, Volume 67, Issue 13, pp 1803–1812 | Cite as

Changing Epidemiology of Rare Mould Infections

Implications for Therapy
Current Opinion


There has been an increase in rare mould infections in recent decades. These infections have been reported primarily in severely immunocompromised patients. The emergence of these organisms is multifactorial and can be related to more intense immunosuppression, the prolonged survival of patients who have what were previously fatal diseases, and the selective pressure of broad spectrum antifungal agents used for prophylaxis or therapy. Among these rare mould infections, the Zygomycetes are the most commonly encountered, and in some institutions the increase in these organisms appears to be associated with the use of voriconazole. Aspergillus terreus, a species that is resistant to amphotericin B, and less frequently, A. ustus and A. lentulus, have been noted increasingly as causes of invasive aspergillosis in tertiary care centres in the US. Several species of Scedosporium with innate resistance to many antifungal agents have emerged as major causes of disseminated mould infections that are frequently very difficult to treat. Among patients who have haematological malignancies, are neutropenic or have received a haematopoietic stem cell transplant, infections due to Fusarium species respond poorly to many antifungal agents. Dematiaceous, or brown-black, fungi, most often associated with chronic localised infections, are now increasingly reported as a cause of disseminated infection in immunosuppressed hosts.

Concomitant with the increased number of infections with these rare moulds, several new mould-active antifungal agents have been developed. The new expanded spectrum azole, voriconazole, has changed our approach to moulds such as S. apiospermum, Fusarium species and A. terreus that are amphotericin B resistant. Posaconazole, the most recently approved expanded spectrum azole, is the first drug in the azole class to show activity against the Zygomycetes and has proven extremely useful for step-down therapy after initial treatment with amphotericin B. It is not known whether posaconazole is effective as primary therapy for zygomycosis; the use of this agent for that purpose awaits clinical trials with the recently developed intravenous formulation of posaconazole.


  1. 1.
    Nucci M, Marr KA. Emerging fungal diseases. Clin Infect Dis 2005; 41: 521–6PubMedCrossRefGoogle Scholar
  2. 2.
    Walsh TJ, Groll A, Hiemenz J, et al. Infections due to emerging and uncommon medically important fungal pathogens. Clin Microbiol Infect 2004; 10 Suppl. 1: 48–66PubMedCrossRefGoogle Scholar
  3. 3.
    Husain S, Alexander BD, Munoz P, et al. Opportunistic mycelial fungal infections in organ transplant recipients: emerging importance of non-Aspergillus mycelial fungi. Clin Infect Dis 2003; 37: 221–9PubMedCrossRefGoogle Scholar
  4. 4.
    Marr KA, Carter RA, Crippa F, et al. Epidemiology and outcome of mould infections in hematopoietic stem cell transplant recipients. Clin Infect Dis 2002; 34: 909–17PubMedCrossRefGoogle Scholar
  5. 5.
    Copelan EA. Hematopoietic stem cell transplantation. New Engl J Med 2006; 354: 1813–26PubMedCrossRefGoogle Scholar
  6. 6.
    Marty FM, Lee SJ, Fahey MM, et al. Infliximab use in patients with severe graft-versus-host disease and other emerging risk factors of non-Candida fungal infections in allogeneic hematopoietic stem cell transplant recipients: a cohort study. Blood 2003; 102: 2768–76PubMedCrossRefGoogle Scholar
  7. 7.
    Cordonnier C, Ribaud P, Herbrecht R, et al. Prognostic factors for death due to invasive aspergillosis after hematopoietic stem cell transplantation: a 1-year retrospective study of consecutive patients at French transplantation centers. Clin Infect Dis 2006; 42: 955–63PubMedCrossRefGoogle Scholar
  8. 8.
    Berenguer J, Rodriquez-Tudela JL, Richard C, et al. Deep infections caused by Scedosporium prolificans: a report on 16 cases in Spain and a review of the literature. Medicine 1997; 76: 256–65PubMedCrossRefGoogle Scholar
  9. 9.
    Chayakulkeeree M, Ghannoum MA, Perfect JR. Zygomycosis: the re-emerging fungal infection. Eur J Clin Microbiol Infect Dis 2006; 25: 215–29PubMedCrossRefGoogle Scholar
  10. 10.
    Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005; 41: 634–53PubMedCrossRefGoogle Scholar
  11. 11.
    Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA 2006; 296: 953–63PubMedCrossRefGoogle Scholar
  12. 12.
    Panackal A, Marr KA. Scedosporium/Pseudallescheria infections. Sem Respir Crit Care Med 2004; 25: 171–81CrossRefGoogle Scholar
  13. 13.
    Kauffman CA. Zygomycosis: reemergence of an old pathogen. Clin Infect Dis 2004; 39: 588–90PubMedCrossRefGoogle Scholar
  14. 14.
    Johnson LB, Kauffman CA. Voriconazole: a new triazole antifungal agent. Clin Infect Dis 2003; 36: 630–7PubMedCrossRefGoogle Scholar
  15. 15.
    Torres HA, Hachem RY, Chemaly RF, et al. Posaconazole: a broad-spectrum triazole antifungal. Lancet Infect Dis 2005; 5: 775–85PubMedCrossRefGoogle Scholar
  16. 16.
    Kontoyiannis DP, Wessel VC, Bodey GP, et al. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000; 30: 851–6PubMedCrossRefGoogle Scholar
  17. 17.
    Imhof A, Balajee SA, Fredricks DN, et al. Breakthrough fungal infections in stem cell transplant recipients receiving voriconazole. Clin Infect Dis 2004; 39: 743–6PubMedCrossRefGoogle Scholar
  18. 18.
    Kobayashi K, Kami M, Murashige N, et al. Breakthrough zygomycosis during voriconazole treatment for invasive aspergillosis. Haematologica 2004; 89: ECR42PubMedGoogle Scholar
  19. 19.
    Marty FM, Cosimi LA, Baden LR. Breakthrough zygomycosis after voriconazole treatment in recipients of hematopoietic stem-cell transplants. N Engl J Med 2004; 350: 950–2PubMedCrossRefGoogle Scholar
  20. 20.
    Vigouroux S, Morin O, Moreau P, et al. Zygomycosis after prolonged use of voriconazole in immunocompromised patients with hematological disease: attention required. Clin Infect Dis 2005; 40: e35–7PubMedCrossRefGoogle Scholar
  21. 21.
    Siwek GT, Dodgson KJ, de Magalhaes-Silverman M, et al. Invasive zygomycosis in hematopoietic stem cell transplant recipients receiving voriconazole prophylaxis. Clin Infect Dis 2004; 39: 584–7PubMedCrossRefGoogle Scholar
  22. 22.
    Oren I. Breakthrough zygomycosis during empirical voriconazole therapy in febrile patients with neutropenia. Clin Infect Dis 2005; 40: 770–1PubMedCrossRefGoogle Scholar
  23. 23.
    Kontoyiannis DP, Lionakis MS, Lewis RE, et al. Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy: a case-control observational study of 27 recent cases. J Infect Dis 2005; 191: 1350–60PubMedCrossRefGoogle Scholar
  24. 24.
    Sun QN, Fothergill AW, McCarthy DI, et al. In vitro activities of posaconazole, itraconazole, voriconazole, amphotericin B, and fluconazole against 37 clinical isolates of zygomycetes. Antimicrob Agents Chemother 2002; 46: 1581–2PubMedCrossRefGoogle Scholar
  25. 25.
    van Burik JA, Ratanatharathorn V, Stepan DE, et al. Micafungin versus fluconazole for prophylaxis against invasive fungal infections during neutropenia in patients undergoing hematopoietic stem cell transplantation. Clin Infect Dis 2004; 39: 1407–16PubMedCrossRefGoogle Scholar
  26. 26.
    Boelaert JR, van Roost GF, Verqauwe PL, et al. The role of desferrioxamine in dialysis-associated mucormycosis: report of three cases and review of the literature. Clin Nephrol 1988; 29: 261–6PubMedGoogle Scholar
  27. 27.
    Daly AL, Velazquez LA, Bradley SF, et al. Mucormycosis: association with deferoxamine therapy. Am J Med 1989; 87: 468–71PubMedCrossRefGoogle Scholar
  28. 28.
