Current and future therapeutic options in the management of invasive aspergillosis

The past decade has witnessed significant progress in the management of invasive aspergillosis. Potent, relatively non-toxic antifungal drugs, data on early chest CT scanning and the availability of a non-invasive diagnostic test (serum galactomannan) are the key advances; among these, the contribution of the recently available drugs is the most significant. Safer and earlier intervention resulting in reduced mortality and improved outcome is being demonstrated. Newer strategies enable clinicians to provide drug therapy in a highly targeted manner, such that empirical use of antifungal drugs may decline. Voriconazole has become the drug of choice for primary therapy, while posaconazole shows promise as a prophylactic drug. Echinocandins are effective for salvage therapy and are under evaluation for primary therapy. Preliminary data for efficacy of combination therapy with a mould-active azole plus an echinocandin are of promise and clinical trials are under way. Reports of emergence of less-susceptible Aspergillus spp. during azole therapy are of concern and close monitoring is needed. Remarkably, the era of polyenes appears to be nearing the end in the therapy of invasive aspergillosis. The promise of newer classes of drugs, immune-modulating therapies and vaccines are exciting future additions to the arsenal against invasive aspergillosis.