Selection of Oral Antifungals for Initial Maintenance Therapy in Chronic Pulmonary Aspergillosis: A Longitudinal Analysis

Mortality in chronic pulmonary aspergillosis: a systematic review and individual patient data meta-analysis

BACKGROUND

Despite antifungal treatment, chronic pulmonary aspergillosis (CPA) is associated with substantial morbidity and mortality. We conducted a systematic review and meta-analysis to evaluate rates of mortality and its predictors in CPA.

METHODS

A systematic literature search was conducted across MEDLINE (PubMed), Scopus, Embase, and Web of Science to identify studies in English, reporting mortality in CPA, from database inception to Aug 15, 2023. We included clinical studies, observational studies, controlled trials, and abstracts. Case reports, animal studies, letters, news, and literature reviews were excluded. Authors of studies published since 2016 were also contacted to obtain anonymised individual patient data (IPD); for other studies, summary estimates were extracted. Subgroup analysis was done for differences in overall 1-year and 5-year mortality, data source, study design, risk of bias, country, Human Development Index, age groups, and the underlying lung disease. We used random-effects meta-analyses to estimate pooled mortality rates. Subgroup analyses and meta-regression were done to explore sources of heterogeneity. One-stage meta-analysis with a stratified Cox proportional hazards model was used to estimate the univariable and hazards for mortality, adjusting for age, sex, type of CPA, treatment, and underlying pulmonary comorbidities. This study was registered with PROSPERO (CRD42023453447).

FINDINGS

We included 79 studies involving 8778 patients in the overall pooled analysis and 15 studies involving 1859 patients in the IPD meta-analysis. Pooled mortality (from 70 studies) was estimated at 27% overall (95% CI 22-32; I2 =95·4%), 15% at 1 year (11-19; I2 =91·6%), and 32% at 5 years (25-39; I2 =94·3%). Overall mortality in patients with CPA with pulmonary tuberculosis as the predominant predisposing condition was 25% (16-35; I2 =87·5%; 20 studies) and with chronic obstructive pulmonary disease was 35% (22-49; I2 =89·7%; 14 studies). Mortality in cohorts of patients who underwent surgical resection was low at 3% (2-4). In the multivariable analysis, among predisposing respiratory conditions, pulmonary tuberculosis history had the lowest mortality hazard (relative to an absence of the disease at baseline), whereas worse outcomes were seen with underlying malignancy; subacute invasive pulmonary aspergillosis and chronic cavitary pulmonary aspergillosis subtypes of CPA were also significantly associated with increased mortality relative to simple aspergilloma on multivariable analysis. Mortality hazard increased by 25% with each decade of age (adjusted hazard ratio 1·25 [95% CI 1·14-1·36], p<0·0001).

INTERPRETATION

CPA is associated with substantial mortality. Advancing age, CPA subtype, and underlying comorbidities are important predictors of mortality. Future studies should focus on identifying appropriate treatment strategies tailored to different risk groups.

FUNDING

None.

Risk Factors and Prognostic Effects of Aspergillosis as a Complication of Nontuberculous Mycobacterial Pulmonary Disease: A Nested Case-Control Study

OBJECTIVE

The global prevalence of nontuberculous mycobacterial pulmonary disease (NTM-PD) has been steadily increasing. A few small retrospective studies have reported a poor prognosis associated with chronic pulmonary aspergillosis (CPA) as a complication of NTM-PD. Furthermore, the prognostic impact of CPA may have been inadequately assessed due to differences in background factors. This study aimed to identify the risk factors for CPA in NTM-PD and compare the risk of in-hospital mortality between patients with and without aspergillosis.

METHODS

Data were obtained from a large-scale claims database. Patients with NTM-PD who met the inclusion criteria and those who developed CPA after the NTM diagnosis were identified. The incidence of CPA was evaluated, and risk factors were identified using multiple logistic analyses. Mortality rates were evaluated and compared between patients with and without aspergillosis after adjusting for background CPA risk factors.

