Prevalence of chronic pulmonary aspergillosis and the antifungal drug resistance of Aspergillus spp. in pulmonary tuberculosis patients in Uzbekistan

Abstract

The aim of our study was to determine the prevalence of chronic pulmonary aspergillosis in pulmonary tuberculosis patients and the antifungal resistance of Aspergillus spp. isolates in Uzbekistan. Chronic pulmonary aspergillosis was detected in 11.4% and 20.0% of smear-positive and smear-negative pulmonary tuberculosis patients, respectively.

Keywords

pulmonary tuberculosis chronic pulmonary aspergillosis antifungal resistance

Introduction

Chronic pulmonary aspergillosis (CPA) may present as a chronic and progressive disease occurring mainly in immunocompetent individuals with underlying lung disease, most commonly with pulmonary tuberculosis (PTB). The spectrum of CPA includes simple aspergilloma, chronic cavitary pulmonary aspergillosis, aspergillus nodules, sub-acute invasive aspergillosis, and chronic fibrosing pulmonary aspergillosis.^1,2 The distribution of CPA remains wide, with more than 3 million affected, mostly PTB patients.;^3–6 a high incidence in Asian countries, followed by Africa and North America, has been described.⁵ There is a 5-year prevalence of CPA as a complication of PTB estimated at c. 1.2 million worldwide.⁶ Even with antifungal therapy, its mortality rate is 20–33% in the short term and 50% in a 5-year period.^7,8 Recent studies have shown differences in the global burden of CPA between populations at risk and countries with different socio-economic and geo-ecological characteristics.

Despite a significant decrease in tuberculosis incidence in Uzbekistan over the past ten years, PTB remains one of the most important challenges in the country.⁹ Clinical symptoms such as chronic productive cough, weight loss, fatigue, fever, haemoptysis, and chest pain are clinically indistinguishable between CPA and PTB. Moreover, the progressive cavitation, fibrosis, and pleural thickening seen in CPA are similar features in both.^10–12 However, the precise incidence of CPA post-PTB remains unknown, and deciding which groups of PTB patients should be screened for CPA is unclear.¹³

In low- and middle-income countries, the lack of the availability of the necessary diagnostic tools leads to late diagnoses or misdiagnoses.^14,15 Long-term antifungal therapy, mainly with voriconazole and itraconazole, can significantly improve the survival rate. However, lack of knowledge of the optimal duration of therapy, the high resistance of pathogens to antifungals, and the risk of intolerable side effects can be important limitations of therapy. In addition, relapses occur in c. 33% patients after the cessation of treatment.¹⁶ The prevalence of CPA in smear-positive and smear-negative PTB patients and the antifungal resistance of Aspergillus spp. isolates have not been studied in Central Asian countries, including Uzbekistan.

Materials and methods

Our prospective observational study was conducted by the Republican Specialized Research and Practical Medical Center of Epidemiology, Microbiology, Infectious and Parasitic Diseases and the Republican Specialized Research and Practical Medical Centre of Tuberculosis and Pulmonology, Tashkent, Uzbekistan, during the period from May 2020 until May 2021.

All participants provided written informed consent, and ethical approval was obtained from the Ministry of Health of the Republic of Uzbekistan in accordance with the guidelines of the Declaration of Helsinki. The trial is registered at the US National Institutes of Health (ClinicalTrials.gov #NCT05045391).

A total of 200 patients (aged >18 years) with PTB (140 with smear-positive and 60 smear-negative) were included in the study. Forty-six were excluded, including 12 who refused to participate and 34 who did not meet the inclusion criteria.

The diagnosis of PTB was based on the results of clinical examinations, chest radiographs and laboratory examinations according to the World Health Organization guidelines.¹⁷

The smear-positive PTB group included patients with at least two initial sputum smear examinations positive for Mycobacterium tuberculosis as determined by direct microscopy, or patients with one initial smear examination positive and one positive culture, or patients with one initial smear examination positive and radiographic findings consistent with active PTB.

The smear-negative PTB group included patients with negative sputum smears but positive growth cultures or patients with at least two negative sputum smears and radiological findings consistent with radiologically active PTB.^17–19 According to radiological findings, PTB was presented as infiltrative, fibrotic-cavernous, disseminated, tuberculoma, and focal forms.

