Treatment of solid organ transplant patients with invasive fungal infections: should a combination of antifungal drugs be used?

PURPOSE OF REVIEW: Combined antifungal drug therapy is widely used in severe invasive mycoses in solid organ transplant (SOT) recipients. We have reviewed the available data in the literature. RECENT
FINDINGS: No single randomized study on antifungal combination therapy in SOT patients has been performed. Existing information does not support the use of combination therapy in invasive candidiasis in SOT patients. Indeed, initial combination therapy with amphotericin B and 5-flucytosine is recommended for SOT patients with central nervous system cryptococcosis, mainly with increased white blood cell counts in the cerebrospinal fluid or with altered mental status. No impact on outcome was observed with combination therapy in Scedosporium infections in SOT patients. The combination of voriconazole and terbinafine may be an attractive option for S. prolificans infections. A prospective study of voriconazole plus caspofungin as initial therapy for invasive aspergillosis in SOT patients found that combination therapy was independently associated with reduced mortality in patients with renal failure and in those with Aspergillus fumigatus infection, even when adjusted for other factors predictive of mortality in the study population.
SUMMARY: Combination therapy should be considered for severe forms of invasive fungal infections in SOT patients; however, multicenter studies of such patients are urgently needed.