Treatment outcome definitions in chronic pulmonary aspergillosis: a CPAnet consensus statement

Isavuconazole in chronic pulmonary aspergillosis: What is the evidence?

BACKGROUND

Newer drugs like isavuconazole have been more widely used for invasive aspergillosis, where they are included as first-line treatments in major guidelines, whereas their use in chronic pulmonary aspergillosis (CPA) remains limited. Therefore, the aim of this study is to conduct a systematic review of the literature on the use of isavuconazole in CPA.

METHODS

We searched PubMed/MEDLINE and Embase on August 9th, 2024. Our inclusion criteria included patients with CPA who were treated with isavuconazole. We summarized binary variables with counts and percentages, and continuous variables with mean and SD.

RESULTS

We found 15 articles on CPA using isavuconazole. These studies were published after 2017, with a high predominance in high-income countries, especially US (40 %, n = 6) and UK (33.3 %, n = 5). There were 10 case reports, the majority of which used isavuconazole as salvage therapy. Two articles compared isavuconazole with voriconazole. The overall response rates at the end of treatment for CPA patients were similar, and the incidence of adverse drug reactions was numerically lower in the isavuconazole group compared to voriconazole. We found five articles on blood levels of isavuconazole. The mean isavuconazole serum level was >1 mg/L in all studies, even at a 100-mg daily dose. In the retrospective studies, the rate of isavuconazole discontinuation ranged from 17 % to 36 %.

CONCLUSION

There is limited experience with isavuconazole in treating CPA. This study consolidates existing evidence on its use in CPA, highlighting its potential as a therapeutic option beyond invasive aspergillosis, though further research is needed.

Serial Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography (18FDG-PET-CT) in Assessing Treatment Response in Chronic Pulmonary Aspergillosis

BACKGROUND

The role of 2-deoxy-2-18(F) fluoro-D-glucose (FDG) positron emission tomography (PET)-computed tomography (CT) in assessing treatment response in chronic pulmonary aspergillosis (CPA) remains to be determined. The study objective was to compare FDG-PET/CT parameters in persons with CPA achieving treatment success or failure after 6 months of oral itraconazole.

METHODS

We performed PET-CT at baseline and after 6 months of oral itraconazole therapy. FDG uptake similar to the background uptake or ≥13 units decline in Z-score was considered a complete metabolic response (CMR). A >25%, >30%, and > 45% decline in standardised uptake value (SUVmax), SUVpeak, and total glycolytic activity (TLG) was labelled as a partial metabolic response (PMR). A >30%, >30%, or >75% increase in the SUVmax, SUVpeak, and TLG represented progressive metabolic disease.

RESULTS

We included 94 persons with CPA (63 male) with a mean age of 46.2 years. A follow-up PET-CT was performed on 77 participants. We recorded treatment success and failure in 43 and 34 patients. CMR was seen in 18.6% of those with treatment success and none with treatment failure. A higher proportion of patients with treatment success achieved PMR; 19% of the patients with treatment success had progressive metabolic disease.

CONCLUSIONS

Most PET-CT parameters improved with treatment; however, PET-CT misclassified one-fifth of the participants.

Allergic Bronchopulmonary Aspergillosis in Patients With Prior Pulmonary Tuberculosis: A Study on the Burden, Clinic-Radiological Features, Treatment Outcomes and Comparison With Chronic Pulmonary Aspergillosis and Post-Tubercular Lung Disease Patients

BACKGROUND

Post-tuberculosis lung disease (PTLD) is a precursor to Aspergillus-related lung diseases. While Chronic Pulmonary Aspergillosis (CPA) has been extensively studied in the background of tuberculosis, Allergic Bronchopulmonary Aspergillosis (ABPA) has been reported sporadically with limited information on its prevalence, clinical-radiological features, and treatment outcomes.

OBJECTIVE

This study, conducted in a high TB burden setting, aimed to address this knowledge gap by systematically evaluating ABPA in PTLD patients.

METHODS

This retrospective cohort study screened PTLD patients presenting with respiratory or constitutional symptoms persisting for more than 3 months. The objective was to report the prevalence, clinical-radiological-laboratory data, and outcomes of ABPA-PTLD compared to a cohort of CPA (CPA-PTLD) and patients with PTLD (PTLD only).

