Audience: respiratory physicians, infectious diseases physicians, clinical microbiologists, haematologists, pharmacists, specialist nurses, laboratory scientists and researchers with an interest in aspergillosis.
Contents
Key messages
- Isavuconazole therapeutic drug monitoring may have a selective role. Although isavuconazole is usually more predictable than voriconazole, real-world pharmacokinetic variability remains clinically relevant in some patients.
- Posaconazole prophylaxis should not automatically be avoided with midostaurin. The interaction is real, but clinical consequences may often be manageable with careful monitoring.
- Surrogate azole susceptibility testing has limits. Voriconazole gradient diffusion testing may help screen for broader azole resistance, but it should not replace direct susceptibility testing where treatment decisions depend on the result.
- Invasive fungal sinusitis remains a high-mortality emergency in haematological malignancy. Early tissue diagnosis, ENT involvement and multidisciplinary management remain central.
- Non-fumigatus Aspergillus species are becoming more important research targets. New CRISPR-Cas9 tools for Aspergillus calidoustus may support future work on virulence and antifungal resistance.
Top papers this month
1. Isavuconazole pharmacokinetics and pharmacodynamics in real-world practice
Guidi M, Couchepin J, Reinhold I, Kronig I, Neofytos D, Schreiber PW, André P, Buclin T, Lamoth F.
Characterization of isavuconazole pharmacokinetics and pharmacodynamics in a real-life cohort.
JAC Antimicrobial Resistance. 2026;8(3):dlag071.
PMID: 42088097
Why this paper was selected
Isavuconazole is increasingly used for invasive aspergillosis because of its favourable safety profile and generally more predictable pharmacokinetics compared with voriconazole. This study provides important real-world evidence that clinically relevant interpatient variability still occurs and that therapeutic drug monitoring may have a role in selected patients.
Key findings
- Isavuconazole showed relatively predictable pharmacokinetics overall.
- Clinically relevant variability in drug exposure was still observed between patients.
- Therapeutic drug monitoring identified patients with atypically low or high exposure.
- Exposure relative to fungal minimum inhibitory concentration may be more informative than plasma concentration alone.
- No strong concentration-dependent toxicity signal was observed within the exposure range studied.
Clinical significance
This paper challenges the assumption that isavuconazole therapeutic drug monitoring is rarely useful. While the findings do not justify universal routine monitoring, they support selective monitoring in complex patients, particularly where there is treatment failure, suspected malabsorption, significant drug interactions, unusual body composition, long-term therapy, or infection with isolates showing elevated minimum inhibitory concentrations.
Implications for practice
Classification: Important but not yet practice changing.
The study supports a more individualised approach to isavuconazole use. It also reinforces the direction of travel in antifungal stewardship: interpreting drug exposure alongside fungal susceptibility rather than considering plasma concentrations in isolation.
Evidence assessment
Evidence quality: Moderate. The real-world dataset and pharmacokinetic-pharmacodynamic modelling strengthen the evidence base, but the observational design limits causal inference and definitive exposure targets were not established.
Editorial assessment
This is one of the most clinically relevant antifungal pharmacology papers in this update. It does not establish mandatory isavuconazole monitoring, but it provides a strong argument for selective therapeutic drug monitoring in high-risk or complex aspergillosis patients.
2. Managing posaconazole and midostaurin interactions in FLT3-mutated AML
Joisten CS, Mellinghoff SC, Seidel D, Müller C, Müller-Ohrem C, Kreuzer K-A, Frenzel LP, Simon F, Hallek M, Koehler P, Cornely OA, Stemler J.
Clinical impact of potential drug-drug interactions between midostaurin and posaconazole in FLT3-mutated AML.
Antimicrobial Agents and Chemotherapy. 2026;70(6):e01951-25.
PMID: 42118097
Why this paper was selected
Posaconazole prophylaxis is central to prevention of invasive aspergillosis in patients undergoing intensive acute myeloid leukaemia treatment. Midostaurin is metabolised through CYP3A4, and posaconazole is a potent CYP3A4 inhibitor. This study addresses a common real-world dilemma: whether this interaction should alter antifungal prophylaxis practice.
Key findings
- The pharmacokinetic interaction between posaconazole and midostaurin was confirmed.
- Clinical toxicity appeared less severe than theoretical concerns might suggest.
- Many patients were able to receive both agents without major treatment-limiting toxicity.
- Individual variability in exposure and tolerability remained important.
- The findings support continued attention to monitoring rather than automatic avoidance of posaconazole.
Clinical significance
This paper is important because it addresses an immediate bedside decision. Avoiding posaconazole because of interaction concerns may leave high-risk acute myeloid leukaemia patients vulnerable to invasive aspergillosis. The study suggests that the interaction is clinically manageable in many patients when appropriate monitoring and multidisciplinary oversight are in place.
Implications for practice
Classification: Important but not yet practice changing.
The paper supports continued use of posaconazole prophylaxis where clinically indicated, with careful monitoring for toxicity and close collaboration between haematology, infectious diseases, microbiology and pharmacy teams.