RESULTS

The incidence of CPA was 2.29% (265/11,587). The identified risk factors included male sex, chronic respiratory failure, asthma, interstitial pneumonia, pulmonary tuberculosis sequelae and systemic corticosteroid use. A total of 219 patients with CPA were matched with control cases using propensity scores based on age and identified risk factors for CPA. The adjusted hazard ratio for in-hospital mortality was 2.6 (95% CI: 1.8-3.9).

CONCLUSIONS

CPA as a complication of NTM-PD is associated with significantly higher mortality rates. Clinicians should consider the necessity of promptly diagnosing CPA in patients with NTM-PD and the associated risk factors.

Antifungal Treatment for Japanese Patients with Chronic Pulmonary Aspergillosis

INTRODUCTION

Despite the ongoing efforts to refine treatment durations and methods for patients with chronic pulmonary aspergillosis, the clinical use of antifungal agents remains unclear. This study aimed to describe the treatment practices, trajectories, and prognoses of newly diagnosed patients with chronic pulmonary aspergillosis.

METHODS

Data from a longitudinal database from hospitals in Japan was used. The target population included patients who started antifungal treatment following their initial diagnosis of pulmonary aspergillosis, pulmonary aspergilloma, or chronic necrotizing pulmonary aspergillosis between October 2015 and September 2017. We described patient characteristics and treatment practices.

RESULTS

Of the 680 patients analyzed, 253 (37.2%), 231 (34.0%), 155 (22.8%), 31 (4.6%), and 10 (1.5%) patients received the initial treatment with voriconazole, itraconazole, micafungin, caspofungin, and liposomal amphotericin B, respectively. Over 50% of the patients initially treated with micafungin or caspofungin switched to azoles within a month. Of the patients treated with antifungal agents, only 46.8% continued treatment for 6 months, indicating a lower retention rate. The overall mortality rate at 1 year was 24.7%. The median treatment duration of initial treatment until switching was 83 days (interquartile range [IQR], 159) for voriconazole and 162 days (IQR, 310) for itraconazole, indicating a significant variation in treatment duration. Notably, 15.7% (76/484) of the patients underwent a treatment switch between voriconazole and itraconazole in the initial azole treatment group.

CONCLUSIONS

Our findings highlight the challenges associated with sustaining long-term antifungal treatment.

Uncommon Occurrence of Pulmonary Aspergillosis Caused by Aspergillus sydowii: A Case Report

This case report presents an unusual occurrence of pulmonary aspergillosis caused by Aspergillus sydowii in a 26-year-old male patient. The patient is from Nepal and had no significant medical history and was previously in good health. Chest computed tomography (CT) scans revealed localized bronchiectasis primarily in the left inferior lingular segment and the left lower lobe. Subsequently, bronchial lavage fluid was collected, and a comprehensive culture examination was conducted to confirm the cause of the infection. While Aspergillus fumigatus typically predominates as the cause of pulmonary aspergillosis, our bronchial lavage fluid culture revealed the presence of a filamentous fungus, identified as Aspergillus sydowii through molecular analysis. Thus, we conclusively identified this particular strain of fungus as the etiological factor behind the patient's condition. Notably, pulmonary aspergillosis due to Aspergillus sydowii is exceedingly rare, and we present this case alongside relevant prior data for comprehensive clinical insight. This case underscores the clinical significance of Aspergillus sydowii as a fungal pathogen, emphasizing the importance of early recognition and managing fungal infections.

Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample

Background

The role of lung resection in patients with pulmonary aspergillosis is generally reserved for those with localized disease who fail medical management. We used a national database to investigate the influence of preoperative patient comorbidities on inpatient mortality and need for surgery.

Methods

Patients admitted with pulmonary aspergillosis between 2007 to 2015 were identified in the National Inpatient Sample dataset. Inpatient mortality rates were compared between patients treated medically and surgically. Predictors of mortality, surgical intervention, and non-elective admission were evaluated using multivariable logistic regression.