    Spellberg B, Edwards J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clin Microbiol Rev 2005; 18: 556–69PubMedCrossRefGoogle Scholar
  29. 29.
    Perfect JR. Treatment of non-Aspergillus moulds in immunocompromised patients, with amphotericin B lipid complex. Clin Infect Dis 2005; 40: S401–8PubMedCrossRefGoogle Scholar
  30. 30.
    Greenberg RN, Mullane K, van Burik JA, et al. Posaconazole as salvage therapy for zygomycosis. Antimicrob Agents Chemother 2006; 50: 126–33PubMedCrossRefGoogle Scholar
  31. 31.
    Tobon AM, Arango M, Fernandez D, et al. Mucormycosis (zygomycosis) in a heart-kidney transplant recipient: recovery after posaconazole therapy. Clin Infect Dis 2003; 36: 1488–91PubMedCrossRefGoogle Scholar
  32. 32.
    van Burik JA, Hare RS, Solomon HF, et al. Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases. Clin Infect Dis 2006; 42: e61–5PubMedCrossRefGoogle Scholar
  33. 33.
    Sansone-Parsons A, Krishna G, Calzetta A, et al. Effect of a nutritional supplement on posaconazole pharmacokinetics following oral administration to healthy volunteers. Antimicrob Agents Chemother 2006; 50: 1881–3PubMedCrossRefGoogle Scholar
  34. 34.
    Ullmann AJ, Comely OA, Burchardt A, et al. Pharmacokinetics, safety, and efficacy of posaconazole in patients with persistent febrile neutropenia or refractory invasive fungal infection. Antimicrob Agents Chemother 2006; 50: 658–66PubMedCrossRefGoogle Scholar
  35. 35.
    Ferguson BJ, Mitchell TG, Moon R, et al. Adjunctive hyperbaric oxygen for treatment of rhinocerebral mucormycosis. Rev Infect Dis 1988; 10: 551–9PubMedCrossRefGoogle Scholar
  36. 36.
    Garcia-Diaz JB, Palau L, Pankey GA. Resolution of rhinocerebral zygomycosis associated with adjuvant administration of granulocyte-macrophage colony-stimulating factor. Clin Infect Dis 2001; 32: e145–50PubMedCrossRefGoogle Scholar
  37. 37.
    Sahin B, Paydas S, Cosar E, et al. Role of granulocyte colonystimulating factor in the treatment of mucormycosis. Eur J Clin Microbiol Infect Dis 1996; 15: 866–9PubMedCrossRefGoogle Scholar
  38. 38.
    Reed C, Ibrahim A, Edwards Jr JE, et al. Deferasirox, an iron chelating agent, as salvage therapy for rhinocerebral mucormycosis. Antimicrob Agents Chemother 2006; 50: 3968–9PubMedCrossRefGoogle Scholar
  39. 39.
    Ibrahim AS, Edwards Jr JE, Fu Y, et al. Deferiprone iron chelation as a novel therapy for experimental mucormycosis. J Antimicrob Chemother 2006; 58: 1070–3PubMedCrossRefGoogle Scholar
  40. 40.
    Perfect JR, Cox GM, Lee JY, et al. The impact of culture isolation of Aspergillus species: a hospital-based survey of aspergillosis. Clin Infect Dis 2001; 33: 1824–33PubMedCrossRefGoogle Scholar
  41. 41.
    Baddley JW, Pappas PG, Smith AC, et al. Epidemiology of Aspergillus terreus at a university hospital. J Clin Microbiol 2003; 41: 5525–9PubMedCrossRefGoogle Scholar
  42. 42.
    Steinbach WJ, Benjamin DK, Kontoyiannia DP, et al. Infections due to Aspergillus terreus: a multicenter retrospective analysis of 83 cases. Clin Infect Dis 2004; 39: 192–8PubMedCrossRefGoogle Scholar
  43. 43.
    Iwen PC, Rupp ME, Langnas AN, et al. Invasive pulmonary aspergillosis due to Aspergillus terreus: 12-year experience and review of the literature. Clin Infect Dis 1998; 26: 1092–7PubMedCrossRefGoogle Scholar
  44. 44.
