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How We Approach Combination Antifungal Therapy for Invasive Aspergillosis and Mucormycosis in Transplant Recipients

Haidar, Ghady, MD1; Singh, Nina, MD2

doi: 10.1097/TP.0000000000002353

Invasive aspergillosis and mucormycosis are life-threatening infections in solid organ and hematopoietic cell transplant recipients. Despite medical advancements in the care of these patients and the availability of new mold-active drugs, the outcomes remain suboptimal. Therefore, there has been increased interest in the use of combination antifungal therapy, in hopes that leveraging the possible in vitro synergy of these agents will improve the prognosis of invasive mold disease. However, there has been a large disconnect between the results of experimental and clinical investigations, as clinical studies have not unequivocally demonstrated the superiority of combination therapy over monotherapy. This is particularly true for mucormycosis, where the rarity of the condition has made it nearly impossible to prospectively study novel therapeutic strategies. We review the current standard of antifungal therapy and the preclinical and clinical data addressing the merit of combination therapy, and we provide guidance to optimize the management of these mycoses.

This expert overview performs a critical analysis on the use of approved or investigational antifungal agents, either as monotherapy or combined therapy, proposing recommendations and treatment algorithms for the management of invasive aspergillosis and mucormycosis in transplant recipients.

1Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA.

2 Infectious Diseases Section, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA.

Received 4 June 2018. Revision received 22 June 2018.

Accepted 26 June 2018.

The authors declare no conflicts of interest.

G.H. wrote the first draft of the article. N.S. made revisions to the article and approved the final draft.

Correspondence: Nina Singh, MD, Infectious Diseases Section, Veterans Affairs Medical Center, University Drive C, Pittsburgh, PA 15240. (

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