Liposomal Amphotericin B Has Comparable Outcomes With Triazoles in Invasive Aspergillosis, Finds Study
Italy: Current guidelines recommend triazoles as first-line therapy for most patients with invasive aspergillosis, while liposomal amphotericin B (L-AmB) is commonly reserved for breakthrough or refractory cases.
In a recent retrospective observational study, 90-day mortality was similar across groups: 37.1% with initial triazole therapy versus 41.3% with initial L-AmB. These findings are reassuring, indicating that L-AmB is an effective alternative to triazole-based therapy when used as initial treatment for invasive aspergillosis.
Building on existing treatment paradigms, investigators from Italy assessed whether outcomes truly differ when L-AmB is used upfront rather than as a fallback option. The multicenter retrospective study, published in Open Forum Infectious Diseases, was led by Matteo Rinaldi from the Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, along with his colleagues. The research aimed to compare real-world clinical outcomes between patients receiving L-AmB and those treated with mold-active triazoles as primary therapy for invasive aspergillosis.
The analysis included adult patients with proven or probable invasive aspergillosis treated at two academic hospitals over a decade-long period. A total of 401 patients were evaluated, with a median age of 65 years, and nearly two-thirds were men.
The study led to the following findings:
- Hematologic malignancies were the most common predisposing condition, followed by severe respiratory viral infections and long-term corticosteroid therapy, highlighting the heterogeneous and high-risk nature of the study population.
- Nearly three-quarters of patients received triazoles as initial treatment, while a little over one-quarter were started on liposomal amphotericin B.
- Treatment changes occurred more frequently in patients who initially received liposomal amphotericin B.
- Most therapy modifications in the liposomal amphotericin B group involved switching to oral triazoles as part of step-down treatment.
- In contrast, treatment changes among patients started on triazoles were less frequent and were mainly prompted by drug-related adverse events.
To minimize bias inherent in retrospective comparisons, the researchers applied a landmark analysis at seven days after diagnosis and used inverse probability of treatment weighting to adjust for differences in baseline characteristics. Survival outcomes were then analyzed using weighted and covariate-adjusted Cox regression models. These robust statistical approaches demonstrated no significant difference in 90-day all-cause mortality between the two treatment strategies.
Adjusted survival analyses further confirmed that initiating therapy with L-AmB did not confer a higher risk of death compared with triazoles. The investigators also reported that primary L-AmB therapy was generally well tolerated, supporting its feasibility in routine clinical practice.
Overall, the study suggests that liposomal amphotericin B can be considered a viable first-line option for invasive aspergillosis in selected patients, particularly when triazoles are contraindicated or not ideal. While the authors emphasize the need for prospective studies to validate these findings, the results provide clinically meaningful reassurance for physicians managing complex cases of invasive aspergillosis.
Reference:
Rinaldi, M., Lewis, R. E., Susini, M. C., Nuti, B., Casarini, M., Riccucci, D., Grassi, I., Toschi, A., Bartoletti, M., Bussini, L., Bavaro, D. F., Cento, V., Diella, L., Belati, A., De Angelis, A., Barbanotti, D., Pensalfine, G., Ambretti, S., Roncarati, G., . . . Giannella, M. (2026). Primary Therapy for Invasive Aspergillosis With Triazoles or L-AmB: A Multicenter Retrospective Study. Open Forum Infectious Diseases, 13(2). https://doi.org/10.1093/ofid/ofaf777
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