    Steinbach WJ, Perfect JR, Schell WA, et al. In vitro analyses, animal models, and 60 clinical cases of invasive Aspergillus terreus infection. Antimicrob Agents Chemother 2004; 48: 3217–25PubMedCrossRefGoogle Scholar
  45. 45.
    Walsh TJ, Petraitis V, Petraitiene R, et al. Experimental pulmonary aspergillosis due to Aspergillus terreus: pathogenesis and treatment of an emerging fungal pathogen resistant to amphotericin B. J Infect Dis 2003; 188: 305–19PubMedCrossRefGoogle Scholar
  46. 46.
    Walsh TJ, Raad I, Patterson TF, et al. Treatment of invasive aspergillosis with posaconazole in patients who are refractory to or intolerant of conventional therapy: an externally controlled trial. Clin Infect Dis 2007; 44: 2–12PubMedCrossRefGoogle Scholar
  47. 47.
    Barchiesi F, Spreghini E, Santinelli A, et al. Efficacy of caspofungin against Aspergillus terreus. Antimicrob Agents Chemother 2005; 49: 5133–5PubMedCrossRefGoogle Scholar
  48. 48.
    Cooke FJ, Terpos E, Boyle J, et al. Disseminated Aspergillus terreus infection arising from cutaneous inoculation treated with caspofungin. Clin Microbiol Infect 2003; 9: 1238–41PubMedCrossRefGoogle Scholar
  49. 49.
    Lass-Florl C, Rath P, Niederwieser D, et al. Aspergillus terreus infections in haematological malignancies: molecular epidemiology suggests association with in-hospital plants. J Hosp Infect 2000; 46: 31–5PubMedCrossRefGoogle Scholar
  50. 50.
    Panackal AA, Imhof A, Hanley EW, et al. Aspergillus ustus infections among transplant recipients. Emerg Infect Dis 2006; 12: 403–8PubMedCrossRefGoogle Scholar
  51. 51.
    Pavie J, Lacroix C, Hermoso DG, et al. Breakthrough disseminated Aspergillus ustus infection in allogeneic hematopoietic stem cell transplant recipients receiving voriconazole or caspofungin prophylaxis. J Clin Microbiol 2005; 43: 4902–4PubMedCrossRefGoogle Scholar
  52. 52.
    Balajee SA, Weaver M, Imhof A, et al. Aspergillus fumigatus variant with decreased susceptibility to multiple antifungals. Antimicrob Agents Chemother 2004; 48: 1197–203PubMedCrossRefGoogle Scholar
  53. 53.
    Guarro J, Kantarcioglu AS, Horre R, et al. Scedosporium apiospermium: changing clinical spectrum of a therapy-refractory opportunist. Med Mycol 2006; 44: 295–327PubMedCrossRefGoogle Scholar
  54. 54.
    Castiglioni B, Sutton DA, Rinaldi MG, et al. Pseudallescheria boydii (anamorph Scedosporium apiospermum) infection in solid organ transplant recipients in a tertiary medical center and review of the literature. Medicine 2002; 81: 333–48PubMedCrossRefGoogle Scholar
  55. 55.
    Dworzack DL, Clark RB, Borkowski Jr WJ, et al. Pseudallescheria boydii brain abscess: association with near-drowning and efficacy of high-dose, prolonged miconazole therapy in patients with multiple abscesses. Medicine (Baltimore) 1989; 68: 218–24Google Scholar
  56. 56.
    Bartczak JC, Steele RW, Lopez AA, et al. A near-drowning victim with pneumonia and hemiparesis. Infect Med 2002; 19: 98–103Google Scholar
  57. 57.
    Gosbell IB, Morris ML, Gallo JH, et al. Clinical, pathologic, and epidemiologic features of infection with Scedosporium prolificans: four cases and review. Clin Microbiol Infect 1999; 5: 672–86CrossRefGoogle Scholar
  58. 58.
    Malloch D, Salkin IF. A new species of Scedosporium associated with osteomyelitis in humans. Mycotaxon 1984; 21: 247–55Google Scholar
  59. 59.
    Husain S, Munoz P, Forrest G, et al. Infections due to Scedosporium apiospermum and Scedosporium prolificans in transplant recipients: clinical characteristics and impact of antifungal therapy on outcome. Clin Infect Dis 2005; 40: 89–99PubMedCrossRefGoogle Scholar
  60. 60.
