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PRACTICE GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF ASPERGILLOSIS: 2016 UPDATE BY THE INFECTIOUS DISEASES SOCIETY OF AMERICA§Thomas F. Patterson1+*, George R. Thompson III2, David W. Denning3, Jay A. Fishman4, Susan Hadley5, Raoul Herbrecht6, Dimitrios P. Kontoyiannis7, Kieren A. Marr8, Vicki A. Morrison9, M. Hong Nguyen10, Brahm H. Segal11, William J. Steinbach12, David A. Stevens13, Thomas J. Walsh14, John R. Wingard15, Jo-Anne H. Young9, John E. Bennett16+Dedication: The panel dedicates these guidelines to the memory of our dear friend Susan Hadley MD, a core member of the Mycoses Study Group, caring physician, and wonderful colleague.1The University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX2Departments of Medicine/Division of Infectious Diseases and Medical Microbiology and Immunology, University of California, Davis, CA3National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom.4Massachusetts General Hospital and Harvard Medical School, Boston, MA.5Department of Medicine Tufts Medical Center Boston, MA.§ It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.6Department of Oncology and Hematology, Hautepierre Hospital, University of Strasbourg, Strasbourg, France7Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, TX8Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD9Department of Medicine/Division of Infectious Diseases, University of Minnesota, Minneapolis, MN 10Department of Medicine and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA11Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, and Departments of Medicine and Immunology, Roswell Park Cancer Institute, Buffalo, NY12Department of Pediatrics/Division of Pediatric Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University Medical Center Durham, NC13 California Institute for Medical Research, San Jose, CA14Departments of Medicine, Pediatrics, and Microbiology and Immunology, New York-Presbyterian Hospital -Weill Cornell Medical Center, New York15Department of Medicine, University of Florida, Gainesville, FL16Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MDRunning head: IDSA guidelines for aspergillosis+Thomas F. Patterson and John E. Bennett served as co-chairs for the IDSA Aspergillus Guidelines Committee*Corresponding Author:Thomas F. Patterson, MD, FACP, FIDSADivision of Infectious DiseasesProfessor of MedicineDirector, San Antonio Center for Medical MycologyThe University of Texas Health Science Center at San Antonio 7703 Floyd Curl Drive -- MSC 7881San Antonio TX 78229-3900Email: patterson@uthscsa.eduEXECUTIVE SUMMARYBackgroundAspergillus species continue to be an important cause of life-threatening infection in immunocompromised patients. This at-risk population is comprised of patients with prolonged neutropenia, allogeneic hematopoietic stem cell transplantation (HSCT), solid-organ transplantation, inherited or acquired immunodeficiencies, corticosteroid use, and others. This document constitutes the Guidelines of the Infectious Diseases Society of America (IDSA) for treatment of aspergillosis and replaces the Practice Guidelines for Aspergillus published in 2008. Since that publication, clinical studies evaluating new and existing therapies including combination therapy for the management of Aspergillus infection have been conducted and the data on use of non-culture-based biomarkers for diagnosing infection has been expanded. The objective of these Guidelines is to summarize the current evidence for treatment of different forms of aspergillosis. This document reviews guidelines for management of the three major forms of aspergillosis: invasive aspergillosis (IA); chronic (and saprophytic) forms of aspergillosis; and allergic forms of aspergillosis. Given the clinical importance of IA, emphasis is placed upon the diagnosis, treatment, and prevention of the different forms of invasive aspergillosis, including invasive pulmonary aspergillosis (IPA), Aspergillus sinusitis, disseminated aspergillosis, and several types of single organ IA. Summarized below are the 2016 recommendations for the management of aspergillosis. Due to the guidelines relevance to pediatrics, the guideline has been reviewed and endorsed by the Pediatric Infectious Diseases Society (PIDS). The panel followed a guideline development process that has been adopted by IDSA, which includes use of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, a systematic method of grading both the strength of the recommendation (weak or strong) and the quality of evidence (very low, low, moderate, and high) (Figure 1). The guidelines are not intended to replace clinical judgment in the management of individual patients. A detailed description of the methods, background, and evidence summaries that support each recommendation can be found in the full text of the guideline.EPIDEMIOLOGY AND RISK FACTORS FOR INFECTIONI. How can the most susceptible patients be protected from aspergillosis and which patients are most susceptible? What are sources of exposure to Aspergillus and how can exposure be decreased? Is environmental surveillance useful?Recommendations1.Hospitalized allogeneic HSCT recipients should be placed in a protected environment to reduce mould exposure (Strong Recommendation; Low Quality Evidence). 2.These precautions can be reasonably applied to other highly immunocompromised patients at increased risk for IA, such as patients receiving induction/re-induction regimens for acute leukemia (Strong Recommendation; Low Quality Evidence). 3.In hospitals in which a protected environment is not available, we recommend admission to a private room, no connection to construction sites, and not allowing plants or cut flowers to be brought into the patient’s room (Strong Recommendation; Low Quality Evidence:).4.We recommend reasonable precautions to reduce mould exposure among outpatients at high risk for IA, including avoidance of gardening, spreading mulch (compost) or close exposure to construction or renovation (Strong Recommendation; Low Quality Evidence). 5.Leukemia and transplant centers should perform regular surveillance of cases of invasive mould infection. An increase in incidence over baseline or the occurrence of invasive mould infections in patients who are not at high risk for such infections should prompt evaluation for a hospital source (Strong Recommendation; Low Quality Evidence). DIAGNOSIS OF ASPERGILLOSIS II. How can a diagnosis of IA be established?How should Aspergillus be identified and how does this influence management? Recommendation6.Until molecular tools are more widely used in clinical laboratories, we recommend that tissue and fluid specimens be submitted in adequate quantities for simultaneous histopathologic/cytologic and culture examination. In the case of isolates with atypical growth or concerns for resistance, species identification by molecular methods should be employed. (Strong Recommendation; High Quality Evidence).What is the diagnostic value of nucleic acid testing in clinical specimens?Recommendations7.There was debate among the committee members regarding the clinical utility of blood-based PCR in diagnosing IA and experts were not in agreement.? One group favored recommendations for PCR testing, based on publications validating its?role when used in conjunction with other tests such as antigen detection assays to diagnose IA and/or reduce pre-emptive antifungal usage.? The other group felt that PCR assays are promising, but could not be recommended for routine use in clinical practice at present due to the lack of conclusive validation for commercially available assays, the variety of?methodologies in the literature, and questions about the extent to which results assisted diagnosis.???8.As research in the area continues, we recommend that clinicians?choosing to?use PCR assays employ them carefully in the management of individual patients on a case-by-case basis.? Clinicians should be aware of the methodologies and performance?characteristics of the specific assay used, and interpret results accordingly.?When PCR assays are used, results should be considered in conjunction with other diagnostic tests and the clinical context (Strong Recommendation; Moderate Quality Evidence).?How should galactomannan (GM) and (1→3)-β-D-glucan be used for the diagnosis of aspergillosis? Recommendations9.Serum and BAL GM is recommended as an accurate marker for the diagnosis of IA in adult and pediatric patients when used in certain patient subpopulations (hematologic malignancy, HSCT) (Strong Recommendation; High Quality Evidence). 10.GM is not recommended for routine blood screening in patients receiving mould-active antifungal therapy or prophylaxis, but can be applied to bronchoscopy specimens from those patients (Strong Recommendation; High Quality Evidence). 11.GM is not recommended for screening in solid organ transplant recipients or patients with chronic granulomatous disease (CGD) (Strong Recommendation; High Quality Evidence). 12.Serum assays for (1→3)-β-D-glucan are recommended for diagnosing IA in high risk patients (hematologic malignancy, allogeneic HSCT), but are not specific for Aspergillus (Strong Recommendation; Moderate Quality Evidence).What is the approach to the radiographic diagnosis of IPA?Recommendations13.We recommend performing a chest computed tomographic (CT) scan whenever there is a clinical suspicion for IPA regardless of chest radiograph results (Strong Recommendation; High Quality Evidence). 14.Routine use of contrast during a chest CT scan for a suspicion of IPA is not recommended (Strong Recommendation; Moderate Quality Evidence). Contrast is recommended when a nodule or a mass is close to a large vessel (Strong Recommendation; Moderate Quality Evidence). 15.We suggest a follow-up chest CT-scan to assess the response of IPA to treatment after a minimum of two weeks of treatment; earlier assessment is indicated if the patient clinically deteriorates (Weak Recommendation; Low Quality Evidence). When a nodule is close to a large vessel, more frequent monitoring may be required (Weak Recommendation; Low Quality Evidence).What is the role of bronchoscopy in the diagnosis of IPA? Recommendation16.We recommend performing a bronchoscopy with bronchoalveolar lavage (BAL) in patients with a suspicion of IPA (Strong Recommendation; Moderate Quality Evidence) Significant comorbidities such as severe hypoxemia, bleeding, and platelet transfusion-refractory thrombocytopenia may preclude BAL. The yield of BAL is low for peripheral nodular lesions, so that percutaneous or endobronchial lung biopsy should be considered. We recommend the use of a standardized BAL procedure and sending the BAL sample for routine culture and cytology as well as non-culture-based methods (e.g. GM) (Strong Recommendation; Moderate Quality Evidence). III. What antifungal agents are available for the treatment and prophylaxis of IA including pharmacologic considerations and what is the role for susceptibility testing? Amphotericin B (AmB)Recommendations17.AmB deoxycholate and its lipid derivatives are appropriate options for initial and salvage therapy of Aspergillus infections when voriconazole cannot be administered. However, AmB deoxycholate should be reserved for use in resource-limited settings in which no alternative agents are available. Lipid formulations of AmB should be considered in settings in which azoles are contraindicated or not tolerated (Strong Recommendation; Moderate Quality Evidence).18.Aerosolized formulations of AmB may be considered as prophylaxis in patients with prolonged neutropenia (patients receiving induction/re-induction therapy for acute leukemia and allogeneic HSCT recipients following conditioning or during treatment of Graft versus Host Disease [GVHD]) and in lung transplant recipients (Weak Recommendation; Low Quality Evidence).EchinocandinsRecommendation19.Echinocandins are effective in salvage therapy (either alone or in combination) against IA, but we do not recommend their routine use as monotherapy for the primary treatment of IA (Strong Recommendation; Moderate Quality Evidence). TriazolesRecommendations20.Triazoles are preferred agents for treatment and prevention of IA in most patients (Strong Recommendation; High Quality Evidence). 