The role of azoles in the treatment of invasive mycoses: review of the Infectious Diseases Society of America guidelines

Purpose of review The antifungal armamentarium for invasive mycoses has increased in recent years. Understanding the appropriate roles of standard and newer antifungals in the management of the various invasive mycoses encountered in clinical practice is critical for optimal patient care. This review examines the most current treatment guidelines from the Infectious Diseases Society of America for the management of patients with invasive mycoses with a focus on triazole therapies. Recent findings Voriconazole has emerged as the treatment of choice for most forms of invasive aspergillosis. Fluconazole remains the triazole of choice for most nonneutropenic patients with mild-to-moderate invasive candidiasis, whereas an echinocandin is preferred for those with moderate-to-severe illness or recent triazole therapy. An echinocandin or lipid formulation of amphotericin B is recommended for most neutropenic candidiasis patients, with fluconazole being considered an alternative for less critically ill patients with no recent triazole exposure. Voriconazole may be used to replace fluconazole in candidiasis patients with Candida krusei and fluconazole-resistant, voriconazole-susceptible isolates. Standard triazoles (fluconazole or itraconazole) are the cornerstone treatment for milder forms of endemic mycoses, whereas initial treatment with amphotericin B followed by step down therapy with fluconazole/itraconazole is the usual course for more serious endemic mycoses. Increasing evidence suggests voriconazole and posaconazole may play important roles in salvage therapy for central nervous system blastomycosis and cryptococcosis, respectively. Summary Standard triazoles continue to play a prominent role in the management of patients with invasive mycoses. Newer triazoles are beginning to gain a foothold in particular mycoses or subsets of patients, but more research is needed to better define the place of these broad-spectrum triazoles in the treatment of invasive mycoses.