voriconazole 6 mg/kg IV Q12H for 1 day, then 4 mg/kg
IV Q12H until clinical improvement, then 200 mg PO
Q12H
 Significant interactions with protease inhibitors and efavirenz
 Duration of therapy: not established; continue at
least until CD4 >200 cells/µL and infection
appears resolved
www.aidsetc.org
May 2013
8
Aspergillosis: Treatment (2)
 Alternative:






Lipid formulation amphotericin B 5 mg/kg IV QD
Amphotericin B deoxycholate 1 mg/kg IV QD
Caspofungin 70 mg IV for 1 dose, then 50 mg IV QD
Micafungin 100-150 mg IV QD
Anidulafungin 200 mg IV for 1 dose, then 100 mg IV QD
Posaconazole 200 mg PO 4 times per day until clinical
improvement, then 400 mg PO BID
 Duration of therapy: not established; continue at
least until CD4 >200 cells/µL and infection appears
resolved
www.aidsetc.org
May 2013
9
Aspergillosis: ART Initiation
 Start ART as soon as possible after start of
antifungal therapy
 IRIS has rarely been reported
 Triazoles have complex, sometimes bidirectional
interactions with certain ARVs; dosage
adjustments may be needed
www.aidsetc.org
May 2013
10
Aspergillosis: Monitoring and Adverse
Events
 If new or recurrent signs and symptoms, evaluate
for relapse or recurrence
 IRIS reported rarely
 Limited data regarding monitoring of
galactomannan levels in response to therapy
www.aidsetc.org
May 2013
11
Aspergillosis: Treatment Failure
 Prognosis is poor in advanced
immunosuppression without effective ART
 No data to guide management of treatment
failure
 If voriconazole used initially, consider change to
amphotericin B, or echinocandins in combination
with voriconazole or amphotericin B
www.aidsetc.org
May 2013
12
Aspergillosis: Preventing Recurrence
 Chronic maintenance: insufficient data to
recommend for or against
www.aidsetc.org
May 2013
13
Aspergillosis: Considerations in
Pregnancy
 Amphotericin B or its lipid formulations are
preferred initial regimen
 At delivery, evaluate neonate for renal dysfunction and
hypokalemia
 Voriconazole and posaconazole: teratogenic and
embryotoxic in animals; generally avoid in
pregnancy, especially 1st trimester
 Echinocandins: bone and visceral abnormalities
in animals; avoid in 1st trimester
www.aidsetc.org
May 2013
14
Access the Guidelines Online
 AIDS Info: http://aidsinfo.nih.gov
www.aidsetc.org
May 2013
15
About This Slide Set
 This presentation was prepared by Susa Coffey,
MD, for the AETC National Resource Center in
May 2013
 See the AETC NCRC website for the most
current version of this presentation:
http://www.aidsetc.org
www.aidsetc.org
May 2013
16