21.For patients receiving triazole-based therapy for IA, prolonged azole prophylaxis, or other therapies for which drug interactions with azoles are anticipated, the committee recommends therapeutic drug monitoring (TDM) once the steady state has been reached. A moderate amount of data for itraconazole, voriconazole, and posaconazole suspension suggests this approach may be valuable in enhancing therapeutic efficacy, in evaluating therapeutic failures attributable to suboptimal drug exposures, and to minimize toxicities potentially attributable to the azoles. (Strong Recommendation; Moderate Quality Evidence). Further studies are needed to address whether TDM is helpful or necessary with the extended release or intravenous formulations of posaconazole or for isavuconazole.22.Clinicians should obtain serum trough drug levels for azole antifungal agents (itraconazole, voriconazole, posaconazole, and possibly isavuconazole) and for potentially interacting drugs such as cyclosporine, tacrolimus, and sirolimus (and other CYP450 3A4 substrates such as tyrosine kinase inhibitors) to optimize therapeutic efficacy and to avoid potential toxicities of both groups of agents (Strong Recommendation; Moderate Quality Evidence). Preclinical and Laboratory Assessment of Combination antifungal binations of polyenes or azoles with echinocandins suggest additive or synergistic effects in some pre-clinical studies.? However, variable test designs and conflicting results of preclinical and in vitro testing have led to uncertainty as to how to interpret the findings.? (Weak Recommendation; Low Quality Evidence).When should antifungal susceptibility testing be performed and how should results be interpreted and affect management?Recommendation24.Routine antifungal susceptibility testing of isolates recovered during initial infection is not recommended. Antifungal susceptibility testing of Aspergillus isolates using a reference method is reserved for patients suspected to have an azole resistant isolate, who are unresponsive to antifungal agents, or for epidemiological purposes (Strong Recommendation; Moderate Quality Evidence).INVASIVE SYNDROMES OF ASPERGILLUSIV. What are the recommended treatment regimens and adjunctive treatment measures for the various clinical presentation of IA?How should IPA be treated?Recommendations25.We recommend primary treatment with voriconazole (Strong Recommendation; High Quality Evidence). 26.Early initiation of antifungal therapy in patients with strongly suspected IPA is warranted while a diagnostic evaluation is conducted (Strong Recommendation; High Quality Evidence)27.Alternative therapies include liposomal AmB (Strong Recommendation; Moderate Quality Evidence), isavuconazole (Strong Recommendation; Moderate Quality Evidence), or other lipid formulations of AmB (Weak Recommendation; Low Quality Evidence). bination antifungal therapy with voriconazole and an echinocandin may be considered in select patients with documented IPA (Weak Recommendation; Moderate Quality Evidence).29.Primary therapy with an echinocandin is not recommended (Strong Recommendation; Moderate Quality Evidence). Echinocandins (micafungin or caspofungin) can be used in settings in which azole and polyene antifungals are contraindicated (Weak Recommendation; Moderate Quality Evidence).30.We recommend that treatment of IPA be continued for a minimum of 6-12 weeks, largely dependent on the degree and duration of immunosuppression, site of disease, and evidence of disease improvement (Strong Recommendation; Low Quality Evidence). 31.For patients with successfully treated IPA who require subsequent immunosuppression, secondary prophylaxis should be initiated to prevent recurrence (Strong Recommendation; Moderate Quality Evidence). Adjunctive measures and immunomodulation: When should withdrawal of immunosuppressive agents, or addition of colony stimulating factors (CSFs) or granulocyte transfusions be considered in the treatment of IA?Recommendations32.Reducing doses of, or eliminating altogether, immunosuppressive agents, when feasible, is advised as a component of anti-Aspergillus therapy (Strong Recommendation; Low Quality Evidence).33.Colony stimulating factors may be considered in neutropenic patients with diagnosed or suspected IA (Weak Recommendation; Low Quality Evidence). There is insufficient evidence regarding the value of G-CSF versus GM-CSF in this setting.34.Granulocyte transfusions can be considered for neutropenic patients with IA that is refractory or are unlikely to respond to standard therapy, and for an anticipated duration of more than one week (Weak Recommendation; Low Quality Evidence). 35.Recombinant interferon- is recommended as prophylaxis in CGD patients (Strong Recommendation; High Quality Evidence). Its benefit as adjunctive therapy for IA is unknown.36.Surgery for aspergillosis should be considered for localized disease that is easily accessible to debridement (e.g., invasive fungal sinusitis or localized cutaneous disease) (Strong Recommendation; Low Quality Evidence). The benefit for IA in other settings such as in the treatment of endocarditis, osteomyelitis or focal central nervous system (CNS) disease appears rational. Other indications are less clear and require consideration of the patient’s immune status, co-morbidities, confirmation of a single focus, and the risks of surgery.When is it safe to proceed with chemotherapy or transplantation in a patient with IA?Recommendations37.IA is not an absolute contraindication to additional chemotherapy or HSCT (Strong Recommendation; Moderate Quality Evidence).38.Decisions about when to proceed with additional chemotherapy or HSCT following the diagnosis of aspergillosis should involve both Infectious Diseases specialists and Hematologists/Oncologists. These decisions must consider the risk of progressive aspergillosis during periods of subsequent anti-neoplastic treatment versus the risk of death from the underlying malignancy if this treatment is delayed (Strong Recommendation; Low Quality Evidence).What approaches are needed for refractory or progressive aspergillosis (salvage therapy)?Recommendations39.We recommend an individualized approach that takes into consideration the rapidity, severity, extent of infection, patient co-morbidities, and to exclude the emergence of a new pathogen (Strong Recommendation; Low Quality Evidence). The general strategies for salvage therapy typically include, (i) changing the class of antifungal; (ii) tapering or reversal of underlying immunosuppression when feasible, and (iii) surgical resection of necrotic lesions in selected cases.40. In the context of salvage therapy, an additional antifungal agent may be added to current therapy, or combination antifungal drugs from different classes other than those in the initial regimen may be used (Weak Recommendation; Moderate Quality Evidence).41.In patients currently receiving an antifungal and exhibiting an adverse event attributable to this agent, we recommend changing to an alternative class of antifungal, or the use of an alternative agent with a non-overlapping side-effect profile (Strong Recommendation; Low Quality Evidence).42.For salvage therapy, agents include lipid formulations of AmB, micafungin, caspofungin, posaconazole or itraconazole. The use of a triazole as salvage therapy should take into account prior antifungal therapy, host factors, pharmacokinetic considerations, and possible antifungal resistance (Strong Recommendation; Moderate Quality Evidence).How can biomarkers be used to assess patient response to therapy?Recommendations43.Serial monitoring of serum GM can be used in the appropriate patient subpopulations (hematologic malignancy, HSCT) who have an elevated GM at baseline to monitor disease progression, therapeutic response, and predict outcome (Strong Recommendation; Moderate Quality Evidence). 44.(1→3)-β-D-glucan has not been extensively studied in IA to predict outcome (Weak Recommendation; Low Quality Evidence).What are the recommended treatments for pediatric patients with aspergillosis?Recommendation45.Treatment of aspergillosis in children uses the same recommended therapies as in adult patients, however the dosing is different and for some antifungals is unknown (Strong Recommendation; High Quality Evidence).What are treatment options for aspergillosis of the airways in transplant and nontransplant recipients and how does it differ from IPA?Recommendations46.Saprophytic forms of tracheobronchial aspergillosis (TBA) do not require antifungal treatment except for symptomatic or immunosuppressed patients. Treatment includes bronchoscopic removal of mucoid impaction. Mould-active triazole agents are recommended for immunocompromised patients in whom the possibility of invasive disease cannot be eliminated (Strong Recommendation; Moderate Quality Evidence) 47.Bronchocentric granulomatosis is treated in the same fashion as allergic bronchopulmonary aspergillosis (ABPA) (Strong Recommendation; Low Quality Evidence). 48.Invasive forms of TBA are treated with a mould-active triazole or intravenous lipid formulations of AmB (Strong Recommendation; Moderate Quality Evidence). We also recommend minimization or reversal of underlying immunosuppression when feasible, and bronchoscopic debridement of airway lesions in selected cases (Strong Recommendation; Low Quality Evidence).49.In lung transplant recipients, we recommend treatment with a systemic anti-mould antifungal for TBA, including saprophytic forms. We also recommend adjunctive inhaled AmB in the setting of TBA associated with anastomotic endobronchial ischemia or ischemic reperfusion injury due to airway ischemia associated with lung transplantation (Strong Recommendation; Moderate Quality Evidence). Duration of antifungal therapy is at least 3 months or until TBA is completely resolved, whichever is longer. MANAGEMENT OF EXTRAPULMONARY ASPERGILLOSISWhat are the treatment considerations for CNS aspergillosis?Recommendation50.We recommend voriconazole as primary therapy for CNS aspergillosis (Strong Recommendation; Moderate Quality Evidence). Lipid formulations of AmB are reserved for those intolerant or refractory to voriconazole (Strong Recommendation; Moderate Quality Evidence).How is Aspergillus endophthalmitis treated?Recommendation51.We recommend that Aspergillus endophthalmitis be treated with systemic oral or intravenous voriconazole plus intravitreal voriconazole or intravitreal AmB deoxycholate (Strong Recommendation; Weak Quality Evidence).What is the role of surgery in aspergillosis of the paranasal sinuses?Recommendation52.We recommend that both surgery and either systemic voriconazole or a lipid formulation of AmB be used in invasive Aspergillus fungal sinusitis but that surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus. Enlargement of the sinus ostomy may be needed to improve drainage and prevent recurrence (Strong Recommendation; Moderate Quality Evidence). What are the treatment recommendations for Aspergillus endocarditis, pericarditis, and myocarditis?Recommendation53.In Aspergillus endocarditis, we recommend early surgical intervention combined with antifungal therapy in attempts to prevent embolic complications and valvular decompensation (Strong Recommendation; Moderate Quality Evidence). Voriconazole or a lipid formulation of AmB is recommended as initial therapy (Strong Recommendation; Low Quality Evidence). Following surgical replacement of an infected valve, lifelong antifungal therapy should be considered (Strong Recommendation; Low Quality Evidence).What are the treatment recommendations for Aspergillus osteomyelitis and septic arthritis?Recommendation54.Surgical intervention is recommended, where feasible, for management of Aspergillus osteomyelitis and arthritis, combined with voriconazole (Strong Recommendation; Moderate Quality Evidence).What are the treatment recommendations for cutaneous aspergillosis? Recommendations55.As cutaneous lesions may reflect disseminated infection, we recommend treatment with voriconazole in addition to evaluation for a primary focus of infection (Strong Recommendation; Low Quality Evidence). 56.In cases of aspergillosis in burns or massive soft tissue wounds, surgical debridement is recommended, in addition to antifungal therapy (Strong Recommendation; Moderate Quality Evidence). What are the treatment recommendations for Aspergillus peritonitis?Recommendation57.We recommend prompt peritoneal dialysis catheter removal accompanied by systemic antifungal therapy with voriconazole (Strong Recommendation; Weak Quality Evidence). What are the treatment recommendations for esophageal, gastrointestinal, and hepatic aspergillosis?Recommendations58.We suggest voriconazole and surgical consultation in attempts to prevent complications of hemorrhage, perforation, obstruction or infarction (Weak Recommendation; Low Quality Evidence). 