All PTB patients were treated with standard 5-medicine therapy. Patients with neutropenia or severe immunosuppression owing to chemotherapy, haematopoietic stem cells or solid organ transplantation, prolonged immunosuppressive therapy or HIV, were excluded from the study.

The CPA diagnosis was made according to the guidelines established by the European Society for Clinical Microbiology and Infectious Diseases/European Respiratory Society and Infectious Disease Society of America,^20,21 according to the following criteria: (1) chronic pulmonary or systemic symptoms compatible with CPA, for a minimum 3 months, including at least one of the following symptoms: weight loss, productive cough, or haemoptysis; (2) radiological findings showing cavitary pulmonary lesion(s) with evidence of para-cavitary infiltrates and adjacent pleural thickening with or without a fungal ball; (3) positive Aspergillus IgG in blood serum and/or a positive Aspergillus culture or sputum as determined by microscopy; and (4) the exclusion of similar presentations caused by a neoplasm, abscess, Wegener's granulomatosis, etc.

The identification of Aspergillus spp. was performed based on direct examination, colony colour, and mould counts exceeding 10⁵CFU/mL on Sabouraud Agar medium (Geetapharm, India) at 35°C for 24 h.

The E-test was performed according to the instructions of the manufacturer: strips (HiMedia, India) of amphotericin B, voriconazole and itraconazole containing concentration gradients of 32–0.002 µg/ml of the respective drug, were placed on Mueller-Hinton agar, and the plates incubated at 35 °C and read after 24h and 48h. The minimum inhibitory concentration (MIC), determined from the inhibition ellipse that intersected the scale on the strip, was read at the point of significant inhibition of fungal growth. Quality control was ensured by testing the following strains: Aspergillus flavus ATCC 204304 and Aspergillus fumigatus ATCC 204305. The interpretation of MICs for antifungal agents was carried out according the European Committee on Antimicrobial Susceptibility Testing Antifungal Susceptibility Testing Committee (EUCAST-AFST) document.²²

Venous blood was drawn before the administration of any drugs. Serum was separated from 5 mL for immediate testing or was stored at − 80°C for later testing. A commercial ELISA kit (Vector-Best, Russia) was used to detect Aspergillus IgG antibodies, and the experimental procedure followed the manufacturers’ instructions. The optical density (OD), measured at 450 nm, using a Humareader HS (Human Diagnostics Worldwide, Germany), gave an OD index (coefficient of positivity) calculated as the ratio of sample to kit cutoff or the critical OD, (COD) equal to half the sum of OD values of two negative control samples plus a correction factor of 0.3. COD = (OD-1 + OD-2)/2 + 0.3. OD index values of ≥1 were considered positive.

Results are expressed as the mean ± standard deviation (SD) for continuous variables and the percentage for categorical data. Data were analyzed by the odd ratio (OR), 95% confidence interval (CI) of the mean and Pearson Chi-square test for numerical variables. All statistical procedures were performed using Origin 8 software (OriginLab, Northampton, MA), and the level of statistical significance was set at p < 0.05.

Results

The baseline characteristics of study participants (n = 200) are illustrated in Table 1.

Table 1.

Baseline characteristics of PTB patients and the diagnostic criteria for CPA.

