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Objectives <p>To develop consensus-based, pragmatic recommendations for the diagnosis and management of fungal pneumonia in non-neutropenic critically ill adults in India and Asia, where the dual burden of mucormycosis and resource-limited healthcare settings creates distinct challenges.</p> Methods <p>Using a modified Delphi process, 20 multidisciplinary experts participated in the first round, and 19 completed the second and third rounds of anonymous voting on risk factors, diagnostic strategies, and management of invasive pulmonary aspergillosis (IPA), pulmonary mucormycosis (PM), and <i>Pneumocystis jirovecii</i> pneumonia (PCP). Consensus was defined as ≥ 70% agreement or disagreement; statements with 60–69% agreement were categorized as “suggest,” while the remaining were classified as “no consensus.”</p> Results <p>Key risk factors included severe chronic obstructive pulmonary disease, influenza, COVID-19, diabetes mellitus, and chronic liver or kidney disease. A multimodal diagnostic strategy combining contrast-enhanced computed tomography (CT), early bronchoalveolar lavage (BAL), microscopy, culture, and galactomannan (BAL threshold ≥ 1.0) was recommended, with molecular methods used where available. Liposomal amphotericin B was the preferred empiric agent in regions with high mucormycosis prevalence; voriconazole, posaconazole, or isavuconazole are first-line for proven IPA. Therapeutic drug monitoring is essential for azole antifungals, with a minimum treatment duration of 6–12 weeks. For PCP, empiric trimethoprim-sulfamethoxazole is recommended in immunosuppressed patients with diffuse ground-glass opacities on CT after exclusion of competing diagnoses. Adjunctive corticosteroids are recommended for PCP with severe hypoxemia (PaO₂ &lt;70 mmHg) despite limited evidence in non-HIV patients.</p> Conclusion <p>We provide practical, resource-adapted guidance for managing fungal pneumonia in non-neutropenic ICU patients, while highlighting research priorities. The proposed diagnostic criteria for IPA and PM are provisional consensus-based frameworks intended to support clinical decision-making and require prospective multicentre validation.</p> Clinical trial number <p>Not applicable.</p>

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Fungal pneumonia in non-neutropenic critically ill patients: a Delphi consensus from the Fungal Infection Study Forum, India, with implications for resource-limited settings

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年8月4日

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  • Valliappan Muthu,
  • Ritesh Agarwal,
  • Inderpaul Singh Sehgal,
  • Shivaprakash Mandya Rudramurthy,
  • Atul Patel,
  • Soundappan Kathirvel,
  • Ooriapadickal Cherian Abraham,
  • Pradip Kumar Bhattacharya,
  • Dedeepiya Devaprasad,
  • Mandeep Garg,
  • Randeep Guleria,
  • Neha Gupta,
  • Ravindra Mehta,
  • Puneet Saxena,
  • Prakash Shastri,
  • Tanu Singhal,
  • Rajeev Soman,
  • Deepak Talwar,
  • Subhash Todi,
  • George Varghese,
  • Arunaloke Chakrabarti

摘要

Objectives

To develop consensus-based, pragmatic recommendations for the diagnosis and management of fungal pneumonia in non-neutropenic critically ill adults in India and Asia, where the dual burden of mucormycosis and resource-limited healthcare settings creates distinct challenges.

Methods

Using a modified Delphi process, 20 multidisciplinary experts participated in the first round, and 19 completed the second and third rounds of anonymous voting on risk factors, diagnostic strategies, and management of invasive pulmonary aspergillosis (IPA), pulmonary mucormycosis (PM), and Pneumocystis jirovecii pneumonia (PCP). Consensus was defined as ≥ 70% agreement or disagreement; statements with 60–69% agreement were categorized as “suggest,” while the remaining were classified as “no consensus.”

Results

Key risk factors included severe chronic obstructive pulmonary disease, influenza, COVID-19, diabetes mellitus, and chronic liver or kidney disease. A multimodal diagnostic strategy combining contrast-enhanced computed tomography (CT), early bronchoalveolar lavage (BAL), microscopy, culture, and galactomannan (BAL threshold ≥ 1.0) was recommended, with molecular methods used where available. Liposomal amphotericin B was the preferred empiric agent in regions with high mucormycosis prevalence; voriconazole, posaconazole, or isavuconazole are first-line for proven IPA. Therapeutic drug monitoring is essential for azole antifungals, with a minimum treatment duration of 6–12 weeks. For PCP, empiric trimethoprim-sulfamethoxazole is recommended in immunosuppressed patients with diffuse ground-glass opacities on CT after exclusion of competing diagnoses. Adjunctive corticosteroids are recommended for PCP with severe hypoxemia (PaO₂ <70 mmHg) despite limited evidence in non-HIV patients.

Conclusion

We provide practical, resource-adapted guidance for managing fungal pneumonia in non-neutropenic ICU patients, while highlighting research priorities. The proposed diagnostic criteria for IPA and PM are provisional consensus-based frameworks intended to support clinical decision-making and require prospective multicentre validation.

Clinical trial number

Not applicable.