Results

Among a population estimate of 112,998 patients with pulmonary aspergillosis, 107,606 (95.2%) underwent medical management alone and 5,392 (4.8%) underwent surgical resection. Positive predictors for surgery included hemoptysis, and history of lung cancer or chronic pulmonary diseases. Surgically treated patients had a lower inpatient mortality when compared to those treated medically (11.5% vs. 15.1%, P<0.001) in univariate analysis, but this finding did not persist in multivariable analysis (AOR 0.97, P=0.509). The odds of mortality were lower in patients undergoing video assisted thoracoscopic surgery compared to an open approach (AOR 0.77, P=0.001). Among patients treated surgically, mortality was higher in those with a history of lung cancer, solid organ transplantation, liver disease, human immunodeficiency virus infection, hematologic diseases, chronic pulmonary diseases, and those admitted non-electively requiring surgery.

Conclusions

In this generalizable study, medical and surgical management of pulmonary aspergillosis were comparable in terms of inpatient mortality. However, non-elective admission and patients with select comorbidities have significantly worse outcomes after surgical intervention.

Association between airflow limitation and prognosis in patients with chronic pulmonary aspergillosis

Background

Previous studies have shown that reduced levels of lung function, characterized by forced expiratory volume in 1 second (FEV₁), are associated with higher respiratory events and mortality in general population and some chronic lung diseases. Chronic pulmonary aspergillosis (CPA) is a destructive, fatal lung disease caused by Aspergillus infection in non-immunocompromised patients with suboptimal pulmonary function. However, there is limited information on the status and features of CPA according to FEV₁.

Methods

We performed a retrospective observational study to investigate the FEV₁ and airflow limitation in patients with CPA between March 2017 and February 2019 at a tertiary hospital in South Korea.

Results

Of the 144 CPA patients, 104 underwent spirometry, demonstrating median forced vital capacity (FVC) and FEV₁ of 2.35 L (68%) and 1.43 L (62%), respectively. Among them, 56 patients had airflow limitation on PFT, with median FVC, and FEV₁ of 2.47 L (73%) and 1.11 L (47%), respectively. Low body mass index (BMI) (20.1 vs. 22.1 kg/m²; P=0.011), breathlessness (60% vs. 20%; P=0.002), and bilateral pulmonary lesions (33.3% vs. 4%; P=0.006) were more common in patients with moderate to very severe airflow limitation than in those with normal to mild airflow limitation.

Conclusions

Moderate to very severe airflow limitation was observed in 43.3% of patients with CPA. Additionally, low BMI, breathlessness, and bilateral pulmonary lesions contributing to poor prognosis were more common in patients with moderate to very severe airflow limitation than in those with normal to mild airflow limitation. Our findings suggest that airflow limitation can be associated with the prognosis of CPA. Further investigations are needed to demonstrate the clinical significance of this association.

Transition of triazole-resistant Aspergillus fumigatus isolates in a Japanese tertiary hospital and subsequent genetic analysis

OBJECTIVE

To evaluate the annual variation in the frequency of patient-acquired azole-resistant Aspergillus fumigatus (ARAf), and correlate it to the amount of oral triazole prescribed, in Nagasaki, Japan.

METHODS

A. fumigatus isolates from respiratory specimens collected in the Nagasaki University Hospital (NUH) between 1996 and 2017 were included in the study. The amount of oral triazole prescribed in NUH since 2001 was obtained from the medical ordering system. Mutations in cyp51A, hmg1, and erg6 genes of ARAf were also analysed.

RESULTS

From a total of 240 ARAf strains, 12 (5%), 6 (2.5%), 15 (6.25%), and 3 (1.25%) strains were resistant to itraconazole (ITC), voriconazole (VRC), to either ITC or VRC, and both triazoles, respectively. The amount of prescribed VRC increased annually, and was three times as large as that of ITC in 2017. All eleven patients harbouring ITC-resistant strains had a history of prior ITC treatment, while only one of six patients harbouring VRC-resistant strains had a history of prior VRC treatment. cyp51A mutations were recorded in 10 strains; however, tandem repeat mutations of the promoter region of cyp51A were not observed. Several azole-resistant strains had non-cyp51A mutations.