Characteristics	All PTB patients Total number of PTB patients (n = 200)	PTB (smear-positive) patients (n = 140)	PTB (smear-negative) patients (n = 60)	P value*
Age
≤45	105 (52.5 ± 3.5)	70 (50 ± 4.2)	35 (58.3 ± 6.3)	0.28
46–65	60 (30.0 ± 3.2)	40 (28.5 ± 3.8)	20 (33.3 ± 6.0)	0.49
≥66	35 (17.5 ± 2.6)	30 (21.4 ± 3.4)	5 (8.3 ± 3.5)	0.02
Sex
Male	55 (27.5 ± 3.15)	55 (39.2 ± 4.1)	—	—
Female	145 (72.5 ± 3.15)	85 (60.7 ± 4.1)	60 (100)	0.0001
Body mass index
<18	104 (52.0 ± 3.5)	88 (62.8 ± 4.0)	16 (26.7 ± 5.7)	0.0001
18 − 25	76 (38.0 ± 3.4)	47 (33.6 ± 3.9)	29 (48.3 ± 6.4)	0.05
>25	20 (10.0 ± 2.8)	5 (3.6 ± 1.5)	15 (25.0 ± 5.5)	0.0001
Smoking status
Ex-smoker	3 (1.5 ± 0.8)	3 (2.1 ± 1.2)	—	—
Non-smoker	186 (93.0 ± 1.8)	126 (90.0 ± 2.5)	60 (100.0)	0.01
Current smoker	11 (5.5 ± 1.6)	11 (7.9 ± 2.2)	—	—
First episode of PTB	161 (80.5 ± 3.3)	117 (83.5 ± 3.1)	44 (73.3 ± 5.7)	0.09
Symptoms (≥3 months)
Cough	160 (80.0 ± 2.8)	121 (86.4 ± 2.8)	39 (65.0 ± 6.1)	0.001
Dyspnoea	122 (61.0 ± 3.4)	82 (58.5 ± 4.1)	40 (66.6 ± 6.0)	0.28
Haemoptysis	77 (38.5 ± 3.4)	49 (35.0 ± 4.0)	28 (46.7 ± 6.4)	0.12
Fever	119 (59.5 ± 3.4)	80 (57.1 ± 4.1)	39 (65.0 ± 6.1)	0.29
Fatigue	139 (69.5 ± 3.2)	97 (69.2 ± 3.9)	42 (70.0 ± 5.9)	0.91
Blood test
Haemoglobin, g/L	115.6 ± 2.8 (90.0−140.0)	115.6 ± 3.6 (90.0 − 140.0)	115.6 ± 4.4 (102.0 − 130.0)	1.00
Red blood cells, × 10¹²/L	3.7 ± 0.07 (3.0 − 4.5)	3.7 ± 0.09 (3.0 − 4.5)	3.7 ± 0.08 (3.6 − 4.1)	1.00
White blood cells, × 10⁹/L	7.0 ± 0.57 (3.6 − 12.5)	7.3 ± 0.6 (4.0 − 12.5)	6.1 ± 1.3 (3.6 − 11.9)	0.0001
Eosinophils, %	2.2 ± 0.4 (1.0 − 8.0)	2.0 ± 0.3 (1.0 − 6.0)	2.8 ± 1.1 (1.0 − 8.0)	0.0001
Neutrophils, %	64.7 ± 0.9 (55.0 − 73.0)	64.7 ± 1.0 (55.0 − 71.0)	64.8 ± 1.8 (61.0 − 73.0)	0.61
Lymphocytes, %	25.7 ± 0.7 (19.0 − 34.0)	25.9 ± 0.9 (19.0 − 34.0)	25.3 ± 1.4 (19.0 − 28.0)	0.001
Monocytes, %	7.1 ± 0.3 (4.0 − 10.0)	7.2 ± 0.3 (4.0 − 9.0)	7.0 ± 0.6 (6.0 − 10.0)	0.002
ESR, mm/h	31.2 ± 3.4 (3.0 − 60.0)	30.7 ± 3.9 (7.0 − 60.0)	32.6 ± 7.3 (3.0 − 50.0)	0.01
Glucose, mmol/L	6.7 ± 0.7 (3.1 − 13.8)	6.9 ± 0.9 (3.1 − 13.8)	6.2 ± 1.3 (4.0 − 12.7)	0.0001
Total IgE, IU/ml	33.3 ± 3.8 (0.0 − 127.0)	36.3 ± 4.6 (0.0 − 127.0)	26.3 ± 6.7 (0.0 − 94.0)	0.0001
Diagnostic criteria CPA clinical + radiographic + serological	6 (3.0 ± 1.2)	3 (2.1 ± 1.2)	3 (5.0 ± 2.8)	0.27
clinical + radiographic + serological + microbiology	22 (11.0 ± 2.2)	13 (9.2 ± 2.4)	9 (15.0 ± 4.6)	0.23

Note: ESR – erythrocyte sedimentation rate; total IgE – total immunoglobulin E;.

Data are presented as the number (percentage ± standard deviation) or mean ± standard deviation (minimum-maximum); *Significant difference between smear-positive and smear-negative PTB patients.

