Diagnostic and therapeutic approach to fungal pneumonia in the critically ill patient

Aspergillus spp. is the fungus most frequently producing ventilator-associated pneumonia (VAP), constituting 8% of them. This risk is significantly increased in onco-hematological patients: solid organ transplant recipients, chronic obstructive pulmonary disease (COPD), corticotherapy, cirrhosis, solid cancer, or viral pneumonias. The European Organization for Research and Treatment of Cancer Mycoses (EORT/MSG criteria) developed for onco-hematological patients with angioinvasive forms of aspergillosis have important limitations for broncho-pulmonary forms, such as aspergillosis cases in the ICU. In recent years, new diagnostic criteria were developed to have a greater role in broncho-alveolar lavage, especially GM and lateral flow assay (LFA). Voriconazole and isavuconazole are the first treatment option. However, drug-drug interaction, level requirements, toxicity, and QT-interval modification are limitations that may favor isavuconazole or liposomal amphotercin B in the ICU.