59.We suggest antifungal therapy with voriconazole or a lipid formulation of AmB as initial therapy for hepatic aspergillosis. For extrahepatic or perihepatic biliary obstruction, or localized lesions that are refractory to medical therapy, surgical intervention is should be considered (Weak Recommendation; Low Quality Evidence). What are the treatment recommendations for renal aspergillosis?Recommendation60.We suggest a combined approach of medical and urologic management for renal aspergillosis. Obstruction of one or both ureters should be managed with decompression if possible and local instillation of AmB deoxycholate. Parenchymal disease is best treated with voriconazole (Weak Recommendation; Low Quality Evidence).What are the treatment regimens for Aspergillus ear infections?Recommendations61.Noninvasive Aspergillus otitis externa, also called otomycosis, is treated by thorough mechanical cleansing of the external auditory canal followed by topical antifungals or boric acid (Strong Recommendation; Moderate Quality Evidence).62.We recommend that clinicians treat IA of the ear with a prolonged course of systemic voriconazole, usually combined with surgery (Strong Recommendation; Low Quality Evidence). What are the treatment recommendations for Aspergillus keratitis?Recommendation63.We recommend that clinicians treat Aspergillus keratitis with topical natamycin 5% ophthalmic suspension or topical voriconazole (Strong Recommendation; Moderate Quality Evidence).How should Aspergillus bronchitis be diagnosed and treated in the non-transplant population?Recommendations64.We suggest the diagnosis of aspergillus bronchitis in non-transplant patients be confirmed by detection of Aspergillus spp. in respiratory secretions, usually sputum, with both PCR and GM on respiratory samples being much more sensitive than culture (Weak Recommendation; Low Quality Evidence).65.??? We suggest treatment with oral itraconazole or voriconazole with therapeutic drug monitoring (Weak Recommendation; Low Quality Evidence).V. What are the recommended prophylactic regimens: who should receive them and how should breakthrough infection be managed?PROPHYLAXIS OF IAIn what patients should antifungal prophylaxis against aspergillosis be used? Recommendation66.We recommend prophylaxis with posaconazole (Strong Recommendation; High Quality Evidence), voriconazole (Strong Recommendation; Moderate Quality Evidence), and/or micafungin (Weak Recommendation; Low Quality Evidence) during prolonged neutropenia for those who are at high risk for IA (Strong Recommendation; High Quality Evidence). Prophylaxis with caspofungin is also probably effective (Weak Recommendation; Low Quality Evidence). Prophylaxis with itraconazole is effective, but therapy may be limited by absorption and tolerability (Strong Recommendation; Moderate Quality Evidence). Triazoles should not be co-administered with other agents known to have potentially toxic levels with concurrent triazole coadministration (such as vinca alkaloids, and others) (Strong Recommendation; Moderate Quality Evidence).What are the recommended prophylactic regimens for patients with GVHD? Recommendations67.We recommend prophylaxis with posaconazole for allogeneic HSCT recipients with GVHD who are at high risk for IA (Strong Recommendation; High Quality Evidence). Prophylaxis with other mould-active azoles is also effective. Voriconazole is commonly used for prophylaxis against IA in high risk patients but did not show improved survival in clinical trials (Strong Recommendation; Moderate Quality Evidence). Prophylaxis with itraconazole is limited by tolerability and absorption (Strong Recommendation; High Quality Evidence). 68.We recommend continuation of antifungal prophylaxis throughout the duration of immunosuppression in patients with chronic immunosuppression associated with GVHD (corticosteroid equivalent of >1 mg/kg/day of prednisone for >2 weeks and/or the use of other anti-GVHD therapies, such as lymphocyte depleting agents, or tumor necrosis factor α (TNF-α) inhibition, for refractory GVHD) (Strong Recommendation; High Quality Evidence).What are the recommendations for antifungal prophylaxis in lung transplant patients?Recommendations69.We recommend antifungal prophylaxis with either a systemic triazole such as voriconazole or itraconazole or an inhaled AmB product for 3 to 4 months after lung transplant (Strong Recommendation; Moderate Quality Evidence).70.Systemic voriconazole or itraconazole is suggested over inhaled amphotericin B for lung transplant recipients with mould colonization pre- or post- lung transplantation, mould infections found in explanted lungs, fungal infections in the sinus, and single lung transplant recipients. (Weak Recommendation; Low Quality Evidence).71.We recommend reinitiating antifungal prophylaxis for lung transplant recipients receiving immunosuppression augmentation with either thymoglobulin, alemtuzumab, or high dose corticosteroids (Strong Recommendation; Moderate Quality Evidence).What are the recommendations for antifungal prophylaxis in non-lung solid organ transplant recipients?Recommendation72.We recommend prophylactic strategies in solid organ transplant recipients based on the institutional epidemiology of infection and assessment of individual risk factors (Strong Recommendation; Low Quality Evidence).? Prospective trials are lacking to address the need for routine anti-Aspergillus prophylaxis other than for lung transplant recipients.? Individual risk factors have been identified in cardiac (pre-transplant colonization, reoperation, cytomegalovirus (CMV) infection, renal dysfunction, institutional outbreak), liver (fulminant hepatic failure, reoperation, retransplantation or renal failure), and others with institutional outbreaks or prolonged or high-dose corticosteroid use.? In such patients, the optimal duration of prophylaxis is not known.? MANAGEMENT OF BREAKTHROUGH INFECTION How should breakthrough aspergillosis be managed?Recommendation73.We suggest an individualized approach that takes into consideration the rapidity and severity of infection and local epidemiology. As principles, we recommend an aggressive and prompt attempt to establish a specific diagnosis with bronchoscopy and/or CT-guided biopsy for peripheral lung lesions. Documentation of serum azole levels should be verified if TDM is available for patients receiving mould-active triazoles. Antifungal therapy should be empirically changed to an alternative class of antifungal with Aspergillus activity. Other considerations include reduction of underlying immunosuppression if feasible, and susceptibility testing of any Aspergillus isolates recovered from the patient (Weak Recommendation; Moderate Quality Evidence).VI. When should patients be treated empirically?What strategies are recommended for empirical and pre-emptive strategies in allogeneic HSCT recipients and patients treated for acute myelogenous leukemia (AML)? Recommendations74.Empirical antifungal therapy is recommended for high-risk patients with prolonged neutropenia who remain persistently febrile despite broad-spectrum antibiotic therapy. Antifungal options include a lipid formulation of AmB (Strong Recommendation; High Quality Evidence), an echinocandin (caspofungin or micafungin) (Strong Recommendation; High Quality Evidence), or voriconazole (Strong Recommendation; Moderate Quality Evidence). 75.Empirical antifungal therapy is not recommended for patients who are anticipated to have short durations of neutropenia (duration of neutropenia <10 days), unless other findings indicate a suspected invasive fungal infection (Strong Recommendation; Moderate Quality Evidence).76.The use of serum or BAL fungal biomarkers such as GM or (1→3)-β-D-glucan to guide antifungal therapy in asymptomatic or febrile high risk patients (often referred to as pre-emptive or biomarker-driven antifungal therapy) can reduce unnecessary antifungal therapy. The pre-emptive approach can result in more documented cases of invasive aspergillosis without compromise in survival and can be used as an alternative to empirical antifungal therapy (Strong Recommendation; Moderate Quality Evidence).77.Early initiation of antifungal therapy in patients with strongly suspected IPA is warranted while a diagnostic evaluation is conducted (Strong Recommendation; Moderate Quality Evidence). 78.Management of suspected or documented breakthrough IPA in the context of mould-active azole prophylaxis or empirical suppressive therapy is not defined by clinical trial data but a switch to another drug class is suggested (Weak Recommendation; Low Quality Evidence). How do lung transplant recipients differ from other immunosuppressed patients in management of suspected IPA?Recommendations79.In lung transplant recipients not on anti-mould prophylaxis, we suggest pre-emptive therapy with an anti-mould antifungal for asymptomatic patients with Aspergillus colonization of the airways within 6 months of lung transplantation or within 3 months of receiving immunosuppression augmentation for rejection (Weak Recommendation; Moderate Quality Evidence).80.Six months after lung transplantation and in the absence of recent immunosuppression augmentation for rejection, it may be prudent to withhold antifungal therapy for Aspergillus airway colonization (i.e., Aspergillus respiratory cultures in the absence of clinical features that suggest disease, such as compatible symptoms, or bronchoscopic, histopathologic and/or radiographic findings) (Weak Recommendation; Low Quality Evidence).CHRONIC AND SAPROPHYTIC SYNDROMES OF ASPERGILLUSVII. How should chronic aspergillosis, allergic or non-invasive syndromes be managed?How can chronic cavitary pulmonary aspergillosis (CCPA) be diagnosed and treated?Recommendations81.??The diagnosis of CCPA requires: (1) 3 months of chronic pulmonary symptoms or chronic illness or progressive radiographic abnormalities, with cavitation, pleural thickening, peri-cavitary infiltrates and sometimes a fungal ball; (2) Aspergillus IgG antibody elevated or other microbiological data; and (3) no or minimal immunocompromise, usually with one or more underlying pulmonary disorders. The Aspergillus IgG antibody test is the most sensitive microbiological test (Strong Recommendation; Moderate Quality Evidence). Sputum Aspergillus PCR testing is more sensitive than culture (Weak Recommendation; Moderate Quality Evidence).82.Patients with CCPA without pulmonary symptoms, weight loss or significant fatigue, and those without major impairment of pulmonary function or gradual loss of pulmonary function may be observed without antifungal therapy and followed every 3-6 months (Weak Recommendation; Low Quality Evidence).83. Patients with CCPA and either pulmonary or general symptoms or progressive loss of lung function or radiographic progression should be treated with a minimum of 6 months of antifungal therapy (Strong Recommendation; Low Quality Evidence).84. Oral itraconazole and voriconazole are the preferred oral antifungal agents (Strong Recommendation; High Quality Evidence); posaconazole is a useful third-line agent for those with adverse events or clinical failure (Strong Recommendation; Moderate Quality Evidence).85.Hemoptysis may be managed with oral tranexamic acid (Weak Recommendation; Low Quality Evidence), bronchial artery embolization (Strong Recommendation; Moderate Quality Evidence) or antifungal therapy to prevent recurrence (Strong Recommendation; Low Quality Evidence). Patients failing these measures may require surgical resection (Weak Recommendation; Moderate Quality Evidence). 86.In those who fail therapy, who develop triazole resistance and/or have adverse events, intravenous micafungin (Weak Recommendation; Low Quality Evidence), caspofungin (Weak Recommendation; Low Quality Evidence), or amphotericin B (Weak Recommendation; Low Quality Evidence) yield some responses. Treatment may need to be prolonged.87.Surgical resection is an option for some patients with localized disease, unresponsive to medical therapy, including those with pan-azole resistant A. fumigatus infection or persistent hemoptysis despite bronchial artery embolization (Strong Recommendation; Moderate Quality Evidence). The outcomes from surgery are less favorable than those with single aspergilloma, and a careful risk assessment prior to surgical intervention is required. 