Background: Invasive aspergillosis is still associated with a high mortality. Thus far little data on combination therapy using Voriconazole and Caspofungin in surgical patients are available.

Patient and methods: Between January 2002 and December 2008, 21 surgical patients received combination therapy of Caspofungin and Voriconazole for treatment of proven invasive aspergillosis. Immunosuppressive status was found in nineteen patients due to solid organ transplantation n=16 and malignancies n=3.

Results: In 16 cases the site of infection was the lung (14 were lung transplant recipients), four patients had Aspergillus pleural empyema and one patient developed an Aspergillus liver abscess following open abdominal treatment in the course of streptococcal gangrene of the abdominal wall complicating caesarean section. Caspofungin was given for induction between 4 and 32 days, voriconazole was started intravenously and switched to oral and given up to 166 days. In four patients with Aspergillus pleural emyema following pneumonectomy for previously diagnosed pulmonary aspergillosis, surgical debridement was performed and a thoracostoma closed during a second surgical procedure in two of them. These two patients received two courses of antifungal therapy. Two lung recipients had recurrent pulmonary aspergillosis and received additional courses of treatment. Infection was cleared clinically and microbiolocically in 17 patients, in four patients aspergillosis was ongoing. Nine patients died during follow up (invasive penicillinosis 1, sepsis 1, tumor recurrence 1, PTLD 1, pneumonia 1, suicide 1 and recurrent aspergillosis 3).

Conclusion: Caspofungin/voriconazole combination therapy was found highly active in the treatment of invasive aspergillosis in this pilot study. A prospective trial is urgently needed to establish guidelines for the use of these new agents.