Anticonvulsants and rifampin reduce azole levels significantly
Review and adjust all concurrent medications
ID pharmacy consultation for complex regimens
Drug level monitoring for immunosuppressants
Resistance and treatment failure
Suspected when clinical deterioration on appropriate azole therapy
Antifungal susceptibility testing indicated
Switch to liposomal amphotericin B as empiric salvage
Breakthrough IA definition
IA developing while on azole prophylaxis or treatment
Approximately 44% of breakthrough cases have resistant organisms in some series
Prevention and prophylaxis
Primary prophylaxis in highest-risk patients
Posaconazole for AML or MDS with chemotherapy
Voriconazole or posaconazole for allogeneic HSCT
Secondary prophylaxis when re-immunosuppression anticipated
Continue antifungal throughout period of immunosuppression
Monitor for breakthrough despite prophylaxis
Patient Discharge Instructions
copy discharge instructions
Invasive aspergillosis home care
Antifungal medication must be taken exactly as prescribed
Do not skip doses — subtherapeutic levels cause treatment failure
Voriconazole or isavuconazole to be taken at same time each day
Posaconazole oral suspension taken with a full meal or acidic drink
Tablet or IV formulation preferred if available
Blood tests are required regularly to check medication levels and liver function
Do not miss scheduled bloodwork appointments
Medication side effects to monitor
Voriconazole: visual changes including seeing flashes of light
Usually transient and improve over days to weeks
Avoid driving at night initially
Voriconazole: skin sensitivity to sunlight
Use sunscreen and protective clothing outdoors
Long-term risk of skin cancer with prolonged use — report any new skin lesions
Any medication: nausea, abdominal pain, or yellowing of eyes or skin
May indicate liver irritation — contact care team immediately
Activity and diet
Avoid construction sites, heavy gardening, and dusty environments
Airborne fungal spores can worsen or cause new infection
Avoid grapefruit and other foods that interfere with medication metabolism
Ask pharmacist or doctor about specific interactions
Maintain adequate hydration especially if on amphotericin B therapy
Warning signs to return to the emergency department
New or worsening coughing up blood
Severe shortness of breath at rest
New headache, vision changes, seizures, or confusion
Weakness or numbness in face, arms, or legs
New skin nodules or areas of black discolouration
Fever not improving or returning after initial improvement
Severe nausea, vomiting, or inability to take medications
Follow-up instructions
Infectious disease clinic within 1 week of discharge
Repeat blood tests including medication levels as scheduled
Repeat CT scan at 2 to 4 weeks as directed by ID team
Contact ID team if any new medications started by another provider
References
Guidelines and key sources
Primary clinical guidelines
Patterson TF et al. IDSA Practice Guidelines for the Diagnosis and Management of Aspergillosis 2016 Update. Clinical Infectious Diseases 2016
Epelbaum O et al. ATS Clinical Practice Guideline Treatment of Invasive Pulmonary Aspergillosis 2024. American Journal of Respiratory and Critical Care Medicine 2024
Hage CA et al. ATS Clinical Practice Guideline Microbiological Laboratory Testing for Fungal Infections 2019. American Journal of Respiratory and Critical Care Medicine 2019
Landmark studies and reviews
Herbrecht R et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. NEJM 2002
Segal BH. Aspergillosis review. New England Journal of Medicine 2009
Thompson GR and Young JH. Aspergillus Infections review. New England Journal of Medicine 2021
Heylen J et al. Acute Invasive Pulmonary Aspergillosis Clinical Presentation and Treatment. Seminars in Respiratory and Critical Care Medicine 2024
Systematic reviews and meta-analyses
de Heer K et al. Galactomannan Detection in BAL for Invasive Aspergillosis. Cochrane Database of Systematic Reviews 2019
Cruciani M et al. PCR Blood Tests for the Diagnosis of Invasive Aspergillosis. Cochrane Database of Systematic Reviews 2019
Society guidelines for specific populations
Dadwal SS et al. ASTCT Management and Prevention of Aspergillosis in HCT Recipients 2021
Husain S and Camargo JF. AST Invasive Aspergillosis in Solid-Organ Transplant Recipients 2019
Koehler P et al. ECMM/ISHAM Consensus Criteria COVID-19-associated Pulmonary Aspergillosis 2021
Coding reference
ICD-10 B44.1 Other pulmonary aspergillosis
ICD-10 B44.7 Disseminated aspergillosis
ICD-10 B44.0 Invasive pulmonary aspergillosis
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.