CME/CE: Updated Guidance on Invasive Aspergillosis

CME/CE: Updated Guidance on Invasive Aspergillosis
Author Information (click to view)

Thomas Patterson, MD

Chief, Division of Infectious Disease
Professor of Medicine
University of Texas Health Science Center at San Antonio
Director
San Antonio Center for Medical Mycology
Attending Physician
South Texas Veterans Health Care System, San Antonio

Thomas Patterson, MD, has indicated to Physician’s Weekly that he has no financial interests to disclose.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians and nurses.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  • Discuss the latest update to the Infectious Disease Society of America guideline on treating invasive aspergillosis.

Method of Participation(click to view)

Release Date: 6/27/2017
Expiration Date: 6/27/2018

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at intivahealth.akhcme.com/procial/lessons/4.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. dcotterman@akhcme.com.

Credit Available(click to view)

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Physician Assistants
NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

 

Nursing
AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is awarded 0.5 contact hours.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Chris Cole – Managing Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Thomas F. Patterson, MD

Discloses the following financial relationships with pharmaceutical or medical product manufacturers: Served as Consultant and/or Advisory Board for Amplyx, Astellas, Durata, Cidara Therapeutics, Gilead, Merck, Pfizer, Revolution Medicines, Scynexis, Toyama, Vical and Viamet for activities outside the submitted work.

Received Grant Support to the University of Texas Health Science Center from Astellas, Merck and Revolution Medicines for activities outside the submitted work.

AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.

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Thomas Patterson, MD (click to view)

Thomas Patterson, MD

Chief, Division of Infectious Disease
Professor of Medicine
University of Texas Health Science Center at San Antonio
Director
San Antonio Center for Medical Mycology
Attending Physician
South Texas Veterans Health Care System, San Antonio

Thomas Patterson, MD, has indicated to Physician’s Weekly that he has no financial interests to disclose.

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The Infectious Diseases Society of America has released an updated guideline for treating invasive aspergillosis that stress the importance of early diagnosis and treatment to improve clinical outcomes.
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In 2008, the Infectious Diseases Society of America (IDSA) released a guideline on the diagnosis and treatment of aspergillosis, a fungal infection caused by the airborne mold Aspergillus. With more data emerging and the recent FDA approval of new drugs for aspergillosis, the IDSA has updated its guideline and published it in Clinical Infectious Diseases. The update focuses heavily on invasive aspergillosis, which can be fatal in 40% to 80% of vulnerable patients with widespread infection.

“Since the last guideline, several developments have occurred regarding the drugs used for aspergillosis,” explains Thomas Patterson, MD, who was lead author of the guideline update. “Isavuconazole and a new formulation of posaconazole were approved by the FDA, and we now have more robust clinical experience with voriconazole.” Dr. Patterson notes that other factors have also changed the treatment landscape for aspergillosis, including further developed diagnostics, the influence of biomarkers like polymerase chain reaction (PCR), and increasing antifungal resistance.

 

Diagnosis

The updated guideline emphasizes that early diagnosis and therapy are critical to successfully treating patients with aspergillosis. “This has been well established, but the evidence is even stronger now to support it,” says Dr. Patterson. The guideline-writing panel stresses the importance of using cultures to establish a firm diagnosis, the etiology of infection, and help identify the organism to the species level. “This is important because of the variable susceptibilities that might be predicted from the different species,” Dr. Patterson adds.  “We also recognize that susceptibility testing could be recommended in certain patients. Routine susceptibility testing was not recommended for all patients because local susceptibilities are not available at many locations in the United States.”

The update also focuses on the importance of radiology as an adjunct to diagnosis and early establishment of infection and the role of biomarkers in diagnosis. “The most common biomarker is the measurement of galactomannan,” says Dr. Patterson, “which can be significantly lower in patients on prophylactic or empirical therapy for aspergillus, for example. In that setting, screening with routine evaluation is not recommended. However, in patients with suspected disease, galactomannan measurements may be useful.” PCR was not recommended for routine use in most patients for several reasons, mostly because no PCR-based assays are currently approved for clinical laboratories in the U.S., although testing in reference laboratories is available.

 

Invasive Disease

The IDSA strongly recommends using voriconazole as the primary treatment for most patients with aspergillosis, based on support from clinical trials and numerous real-world clinical investigations (Table). “In patients with intolerance, or even possible intolerance to voriconazole, isavuconazole may be a good alternative,” Dr. Patterson says. “Posaconazole may be another effective and tolerable alternative, but published studies have not yet evaluated it in head-to-head comparisons with voriconazole.”

The guidelines also do not recommend using echinocandins as primary therapy in most patients. Similarly, amphotericin B deoxycholate is not recommended unless alternatives are unavailable. The panel also did not recommend combination therapy as a routine measure in all patients with aspergillosis, based on the results of a randomized study that did not show combination therapy to be superior to voriconazole alone. “However, that same study showed that patients with presumed early disease had superior outcomes with combination therapy,” says Dr. Patterson. “In addition, combination therapy may be considered in patients with more progressive disease or with high rates of failures. Unfortunately, the evidence is still limited to guide the use of combination therapy.”

 

 Non-Invasive Diseases

In high-risk patients with chronic aspergillosis, allergic syndromes, or non-invasive syndromes, the IDSA writing panel notes that mold-active antifungals, including itraconazole, can effectively reduce dependence on steroids. “While invasive disease rarely develops in these patients, they can and should be managed with antifungals to limit the use of corticosteroids, with their attendant side effects,” Dr. Patterson says.

Evidence strongly supports the use of posaconazole as a prophylactic regimen, according to Dr. Patterson. “Posaconazole was shown to be superior to standard therapies in reducing aspergillosis infections in patients with acute myelogenous leukemia as well as myelodysplastic syndromes,” he adds. “Posaconazole is also recommended as prophylaxis in patients with graft-vs-host disease. Other regimens, such as voriconazole and isavuconazole, could be effective in that setting, but none have been studied to the same extent as posaconazole.”

 

Implications

Clinicians should use the guideline update as an aid when developing management strategies that target early diagnosis and use available tools and strategies to enhance the diagnosis of these potentially deadly infections, says Dr. Patterson. “Considering the potential lethal outcomes of these infections, it’s our hope that clinicians will use this evidence-based guidance to select and manage antifungal therapy in this patient population.”

Readings & Resources (click to view)

Patterson T, Thompson G, Denning D, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63:e1-e60. Available at http://cid.oxfordjournals.org/content/63/4/e1.

Walsh T, Anaissie E, Denning D, et al. Treatment of Aspergillosis: Clinical Practice Guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008;16:327-360.

Panackal A, Li H, Kontoyiannis D, Mori M, Perego C, Boeckh, Marr K. Geoclimatic Influences on Invasive Aspergillosis after Hematopoietic Stem Cell Transplantation. Clin Infect Dis. 2010;50:1588-1597.

Etienne K, Subudhi C, Chadwick P, et al. Investigation of a cluster of cutaneous aspergillosis in a neonatal intensive care unit. J Hosp Infect. 2011;79:344-348.

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