CONCLUSIONS

The frequency of patient-acquired ARAf is not increasing in Nagasaki, Japan. Furthermore, the prevalence of VRC-induced ARAf was rare despite the remarkable increase in the amount of prescribed VRC. Mutations in genes other than cyp51A should also be considered when ARAf strains are obtained from patients treated with azole antifungals.

Tolerability of oral itraconazole and voriconazole for the treatment of chronic pulmonary aspergillosis: A systematic review and meta-analysis

BACKGROUND

Chronic pulmonary aspergillosis (CPA) requires prolonged treatment with itraconazole or voriconazole. However, adverse events (AEs) are common with the use of these agents, with the need to discontinue the offending drug in a significant proportion of the patients. The aim of this study was to evaluate the frequency of adverse events of itraconazole and voriconazole for the treatment of CPA.

METHODS

We searched Embase and Medline to select clinical studies providing information on AEs to itraconazole or voriconazole for the treatment of CPA from inception to May 2020. Reviews, single case reports, and case series reporting less than 10 patients were excluded. Random effect meta-analysis was performed using STATA 16.0.

RESULTS

We included 9 eligible studies with an overall total of 534 CPA patients enrolled. Of these, 69% (n = 366) were treated with voriconazole and 31% (n = 168) with itraconazole. The median daily dose of both itraconazole and voriconazole used was 400mg. In a pooled analysis, AEs were observed in 36% (95% CI: 20-52%, N = 366) of patients on voriconazole and 25% (95% CI: 18 to 31%, N = 168) in those treated with itraconazole. Discontinuation rate due to AEs was the same for both drugs; 35% (47/366) and 35% (15/168) for voriconazole and itraconazole, respectively. There were 70 AEs reported with itraconazole use, the commonest being cardiotoxicity (29%). Skin AEs (28%) were the most frequent among the 204 AEs reported with voriconazole use. None of the studies compared the tolerability of itraconazole head-to-head with voriconazole.

CONCLUSIONS

AEs due itraconazole and voriconazole are common and may lead to discontinuation of treatment in a significant proportion of patients. This information can be used to educate patients prior to commencement of these antifungal therapies.

PROSPERO REGISTRATION NUMBER

CRD42020191627.

A Collaborative Tale of Diagnosing and Treating Chronic Pulmonary Aspergillosis, from the Perspectives of Clinical Microbiologists, Surgical Pathologists, and Infectious Disease Clinicians

Chronic pulmonary aspergillosis (CPA) refers to a spectrum of Aspergillus-mediated disease that is associated with high morbidity and mortality, with its true prevalence vastly underestimated. The diagnosis of CPA includes characteristic radiographical findings in conjunction with persistent and systemic symptoms present for at least three months, and evidence of Aspergillus infection. Traditionally, Aspergillus infection has been confirmed through histopathology and microbiological studies, including fungal culture and serology, but these methodologies have limitations that are discussed in this review. The treatment of CPA requires an individualized approach and consideration of both medical and surgical options. Most Aspergillus species are considered susceptible to mold-active triazoles, echinocandins, and amphotericin B; however, antifungal resistance is emerging and well documented, demonstrating the need for novel therapies and antifungal susceptibility testing that correlates with clinical response. Here, we describe the clinical presentation, diagnosis, and treatment of CPA, with an emphasis on the strengths and pitfalls of diagnostic and treatment approaches, as well as future directions, including whole genome sequencing and metagenomic sequencing. The advancement of molecular technology enables rapid and precise species level identification, and the determination of molecular mechanisms of resistance, bridging the clinical infectious disease, anatomical pathology, microbiology, and molecular biology disciplines.