88.In those with progressive disease, long term, even life-long antifungal therapy may be required to control disease (Weak Recommendation; Low Quality Evidence), with continual monitoring for toxicity and resistance.What are the management options for an Aspergillus fungal ball of the lung (aspergilloma)?Recommendations89.Asymptomatic patients with a single aspergilloma and no progression of the cavity size over 6-24 months should continue to be observed (Strong Recommendation; Moderate Quality Evidence).90.Patients with symptoms, especially significant hemoptysis, with a single aspergilloma, should have it resected, assuming that there are no contraindications (Strong Recommendation; Moderate Quality Evidence).91.Peri/post-operative antifungal therapy is not routinely required, but if the risk of surgical spillage of the aspergilloma is moderate (related to location and morphology of the cavity) antifungal therapy with voriconazole (or another mould active azole) or an echinocandin is suggested to prevent Aspergillus empyema (Weak Recommendation; Low Quality Evidence). ALLERGIC SYNDROMES OF ASPERGILLUSHow is ABPA identified and managed, in patients with asthma and cystic fibrosis (CF)?Recommendations92.Elevated Aspergillus IgE and total IgE are recommended to establish the diagnosis and are useful for screening (Strong Recommendation; High Quality Evidence).93.We suggest treating symptomatic asthmatic patients with bronchiectasis or mucoid impaction, despite oral or inhaled corticosteroid therapy, with oral itraconazole therapy with therapeutic drug monitoring (Weak Recommendation; Low Quality Evidence).94.In CF patients with frequent exacerbations and/or falling FEV1, we suggest treating with oral itraconazole to minimize corticosteroid use with therapeutic drug monitoring, and consideration of other mould-active azole therapy if therapeutic levels cannot be achieved. (Weak Recommendation; Low Quality Evidence).What is the medical management of allergic fungal rhinosinusitis caused by Aspergillus spp.?Recommendations95.We recommend establishing the diagnosis of allergic fungal rhinosinusitis (AFRS) in patients with nasal polyposis and thick eosinophilic mucin by visualizing hyphae in mucus, which is supported by a positive anti-Aspergillus IgE serum antibody assay or skin prick test (where available) (Strong Recommendation; Moderate Quality Evidence). 96.We recommend polypectomy and sinus washout as the optimal means of symptom control and inducing remission, however relapse is frequent (Strong Recommendation; Moderate Quality Evidence).97.We recommend the use of topical nasal steroids to reduce symptoms and increase time to relapse, especially if given after surgery (Strong Recommendation; Moderate Quality Evidence).98.We suggest oral antifungal therapy using mould-active triazoles for refractory infection and/or rapidly relapsing disease, although this approach is only partially effective (Weak Recommendation; Low Quality Evidence).INTRODUCTIONIA remains a major cause of morbidity and mortality in high risk immunocompromised patients. Additionally, chronic and allergic syndromes due to Aspergillus are recognized to affect an even greater number of additional patients. In recent years, the clinical evidence for the diagnosis and management of patients with Aspergillus syndromes has vastly increased. New agents and formulations along with studies for the use of older agents are available for treating patients with these infections, and new diagnostic tools have increased the ability to diagnose these infections in a timely manner. This document constitutes the Guidelines of the Infectious Diseases Society of America (IDSA) for treatment of aspergillosis. These guidelines replace the Practice Guidelines for Aspergillus published in 2008 PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWxzaDwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [1] and incorporate new clinical evidence in the recommendations. The objective of these Guidelines is to summarize the current evidence for treatment of different forms of aspergillosis. The panel followed the GRADE framework as adopted by the IDSA. In the recommendation section which follows, the panel answered a series of broad questions for managing syndromes of aspergillosis and the background and evidence for the recommendations are presented: I. How can the most susceptible patients be protected from aspergillosis and which patients are most susceptible? II. How can a diagnosis of IA be established?III. What antifungal agents are available for the treatment and prophylaxis of IA including pharmacologic considerations and role for susceptibility testing?IV. What are the recommended treatment regimens and adjunctive treatment measures for the various clinical presentations of IA?V. What are the recommended prophylactic regimens: who should receive them and how should breakthrough infection be managed?VI. When should patients be treated empirically?VII. How should chronic aspergillosis, allergic or non-invasive syndromes be managed?METHODOLOGYPanel CompositionThe most recent version of the IDSA guidelines on the management of patients with aspergillosis was published in 2008 PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWxzaDwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [1]. For this update, the IDSA Standards and Practice Guidelines Committee convened a multidisciplinary panel of 17 experts in the management of patients with aspergillosis. The panel consisted of 17 members of the IDSA, and included 16 adult infectious diseases physicians and 1 pediatric infectious diseases physician. All panel members were selected on the basis of their expertise in clinical and/or laboratory mycology with a focus on aspergillosis.Evidence Review - The GRADE Method GRADE is a systematic approach to guideline development that has been described in detail elsewhere PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdXlhdHQ8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [2, 3]. The IDSA/HIV Medicine Association (HIVMA) adopted GRADE in 2008. In the GRADE system, the guideline panel assigns each recommendation with separate ratings for the underlying quality of evidence supporting the recommendation and for the strength with which the recommendation is made (Figure 1) ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1" ExcludeYear="1"><RecNum>1113</RecNum><DisplayText>[4]</DisplayText><record><rec-number>1113</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1461689151">1113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>U.S. GRADE Network. Approach and implications to rating the quality of evidence and strength of recommendations using the GRADE methodology. Available at: . Accessed April, 2016</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[4]. Data from randomized controlled trials begin as “high” quality, and data from observational studies begin as “low” quality. However, the panel may judge that specific features of the data warrant decreasing or increasing the quality of evidence rating, and GRADE provides guidance on how such factors should be weighed ADDIN EN.CITE <EndNote><Cite><Author>Guyatt</Author><Year>2011</Year><RecNum>178</RecNum><DisplayText>[3]</DisplayText><record><rec-number>178</rec-number><foreign-keys><key app="EN" db-id="teffsv9psevveiedfz35tttlf9tz5es2dwtp">178</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guyatt, G. H.</author><author>Oxman, A. D.</author><author>Schunemann, H. J.</author><author>Tugwell, P.</author><author>Knottnerus, A.</author></authors></contributors><auth-address>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8N 3Z5, Canada. guyatt@mcmaster.ca</auth-address><titles><title>GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology</title><secondary-title>Journal of clinical epidemiology</secondary-title><alt-title>J Clin Epidemiol</alt-title></titles><periodical><full-title>Journal of clinical epidemiology</full-title><abbr-1>J Clin Epidemiol</abbr-1></periodical><alt-periodical><full-title>Journal of clinical epidemiology</full-title><abbr-1>J Clin Epidemiol</abbr-1></alt-periodical><pages>380-2</pages><volume>64</volume><number>4</number><edition>2010/12/28</edition><keywords><keyword>Evidence-Based Medicine/*standards</keyword><keyword>Guideline Adherence</keyword><keyword>Humans</keyword><keyword>Periodicals as Topic/standards</keyword><keyword>Practice Guidelines as Topic/standards</keyword><keyword>Publication Bias</keyword><keyword>Quality Assurance, Health Care/*standards</keyword></keywords><dates><year>2011</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1878-5921 (Electronic)&#xD;0895-4356 (Linking)</isbn><accession-num>21185693</accession-num><urls><related-urls><url>;[3]. The strength assigned to a recommendation reflects the panel’s confidence that the benefits of following the recommendation are likely to outweigh potential harms. While the quality of evidence is an important factor in choosing recommendation strength, it is not prescriptive. Process Overview Panel members were each assigned to review the recent literature for at least one topic, evaluate the evidence, determine the strength of recommendations and develop written evidence in support of these recommendations. The panel met face-to-face once and conducted a series of conference calls over a 10-month period. The panel reviewed and discussed all recommendations, their strength, and the quality of evidence. Discrepancies were discussed and resolved, and all final recommendations represent a consensus opinion of the entire panel. For the final version of these guidelines, the panel as a group reviewed all individual sections. Panel subgroups generated a list of keywords that were used by librarians at the Health Sciences Library—University of Pittsburg (with grateful acknowledgement to Michele Klein-Fedyshin and Charles B. Wessel) to develop PICO (population, intervention, comparison, outcomes) search strings for use in PubMed and results were returned to each primary author and the chairs for review. Searches were restricted to English language publications and covered the period of January, 2008 (when the last guideline was published) through December, 2014. Abstracts presented at international conferences within the past two years were also reviewed for inclusion. Systematic reviews of relevant topics were identified using PubMed and the Cochrane library. Each primary topic author was responsible for reviewing the literature relevant to their section, and drafting recommendations and evidence summaries for review and discussion by the full panel.Conflicts of InterestsThe expert panel complied with the IDSA policy on conflicts of interest, which requires disclosure of any financial or other interest that may be construed as constituting an actual, potential, or apparent conflict. Panel members were provided IDSA's conflicts of interest disclosure statement and were asked to identify ties to companies developing products that may be affected by promulgation of the guideline. Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, and membership on company advisory committees. Decisions were made on a case-by-case basis as to whether an individual's role should be limited as a result of a conflict. Potential conflicts of interests are listed in the Acknowledgments section. Review and Approval Process The panel obtained feedback from two external peer reviewers. The guidelines were reviewed and endorsed by the Pediatric Infectious Diseases Society (PIDS). The guideline was reviewed and approved by the IDSA Standards and Practice Guidelines Committee and the IDSA Board of Directors prior to dissemination.Future Guideline RevisionsAt annual intervals, the panel chairs will be asked for their input on the need to update the guideline based on an examination of the current literature. The Standards and Practice Guidelines Committee of the IDSA will consider this input and determine the necessity and timing of an update. If warranted, the entire panel or a subset thereof will be convened to discuss potential changes. EPIDEMIOLOGY AND RISK FACTORS FOR INFECTIONI. How can the most susceptible patients be protected from aspergillosis and which patients are most susceptible? What are sources of exposure to Aspergillus and how can exposure be decreased? Is environmental surveillance useful?Recommendations1.Hospitalized allogeneic HSCT recipients should be placed in a protected environment to reduce mould exposure (Strong Recommendation; Low Quality Evidence). 2.These precautions can be reasonably applied to other highly immunocompromised patients at increased risk for IA, such as patients receiving induction/re-induction regimens for acute leukemia (Strong Recommendation; Low Quality Evidence). 3.In hospitals in which a protected environment is not available, we recommend admission to a private room, no connection to construction sites, and not allowing plants or cut flowers to be brought into the patient’s room (Strong Recommendation; Low Quality Evidence).4.We recommend reasonable precautions to reduce mould exposure among outpatients at high risk for IA, including avoidance of gardening, spreading mulch (compost) or close exposure to construction or renovation (Strong Recommendation; Low Quality Evidence). 5.Leukemia and transplant centers should perform regular surveillance of cases of invasive mould infection. An increase in incidence over baseline or the occurrence of invasive mould infections in patients who are not at high risk for such infections should prompt evaluation for a hospital source (Strong Recommendation; Low Quality Evidence). Evidence summaryAspergillus species and other filamentous fungi are ubiquitous in the environment. The risks of exposure vary both temporally and geographically and are dependent on precipitation patterns, humidity, temperature, and wind conditions PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYW5hY2thbDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+

