Prophylaxis and Treatment of Invasive Aspergillosis: Who and How of Prophylaxis, Treatment, and New Therapies

Abstract

To discuss the approach to antifungal prophylaxis and treatment for invasive aspergillosis in immunocompromised patients with hematologic malignancies, hematopoietic stem cell transplant, and solid organ transplant recipients. Primary prophylaxis against Aspergillus is recommended for patients with acute myelogenous leukemia receiving remission-induction chemotherapy. Posaconazole or voriconazole are appropriate antifungal agents. A new formulation of itraconazole (SUBA-itraconazole) is an alternative option. Breakthrough infections on isavuconazole prophylaxis have been recently reported. For liver transplant recipients, targeted prophylaxis is recommended in the presence of certain risk factors. Voriconazole and isavuconazole are the preferred agents for the treatment of invasive aspergillosis. Isavuconazole, a novel extended-spectrum triazole with activity against Aspergillus and Mucorales, was found to be non-inferior compared to voriconazole. Combination of voriconazole with an echinocandin is generally not recommended. Reduction in immunosuppression is recommended as part of the management of invasive aspergillosis. The adjunctive use of interferon-γ may be considered in patients with severe or refractory disease, although a benefit has not been clearly demonstrated. The approach to prevention and treatment of invasive aspergillosis has evolved along with changes in immunosuppressive treatment and introduction of novel antifungal agents.