RESULTS

Out of a total of 1012 PTLD patients, ABPA was seen in 2.27%, CPA in 20.75% and Aspergillus sensitization in 0.7%. ABPA patients primarily presented with breathlessness (91.3%) and cough (82.6%) while haemoptysis (43.5%), weight loss (13%), and anorexia (21.7%) were also observed, albeit less commonly than in CPA-PTLD. Bronchiectasis (100%) and nodules (87%) were more frequent in ABPA-PTLD patients, whereas consolidation (21.7%), cavities (30.4%), pleural thickening (8.7%), and 'fungal ball' (9.1%) were also seen, although less commonly than in CPA-PTLD. Most patients received azoles (78%) as first-line therapy, with symptomatic improvement (partial/complete) observed in ~78%.

CONCLUSION

ABPA may occur in PTLD patients, with specific clinical (e.g., haemoptysis) and radiological (e.g., cavity and fungal ball) features uncommon in other types of ABPA, but resembling other PTLD conditions. Future studies should focus on identifying differences in the natural course and appropriate treatment paradigms of ABPA-PTLD patients compared to ABPA occurring in asthma and cystic fibrosis patients.

Chronic pulmonary aspergillosis in Taiwan: Disease burden, diagnosis, treatment, and outcomes

Aspergillus is a common filamentous fungus found in various natural environments, with spores frequently inhaled by humans. While healthy individuals typically resist infection, immunocompromised individuals and those with pre-existing lung diseases are at higher risk for aspergillosis. Chronic pulmonary aspergillosis (CPA) often develops in individuals with conditions like tuberculosis and chronic obstructive pulmonary disease. Recent studies in Taiwan reveal a significant incidence of CPA among elderly patients with these underlying conditions. The most common clinical manifestations include cavitation, nodules, and consolidation in the lungs. Aspergillus-specific IgG antibodies have emerged as key diagnostic markers, with varying optimal cut-off values across different regions. Studies indicate a strong correlation between high IgG levels and severe CPA, alongside associations with specific radiographic features. Additionally, elevated inflammatory markers such as IL-1β and TNF-α are linked to poor outcomes, emphasizing the need for early detection and intervention. The preferred treatment regimen consists of itraconazole, voriconazole, posaconazole, and isavuconazole, with itraconazole and voriconazole being the most extensively documented in the context of CPA. Overall, this review underscores the importance of localized diagnostic validation and comprehensive studies to improve the understanding and treatment of CPA in Taiwan.

The minimal important difference of one-minute-sit-to-stand test in subjects with chronic pulmonary aspergillosis

BACKGROUND AND OBJECTIVE

There is a need for simple functional test to assess treatment response in chronic pulmonary aspergillosis (CPA) in resource-constrained settings. The one-minute-sit-to-stand test (1-min-STS) is one such test. However, the minimal important difference (MID) for 1-min-STS in subjects with CPA remains unknown. Herein, we estimate the MID for 1-min-STS for CPA subjects.

MATERIALS AND METHODS

We retrospectively reviewed the clinical details of CPA subjects treated with oral azoles for 6 months. We included only subjects who completed the 1-min-STS test at baseline and 6 months. We used the change in VAS (visual analogue scale, for overall improvement) as an external anchor. We used the anchor and the distribution (standard deviation-based) methods to determine the MID estimates. We used the anchor-based method only if there was correlation of 0.3 with the 1-min-STS test.

RESULTS

One hundred-eight subjects completed the 1-min-STS test at baseline and 6 months. We did not find significant correlation between the change in VAS for overall improvement (r2 = 0.024, P value = 0.809) and the 1-min-STS test. The MID for the 1-min-STS test was 2 repetitions (range, 1.5-2.8 repetitions).

CONCLUSION

The MID for the 1-min-STS test in subjects with CPA was 2 repetitions. Future studies using a global rating of change scale as an anchor must confirm our findings.