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ADDIN EN.CITE.DATA [8-11]. Contamination of water systems has also been considered a source of nosocomial aspergillosis and other mould infections PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmFpc3NpZTwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+

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ADDIN EN.CITE.DATA [12-17].Since there are numerous sources of mould in the environment, reasonable efforts should be made to decrease exposure to fungal spores in highly immunocompromised patients. Detailed guidelines have been published regarding hospital room design and ventilation to reduce mould exposure among allogeneic HSCT recipients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub21ibHluPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48

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ADDIN EN.CITE.DATA [18]. A “protected environment” is recommended, which includes high efficiency particulate air (HEPA) filtration (and/or laminar airflow), maintenance of positive pressure rooms, and a minimum number of air exchanges per hour. Other at risk groups such as solid organ transplant and burn patients are often also placed in HEPA filtered rooms. Additional guidelines are provided to minimize mould exposure during hospital construction, renovation, and building PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXJ0cmlkZ2UtSGluY2tsZXk8L0F1dGhvcj48WWVhcj4y

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ADDIN EN.CITE.DATA [19]. These guidelines can reasonably be applied to other highly immunocompromised patients, such as those receiving induction/re-induction chemotherapy for acute leukemia. We are in agreement with these guidelines, but note that they are consensus criteria rather than evidence-based. We recognize that highly immunocompromised patients may be admitted to hospitals that lack the engineering standards providing for a “protected environment”. In these settings, reasonable standards include admission to a private room without connection to construction sites, and not allowing plants/cut flowers to be brought into the patient’s room. Patients at risk for mould infections are commonly managed as outpatients where engineering standards are not comparable to the “protected” environment of inpatients. We advise reasonable precautions to reduce mould exposure, including the avoidance of gardening, spreading mulch, or close exposure to construction or renovation. The effectiveness of masks (surgical or N95) to protect against mould infections associated with these exposures is unknown. The majority of cases of invasive mould infections are sporadic, although outbreaks are well-recognized PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaGlvPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [24]. In the absence of an outbreak with an identified environmental source (e.g. a contaminated air vent) or molecular analysis that demonstrates clustering of fungal isolates, it is not possible to reliably distinguish community-acquired from nosocomial aspergillosis. As a quality control measure, leukemia and transplant centers should perform regular surveillance (e.g. every 3 months) documenting the number of invasive mould infections within their institution. Due to the paucity of culture confirmed cases of IA and lack of autopsy data in most medical centers, surveillance using case definitions for moulds including GM and radiographic evidence of infection such as the revised European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria is reasonable. An increase in incidence over baseline or the occurrence of invasive mould infections in patients who are not considered high-risk for such infections should prompt evaluation for a hospital source. Environmental sampling can provide important insight about sources of aspergillosis, including the spread of azole-resistant strains PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVyIExpbmRlbjwvQXV0aG9yPjxZZWFyPjIwMTM8

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ADDIN EN.CITE.DATA [26, 27]. In the absence of an outbreak, there is insufficient evidence that environmental sampling of fungal spores is of value. In the setting of a documented or suspected nosocomial outbreak, a number of measures should be undertaken, including evaluation of the ventilation system to ensure adequate filtration, air flow, maintenance of positive pressure, and consideration of environmental sampling e.g., air vents and water system.What acquired or inherited defects in host immunity increase the risk of aspergillosis? Patients at risk for IA include those with prolonged neutropenia, allogeneic HSCT recipients, solid organ transplant recipients, patients receiving corticosteroids, advanced acquired immunodeficiency syndrome (AIDS), and CGD. In patients with hematologic malignancies, myelodysplastic syndrome, and other diseases associated with marrow failure (e.g., aplastic anemia), the intensity and duration of neutropenia predict the risk of IA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWluYmVyZ2VyPC9BdXRob3I+PFllYXI+MTk5MjwvWWVh

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ZE5vdGU+AG==

ADDIN EN.CITE.DATA [30]. In allogeneic HSCT recipients, three periods of risk for invasive mould disease occur: 1) neutropenia following the conditioning regimen; 2) exogenous immunosuppression for treatment of acute GVHD; and 3) exogenous immunosuppression for treatment of chronic GVHD (after day 100 of transplant). The level of allogeneic donor and recipient HLA disparity is the major determinant for GVHD severity and intensity of immunosuppression to control GVHD, which, in turn, is the major predisposing factor for opportunistic fungal infections PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb250b3lpYW5uaXM8L0F1dGhvcj48WWVhcj4yMDEwPC9Z

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Pn==

ADDIN EN.CITE.DATA [32, 33]. Among allogeneic HSCT recipients, polymorphisms in specific host defense genes of the donor or recipient can also influence the risk of aspergillosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb2NodWQ8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [34-37].In solid organ transplant recipients, the intensity of immunosuppression to prevent or treat allograft rejection, colonization, and coinfection with CMV drive the risk of invasive aspergillosis. As in allogeneic HSCT recipients, polymorphisms in specific host defense genes in solid organ transplant recipients can also influence the risk of aspergillosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Xb2p0b3dpY3o8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy

