New antifungal drugs and new clinical trials: interpreting results may be difficult

In recent years, considerable progress in the management of invasive mycoses in immunocompromised patients has been achieved. However, the prognosis of these infections, in particular those caused by filamentous fungi, continues to be dramatically poor, with mortality rates reaching more than 80% in selected categories of patients. New antifungal drugs in the classes of triazoles and echinocandins, with interesting antimicrobial and pharmacokinetic characteristics, are under investigation, and important trials have been reported in the last 2 years. These studies seem to suggest the relevant role of these new drugs in the antifungal armamentarium.

The triazole voriconazole and the echinocandin caspofungin demonstrated significant advantages in term of toxicity and response rate, when compared with conventional amphotericin B in the treatment of aspergillosis and candidiasis, respectively. However, because of the peculiar characteristics of the design of both studies, the interpretation of the results may be difficult, and further confirmatory experiences are needed. Other noncontrolled studies showed a promising role of caspofungin in the treatment of Aspergillus infections and of voriconazole in the treatment of other rare mycoses.

The increasing incidence and severity of invasive mycoses have led to the development of new strategies with new antifungal agents, and amphotericin B no longer is the gold standard for a variety of fungal infections. However, these results should be considered with caution. The latest generation drugs need to be investigated further in proper trials, and old drugs, especially conventional amphotericin B, continue to have a central role in the antifungal armamentarium.