In neutropenic patients
amphotericin B remains the
drug of choice for the treatment of systemic
fungal infections. On the basis of a superior efficacy in combination with a lower toxicity, the
triazoles have superseded the older
azoles. Regularly,
amphotericin B and a
triazole are used simultaneously without any evidence from clinical trials that such a strategy is safe and efficacious. Liposomal preparation,
lipid complex or colloidal dispersion of
amphotericin B have been produced successfully to reduce toxicity. However, there is only one small randomised study that hints at the superiority of
liposomal amphotericin B over
amphotericin B deoxycholate. Promising new agents like candins, sordarins, high dose oral
terbinafine, the third generation
azoles, and liposomal
nystatin are under development. The first phase II study on
voriconazole in the treatment of
pulmonary aspergillosis has produced encouraging results. The major promise of the new candins lies in the activity against Candida species, including those resistant to the
azoles and
polyenes, and in a mechanism of action totally different from the established antifungals.
Cytokines and
colony stimulating factors are theoretically very promising but there are no clinical studies that warrant routine use.