TREATMENT OF ASPERGILLOSIS WITH ITRACONAZOLE

OBJECTIVE: To review the role of itraconazole as oral therapy for the major infections caused by Aspergillus spp.: allergic bronchopulmonary aspergillosis, aspergilloma, and invasive aspergillosis. DATA SOURCES : A MEDLINE search of articles published in the English language betwe en 1986 arid 1993 was used to identify relevant citations, including r eview articles. In addition, a search of die published abstracts of th e past two Interscience Conferences on Antimicrobial Agents and Chemot herapy (ICAAC) was performed. STUDY SELECTION: Clinical trials that ev aluated itraconazole therapy in either allergic bronchopulmonary asper gillosis, aspergilloma, or invasive aspergillosis were critically revi ewed. Trials were evaluated based upon entry criteria for die diagnosi s of each type of aspergillosis, risk factors for the development of a spergillosis (neutropenia, transplant recipient, hematologic malignanc y), prior antifungal chemotherapy, and dose and duration of itraconazo le therapy. DATA SYNTHESIS: Overall, the clinical trials of itraconazo le therapy for aspergillosis are limited and of variable quality. In t he treatment of allergic bronchopulmonary aspergillosis, itraconazole has been reported to prompt a reduction in corticosteroid dosage in se lected patients. There have been no controlled trials of itraconazole as treatment for aspergilloma, but data from several open-label trials suggest that this agent may be of clinical benefit in aspergilloma, p rimarily as an alternative to surgery. The use of itraconazole for inv asive aspergillosis has been evaluated in several trials, most often i n patients who were intolerant to amphotericin B treatment. Response t o oral itraconazole has generally been promising. CONCLUSIONS: Althoug h itraconazole offers promise for oral therapy against infections caus ed by Aspergillus spp., it should not presently be regarded as primary therapy for any of these diseases. Amphotericin B, in doses ranging f rom 1 to 1.5 mg/kg to a total dose of 1.5-4.0 g, should remain the tre atment of choice in both aspergilloma and invasive aspergillosis. Itra conazole use should be restricted to patients who experience severe to xicity with amphotericin B therapy. Corticosteroids continue to be fir st-line therapy for allergic bronchopulmonary aspergillosis, with the use of itraconazole reserved for those patients who would benefit from a reduction in corticosteroid dose.