Evidence assessment
Evidence quality: Moderate. The study is clinically relevant and real-world, but observational. It does not establish definitive dose-adjustment protocols or replace existing guideline recommendations.
Editorial assessment
The key message is that proven antifungal prophylaxis should not be abandoned solely because of theoretical interaction concerns. The interaction is real, but careful monitoring is generally preferable to withholding protection against invasive aspergillosis in a very high-risk group.
3. Can voriconazole susceptibility predict isavuconazole or posaconazole susceptibility?
Vahedi-Shahandashti R, Nickel A-S, Eisele D, Lass-Flörl C; ISHAM Working Group Member of Intrinsic Antifungal Resistance.
Can voriconazole gradient diffusion testing results be extrapolated to isavuconazole and posaconazole in Aspergillus spp.? Comparative analysis with CLSI broth microdilution and cyp51A gene sequencing.
Antimicrobial Agents and Chemotherapy. 2026;70(6):e01813-25.
PMID: 42138696
Why this paper was selected
Azole resistance in Aspergillus species is a growing problem, but not all laboratories can perform comprehensive susceptibility testing for every triazole. This paper asks whether voriconazole gradient diffusion testing can be used as a practical surrogate marker for broader azole susceptibility.
Key findings
- Voriconazole susceptibility often correlated with broader azole susceptibility patterns.
- Elevated voriconazole minimum inhibitory concentrations frequently corresponded with reduced isavuconazole susceptibility.
- Prediction of posaconazole susceptibility was less reliable.
- Discordant susceptibility profiles occurred, particularly among resistant isolates.
- cyp51A sequencing helped explain many resistance patterns but did not account for all phenotypes.
Clinical significance
The study supports voriconazole gradient diffusion testing as a useful first-line screening approach, especially where full reference testing is not immediately available. However, it also highlights a critical limitation: susceptibility to one triazole cannot be assumed to guarantee susceptibility to another.
Implications for practice
Classification: Important but not yet practice changing.
Voriconazole gradient diffusion testing may help identify isolates that require further investigation, but it should not replace direct isavuconazole or posaconazole susceptibility testing where treatment decisions depend on accurate results.
Evidence assessment
Evidence quality: Moderate to high for a laboratory diagnostic study. The use of CLSI broth microdilution and cyp51A sequencing strengthens the analysis, but clinical outcome data were not assessed.
Editorial assessment
This is a practical paper for clinical mycology laboratories. The main message is that surrogate azole testing can support screening and stewardship, but definitive treatment decisions should still be based on agent-specific susceptibility testing and molecular resistance analysis where available.
4. Invasive fungal sinusitis in haematological malignancy
Athni TS, Strauch CB, Kovac V, Arbona-Haddad E, Villa IP, Gupta S, Aleissa MM, Liakos AD, Tong A, Vedula RS, Maxfield AZ, Bergmark RW, Sherman AC.
Invasive fungal sinusitis in patients with hematological malignancies: a 20-year study from a tertiary academic US hospital system.
Open Forum Infectious Diseases. 2026;13(6):ofag304.
PMID: 42238379
Why this paper was selected
Invasive fungal sinusitis is a severe but less commonly discussed manifestation of invasive mould disease. In haematological malignancy, delayed recognition can lead to orbital, intracranial and fatal complications. This 20-year cohort provides useful long-term clinical insight.
Key findings
- Aspergillus species and Mucorales were the dominant pathogens.
- Mortality remained substantial despite modern antifungal therapy and supportive care.
- Early imaging, endoscopic assessment, tissue biopsy and histopathology remained central to diagnosis.
- Successful management frequently required combined medical and surgical approaches.
- Multidisciplinary care involving haematology, infectious diseases, ENT, microbiology and radiology was essential.
Clinical significance
This study reinforces that invasive aspergillosis is not solely a pulmonary disease. Sinonasal invasive fungal disease remains an emergency in profoundly immunocompromised patients. Distinguishing aspergillosis from mucormycosis is particularly important because antifungal treatment choices differ substantially.
Implications for practice
Classification: Important but not practice changing.
The paper reinforces existing best practice: early suspicion, urgent ENT involvement, tissue diagnosis, prompt antifungal therapy and multidisciplinary management.
Evidence assessment
Evidence quality: Moderate. The long observation period and detailed clinical experience are strengths, but the retrospective single-system design limits causal conclusions.
Editorial assessment
This paper is a useful reminder that early recognition remains one of the strongest determinants of outcome in invasive fungal disease. Persistent or atypical sinus symptoms in high-risk haematology patients should prompt urgent assessment rather than routine treatment as uncomplicated bacterial sinusitis.
Important development
5. Invasive mould infections in transplant recipients
Sudhaharan S, Pamidimukkala U, Bojja S, Raju DSB, Kk R, Gopal PSS.
Invasive mold infections among transplant recipients: a single-center observational study.
Journal de Mycologie Médicale / Journal of Medical Mycology. 2026;36(2):101629.
