International expert opinion on the management of infection caused by azole-resistant Aspergillus fumigatus.

In the absence of treatment recommendations, an international expert meeting was held to discuss the management of azole-resistant aspergillosis. In vitro susceptibility testing should always be performed if antifungal therapy has been initiated and the culture is positive. In azole-resistant invasive pulmonary aspergillosis the experts would switch treatment from voriconazole to liposomal amphotericin B (L-AmB). In regions with a resistance rate due to environmental resistance mechanisms of >10%, the majority of experts favoured L-AmB as initial therapy, with a minority favouring voriconazole combined with an echinocandin. All experts would use L-AmB as core therapy for suspected azole-resistant aspergillosis of the central nervous system, and would consider the addition of a second agent; the majority favouring flucytosine. In pan-azole resistant chronic pulmonary aspergillosis, intravenous therapy with a non-azole agent is the only therapeutic option. Surveillance, a case registry, improved diagnostics and greater understanding of resistance selection in the environment are areas where researched is urgently needed, in addition to the development of new oral agents. (164).