Recent guidelines for the diagnosis and treatment of aspergillosis

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  • Bennett John E.
    Clinical Mycology Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA

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The diagnostic guidelines for invasive aspergillosis have recently been revised by the EORTC-MSG, a European-USA group of clinical investigators. The purpose of the guidelines is to provide a consensus that is reproducible and feasible to perform for clinical trials of antifungal agents. The category of "probable" aspergillosis is to include patients with early disease that should receive antifungal therapy despite absence of firm proof of diagnosis. Patients in this group are defined by (1) an immunodepressed state that increases risk of aspergillosis, (2) clinical findings consistent with this mycosis and (3) microbiologic evidence of a mould infection. One change in the criteria from the prior guidelines was to upgrade the significance of bronchoalveolar lavage cultures and specific thoracic CT findings in patients at very high risk of aspergillosis. These patients are recipients of allogeneic hematopoietic stem cell transplant or have had prolonged, severe neutropenia. Another change was to recognize the utility of galactomannan and glucan testing, although definitions of what constitutes a positive test have not yet been decided.<BR>The guidelines from the Infectious Diseases Society of America omit diagnostic criteria but provide detailed treatment recommendations for the different clinical forms of aspergillosis, as well as brief recommendations about empirical therapy and prophylaxis. Voriconazole is recommended as the treatment of choice for most clinical forms of invasive aspergillosis, with alternatives including a lipid formulation of amphotericin B, itraconazole or caspofungin. Reduction of immunosuppression is advocated as vitally important. Surgery has a role for selected conditions.

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