    Cimon B, Carrere J, Vinatier JF, et al. Clinical significance of Scedosporium apiospermum in patients with cystic fibrosis. Eur J Clin Microbiol Infect Dis 2000; 19: 53–6PubMedCrossRefGoogle Scholar
  61. 61.
    Lake FR, Tribe AE, McAleer R, et al. Mixed allergic bronchopulmonary fungal disease due to Pseudallescheria boydii and Aspergillus. Thorax 1990; 45: 489–91PubMedCrossRefGoogle Scholar
  62. 62.
    Meletiadis J, Meis JFGM, Mouton JW, et al. In vitro activities of new and conventional antifungal agents against clinical Scedosporium isolates. Antimicrob Agents Chemother 2002; 46: 62–8PubMedCrossRefGoogle Scholar
  63. 63.
    Gilgado F, Serena C, Cano J, et al. Antifungal susceptibilities of the species of the Pseudallescheria boydii complex. Antimicrob Agents Chemother 2006; 50: 4211–3PubMedCrossRefGoogle Scholar
  64. 64.
    Meletiadis J, Mouton JW, Meis JFGM, et al. In vitro drug interaction modeling of combinations of azoles with terbinafine against clinical Scedosporium prolificans isolates. Antimicrob Agents Chemother 2003; 47: 106–17PubMedCrossRefGoogle Scholar
  65. 65.
    Perfect JR, Marr KA, Walsh TJ, et al. Voriconazole treatment for less-common, emerging, or refractory fungal infections. Clin Infect Dis 2003; 36: 1122–31PubMedCrossRefGoogle Scholar
  66. 66.
    Raad II, Graybill JR, Bustamante AB, et al. Safety of long-term oral posaconazole use in the treatment of refractory invasive fungal infections. Clin Infect Dis 2006; 42: 1726–34PubMedCrossRefGoogle Scholar
  67. 67.
    Howden BP, Slavin MA, Schwarer AP, et al. Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine. Eur J Clin Microbiol Infect Dis 2003; 22: 111–3PubMedGoogle Scholar
  68. 68.
    Nelson PE, Dignani MC, Anaissie EJ. Taxonomy, biology, and clinical aspects of Fusarium species. Clin Microbiol Rev 1994; 7: 479–504PubMedGoogle Scholar
  69. 69.
    Lionakis MS, Kontoyiannis DP. Fusarium infections in critically ill patients. Semin Respir Crit Care Med 2004; 25: 159–69PubMedCrossRefGoogle Scholar
  70. 70.
    Boutati EI, Anaissie EJ. Fusarium, a significant emerging pathogen in patients with hematologic malignancy: ten years’ experience at a cancer center and implications for management. Blood 1997; 90: 999–1008PubMedGoogle Scholar
  71. 71.
    Nucci M, Anaissie EJ, Queiroz-Telles F, et al. Outcome predictors of 84 patients with hematologic malignancies and Fusarium infection. Cancer 2003; 98: 315–9PubMedCrossRefGoogle Scholar
  72. 72.
    Nucci M, Anaissie E. Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis 2002; 35: 909–20PubMedCrossRefGoogle Scholar
  73. 73.
    Nucci M, Marr KA, Queiroz-Telles F, et al. Fusarium infection in hematopoietic stem cell transplant recipients. Clin Infect Dis 2004; 38: 1237–42PubMedCrossRefGoogle Scholar
  74. 74.
    Patel R, Paya CV. Infections in solid organ transplant recipients. Clin Microbiol Rev 1997; 10: 86–124PubMedGoogle Scholar
  75. 75.
    Raad I, Tarrand J, Hanna H, et al. Epidemiology, molecular mycology, and environmental sources of Fusarium infection in patients with cancer. Infect Control Hosp Epidemiol 2002; 23: 532–7PubMedCrossRefGoogle Scholar
  76. 76.
    Anaissie EJ, Kuchar RT, Rex JH, et al. Fusariosis associated with pathogenic Fusarium species colonization of a hospital water system: a new paradigm for the epidemiology of opportunistic mold infections. Clin Infect Dis 2001; 33: 1871–8PubMedCrossRefGoogle Scholar
  77. 77.