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ADDIN EN.CITE.DATA [38, 39]. Lung transplant recipients have the highest risk of invasive aspergillosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXBwYXM8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [40-42]. In a multicenter surveillance study, approximately one-half of cases of invasive aspergillosis in lung transplant recipients were late-onset, occurring 1 year or more after transplantation ADDIN EN.CITE <EndNote><Cite><Author>Doligalski</Author><Year>2014</Year><RecNum>26021</RecNum><DisplayText>[41]</DisplayText><record><rec-number>26021</rec-number><foreign-keys><key app="EN" db-id="a9a0zdws9s90ave9xrmxtf9h90pw2dxzptep">26021</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Doligalski, C. T.</author><author>Benedict, K.</author><author>Cleveland, A. A.</author><author>Park, B.</author><author>Derado, G.</author><author>Pappas, P. G.</author><author>Baddley, J. W.</author><author>Zaas, D. W.</author><author>Harris, M. T.</author><author>Alexander, B. D.</author></authors></contributors><auth-address>Department of Pharmacy, Tampa General Hospital, Tampa, FL.</auth-address><titles><title>Epidemiology of invasive mold infections in lung transplant recipients</title><secondary-title>Am J Transplant</secondary-title><alt-title>American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons</alt-title></titles><periodical><full-title>Am J Transplant</full-title></periodical><pages>1328-33</pages><volume>14</volume><number>6</number><edition>2014/04/15</edition><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1600-6143 (Electronic)&#xD;1600-6135 (Linking)</isbn><accession-num>24726020</accession-num><work-type>Research Support, N.I.H., Extramural&#xD;Research Support, U.S. Gov&apos;t, P.H.S.</work-type><urls><related-urls><url>;[41]. CMV infection is a risk factor for aspergillosis, notably in heart and lung transplant recipients ADDIN EN.CITE <EndNote><Cite><Author>Singh</Author><Year>2013</Year><RecNum>515</RecNum><DisplayText>[43]</DisplayText><record><rec-number>515</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1432753735">515</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Singh, N.</author><author>Husain, S.</author><author>A. S. T. Infectious Diseases Community of Practice</author></authors></contributors><auth-address>VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA. nis5@pitt.edu</auth-address><titles><title>Aspergillosis in solid organ transplantation</title><secondary-title>Am J Transplant</secondary-title><alt-title>American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons</alt-title></titles><periodical><full-title>American Journal of Transplantation</full-title><abbr-1>Am. J. Transplant.</abbr-1><abbr-2>Am J Transplant</abbr-2></periodical><pages>228-41</pages><volume>13 Suppl 4</volume><keywords><keyword>Antifungal Agents/therapeutic use</keyword><keyword>*Aspergillosis/diagnosis/drug therapy/epidemiology/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>*Organ Transplantation</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2013</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1600-6143 (Electronic)&#xD;1600-6135 (Linking)</isbn><accession-num>23465016</accession-num><urls><related-urls><url>;[43]. Pre-transplant Aspergillus airway colonization is frequent among cystic fibrosis patients, and increases the risk of post-lung transplant invasive aspergillosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdW9uZzwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [44]. Invasive aspergillosis in patients with autoimmune diseases is uncommon. Prolonged use of corticosteroids and other immunosuppressive agents and possibly pre-existing lung disease are risk factors ADDIN EN.CITE <EndNote><Cite><Author>Su</Author><Year>2009</Year><RecNum>797</RecNum><DisplayText>[45]</DisplayText><record><rec-number>797</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1454362491">797</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Su, T.</author><author>Li, H. C.</author><author>Chen, M.</author><author>Gao, L.</author><author>Zhou, F. D.</author><author>Wang, R. G.</author><author>Zhang, H.</author><author>Li, X. M.</author><author>Zhao, M. H.</author></authors></contributors><auth-address>Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.</auth-address><titles><title>Invasive pulmonary aspergillosis in patients with antineutrophil cytoplasmic antibody associated vasculitis</title><secondary-title>J Clin Rheumatol</secondary-title></titles><periodical><full-title>Journal of Clinical Rheumatology</full-title><abbr-1>J. Clin. Rheumatol.</abbr-1><abbr-2>J Clin Rheumatol</abbr-2></periodical><pages>380-2</pages><volume>15</volume><number>8</number><keywords><keyword>Aged</keyword><keyword>Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis/*drug</keyword><keyword>therapy/immunology</keyword><keyword>Antifungal Agents/therapeutic use</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Immunocompromised Host</keyword><keyword>Immunosuppressive Agents/*adverse effects</keyword><keyword>Invasive Pulmonary Aspergillosis/drug therapy/*immunology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>2009</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1536-7355 (Electronic)&#xD;1076-1608 (Linking)</isbn><accession-num>19279506</accession-num><urls><related-urls><url>;[45]. In the era of highly active antiretroviral therapy, invasive aspergillosis is a rare complication of human immunodeficiency virus (HIV) infection. AIDS -associated aspergillosis is most frequently associated with advanced AIDS and additional risk factors, such as neutropenia, corticosteroid use, and concurrent opportunistic infections PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NeWxvbmFraXM8L0F1dGhvcj48WWVhcj4xOTk4PC9ZZWFy

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ADDIN EN.CITE.DATA [46, 47]. CGD, an inherited disorder of the phagocyte NADPH oxidase, is characterized by recurrent bacterial and fungal infections including IA, and other moulds, which can be life-threatening PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVuIEJlcmc8L0F1dGhvcj48WWVhcj4yMDA5PC9Z

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ADDIN EN.CITE.DATA [48-51]. Several agents that target immune cell populations and signaling pathways, including malignancies and autoimmune disorders, have also been identified as risk factors for IA. For example, alemtuzumab (anti-CD52) can lead to neutropenia and prolonged suppression of cell-mediated immunity, potentially cytomegalovirus reactivation ADDIN EN.CITE <EndNote><Cite><Author>Skoetz</Author><Year>2012</Year><RecNum>26484</RecNum><DisplayText>[52]</DisplayText><record><rec-number>26484</rec-number><foreign-keys><key app="EN" db-id="a9a0zdws9s90ave9xrmxtf9h90pw2dxzptep">26484</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Skoetz, N.</author><author>Bauer, K.</author><author>Elter, T.</author><author>Monsef, I.</author><author>Roloff, V.</author><author>Hallek, M.</author><author>Engert, A.</author></authors></contributors><auth-address>Cochrane Haematological Malignancies Group, Department I of Internal Medicine, University Hospital of Cologne, Cologne,Germany. nicole.skoetz@uk-koeln.de.</auth-address><titles><title>Alemtuzumab for patients with chronic lymphocytic leukaemia</title><secondary-title>Cochrane Database Syst Rev</secondary-title><alt-title>The Cochrane database of systematic reviews</alt-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD008078</pages><volume>2</volume><edition>2012/02/18</edition><keywords><keyword>Antibodies, Monoclonal, Humanized/*therapeutic use</keyword><keyword>Antibodies, Monoclonal, Murine-Derived/therapeutic use</keyword><keyword>Antineoplastic Agents/*therapeutic use</keyword><keyword>Chlorambucil/therapeutic use</keyword><keyword>Humans</keyword><keyword>Leukemia, Lymphocytic, Chronic, B-Cell/*drug therapy/mortality</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Vidarabine/analogs &amp; derivatives/therapeutic use</keyword></keywords><dates><year>2012</year></dates><isbn>1469-493X (Electronic)&#xD;1361-6137 (Linking)</isbn><accession-num>22336834</accession-num><work-type>Meta-Analysis&#xD;Research Support, Non-U.S. Gov&apos;t&#xD;Review</work-type><urls><related-urls><url>;[52], and subsequent IA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdW5kaW48L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [55]. An analysis of non-viral opportunistic infections in patients with autoimmune diseases documented the overall risk was greater in patients receiving TNF-α antagonists compared to non-biological disease-modifying antirheumatic drugs; however, IA was only observed in 1 of over 30,000 patients receiving a TNF-α antagonist PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWRkbGV5PC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA [56]. By contrast, the use of infliximab for severe GVHD is associated with high risk for the development of IA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJ0eTwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [57]. Therefore, in assessing the risk for aspergillosis from a specific drug or antibody, one must consider all relevant factors, including the underlying disease being treated, comorbidities (e.g., pre-existing lung disease), neutropenia, and the use of concurrent immunosuppressive agents. IA has also been recognized in critically ill patients without traditional risk factors. The exact proportion of critically ill patients with IA in the absence of other risk factors is difficult to determine. In a retrospective analysis, Meersseman et al. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWVyc3NlbWFuPC9BdXRob3I+PFllYXI+MjAwNDwvWWVh

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ADDIN EN.CITE.DATA [58] identified 127 patients out of 1,850 intensive care unit (ICU) admissions (6.9%) with microbiological or histopathologic evidence of Aspergillus infection; however, only 5 of these patients had proven IA without predisposing host factors. Trials that evaluate clinical approaches to diagnose IA in critically ill patients include a substantial proportion with classic risk factors for IA and other risk factors including chronic obstructive pulmonary disease (COPD) and cirrhosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CbG90PC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [63], it is difficult to delineate the specific role of non-classic risk factors (e.g., multi-organ organ failure, prolonged mechanical ventilation, bacterial and viral infections including influenza) in driving the risk for IA.DIAGNOSIS OF ASPERGILLOSIS II. How can a diagnosis of IA be established?How should Aspergillus be identified and how does this influence management? Recommendation6.Until molecular tools are more widely used in clinical laboratories, we recommend that tissue and fluid specimens be submitted in adequate quantities for simultaneous histopathologic/cytologic and culture examination. In the case of isolates with atypical growth or concerns for resistance, species identification by molecular methods should be employed. (Strong Recommendation; High Quality Evidence).Evidence summaryThe EORTC/MSG revised criteria for defining invasive fungal infections, including IA, require a microbiologic and/or histopathologic diagnosis to define proven infection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZSBQYXV3PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48

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Tm90ZT4A

ADDIN EN.CITE.DATA [65-67]. Moreover, these methods are time consuming and insensitive. The most common specimens obtained are lung tissue by transthoracic percutaneous needle aspiration, or video assisted thoracoscopic biopsy, and bronchial lavage/wash specimens. These specimens should be submitted in adequate quantities for both histopathologic/cytologic testing and culture with a brief clinical history to aid the pathologist and microbiologist in interpretation of findings PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdWFybmVyPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48

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ADDIN EN.CITE.DATA [68-72]. Methods to optimize yield should be employed including adequate quantity of specimens, timely delivery of fresh specimen to the laboratory, or refrigeration if delay is anticipated (although refrigeration may reduce the recovery of some organisms like the Mucorales), incubation of cultures for at least 5 days (and up to 3 weeks for other fungal pathogens) and communication of suspicion for fungal infection with pathology and microbiology laboratory personnel ADDIN EN.CITE <EndNote><Cite><Author>Labarca</Author><Year>1998</Year><RecNum>1111</RecNum><DisplayText>[73]</DisplayText><record><rec-number>1111</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1459876285">1111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Labarca, J. A.</author><author>Wagar, E. A.</author><author>Grasmick, A. E.</author><author>Kokkinos, H. M.</author><author>Bruckner, D. A.</author></authors></contributors><auth-address>Department of Pathology and Laboratory Medicine, Clinical Microbiology Laboratory, UCLA Medical Center, University of California, Los Angeles, California, USA. jlabarca@ucla.edu</auth-address><titles><title>Critical evaluation of 4-week incubation for fungal cultures: is the fourth week useful?</title><secondary-title>J Clin Microbiol</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title><abbr-1>J. Clin. Microbiol.</abbr-1><abbr-2>J Clin Microbiol</abbr-2></periodical><pages>3683-5</pages><volume>36</volume><number>12</number><keywords><keyword>Fungi/*growth &amp; development/isolation &amp; purification</keyword><keyword>Humans</keyword><keyword>Retrospective Studies</keyword><keyword>Time Factors</keyword></keywords><dates><year>1998</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0095-1137 (Print)&#xD;0095-1137 (Linking)</isbn><accession-num>9817896</accession-num><urls><related-urls><url>;[73]. In the pathology laboratory, standard and special fungal stains on fluid or tissue should be performed simultaneously when a fungal infection is suspected and may reveal the characteristic acute angle branching septate hyphae of Aspergillus spp. Molecular assays targeting ribosomal DNA sequences can also be used for detection of Aspergillus in tissues, although these methods have not been standardized nor cleared by the FDA for clinical use. The optical brightener methods, Calcofluor or Blankophor, are rapid stains utilized for direct examination and have a high sensitivity and specificity for detecting Aspergillus-like features PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRyZWFzPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48

