Treatment of invasive pulmonary aspergillosis

Treatment of invasive aspergillosis requires consideration of appropriate antifungal therapy, potential surgical management, and modulation of immunity. In the past several years, advances in therapy include the availability of multiple new antifungal drugs that have activity against Aspergillus species (expanded spectrum azole antifungals and echinocandins), with some studies showing potentially improved outcomes compared to therapies that employ conventional formulations of amphotericin B. The first large randomised trial performed to evaluate therapy for aspergillosis demonstrated improved outcomes and survival in patients randomised to receive voriconazole as primary therapy. Other recent studies have demonstrated activity of the liposomal formulation of amphotericin B in treating aspergillosis, although the relative utility of this drug compared to voriconazole is unclear. Salvage therapy studies, results of which are limited by small numbers of patients and host-related biases in outcomes, demonstrate potential utility with echinocandins (caspofungin, micafungin), posaconazole and amphotericin B lipid complex. Most recently, use of multiple therapies in combination (combination therapy), especially use of regimens including echinocandin antifungals, has attracted much attention, although few data are available to support adoption as standard practice. A comprehensive approach to therapy should consider the potential necessity of surgical management and immune modulation, which are discussed.