Patient handout

Invasive aspergillosis

PRODUCTION

1. Your condition

This handout is for invasive aspergillosis. Your care team identified this based on: ct chest halo or air-crescent sign in immunocompromised host (eortc/msgerc 2020 imaging criterion).

Other reasons your team may use this plan: serum / bal galactomannan elevated (eortc/msgerc 2020 mycology criterion); persistent neutropenic fever despite broad antibacterials (idsa 2016 / ecil-6 2017); sot / hct recipient with new pulmonary infiltrate (idsa 2016 / ecil-6 2017 host criterion).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
voriconazole	6 mg/kg IV q12h × 2 doses (loading) then 4 mg/kg IV q12h; PO 200-300 mg q12h once stable	IV→PO	q12h	Herbrecht NEJM 2002 — superior to AmB; CYP-mediated DDIs; TDM target trough 1-5 µg/mL
isavuconazole	200 mg IV/PO q8h × 6 doses (loading) then 200 mg daily	IV/PO	daily after load	SECURE Lancet 2016 — non-inferior to voriconazole, fewer DDIs, no QTc prolongation, no photosensitivity
posaconazole	300 mg IV/PO BID × 1 d then 300 mg daily	IV/PO	daily after load	Approved alternative; best as DR tablets; TDM target ≥1 µg/mL (IDSA 2024)
liposomal_amphotericin_B	3-5 mg/kg IV daily	IV	daily	IDSA 2016 alternative for refractory or intolerance; nephrotoxicity, hypokalemia, hypomagnesemia monitoring
caspofungin	70 mg IV load then 50 mg/d	IV	daily	Marr Ann Intern Med 2015 — combo with voriconazole considered for severe disease; not monotherapy

Plan: Invasive aspergillosis — voriconazole / isavuconazole first-line (IDSA 2024)

3. When to call your provider

Contact your care team if any of the following happen:

New fever / hemoptysis / new respiratory symptoms during OPAT → return to ED for recurrent or progressive IA workup + repeat HRCT + GM + bronchoscopy if accessible (IDSA 2016)
New neurologic symptoms (focal deficit, headache, altered MS, seizure) → emergent MRI brain + ID/neurosurgery consult; consider CNS aspergillosis dissemination (IDSA 2016)
New sinus / facial / orbital pain / visual changes → emergent ENT + sinus CT/MRI; differential vs mucormycosis especially if reverse-halo (ESCMID 2018)
Azole hepatotoxicity (AST/ALT > 5× ULN) → hold azole + switch to alternate azole or L-AmB; hepatology consult if severe (IDSA 2016)
L-AmB nephrotoxicity (creatinine ≥ 1.5× baseline) → reduce dose / extend interval / switch back to PO azole if feasible (IDSA 2016)
Drug-interaction event (tacrolimus trough > 15, INR > 5, rhabdomyolysis on statin) → adjust per DDI rules + safety consult (DailyMed labels)
Voriconazole TDM out of range (trough < 1 or > 5 µg/mL) → dose adjustment + repeat TDM 5-7 d after change + consider CYP2C19 genotype if unexplained subtherapeutic (IDSA 2016; ESCMID 2018)
GM trend rising or HRCT progression at 2-4 wk → reassess for azole resistance + adherence + drug levels + switch to L-AmB or combination (IDSA 2016)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Brain lesion / meningitis / focal deficit with positive GM or biopsy (IDSA 2016)(life-threatening)
Hemoptysis from cavitary IA — especially angioinvasive disease (IDSA 2016)(life-threatening)
IA developing on posaconazole or isavuconazole prophylaxis (ECIL-6 2017)
ANC <500 not recovering with cytokine support (IDSA 2016)
COVID-19 or severe influenza on ICU corticosteroids + new pulmonary infiltrate + BAL galactomannan ≥ 1.0 OR serum galactomannan ≥ 0.5 OR Aspergillus on BAL culture/PCR (Verweij Lancet ID 2020 CAPA criteria; Schauwvlieghe Lancet RM 2018 IAPA)(life-threatening)
Environmental azole-resistance exposure (agriculture, paint, compost) + treatment failure on appropriate voriconazole / isavuconazole dosing with confirmed TDM in range, OR Aspergillus fumigatus isolate with elevated MIC, OR known TR34/L98H or TR46/Y121F/T289A mutation (IDSA 2016; Lestrade CID 2019; WHO 2022 fungal priority pathogens)
CNS imaging (MRI brain) showing ring-enhancing mass, abscess, or compatible lesion + biopsy/BAL or compatible mycology + host criterion (IDSA 2016)(life-threatening)
Multi-organ involvement (≥ 2 non-contiguous sites — e.g., pulmonary + CNS + skin / liver / spleen / kidney) on imaging or biopsy in immunocompromised host (HSCT, SOT, prolonged neutropenia, high-dose steroids, biologics) (IDSA 2016 — proven/probable disseminated IA)(life-threatening)

5. Follow-up

Step-down to oral voriconazole / isavuconazole (IDSA 2016); long-term secondary prophylaxis through immunosuppression duration (ECIL-6 2017); counsel photosensitivity / SCC risk on voriconazole (IDSA 2016)

6. Sources

Guideline: IDSA 2016 Aspergillosis Guideline (Patterson et al, CID) + ESCMID/ECMM/ERS 2018 (Ullmann) + ECIL-6 2017 + EORTC/MSGERC 2020 definitions + Verweij Lancet ID 2020 CAPA criteria + Schauwvlieghe Lancet RM 2018 IAPA