Purpose of review: The use of combination antifungal therapy in hematopoietic stem-cell transplantation patients is controversial and limited by a paucity of controlled data. The recent literature is reviewed and the relative arguments for and against combination antifungal therapy are outlined with summative recommendations to assist practitioners in decision-making.
Recent findings: There is an abundance of in-vitro and murine in-vivo combination antifungal literature, whereas clinical data are less abundant and controlled. Of the published case series there is a suggested benefit to combination therapy over monotherapy, although there are limitations to the available literature. Other issues in the combination debate that are addressed include the following: improved response rates and a survival advantage have been demonstrated in recent monotherapy studies; response rates in most published combination therapy studies do not suggest large gains over monotherapy; the lack of sustained survival advantage to combination therapy studies; and finally the consideration of host defenses in treatment responses.
Summary: Based on available data, combination therapy is not warranted at the initial diagnosis of invasive aspergillosis. Randomized, controlled trials with rigorous study design are needed.