    Paphitou NI, Ostrosky-Zeichner L, Paetznick VL, et al. In vitro activities of investigational triazoles against Fusarium species: effects of inoculum size and incubation time on broth microdilution susceptibility test results. Antimicrob Agents Chemother 2002; 46: 3298–300PubMedCrossRefGoogle Scholar
  78. 78.
    Arikan S, Lozano-Chiu M, Paetznick V, et al. Microdilution susceptibility testing of amphotericin B, itraconazole, and voriconazole against clinical isolates of Aspergillus and Fusarium species. J Clin Microbiol 1999; 37: 3946–51PubMedGoogle Scholar
  79. 79.
    Pfaller MA, Marco F, Messer SA, et al. In vitro activity of two echinocandin derivatives, LY303366 and MK-0991, against clinical isolates of Aspergillus, Fusarium, Rhizopus, and other filamentous fungi. Diagn Microbiol Infect Dis 1998; 30: 251–5PubMedCrossRefGoogle Scholar
  80. 80.
    Walsh TJ, Hiemenz JW, Seibel NL, et al. Amphotericin B lipid complex for invasive fungal infections: analysis of safety and efficacy in 556 cases. Clin Infect Dis 1998; 26: 1383–96PubMedCrossRefGoogle Scholar
  81. 81.
    Raad II, Hachem RY, Herbrecht R, et al. Posaconazole in the treatment of invasive fusariosis in patients with underlying hematologic malignancy and other conditions. Clin Infect Dis 2006; 42: 1398–403PubMedCrossRefGoogle Scholar
  82. 82.
    Revankar SG, Patterson JE, Sutton DA, et al. Disseminated phaeohyphomycosis: review of an emerging mycosis. Clin Infect Dis 2002; 34: 467–76PubMedCrossRefGoogle Scholar
  83. 83.
    Singh N, Chang FY, Gayowski T, et al. Infections due to dematiaceous fungi in solid organ transplant recipients: case report and review. Clin Infect Dis 1997; 24: 369–74PubMedCrossRefGoogle Scholar
  84. 84.
    Guarro J, Gams W, Pujol I, et al. Acremonium species: new emerging fungal opportunists. In vitro antifungal susceptibilities and review. Clin Infect Dis 1997; 25: 1222–9CrossRefGoogle Scholar
  85. 85.
    Orth B, Frei R, Itin PH, et al. Outbreak of invasive mycosis caused by Paecilomyce lilacinus from a contaminated skin lotion. Ann Intern Med 1996; 125: 799–806PubMedGoogle Scholar
  86. 86.
    Richter S, Cormican MG, Pfaller MA, et al. Fatal disseminated Trichoderma longibrachiatum in adult bone marrow transplant patients: species identification and review of the literature. J Clin Microbiol 1999; 37: 1154–60PubMedGoogle Scholar
  87. 87.
    Revankar SG, Sutton DA, Rinaldi MG. Primary central nervous system phaeohyphomycosis: a review of 101 cases. Clin Infect Dis 2004; 38: 206–16PubMedCrossRefGoogle Scholar
  88. 88.
    McGinnis MR, Pasarell L. In vitro testing of susceptibilities of filamentous ascomycetes to voriconazole, itraconazole, and amphotericin B, with consideration of phylogenetic implications. J Clin Microbiol 1998; 36: 2353–5PubMedGoogle Scholar
  89. 89.
    Sharkey PK, Graybill JR, Rinaldi MG, et al. Itraconazole treatment of phaeohyphomycosis. J Am Acad Dermatol 1990; 23: 577–86PubMedCrossRefGoogle Scholar
  90. 90.
    Ullmann AJ, Lipton JH, Vesole DH, et al. Posaconazole or fluconazole for prophylaxis in severe graft-versus-host disease. New Engl J Med 2007; 356: 335–47PubMedCrossRefGoogle Scholar
  91. 91.
    Comely OA, Maertens J, Winston DJ, et al. Posaconazole vs fluconazole or itraconazole for prophylaxis in patients with neutropenia. New Engl J Med 2007; 356: 348–59CrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2007

Authors and Affiliations

  1. 1.Division of Infectious DiseasesUniversity of Michigan Health System, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborUSA

Personalised recommendations