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ADDIN EN.CITE.DATA [76]. This low yield notwithstanding, culture is critical for species complex identification and susceptibility testing where feasible until molecular methods are more routinely performed in clinical laboratories.What is the diagnostic value of nucleic acid testing in clinical specimens?Recommendations7.There was debate among the committee members regarding the clinical utility of blood-based PCR in diagnosing IA and experts were not in agreement.? One group favored recommendations for PCR testing, based on publications validating its?role when used in conjunction with other tests such as antigen detection assays to diagnose IA and/or reduce pre-emptive antifungal usage.? The other group felt that PCR assays are promising, but could not be recommended for routine use in clinical practice at present due to the lack of conclusive validation for commercially available assays, the variety of?methodologies in the literature, and questions about the extent to which results assisted diagnosis.???8.As research in the area continues, we recommend that clinicians?choosing to?use PCR assays employ them carefully in the management of individual patients on a case-by-case basis.? Clinicians should be aware of the methodologies and performance?characteristics of the specific assay used, and interpret results accordingly.?When PCR assays are used, results should be considered in conjunction with other diagnostic tests and the clinical context (Strong Recommendation; Moderate Quality Evidence).?Evidence summarySince the last IDSA guidelines, there have been numerous publications assessing the performance of Aspergillus PCR in clinical samples. Overall, direct comparison studies have shown Aspergillus PCR to be substantially more sensitive than culture in blood and respiratory fluids. In a meta-analysis of clinical trials evaluating the accuracy of serum or whole-blood PCR assays for IA, sensitivity and specificity were 84% and 76%, respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BcnZhbml0aXM8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy

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ADDIN EN.CITE.DATA [77]. These values are promising, but PCR of blood or serum is unable on its own to confirm or exclude suspected IA in high-risk patients. The sensitivity of Aspergillus PCR on BAL fluid was higher than within blood, but in many instances its specificity was lower PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bdm5pPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [78, 79] . In a systematic review of nine studies using reference IA definitions strictly adherent to the EORTC/MSG criteria, the sensitivity and specificity of PCR of BAL were 77% and 94%, respectively ADDIN EN.CITE <EndNote><Cite><Author>Avni</Author><Year>2012</Year><RecNum>806</RecNum><DisplayText>[78]</DisplayText><record><rec-number>806</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1454370457">806</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Avni, T.</author><author>Levy, I.</author><author>Sprecher, H.</author><author>Yahav, D.</author><author>Leibovici, L.</author><author>Paul, M.</author></authors></contributors><auth-address>Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.</auth-address><titles><title>Diagnostic accuracy of PCR alone compared to galactomannan in bronchoalveolar lavage fluid for diagnosis of invasive pulmonary aspergillosis: a systematic review</title><secondary-title>J Clin Microbiol</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title><abbr-1>J. Clin. Microbiol.</abbr-1><abbr-2>J Clin Microbiol</abbr-2></periodical><pages>3652-8</pages><volume>50</volume><number>11</number><keywords><keyword>Bronchoalveolar Lavage Fluid/*microbiology</keyword><keyword>Case-Control Studies</keyword><keyword>Clinical Laboratory Techniques/*methods</keyword><keyword>Humans</keyword><keyword>Immunoassay/methods</keyword><keyword>Invasive Pulmonary Aspergillosis/*diagnosis</keyword><keyword>Mannans/*analysis</keyword><keyword>Mycology/*methods</keyword><keyword>Polymerase Chain Reaction/*methods</keyword><keyword>Prospective Studies</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2012</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1098-660X (Electronic)&#xD;0095-1137 (Linking)</isbn><accession-num>22952268</accession-num><urls><related-urls><url>;[78] . Data included large 95% confidence intervals that were attributed to the use of different PCR assays and inclusion of heterogeneous patient populations PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bdm5pPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [78, 79]. The lower specificity in BAL has been attributed to the fact that lungs are often colonized by Aspergillus (particularly in many high-risk populations, such as lung transplant recipients), and that PCR is not able to differentiate colonization from disease or to distinguish different Aspergillus spp. The high negative predictive value of BAL PCR (usually ≥95%) suggests a role in ruling out IPA. To date, data suggest that the diagnostic performance of blood or BAL PCR is comparable to that of serum and BAL GM index (GMI; ratio of the optical densities (OD) of the patient samples to the mean OD of control samples) of ≥0.5, respectively, and that sensitivity for both tests is affected by antifungal use. Using both PCR and GM in serum resulted in improved sensitivity with no sacrifice of specificity ADDIN EN.CITE <EndNote><Cite><Author>Avni</Author><Year>2012</Year><RecNum>806</RecNum><DisplayText>[78]</DisplayText><record><rec-number>806</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1454370457">806</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Avni, T.</author><author>Levy, I.</author><author>Sprecher, H.</author><author>Yahav, D.</author><author>Leibovici, L.</author><author>Paul, M.</author></authors></contributors><auth-address>Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.</auth-address><titles><title>Diagnostic accuracy of PCR alone compared to galactomannan in bronchoalveolar lavage fluid for diagnosis of invasive pulmonary aspergillosis: a systematic review</title><secondary-title>J Clin Microbiol</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title><abbr-1>J. Clin. Microbiol.</abbr-1><abbr-2>J Clin Microbiol</abbr-2></periodical><pages>3652-8</pages><volume>50</volume><number>11</number><keywords><keyword>Bronchoalveolar Lavage Fluid/*microbiology</keyword><keyword>Case-Control Studies</keyword><keyword>Clinical Laboratory Techniques/*methods</keyword><keyword>Humans</keyword><keyword>Immunoassay/methods</keyword><keyword>Invasive Pulmonary Aspergillosis/*diagnosis</keyword><keyword>Mannans/*analysis</keyword><keyword>Mycology/*methods</keyword><keyword>Polymerase Chain Reaction/*methods</keyword><keyword>Prospective Studies</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2012</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1098-660X (Electronic)&#xD;0095-1137 (Linking)</isbn><accession-num>22952268</accession-num><urls><related-urls><url>;[78]. Clinical trials incorporating biomarkers into the management of adults with hematologic malignancies or allogeneic HSCT have shown that the combined GM and PCR reduced use of antifungal treatment PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3JyaXNzZXk8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [81]. There have been fewer PCR studies using non-blood and non-BAL samples. In several studies, PCR is superior to culture in detecting Aspergillus spp. in sputum specimens from patients with CF and allergic or chronic pulmonary aspergillosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmFjemVrPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA [82-86]. Small studies of Aspergillus PCR on non-blood and extra-pulmonary body fluids (pleural fluid, CSF, etc.) and paraffin-preserved and fresh tissues (lung, skin, sinus, lymph node) demonstrate sensitivity of 86% and specificity of 100% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWlud2FsZDwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

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ADDIN EN.CITE.DATA [87-89]. Despite these promising results, Aspergillus PCR cannot yet be recommended for routine use in clinical practice because few assays have been standardized and validated, and the role of PCR testing in patient management is not established. Initiatives such as the European Aspergillus PCR Initiative (EAPCRI) have made significant progress in developing a consensus standard protocol for blood-based Aspergillus PCR. PCR assays are commercially available outside the US (MycAssay Aspergillus, Microgen Bioproducts Ltd, Camberley, UK); Septifast (Roche); MycoReal Aspergillus (Ingenetix GmbH); Affigene Aspergillus tracer (Cepheid); and Aspergillus spp. Q-PCR Alert (Nanogen); RenDx multiplex Aspergillus spp. & Candida spp. (whole blood, plasma & serum); AsperGenius (Pathonostics); Mycogenie (Ademtech) and others?) or centralization of PCR testing at a reference laboratory (ViraCor-IBT Laboratories (Lee’s Summit, MO)) and provide standardization but none have been cleared by the U.S. Food and Drug Administration (FDA) for clinical use in the U.S. These efforts now permit multi-center validation of assay performance and studies of clinical utility. Until such studies are completed, however, no specific recommendation about the role of Aspergillus PCR in clinical practice in the U.S. can be made.How should serum GM and (1→3)-β-D-glucan be used for the diagnosis of aspergillosis?Recommendations9.Serum and BAL GM is recommended as an accurate marker for the diagnosis of IA in adult and pediatric patients when used in certain patient subpopulations (hematologic malignancy, HSCT) (Strong Recommendation; High Quality Evidence). 10.GM is not recommended for routine blood screening in patients receiving mould-active antifungal therapy or prophylaxis, but can be applied to bronchoscopy specimens from those patients (Strong Recommendation; High Quality Evidence). 11.GM is not recommended for screening in solid organ transplant recipients or patients with CGD (Strong Recommendation; High Quality Evidence). 12.Serum assays for (1→3)-β-D-glucan are recommended for diagnosing IA in high risk patients (hematologic malignancy, allogeneic HSCT), but are not specific for Aspergillus (Strong Recommendation; Moderate Quality Evidence).Evidence summaryThe Platelia GM enzyme immunoassay (EIA) is a relatively Aspergillus-specific non-invasive diagnostic assay and several studies have demonstrated good sensitivity (~70%) in serum of patients with hematological malignancy or allogeneic HSCT PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZXJicmVjaHQ8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFy

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ADDIN EN.CITE.DATA [90-95]. A GM-based diagnostic strategy can also result in less empiric antifungal therapy usage PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3JyaXNzZXk8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [103]. While earlier reports suggested that GM was not reliable in pediatric patients due to a high false-positive rate, several subsequent studies have shown its usefulness in children and similar operating characteristics to adult patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdGVpbmJhY2g8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy

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ADDIN EN.CITE.DATA [114]. GM in patients with CF colonized with Aspergillus species was consistently negative PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYXJyZW48L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [115]. Several variables, including concurrent mould-active antifungal therapy or prophylaxis, significantly reduce levels of circulating GM PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJyPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [91, 94]. The GMI may be increased in the setting of neutropenia and decreases in response to antifungal agents. In one study, the GMI in patients with absolute neutrophil count (ANC) <100/ ?l and not receiving antifungal therapy was statistically higher than those patients with an ANC >100/ ?l; however the GMI in patients with an ANC <100/?l and receiving antifungal therapy was not statistically different than those patients with an ANC >100 ?l. Laboratory data and clinical observations indicate that this effect may be due to a higher fungal burden in neutropenic patients, or a more robust inflammatory process in non-neutropenic patients with a corresponding decrease in the burden of disease, rate of dissemination, and GM release PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3Jkb25uaWVyPC9BdXRob3I+PFllYXI+MjAwOTwvWWVh