Aspergillus IgG-positive results were detected in 13.5% and 21.6% of smear-positive and smear-negative PTB patients, respectively (OR: 0.567; 95% CI: 0.259 to 1.240; P = 0.15). Cultures were positive in 22 PTB patients, and A. fumigatus was the most frequently isolated species (63.6%), followed by Aspergillus niger (22.7%) and A. flavus (13.6%). The prevalence of Aspergillus culture-positive patients was higher in the smear-negative PTB group (15.0%) than in the smear-positive PTB group (9.2%) (OR: 1.724; 95% CI: 0.694 to 4.282; P = 0.23). Although 32 PTB patients had detectable Aspergillus antibody levels, only 28 met the diagnostic criteria for CPA (Figure 1).

Figure 1.

The frequency of Aspergillus IgG-positive and Aspergillus culture-positive results in patients with PTB. The data show the percentage of Aspergillus IgG-positive and Aspergillus culture-positive results in smear-positive (n = 140) and smear-negative (n = 60) PTB patients.

According to the criteria used in our study, 13 (6.5%) of 200 patients with PTB met the criteria for chronic cavitary pulmonary aspergillosis, 8 (4.0%) met the criteria for sub-acute invasive aspergillosis, 4 (2.0%) met the criteria for chronic fibrosing pulmonary aspergillosis and 3 (1.5%) met the criteria for single aspergilloma. Chronic cavitary pulmonary aspergillosis was the most frequent type of CPA among PTB patients (Figure 2).

Figure 2.

The prevalence of CPA in PTB patients according to the clinical forms of PTB. The data show the percentage of patients with CCPA, CFPA, SAIA and SA among the patients with various forms of PTB. CPA-chronic pulmonary aspergillosis; CCPA-chronic cavitary pulmonary aspergillosis; CFPA-chronic fibrosing pulmonary aspergillosis; SAIA-sub-acute invasive aspergillosis; SA-simple aspergilloma.

A high prevalence of CPA was detected in patients with the disseminated (33.3 ± 11.1%) and fibrous-cavernous (22.7 ± 8.9%) forms of PTB, whereas in patients with the infiltrative (11.5 ± 2.7%) and focal (8.3 ± 7.9%) forms of PTB, morbidity was low. In PTB patients with tuberculoma, CPA was not detected. Figure 3 demonstrates the CPA prevalence in smear-positive and smear-negative PTB patients.

Figure 3.

The prevalence of CPA in smear-positive and smear-negative PTB patients. Data show the distribution of smear-negative (n = 60) and smear-positive (n = 140) patients among those with various clinical forms of PTB.

We analysed the susceptibility of 22 isolates of Aspergillus to three main antifungal drugs. The results showed that the resistance rates of Aspergillus fumigatus to itraconazole and voriconazole were 7.1 and 14.2%, respectively (table 2).

Table 2.

Antifungal susceptibility of Aspergillus spp. isolated from PTB patient sputum.

Aspergillus species (no. of isolates)	No. (%) of isolates with MIC (mg/L)
	Amphotericin B					Itraconazole				Voriconazole
	S				R	S			R	S			R
	0.125	0.25	0.5	1	>1	0.25	0.5	1	>1	0.38	0.5	1	>1
Aspergillus fumigatus (n = 14)	2 (14.2)	9 (64.2)	2 (14.2)	1 (7.1)	—	5 (35.8)	7 (50.0)	1 (7.1)	1 (7.1)	1 (7.1)	8 (57.1)	3 (21.4)	2 (14.2)
Aspergillus niger (n = 5)	—	1 (20)	3 (60)	1 (20)	—	—	5 (100)	—	—	—	2 (40)	3 (60)	—
Aspergillus flavus (n = 3)	—	3 (100)	—	—	—	—	1 (33.3)	2 (66.7)	—	—	3 (100)		—

MIC-Minimum inhibitory concentration; S-Susceptible; R-Resistant.

