Does combination of lipid formulation of amphotericin B and echinocandins improve outcome of invasive aspergillosis in hematological malignancy patients?
BACKGROUND
In vitro and in vivo studies suggested that combination of lipid formulation of amphotericin B (L-AMB) and echinocandins may have a synergistic or additive effect against Aspergillus. Furthermore, clinical studies suggested that this combination may improve response of invasive aspergillosis (IA).


METHODS
Between August 1993 and June 2008, the authors identified a total of 159 patients with hematological malignancies who received salvage therapy for IA, with L-AMB alone, echinocandins alone, or a combination of L-AMB and echinocandins. Clinical characteristics, response to salvage therapy, and death up to 12 weeks after initiation of salvage therapy were retrospectively determined for all patients.


RESULTS
Seventy patients received salvage therapy with L-AMB, 18 patients received echinocandins alone (89% of whom received caspofungin), and 71 patients received the combination therapy of amphotericin B and echinocandins (90% of who received caspofungin). The 3 salvage treatment groups were comparable in regard to clinical characteristics; graft versus host disease was more frequently encountered in the echinocandin group, whereas more patients in the L-AMB and combination groups had neutropenia and received immunotherapy. The response to salvage therapy was better in the echinocandin group (9% L-AMB, 28% echinocandins, and 21% for combination therapy). The 3 groups had a comparable rate of Aspergillus-related death (58%-64%) and overall mortality (61%-67%).


CONCLUSIONS
The combination of L-AMB and echinocandins offered no advantage in terms of improving response or reducing mortality over either drug alone. Hence, this combination will only add to the cost of therapy without any improvement in outcome in patients with hematological malignancies.
Mihu
Coralia N
CN
Department of Infectious Diseases, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. cnmihu@mdanderson.org
Kassis
Christelle
C
Ramos
Elizabeth R
ER
Jiang
Ying
Y
Hachem
Ray Y
RY
Raad
Issam I
II
D000293:Adolescent; D000328:Adult; D000368:Aged; D000666:Amphotericin B / Q000008:administration & dosage* / Q000009:adverse effects; D000935:Antifungal Agents / Q000008:administration & dosage*; D001228:Aspergillosis / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D002648:Child; D004359:Drug Therapy, Combination / Q000009:adverse effects; D054714:Echinocandins / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D019337:Hematologic Neoplasms / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016879:Salvage Therapy; D016896:Treatment Outcome
D000935:Antifungal Agents; D054714:Echinocandins; C068538:liposomal amphotericin B; D000666:Amphotericin B