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ADDIN EN.CITE.DATA [116, 117].False-positive results have been reported in several contexts, including in patients who have received certain antibiotics (historically most notably piperacillin-tazobactam, which appears now to no longer be cross-reactive PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZXJnaWRpczwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA [119-122]. Despite these limitations, this assay is a useful adjunctive test to establish an early diagnosis, particularly when used in serial screening of patients at high risk of infection who are not receiving anti-mould prophylaxis. The optimal rationale for diagnosis in neutropenic patients may be a combined approach guided by clinical, radiographic, and bi-weekly screening of GM in serum PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h3YXJ6aW5nZXI8L0F1dGhvcj48WWVhcj4yMDEzPC9Z

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ADDIN EN.CITE.DATA [123], possibly combined with other biomarkers. In patients receiving mould active antifungal prophylaxis, the use of serum GM as a screening tool results in a very poor predictive value with most positive tests being false positive in this setting ADDIN EN.CITE <EndNote><Cite><Author>Duarte</Author><Year>2014</Year><RecNum>173</RecNum><DisplayText>[124]</DisplayText><record><rec-number>173</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1412206142">173</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Duarte, R. F.</author><author>Sanchez-Ortega, I.</author><author>Cuesta, I.</author><author>Arnan, M.</author><author>Patino, B.</author><author>Fernandez de Sevilla, A.</author><author>Gudiol, C.</author><author>Ayats, J.</author><author>Cuenca-Estrella, M.</author></authors></contributors><auth-address>Department of Hematology, Catalan Institute of Oncology - Hospital Duran i Reynals, Barcelona, Spain rduarte@.&#xD;Department of Hematology, Catalan Institute of Oncology - Hospital Duran i Reynals, Barcelona, Spain.&#xD;Centro Nacional de Microbiologia - Instituto de Salud Carlos III, Madrid, Spain.&#xD;Department of Microbiology, Hospital Universitario de Bellvitge, Barcelona, Spain.</auth-address><titles><title>Serum galactomannan-based early detection of invasive aspergillosis in hematology patients receiving effective anti-mold prophylaxis</title><secondary-title>Clin Infect Dis</secondary-title><alt-title>Clinical infectious diseases : an official publication of the Infectious Diseases Society of America</alt-title></titles><periodical><full-title>Clinical Infectious Diseases</full-title><abbr-1>Clin. Infect. Dis.</abbr-1><abbr-2>Clin Infect Dis</abbr-2></periodical><dates><year>2014</year><pub-dates><date>Aug 27</date></pub-dates></dates><isbn>1537-6591 (Electronic)&#xD;1058-4838 (Linking)</isbn><accession-num>25165088</accession-num><urls><related-urls><url>;[124]. The detection of GM in BAL fluid has been shown to have a sensitivity that exceeds 70% in most studies and provides additional sensitivity compared to cultures even in the setting of mould-active antifungal therapy as discussed below PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdXNhaW48L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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Pn==

ADDIN EN.CITE.DATA [125-128]. Other potential circulating markers for detection of aspergillosis include (1→3)-β-D-glucan (BG) detected by the Tachypleus or Limulus assay PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Pc3Ryb3NreS1aZWljaG5lcjwvQXV0aG9yPjxZZWFyPjIw

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ADDIN EN.CITE.DATA [129, 130]. The Tachypleus or Limulus assay used to detect the presence of (1→3)-β-D-glucan is a variation of the limulus assay used to detect endotoxin. The presence of (1→3)-β-D-glucan in serum signifies the presence of fungal invasion but is not specific for Aspergillus species; other fungal diseases, including candidiasis, fusariosis, and Pneumocystis jirovecii pneumonia can result in a positive test. False-positive results can occur in a variety of contexts, such as through glucan contaminated blood collection tubes, gauze, depth-type membrane filters for blood processing, and various drugs (e.g., antibiotics including some cephalosporins, carbapenems, and ampicillin-sulbactam and possibly chemotherapeutics such as PEG asparaginase) ADDIN EN.CITE <EndNote><Cite><Author>Marty</Author><Year>2006</Year><RecNum>1260</RecNum><DisplayText>[131]</DisplayText><record><rec-number>1260</rec-number><foreign-keys><key app="EN" db-id="fpwed2pr9zavtjetdtj5dtdrpw05ffsfwrex">1260</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marty, F. M.</author><author>Lowry, C. M.</author><author>Lempitski, S. J.</author><author>Kubiak, D. W.</author><author>Finkelman, M. A.</author><author>Baden, L. R.</author></authors></contributors><auth-address>Division of Infectious Diseases, Brigham &amp; Women&apos;s Hospital, Boston, MA 02115, USA. fmarty@</auth-address><titles><title>Reactivity of (1--&gt;3)-beta-d-glucan assay with commonly used intravenous antimicrobials</title><secondary-title>Antimicrobial Agents and Chemotherapy</secondary-title><alt-title>Antimicrobial agents and chemotherapy</alt-title></titles><periodical><full-title>Antimicrobial Agents and Chemotherapy</full-title><abbr-1>Antimicrob Agents Chemother</abbr-1></periodical><alt-periodical><full-title>Antimicrobial Agents and Chemotherapy</full-title><abbr-1>Antimicrob Agents Chemother</abbr-1></alt-periodical><pages>3450-3</pages><volume>50</volume><number>10</number><edition>2006/09/29</edition><keywords><keyword>Anti-Bacterial Agents/administration &amp; dosage/ chemistry</keyword><keyword>False Positive Reactions</keyword><keyword>Humans</keyword><keyword>Injections, Intravenous</keyword><keyword>Mycoses/ diagnosis</keyword><keyword>Reagent Kits, Diagnostic</keyword><keyword>beta-Glucans/ analysis/ blood</keyword></keywords><dates><year>2006</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0066-4804 (Print)&#xD;0066-4804 (Linking)</isbn><accession-num>17005829</accession-num><urls></urls><custom2>1610103</custom2><electronic-resource-num>10.1128/aac.00658-06</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[131]. The Fungitell assay (Associates of Cape Cod) for detection of (1→3)-β-D-glucan is cleared by the FDA for the diagnosis of invasive mycoses, including aspergillosis, and has been evaluated in high risk patients with hematological malignancy and allogeneic HSCT PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PZGFiYXNpPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48

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ADDIN EN.CITE.DATA [137]. Other organizations have recommended the GM over Fungitell for specifically diagnosing IA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJjaGV0dGk8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFy

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ADDIN EN.CITE.DATA [138].What is the approach to the radiographic diagnosis of IPA?Recommendations13.We recommend performing a chest computed tomographic (CT) scan whenever there is a clinical suspicion for IPA regardless of chest radiograph results (Strong Recommendation; High Quality Evidence). 14.Routine use of contrast during a chest CT scan for a suspicion of IPA is not recommended (Strong Recommendation; Moderate Quality Evidence). Contrast is recommended when a nodule or a mass is close to a large vessel (Strong Recommendation; Moderate Quality Evidence). 15.We suggest a follow-up chest CT-scan to assess the response of IPA to treatment after a minimum of two weeks of treatment; earlier assessment is indicated if the patient clinically deteriorates (Weak Recommendation; Low Quality Evidence). When a nodule is close to a large vessel, more frequent monitoring may be required (Weak Recommendation; Low Quality Evidence).Evidence summaryAs clinical signs and symptoms are not specific for the diagnosis of IPA, radiographic imaging is critical. The role of imaging is to identify the site of infection, to assess the type, number and size of lesions, and local extension. Imaging also helps to direct diagnostic procedures (e.g. BAL or CT-guided biopsy) to the most appropriate area PEVuZE5vdGU+PENpdGUgRXhjbHVkZVllYXI9IjEiPjxBdXRob3I+QmVja2VyPC9BdXRob3I+PFll

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ADDIN EN.CITE.DATA [140], and high resolution computed tomography (HRCT, also called thin-section CT scanning with a thin collimation of 0.25 – 1 mm) is the preferred method. CT angiography may be a useful test pending further evaluation ADDIN EN.CITE <EndNote><Cite><Author>Stanzani</Author><Year>2015</Year><RecNum>507</RecNum><DisplayText>[141]</DisplayText><record><rec-number>507</rec-number><foreign-keys><key app="EN" db-id="25ws99rfnw2zfmert5rxzapsprpa5wr2efdr" timestamp="1432662686">507</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stanzani, M.</author><author>Sassi, C.</author><author>Lewis, R. E.</author><author>Tolomelli, G.</author><author>Bazzocchi, A.</author><author>Cavo, M.</author><author>Vianelli, N.</author><author>Battista, G.</author></authors></contributors><auth-address>Institute of Hematology &quot;Lorenzo e Ariosto Seragnoli&quot;, Department of Hematology and Oncology.&#xD;Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Division of Radiology.&#xD;Clinic of Infectious Diseases, Department of Internal Medicine Geriatrics and Nephrologic Diseases, S.Orsola-Malpighi Hospital, University of Bologna.&#xD;Diagnostic and Interventional Radiology, &quot;Rizzoli&quot; Institute, Bologna, Italy.</auth-address><titles><title>High resolution computed tomography angiography improves the radiographic diagnosis of invasive mold disease in patients with hematological malignancies</title><secondary-title>Clin Infect Dis</secondary-title><alt-title>Clinical infectious diseases : an official publication of the Infectious Diseases Society of America</alt-title></titles><periodical><full-title>Clinical Infectious Diseases</full-title><abbr-1>Clin. Infect. Dis.</abbr-1><abbr-2>Clin Infect Dis</abbr-2></periodical><pages>1603-10</pages><volume>60</volume><number>11</number><dates><year>2015</year><pub-dates><date>Jun 1</date></pub-dates></dates><isbn>1537-6591 (Electronic)&#xD;1058-4838 (Linking)</isbn><accession-num>25722200</accession-num><urls><related-urls><url>;[141]. Chest CT-scan performed early after onset of fever helps to identify the cause of fever, may be informative before Aspergillus GM is positive and has been associated with an increased survival in febrile neutropenic patients who have received intensive chemotherapy for a hematologic malignancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXNjYTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJl

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