Discussion

The morbidity and mortality of CPA remain high, especially in countries with a high burden of tuberculosis. Uzbekistan has seen a significant decline in the number of reported cases of PTB over the last 16 years (94/100K in 2003 to 49/100K in 2019).^23,24 Despite this progress, the country is still amongst the 30 countries in the world with the highest multidrug resistant tuberculosis burden.²⁵ Furthermore, the situation is complicated by undiagnosed fungal infections among groups at risk as well as limited fungal diagnosis resources in Uzbekistan.²⁶ The official prevalence of CPA in Uzbekistan (6.3/100K)²⁶ is considerably less than in Kyrgyzstan (51.6),²⁷ Kazakhstan (35.5),²⁸ Tajikistan (46.8)²⁹ and Pakistan (39.0).³⁰ Most likely, the low figures in Uzbekistan are associated with underdiagnosis or poor reporting. Furthermore, accurate official data on the prevalence of CPA among PTB patients are not yet available for Uzbekistan. This is the first such study.

The serodiagnosis for Aspergillus IgG is not widely available in Uzbekistan. Epidemiological data on the resistance of Aspergillus spp. to antifungals in Central Asia are limited. Reports of triazole-resistance in Aspergillus spp. are increasing.³¹ Itraconazole has a significantly lower cost than other antifungals. Amphotericin B was, however, the drug of choice and is still used against aspergillosis. It has excellent activity in vitro, but in clinical trials the survival rate was <60%.^32–35 Underlying disease, immunosuppression, amphotericin B toxicity and antifungal therapy duration significantly affect the mortality in these infections.

Our study has limitations: the number of participants was less than anticipated, and we included only smear-positive and smear-negative PTB patients admitted to the clinic. Additionally, we could not carry out microbiological analysis and detection of antifungal susceptibility in all Aspergillus IgG-positive patients owing to the absence of sputum, as well as bronchoalveolar lavage, samples.

Conclusion

Our study confirmed a high prevalence of CPA in Uzbekistan, mostly in smear-negative PTB patients. Limited availability of Aspergillus IgG testing leads to diagnostic delay. Therefore, it is important to raise awareness not only in Uzbekistan, but wherever tuberculosis is endemic. Antifungal drug resistance also needs further intensive study.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Abdurakhim Toychiev

Supplemental material

Supplemental material for this article is available online.

References

Denning

Cadranel

Beigelman-Aubry

, et al. European Society for clinical microbiology and infectious diseases and European respiratory society. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016; 47: 45–68.

Smith

Denning

. Underlying conditions in chronic pulmonary aspergillosis including simple aspergilloma. Eur Respir J 2011; 37: 65–872.

Brown

Denning

Gow

, et al. Hidden killers: human fungal infections. Sci Transl Med 2012; 4: 165rv13.

Page

Byanyima

Hosmane

, et al. Chronic pulmonary aspergillosis commonly complicates treated pulmonary tuberculosis with residual cavitation. Eur Respir J 2019; 53:1801184.

Bongomin

Gago

Oladele

, et al. Global and multi-national prevalence of fungal diseases-estimate precision. J Fungi (Basel) 2017; 3: 57.

Denning

Pleuvry

Cole

. Global burden of chronic pulmonary aspergillosis as a sequel to pulmonary tuberculosis. Bull World Health Organ 2011; 89: 864–872.

Jewkes

Kay

Paneth

, et al. Pulmonary aspergilloma: analysis of cavitating invasive pulmonary aspergillosis in immunocompromised patients. Ann Thorac Surg 1983; 53: 621.

Camuset

Nunes

Dombret

, et al. Treatment of chronic pulmonary aspergillosis by voriconazole in nonimmunocompromised patients. Chest 2007; 131: 1435–1441.

Safaev

Parpieva

Liverko

, et al. Trends, characteristics and treatment outcomes of patients with drug-resistant Tuberculosis in Uzbekistan: 2013–2018. Int J Environ Res Public Health 2021; 18: 4663.

10.

van Kampen

Wanner

Edwards

, et al. International research and guidelines on post-tuberculosis chronic lung disorders: a systematic scoping review. BMJ Glob Heal 2018; 3: e000745

11.

Khan

Malik

Razaque

. Imaging of pulmonary post-tuberculosis sequelae. Pakistan J Med Sci 2020; 36: S75–S82.

12.

Thoracic British and Association Tuberculosis. Aspergilloma and residual tuberculosis cavities-the results of a resurvey. Tubercle 1970; 51(3): 227–245.

13.

Bongomin

. Post-tuberculosis chronic pulmonary aspergillosis: an emerging public health concern. PLoS Pathog 2020; 16: e1008742.

14.

