First Guidelines Issued for Chronic Pulmonary Aspergillosis

Laurie Barclay, MD

January 04, 2016

The European Respiratory Society and the European Society of Clinical Microbiology and Infectious Diseases have issued their first-ever guidelines on chronic pulmonary aspergillosis (CPA), published online December 23 in the European Respiratory Journal. However, not all the recommendations can be implemented in low- and middle-income countries because of a lack of available resources.

"We welcome the publication of this guideline, which provides key insights into the main features of the disease and treatment recommendations," European Respiratory Society Guidelines Director Marc Miravitlles said in a news release. "By establishing this expert consensus on the topic, we aim to improve the early diagnosis of CPA and increase recognition of the condition to ultimately improve outcomes for patients."

Despite advances during the past decade in understanding CPA, thanks to research from Europe, India, and Japan, the European Medicines Agency has not approved any treatment for CPA. Very few studies have compared diagnostic tests and treatments.

"The UK National Health Service recognised the challenges posed by these patients by setting up the National Aspergillosis Centre and its associated laboratory the Mycology Reference Centre in 2009," guidelines chair Professor David Denning, from the University of Manchester, United Kingdom, said in the release. "The experience gained from seeing hundreds of patients has contributed to the quality of care, although much more research and new oral antifungal drugs are required to reduce the marked disability caused by CPA."

Prevalence of CPA is approximately 3 million worldwide and 240,000 in Europe, occurring in nonimmunocompromised patients with prior or current lung disease. Pulmonologists may not detect CPA until late stages associated with aspergilloma. Without timely diagnosis and long-term antifungal treatment, the 5-year mortality rate is approximately 80%.

"Very many patients with CPA live in low and middle income countries and develop CPA following pulmonary [tuberculosis]," the guidelines authors write. "Not all the recommendations of this guideline can be implemented in low and middle income countries because of a lack of capacity. We have not 'down-graded' our recommendations because of this problem, but would rather encourage our colleagues practicing in these environments to adopt as far as is possible these guidelines and try and develop services using the best tools available," the guidelines authors conclude. "For example, surgical resection may be preferable to long-term antifungal therapy, even if the risk is higher."

Specific recommendations include the following:

  • Diagnosis requires 3 or more months of one or more cavities with or without a fungal ball or nodules on thoracic imaging, direct evidence of Aspergillus infection from microscopy or biopsy culture or an immunological response to Aspergillus spp., and exclusion of alternative diagnoses.

  • More than 90% of patients have elevated Aspergillus antibody (precipitins).

  • Surgically excise simple aspergilloma if technically possible, preferably using video-assisted thoracic surgery.

  • Treat chronic cavitary pulmonary aspergillosis with long-term oral antifungal therapy, with careful monitoring of azole serum concentrations, drug interactions, and possible toxicities.

  • Hemoptysis may reflect therapeutic failure and/or antifungal resistance. It may respond to tranexamic acid and bronchial artery embolization but rarely requires surgical resection.

  • Treat single Aspergillus nodules with antifungal therapy only if not fully resected.

  • Patients with multiple nodules may benefit from antifungal treatment and require careful monitoring.

The guidelines authors have disclosed no relevant financial relationships.

Eur Respir J. Published online December 23, 2015. Abstract

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