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Combination Therapy
Î Combinations of polyenes or azoles with echinocandins suggest
additive or synergistic effects in some pre-clinical studies (W-L).
• However, variable test designs and conflicting results of preclinical and in vitro
testing have led to uncertainty as to how to interpret the findings.
Susceptibility Testing
Î Routine antifungal susceptibility testing of isolates recovered during
initial infection is NOT recommended (S-M).
• 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.
Recommended Therapy for Invasive Disease
Invasive Pulmonary Aspergillosis (IPA)
Î The IDSA recommends primary treatment with voriconazole (S-H).
Î Early initiation of antifungal therapy in patients with strongly suspected
IPA is warranted while a diagnostic evaluation is conducted (S-H).
Î Alternative therapies include liposomal AmB (S-M), isavuconazole
(S-M), or other lipid formulations of AmB (W-L).
Î Combination antifungal therapy with voriconazole and an echinocandin
may be considered in select patients with documented IPA (W-M).
• Primary therapy with an echinocandin is NOT recommended (S-M).
Echinocandins (micafungin or caspofungin) can be used in settings in which azole
and polyene antifungals are contraindicated (W-M).
Î The IDSA recommends 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 (S-L).
Î For patients with successfully treated IPA who require subsequent
immunosuppression, secondary prophylaxis should be initiated to
prevent recurrence (S-M).
Invasive Aspergillosis (IA)
Î Reducing doses of, or eliminating altogether, immunosuppressive
agents, when feasible, is advised as a component of anti-Aspergillus
therapy (S-L).
Î Colony stimulating factors (CSFs) may be considered in neutropenic
patients with diagnosed or suspected IA (W-L).
• There is insufficient evidence regarding the value of G-CSF versus GM-CSF in
this setting.
