Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis.
BACKGROUND
Voriconazole is a broad-spectrum triazole that is active against aspergillus species. We conducted a randomized trial to compare voriconazole with amphotericin B for primary therapy of invasive aspergillosis.


METHODS
In this randomized, unblinded trial, patients received either intravenous voriconazole (two doses of 6 mg per kilogram of body weight on day 1, then 4 mg per kilogram twice daily for at least seven days) followed by 200 mg orally twice daily or intravenous amphotericin B deoxycholate (1 to 1.5 mg per kilogram per day). Other licensed antifungal treatments were allowed if the initial therapy failed or if the patient had an intolerance to the first drug used. A complete or partial response was considered to be a successful outcome.


RESULTS
A total of 144 patients in the voriconazole group and 133 patients in the amphotericin B group with definite or probable aspergillosis received at least one dose of treatment. In most of the patients, the underlying condition was allogeneic hematopoietic-cell transplantation, acute leukemia, or other hematologic diseases. At week 12, there were successful outcomes in 52.8 percent of the patients in the voriconazole group (complete responses in 20.8 percent and partial responses in 31.9 percent) and 31.6 percent of those in the amphotericin B group (complete responses in 16.5 percent and partial responses in 15.0 percent; absolute difference, 21.2 percentage points; 95 percent confidence interval, 10.4 to 32.9). The survival rate at 12 weeks was 70.8 percent in the voriconazole group and 57.9 percent in the amphotericin B group (hazard ratio, 0.59; 95 percent confidence interval, 0.40 to 0.88). Voriconazole-treated patients had significantly fewer severe drug-related adverse events, but transient visual disturbances were common with voriconazole (occurring in 44.8 percent of patients).


CONCLUSIONS
In patients with invasive aspergillosis, initial therapy with voriconazole led to better responses and improved survival and resulted in fewer severe side effects than the standard approach of initial therapy with amphotericin B.
Herbrecht
Raoul
R
Département d'Hématologie et d'Oncologie, Hôpital de Hautepierre, Strasbourg, France. raoul.herbrecht@chru-strasbourg.fr
Denning
David W
DW
Patterson
Thomas F
TF
Bennett
John E
JE
Greene
Reginald E
RE
Oestmann
Jörg-W
JW
Kern
Winfried V
WV
Marr
Kieren A
KA
Ribaud
Patricia
P
Lortholary
Olivier
O
Sylvester
Richard
R
Rubin
Robert H
RH
Wingard
John R
JR
Stark
Paul
P
Durand
Christine
C
Caillot
Denis
D
Thiel
Eckhard
E
Chandrasekar
Pranatharthi H
PH
Hodges
Michael R
MR
Schlamm
Haran T
HT
Troke
Peter F
PF
de Pauw
Ben
B
D000293:Adolescent; D000328:Adult; D000368:Aged; D000666:Amphotericin B / Q000009:adverse effects / Q000627:therapeutic use*; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001228:Aspergillosis / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D005260:Female; D006402:Hematologic Diseases / Q000150:complications; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D011743:Pyrimidines / Q000009:adverse effects / Q000627:therapeutic use*; D015996:Survival Rate; D014230:Triazoles / Q000009:adverse effects / Q000627:therapeutic use*; D065819:Voriconazole
D000935:Antifungal Agents; D011743:Pyrimidines; D014230:Triazoles; D000666:Amphotericin B; D065819:Voriconazole