What are the treatment options for fungal pneumonia?

Updated: Jun 21, 2019
  • Author: Romeo A Mandanas, MD, FACP; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
  • Print
Answer

Answer

In persons with endemic mycoses, spontaneous recovery usually occurs without treatment, especially in patients who are mildly affected and immunocompetent without dissemination; otherwise, administer treatment as outlined in the table below.

In cases in which aspergillosis, mucormycosis, and candidiasis occur in an immunocompromised host, reversing the factors affecting the patient's immune status is linked to successful recovery from the infection. Attempt ancillary interventions that may help to promote recovery from the opportunistic infection. These include (1) ensuring, with the use of growth factors, neutropenia recovery in patients receiving chemotherapy and bone marrow transplants; (2) withdrawing or tapering immunosuppressive drugs and steroids; and (3) removing infected or highly colonized catheters in patients with candidiasis.

Table. Medical and Surgical Fungal Therapy (Open Table in a new window)

Fungal Pathogen

Indication for Antifungal Therapy

Surgical Care and Other Treatments

Antifungal Drugs Used

Histoplasmosis

Acute pulmonary histoplasmosis with hypoxia; prolonged moderate symptoms for more than 1 month; disseminated disease; immunosuppressed host

Mortality rate for untreated disseminated disease at 80%; reduced to 25% with treatment

Significant hemoptysis; recurrent pneumonia; repair of bronchopleural fistula

Corticosteroids in severe hypoxia or ARDS

Anti-inflammatory agents to treat rheumatologic syndromes

Amphotericin B induces rapid response in patients who are severely ill or immunocompromised

Azoles/triazoles in patients with milder illness

Coccidioidomycosis

Disseminated disease; chronic pulmonary disease; acute pulmonary infection with hypoxia or protracted morbidity (>1-2 mo); immunosuppressed host (worst outcome, 70% mortality)

Surgical debridement or resection of infective tissue often necessary adjunct to antifungal treatment

Anti-inflammatory agents for rheumatologic syndromes

Amphotericin B effective in more than 90% of cases; first choice in severe cases or immunocompromised

Fluconazole/itraconazole first choice in mild to moderate infection (or after improvement)

Treatment less effective than in other endemic mycoses

Blastomycosis

Persistent or recurrent symptoms of acute or chronic pulmonary disease or with pleural involvement; disseminated disease

Steroids for ARDS

Amphotericin B response rates of 77-90% of cases; for severe infection or immunocompromised

Itraconazole successful in 90% of cases; for mild to moderate infection

Ketoconazole response of 80%; poor outcome in patients who are immunosuppressed

Fluconazole less effective, 65% response rate

Chronic maintenance treatment essential for all patients with AIDS or meningitis

Cryptococcosis

Patients who are immunosuppressed and symptomatic; patients who are immunocompetent with disease progression; any patients with meningitis or disseminated disease

N/A

Amphotericin B in patients who are severely ill

Fluconazole in milder cases or after clinical response to amphotericin B

Lifelong maintenance therapy in AIDS patients may not be necessary as long as the patient's CD4 count is maintained above 100 cells/µL with HAART [35]

Flucytosine may be of benefit when combined with amphotericin B in patients with severe or disseminated disease. [5]

Aspergillosis

All patients with invasive disease; in patients who are immunosuppressed, early diagnosis and empiric treatment for persistent fever not responding to broad-spectrum antibiotics; high mortality once infiltrates and symptoms appear; prognosis ultimately linked to severity and outcome of underlying disease

Mortality rate of 50-60% in patients with AIDS

Rapid tapering of immunosuppressive agents and corticosteroids and reversal of neutropenia (if possible)

Voriconazole is the new standard of care for invasive aspergillosis based on superiority over amphotericin B in primary therapy

Lipid formulations of amphotericin B have at least equal efficacy but less toxicity compared with amphotericin B desoxycholate

Oral voriconazole can be used to complete treatment with initial response to IV voriconazole or amphotericin B

Posaconazole is second line agent

Echinocandins second line agent when voriconazole is not tolerated or in combination with voriconazole in an attempt to enhance antifungal activity

Isavuconazole has been shown to be not inferior to voriconazole for aspergillosis [36]

Mucormycosis

Mortality rates as high as 70% in patients with invasive pulmonary mucormycosis

Aggressive surgical debridement of necrotic tissue important in mucormycosis, especially if confined to lungs

Lipid amphotericin B is the mainstay of therapy; posaconazol is poorly absorbed, considered second line

Mucor species generally resistant to azoles (voriconazole has no activity against them)

Echinocandins (Caspofungin) useful as salvage therapy

Isavuconazole has been shown to be comparable to amphotericin B and posaconazole for mucormycosis [36]

Candidiasis

All patients with invasive disease or dissemination; important to reverse factors affecting immune status

Expert recommendations and clinical practice guidelines do not recommend antifungal treatment facing isolation in respiratory samples regardless the number of positive samples [15]

Rapid tapering of immunosuppressive agents and corticosteroids; important to remove indwelling infected intravenous lines or urinary catheters in setting of hematogenous spread

Amphotericin B is mainstay

Flucytosine may be of benefit when added to amphotericin B

Fluconazole use in pulmonary disease not studied but is effective in hepatosplenic candidiasis and candidemia

Echinocandins may be useful alternatives

Sporotrichosis

Management should be based in clinico-radiological manifestations; two presentations of pulmonary sporotrichosis: non-cavitary disease (multifocal) and cavitary disease (primary) [16]

Surgical interventions when presence of cavitations and initial medical therapies have failed; used as adjunctive therapy

Itraconazole as first line agent in mild to moderate cases

Amphotericin B first line in life threatening conditions

Scedosporiosis

Emerging opportunistic pathogen in similar scenario as aspergillosis but highly resistant to amphotericin B and echinocandins; mortality rate is 54-78% in transplant recipients

In near-drowning victims, close surveillance for clinical and radiographic findings with low threshold for empiric treatment

Aggressive surgical debridement for disseminated disease in the form of subcutaneous abscesses, brain abscess, and others

Granulocyte transfusions or growth factors to enhance neutrophil recovery

Resistant to amphotericin B and echinocandins

Voriconazole as single agent or in combination with other agents such as terbinafine [37]


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!