Oladele

Irurhe

Foden

, et al. Chronic pulmonary aspergillosis as a cause of smear-negative TB and/or TB treatment failure in Nigerians. Int J Tuberc Lung Dis 2017; 21: 1056–1061

15.

Kwizera

Katende

Teu

, et al. Algorithm-aided diagnosis of chronic pulmonary aspergillosis in low- and middle-income countries by use of a lateral flow device. Eur J Clin Microbiol Infect Dis 2020; 39: 1–3.

16.

Koyama

Ohshima

Suzuki

, et al. Recurrence of chronic pulmonary aspergillosis after discontinuation of maintenance treatment by antifungal triazoles. J Infect Chemother 2014; 20: 375–379.

17.

World Health Organization. Early detection of tuberculosis: an overview of approaches, guidelines and tools. Geneva: World Health Organization, 2011, Available from: https://apps.who.int/iris/handle/10665/70824

18.

World Health Organization. Global tuberculosis report 2013. World Health Organization, 2013. https://apps.who.int/iris/handle/10665/91355

19.

Keflie

Ameni

. Microscopic examination and smear negative pulmonary tuberculosis in Ethiopia. Pan Afr Med J 2014; 19: 162.

20.

Salzer

Heyckendorf

Kalsdorf

, et al. Characterization of patients with chronic pulmonary aspergillosis according to the new ESCMID/ERS/ECMM and IDSA guidelines. Mycoses 2017; 60: 136–142.

21.

Kanj

Abdallah

Soubani

. The spectrum of pulmonary aspergillosis. Respir Med 2018; 141: 121–131.

22.

The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs for antifungal agents, version 10.0, 2020, http://www.eucastorg/astoffungi/clinicalbreakpointsforantifungals/.

23.

World Health Organization. (Global Tuberculosis Programme) Global Tuberculosis Report 2020; World Health Organization: Geneva, Switzerland, 2020. ISBN 9789240013131

24.

Yuldashev

Parpieva

Alimov

, et al. Scaling up molecular diagnostic tests for drug-resistant Tuberculosis in Uzbekistan from 2012–2019: are we on the right track? Int J Environ Res Public Health 2021; 18: 4685.

25.

Stop TB Partnership Stop TB Partnership|High Burden Countries, Available online: http://www.stoptb.org/countries/tbdata.

26.

Tilavberdiev

Denning

Klimko

. Serious fungal diseases in the republic of Uzbekistan. Eur J Clin Microbiol Infect Dis 2017; 36 : 925–929.

27.

Turdumambetova

Osmanov

Denning

. The burden of serious fungal infections in Kyrgyzstan. J Fungi (Basel) 2019; 5: 66.

28.

Kemaykin

Tabinbaev

Khudaibergenova

, et al. An estimate of severe and chronic fungal diseases in the republic of Kazakhstan. J Fungi (Basel) 2018; 4: 34.

29.

Bobokhojaev

Osmanov

Aliev

, et al. The burden of serious fungal infections in Tajikistan. J Fungi (Basel) 2019; 5: 68.

30.

Jabeen

Farooqi

Mirza

, et al. Serious fungal infections in Pakistan. Eur J Clin Microbiol Infect Dis 2017; 36: 949–956.

31.

Sharpe

Lagrou

Meis

, et al. On behalf of the ISHAM/ECMM Aspergillus resistance surveillance working group triazole resistance surveillance in Aspergillus fumigatus. Med Mycol 2018; 56: S83–S92.

32.

Herbrecht

Denning

Patterson

, et al. Invasive fungal infections group of the European organization for research and treatment of cancer and the global Aspergillus study group. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002; 347: 408–415.

33.

Popp

White

Quadri

, et al. Amphotericin B with and without itraconazole for invasive aspergillosis: a three-year retrospective study. Int J Infect Dis 1999; 3: 157–160.

34.

Bowden

Chandrasekar

White

, et al. A double-blind, randomized, controlled trial of amphotericin B colloidal dispersion versus amphotericin B for treatment of invasive aspergillosis in immunocompromised patients. Clin Infect Dis 2002; 35: 359–366.

35.

White

Anaissie

Kusne

, et al. Amphotericin B colloidal dispersion vs. Amphotericin B as therapy for invasive aspergillosis. Clin Infect Dis 1997; 24: 635–642.