CPAnet Registry-An International Chronic Pulmonary Aspergillosis Registry

Chronic pulmonary aspergillosis (CPA) is a chronic fungal infection of the lung associated with high morbidity and mortality. The CPA Research network (CPAnet) registry established in 2018 is an international multicenter collaboration aiming to improve CPA knowledge and patient care. This study's aim was to describe the data collection process and content of CPAnet registry with preliminary clinical data. In the CPAnet registry, clinical data are collected through a web-based questionnaire. Data include CPA phenotype, comorbidities, treatment, outcome, and follow-up from several international centers. An exemplary descriptive analysis was performed on 74 patients, who were registered online before April 2020. CPA patients were predominantly (72%) male, 39% had chronic obstructive pulmonary disease, and 68% had a history of smoking. Chronic cavitary pulmonary aspergillosis was the most common CPA subtype (62%). In 32 patients (52%), voriconazole was the preferred first-line therapy. The multicenter multinational CPAnet registry is a valuable approach to gather comprehensive data on a large study population and reflects real-world clinical practice rather than focusing on specific patient populations in more specialized centers. Additional CPA reference centers are being encouraged to join this promising clinical research collaboration.

Chronic Pulmonary Aspergillosis: Notes for a Clinician in a Resource-Limited Setting Where There Is No Mycologist

Chronic pulmonary aspergillosis (CPA) is a spectrum of several progressive disease manifestations caused by Aspergillus species in patients with underlying structural lung diseases. Duration of symptoms longer than three months distinguishes CPA from acute and subacute invasive pulmonary aspergillosis. CPA affects over 3 million individuals worldwide. Its diagnostic approach requires a thorough Clinical, Radiological, Immunological and Mycological (CRIM) assessment. The diagnosis of CPA requires (1) demonstration of one or more cavities with or without a fungal ball present or nodules on chest imaging, (2) direct evidence of Aspergillus infection or an immunological response to Aspergillus species and (3) exclusion of alternative diagnoses, although CPA and mycobacterial disease can be synchronous. Aspergillus antibody is elevated in over 90% of patients and is the cornerstone for CPA diagnosis. Long-term oral antifungal therapy improves quality of life, arrests haemoptysis and prevents disease progression. Itraconazole and voriconazole are alternative first-line agents; voriconazole is preferred for patients with contra-indications to itraconazole and in those with severe disease (including large aspergilloma). In patients co-infected with tuberculosis (TB), it is not possible to treat TB with rifampicin and concurrently administer azoles, because of profound drug interactions. In those with pan-azole resistance or intolerance or progressive disease while on oral triazoles, short-term courses of intravenous liposomal amphotericin B or micafungin is used. Surgery benefits patients with well-circumscribed simple aspergillomas and should be offered earlier in low-resource settings.

An overview of the available treatments for chronic cavitary pulmonary aspergillosis

INTRODUCTION

Chronic pulmonary aspergillosis (CPA) is a chronic lung infection caused by Aspergillus fumigatus, that complicates structural lung diseases. Of the different types of CPA, chronic cavitary pulmonary aspergillosis (CCPA) is the most common form. The mainstay of treatment of CCPA is oral triazoles. However, many gaps exist in clinical decision-making about the agent of choice, the duration, and the assessment of treatment response.

AREAS COVERED

We discuss the approach to diagnosis and treatment of CCPA. We have searched the PubMed and EmBase databases (from inception till 31 October 2019) to identify studies describing the use of anti-fungal agents in CCPA.

EXPERT OPINION

Treatment for CCPA should be initiated with oral itraconazole for at least six months. In case of poor response or intolerance to itraconazole, voriconazole should be considered. Intravenous agents, including amphotericin B and echinocandins, may be used in those with either treatment failure or those who are intolerant to oral antifungal agents. Posaconazole and isavuconazole may be used as salvage therapy due to a better pharmacokinetic/pharmacodynamic profile of the former and reduced drug-drug interactions with the latter.