Clinical Features, Treatment Outcome and Potential risk Factors for Recurrence Among Patients with Chronic Pulmonary Aspergillosis in a Resource-limited Setting: A Retrospective Observational Study

OBJECTIVE

To evaluate the clinical characteristics and treatment outcomes of patients with chronic pulmonary aspergillosis (CPA) and to determine risk factors for disease recurrence.

METHODS

A total of 43 patients with CPA (mean ± SD age: 61.4 ± 10.5 years, 83.7% were males) were included in this retrospective study. Data on demographic, clinical and disease-related characteristics, galactomannan (GM) test positivity in bronchoalveolar lavage (BAL) samples, histopathological diagnosis, imaging (CT) findings and CPA forms, antifungal therapy, recurrence rate and time to recurrence were recorded.

RESULTS

Chronic obstructive pulmonary disease (COPD;76.7%) was the leading predisposing factor, and the aspergillus nodule (37.2%) was the most prevalent CPA form.GM test positivity was noted in 89.7% (35/39) of BAL samples. Median duration of voriconazole treatment was 180 days. CPA recurrence was noted in 14.0% of patients, while the comorbid tuberculosis sequela (66.7% vs. 16.2%, p = 0.02) and mild immunosuppressive disorder (100.0% vs. 51.4%, p = 0.032) were significantly more common in patients with recurrence vs. those without recurrence. Recurrence rate was 50.0% (3 of 6 patients) in patients with simple aspergilloma, and ranged from 0.0% to 25.0% in those with other CPA forms. Treatment duration and time to recurrence ranged 70-270 days and 1.1-37 months, respectively in simple aspergilloma, while they were ranged 150-180 days and 30-43.3 months, respectively in other CPA forms.

CONCLUSIONS

Our findings indicate the importance of considering CPA in differential diagnosis in patients with predisposing conditions, and emphasize the tuberculosis sequela, immunosuppressive disorder and the certain CPA forms managed with shorter duration of antifungal therapy (i.e., simple aspergilloma) as the potential risk factors of CPA recurrence.

Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease

Post-tuberculosis lung disease (PTLD) has only recently been put in the spotlight as a medical entity. Recent data suggest that up to 50% of tuberculosis (TB) patients are left with PTLD-related impairment after completion of TB treatment. The presence of residual cavities in the lung is the largest risk factor for the development of chronic pulmonary aspergillosis (CPA) globally. Diagnosis of CPA is based on four criteria including a typical radiological pattern, evidence of Aspergillus species, exclusion of alternative diagnosis, and a chronic course of disease. In this manuscript, we provide a narrative review on CPA as a serious complication for patients with PTLD.

Optimized Antifungal Therapy for Chronic Pulmonary Aspergillosis

Chronic pulmonary aspergillosis (CPA) represents a spectrum of lung disorders caused by local proliferation of Aspergillus hyphae in individuals with non-systemic or mildly systemic immunodepression or altered pulmonary integrity due to underlying disease. While long-term systemic antifungal treatment is still the mainstay for management, surgery is considered mainly in rarer invasive disease manifestations such as sinusitis and osteomyelitis. Optimal application of existing antifungal agents with suitable pharmacokinetic properties is important for the treatment of diseases such as CPA, which requires long-term use. Appropriate management of side effects by therapeutic drug monitoring, maintenance of adherence, and assessment of drug resistance to Aspergillus can provide safe and effective treatment in the future. Most available antifungal agents for the management of mycoses in humans have disadvantages that can limit their use in clinical practice. By contrast, second generation antifungals such as triazoles have advantages of extended antifungal spectrum and availability in both oral and intravenous formulations. Isavuconazole, a new extended spectrum triazole, has been shown to be effective against Aspergillus. The safety profile and excellent pharmacokinetic characteristics of isavuconazole make it an attractive option for treatment of invasive fungal infections including CPA. With this drug now available in Japan, new evidence is expected to expand treatment options. This review focuses on the selection of antifungal agents based on national and international guidelines and the characteristics of each agent for their appropriate use in CPA.

Chronic pulmonary aspergillosis - a guide for the general physician

This collaborative article presents a review of chronic pulmonary aspergillosis (CPA) from the perspective of a multidisciplinary team comprising of respiratory physicians, radiologists, mycologists, dietitians, pharmacists, physiotherapists and palliative care specialists. The review synthesises current knowledge on CPA, emphasising the intricate interplay between clinical, radiological, and microbiological aspects. We highlight the importance of assessing each patient as multidisciplinary team to ensure personalised treatment strategies and a holistic approach to patient care.

Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges

Chronic pulmonary aspergillosis (CPA) is a challenging respiratory infection caused by the environmental fungus Aspergillus. CPA has a poor prognosis, with reported 1-year mortality rates ranging from 7% to 32% and 5-year mortality rates ranging from 38% to 52%. A comprehensive understanding of the pathogen, pathophysiology, risk factors, diagnosis, surgery, hemoptysis treatment, pharmacological therapy, and prognosis is essential to manage CPA effectively. In particular, Aspergillus drug resistance and cryptic species pose significant challenges. CPA lacks tissue invasion and has specific features such as aspergilloma. The most critical risk factor for the development of CPA is pulmonary cavitation. Diagnostic approaches vary by CPA subtype, with computed tomography (CT) imaging and Aspergillus IgG antibodies being key. Treatment strategies include surgery, hemoptysis management, and antifungal therapy. Surgery is the curative option. However, reported postoperative mortality rates range from 0% to 5% and complications range from 11% to 63%. Simple aspergilloma generally has a low postoperative mortality rate, making surgery the first choice. Hemoptysis, observed in 50% of CPA patients, is a significant symptom and can be life-threatening. Bronchial artery embolization achieves hemostasis in 64% to 100% of cases, but 50% experience recurrent hemoptysis. The efficacy of antifungal therapy for CPA varies, with itraconazole reported to be 43-76%, voriconazole 32-80%, posaconazole 44-61%, isavuconazole 82.7%, echinocandins 42-77%, and liposomal amphotericin B 52-73%. Combinatorial treatments such as bronchoscopic triazole administration, inhalation, or direct injection of amphotericin B at the site of infection also show efficacy. A treatment duration of more than 6 months is recommended, with better efficacy reported for periods of more than 1 year. In anticipation of improvements in CPA management, ongoing advances in basic and clinical research are expected to contribute to the future of CPA management.

Predictive factors for treatment response and mortality in chronic pulmonary aspergillosis

OBJECTIVES

Chronic pulmonary aspergillosis (CPA) is associated with significant mortality, and suboptimal antifungal treatment response. We describe predictive factors for treatment response and survival.

METHODS

We retrospectively analysed clinical, serological and radiological parameters at baseline and following antifungal treatment in patients with CPA and correlated with clinical and radiological response and survival.

RESULTS

Fifty-nine patients were included with a mean age of 61 years. Thirty (51%) had a diagnosis of COPD. On clinical assessment at 6 months, 21 (36%) had clinically improved, 20 (34%) were clinically stable and 15 (25%) had deteriorated. Radiological improvement was observed in 30 (53%), stability in 11 (19%) and deterioration in 16 (28%). Only a lower C-reactive protein (CRP) at baseline was associated with a favourable clinical-radiological response. On univariate analysis, lower CRP, higher albumin, lower Aspergillus IgG and use of inhaled steroids were associated with lower mortality. An overall favourable response at 6 months was associated with lower mortality.

CONCLUSION

Inflammatory markers and Aspergillus IgG were predictors of mortality in CPA. This suggests that mortality in CPA is driven mainly by the chronic fungal infection itself rather than the underlying disease, therefore early optimised treatment of CPA may lead to improved outcomes.

Characterization of Treatment Response Outcomes in Chronic Pulmonary Aspergillosis: CPAnet Definitions Versus the Existing Criteria

BACKGROUND

The chronic pulmonary aspergillosis network (CPAnet) has recently proposed definitions for treatment outcomes in CPA. However, these definitions need to be validated. Herein, we evaluate the agreement between the existing and the CPAnet definitions for response assessment.

METHODS

We enrolled consecutive treatment-naïve CPA subjects (between January 2021 and June 2021) who received six months of itraconazole therapy and followed them for an additional six months after treatment discontinuation. We retrospectively applied the CPAnet criteria and compared the agreement between the existing and the CPAnet criteria for response assessment (primary objective). We also assessed if adding weight loss (> 5% from baseline) as a component improved the performance of the CPAnet criteria.

