Caspofungin pulses for CPA (chronic pulmonary aspergillosis): A retrospective study

CPA is a fungal disease with high mortality and morbidity. Current guidelines suggest initial treatment with azoles. However, patients often develop treatment failure, triazole intolerance or resistance. Echinocandins (e.g. Caspofungin) have been used with success in invasive aspergillosis, but there is little evidence regarding their use in CPA. We aimed to assess the efficacy of adding pulsed caspofungin therapy to existing azole treatment in patients with treatment failure or intolerance on triazole monotherapy. We retrospectively examined records from 25 patients with a diagnosis of CPA treated with x8 6-weekly cycles of 14 days intravenous Caspofungin therapy (In addition to azoles if tolerant) between 2008 -2012 at the Royal Brompton hospital. Baseline characteristics and HRCT severity scores, FEV1, FVC, BMI and serology (ICAP, IgE, RAST, CRP) were assessed before and after pulsed Caspofungin. Despite treatment 8/25 (32%) of patients died after a median follow-up of 428 days. (IQR 313-660). Improvements in serology were seen after 8 cycles of caspofungin. ICAP declined from 166.3mg/L to 94.2 mg/L. (p=0.006) IgE declined from 502.6 IU/mL to 109.8 IU/mL (p=0.09). Average diameter of cavities rose by 3.6 mm (p=0.09). Cavity wall thickness rose by 0.55 (p=0.002), pleural thickness by 0.2 (p=0.0001), and consolidation diminished by 0.37% on average (p=0.05).A subgroup also being treated for NTM showed reduction in tree-in-bud (p=0.25). BMI and lung function did not change significantly. Patients with CPA have a high mortality despite treatment. Pulsed echinocandin therapy may present a strategy to stabilize aspects of CPA in a subset of patients with failure of, or intolerance to, azole treatment.