TABLE 1.

Possible role and indications for echinocandins in the treatment of invasive aspergillosis

Indication	Aima	Situation	Level of evidence (Ref.)
First-line treatment (monotherapy)	To treat IA when no alternative regimen (or potential risks outweighing benefits for other regimens)	Relative contraindications to azoles (underlying liver disease, drug-drug interactions, prolonged QT interval); relative contraindications to AMB (underlying kidney disease, nephrotoxic comedications)	Noncomparative prospective or retrospective studies (overall success rate, 30–90%) (62)
Second-line treatment (monotherapy)	To treat IA when first-line antifungals have failed or need to be discontinued	Toxicity of triazoles (hepatic test disturbances, visual/neurological side effects); toxicity of AMB (acute renal failure); failure of previous antifungal regimens	Noncomparative prospective or retrospective studies (overall success rate, 30–70%) (62)
In combination with triazoles or AMB	To obtain synergistic interactions (triazoles, AMB)	Severe and/or disseminated IA, galactomannan-positive IA; in case of failure of previous regimen or breakthrough IA; for IA due to azole-resistant A. fumigatus	One randomized controlled trial (trends, benefit limited to subgroup analyses) (81); expert opinion; murine models (75, 77)
	To palliate potential PK/PD defect until first-line drug achieves appropriate serum level (triazoles)	In severe and/or disseminated IA	Expert opinion
	To palliate potential inefficacy of first-line drug (triazoles)	For empirical treatment, if suspicion or high local prevalence of azole-resistant A. fumigatus; breakthrough IA	Expert opinion (82)
	To obtain synergistic interactions on biofilms (triazoles, AMB)	For Aspergillus endocarditis or osteomyelitis with presence of prosthetic material	In vitro studies (79)

^aAMB, amphotericin B; IA, invasive aspergillosis; PK/PD, pharmacokinetic/pharmacodynamic.