RESULTS

We included 43 (mean age, 47.4 years) CPA subjects. The existing and the CPAnet criteria categorized 29 (67.4%) and 30 (69.8%) subjects as treatment success, respectively, at treatment completion. There was substantial (kappa = 0.73; p < 0.0001) agreement between the two definitions. However, both criteria did not identify eight subjects requiring treatment re-initiation within three months. There was an increment in the sensitivity of both criteria (by 36%) for identifying treatment failure after incorporating ≥ 5% weight loss as an element of worsening.

CONCLUSION

The CPAnet definitions correctly categorized treatment outcomes in most cases of CPA. The addition of weight change would further enhance the performance of the CPAnet treatment outcome definitions.

Chronic cavitary pulmonary aspergillosis: Serial clinical and CT findings correlated with antifungal treatment and patient response

BACKGROUND

Chronic cavitary pulmonary aspergillosis (CCPA) is the most common form of chronic pulmonary aspergillosis.

OBJECTIVE

We hypothesise that by observing serial clinical and CT findings of CCPA patients with antifungal therapy, factors helping predict responses to antifungal therapy could be withdrawn.

METHODS

A total of 31 patients with CCPA who received antifungal therapy for greater than six months and who had serial CT studies were included. Clinical finding analyses were performed at initial and last follow-up CT acquisition dates. Clinical characteristics and CT features were compared between clinically improving or stable and deteriorating groups.

RESULTS

With antifungal therapy, neutrophil-to-lymphocyte ratio (2.66 vs. 5.12, p = .038) and serum albumin (4.40 vs. 3.85 g/dl, p = .013) and CRP (1.10 vs. 42.80 mg/L, p = .007) were different between two groups. With antifungal therapy, meaningful CT change, regardless of clinical response grouping, was decrease in cavity wall thickness (from 13.70 mm to 8.28 mm, p < .001). But baseline (p = .668) and follow-up (p = .278) cavity wall thickness was not different between two groups. In univariate analysis, initial maximum diameter of cavity (p = .028; HR [0.983], 95% CI [0.967-0.998]) and concurrent NTM infection (p = .030; HR [0.20], 95% CI [0.05-0.86]) were related factors for poor clinical response.

CONCLUSIONS

With antifungal therapy, cavities demonstrate wall thinning. Of all clinical and radiological findings and their changes, initial large cavity size and concurrent presence of NTM infection are related factors to poor response to antifungal therapy.

EQUAL CPA Score 2022: a tool to measure guideline adherence for chronic pulmonary aspergillosis

BACKGROUND

Chronic pulmonary aspergillosis (CPA) can complicate underlying pulmonary diseases, and clinical management of CPA is challenging. Guidelines support clinicians but due to the complexity of the disease they can be difficult to adhere to.

OBJECTIVES

To map current guideline recommendations for the clinical management of CPA into a scoring tool to facilitate and quantify guideline adherence in clinical practice.

METHODS

Recommendations for diagnosis, treatment and follow-up of CPA presented in the current ESCMID/ERS/ECMM and CPAnet guidance documents were assembled and weighed on the basis of their strength of recommendation and level of evidence.

RESULTS

Twenty-seven recommendations were identified, resulting in a total maximum EQUAL CPA Score of 51. For diagnostics (ScoreMax = 27), a strong emphasis on expert consultation, culture, direct microscopy, histopathology, serology and imaging was reflected in respective points, whereas molecular techniques and susceptibility testing count into the diagnostics score to a lesser extent.Ten treatment recommendations (ScoreMax = 14), including antifungal therapy, therapeutic drug monitoring and treatment duration, were identified. Surgery, where indicated, adds three points. For refractory disease or intolerance of first-line antifungal treatment, optimal second-line treatment added another two points.During follow-up (ScoreMax = 10), response assessment via imaging gave three points, while culture and serology added two points each to the ScoreMax.

CONCLUSION

The EQUAL CPA Score intents to be used as a comprehensive tool for measuring guideline adherence. If adherence to current guidelines is associated with clinical outcome, this will be assessed in future studies.