DOI: 10.1016/j.mycmed.2026.101629
Why this paper was selected
Transplant recipients remain a key high-risk population for invasive aspergillosis and other invasive mould infections. This observational study provides contemporary real-world data on presentation, diagnosis, microbiology, treatment and outcomes in a transplant centre.
Key findings
- Aspergillus species remained the predominant mould pathogen.
- Pulmonary disease was the most common presentation.
- Diagnosis required multimodal assessment combining clinical, radiological and mycological data.
- Invasive mould infections remained associated with substantial morbidity and mortality.
- Earlier diagnosis was associated with more favourable outcomes.
Clinical significance
The study confirms rather than changes current understanding. Its main value is as a contemporary reminder that invasive aspergillosis remains a major threat in transplantation despite advances in prophylaxis, diagnostics and antifungal treatment.
Implications for practice
Classification: Important but not practice changing.
The findings support ongoing vigilance, rapid investigation pathways, early multidisciplinary input and antifungal stewardship in transplant programmes.
Evidence assessment
Evidence quality: Moderate. Real-world applicability is useful, but the single-centre observational design and modest sample size limit generalisability.
Editorial assessment
This paper does not introduce a new management strategy, but it reinforces an enduring message: invasive aspergillosis outcomes in transplant recipients remain strongly dependent on early recognition and timely treatment.
Research horizon
6. CRISPR-Cas9 gene editing in Aspergillus calidoustus
Hollomon JM, Dahlstrom KM.
CRISPR-Cas9-mediated targeted gene deletion in Aspergillus calidoustus, a non-model environmental mold.
Microbiology Spectrum. 2026;14(6):e03899-25.
PMID: 42112836
Why this paper was selected
Most molecular understanding of pathogenic Aspergillus species comes from Aspergillus fumigatus. This study establishes a CRISPR-Cas9 gene-editing system for Aspergillus calidoustus, an emerging opportunistic mould with clinical relevance and reduced susceptibility to some antifungals.
Key findings
- The authors successfully developed a CRISPR-Cas9 platform for targeted gene deletion in A. calidoustus.
- The system provides a method for functional genetic studies in a previously less tractable species.
- The platform may support future research into virulence, environmental adaptation, antifungal resistance and novel drug targets.
Clinical significance
There is no immediate clinical application. However, the study is important as enabling science. As non-fumigatus Aspergillus species are increasingly recognised in clinical practice, tools that allow their biology to be studied directly may become increasingly valuable.
Implications for practice
Classification: Early-stage research requiring further validation.
This paper does not alter clinical management, diagnostics or guidelines. Its value lies in supporting future translational research.
Editorial assessment
This is a foundational research paper. It will not change patient care today, but it may help build the scientific infrastructure needed to understand emerging mould pathogens and their resistance mechanisms over the next decade.
Clinical pearl
7. Primary traumatic cutaneous aspergillosis caused by Aspergillus terreus
Ing SK, Lee YH, Tan YY, Aziz MBA, Chang AKW.
Primary traumatic cutaneous aspergillosis of the hand caused by Aspergillus terreus following a mould-contaminated penetrating injury.
Medical Mycology Case Reports. 2026;52:100798.
PMID: 42237979
Why this case was noted
This case report describes primary traumatic cutaneous aspergillosis of the hand caused by Aspergillus terreus following a mould-contaminated penetrating injury.
Clinical take-home points
- Aspergillosis is not always acquired through inhalation.
- Direct traumatic inoculation can cause localised Aspergillus infection.
- Persistent or atypical wounds following mould-contaminated trauma should prompt consideration of fungal infection.
- Tissue sampling is essential for diagnosis.
- Species-level identification matters because Aspergillus terreus is intrinsically resistant to amphotericin B.
Editorial assessment
This is not a practice-changing paper, but it is a useful educational case. It broadens clinical awareness beyond pulmonary aspergillosis and highlights the importance of early tissue diagnosis when wounds behave unexpectedly after contaminated trauma.
Overall editorial summary
The May 2026 literature contains several papers that are useful for clinicians and laboratory professionals working in aspergillosis and invasive mould disease. The strongest clinical themes are antifungal stewardship, drug exposure, azole resistance, and the continued importance of early diagnosis in high-risk populations.
The isavuconazole pharmacokinetic-pharmacodynamic study and the midostaurin-posaconazole interaction paper are particularly relevant because they address practical treatment decisions. The azole susceptibility study is highly relevant to clinical mycology laboratories and reinforces the need for careful interpretation of surrogate resistance testing. The invasive fungal sinusitis and transplant studies reinforce a familiar but important message: outcomes remain closely linked to early recognition, tissue diagnosis where appropriate, and multidisciplinary management.
Finally, the CRISPR-Cas9 paper and traumatic cutaneous aspergillosis case illustrate the breadth of modern aspergillosis research, from molecular tools for emerging moulds to unusual clinical presentations outside the respiratory tract.
References
- Guidi M, Couchepin J, Reinhold I, Kronig I, Neofytos D, Schreiber PW, André P, Buclin T, Lamoth F. Characterization of isavuconazole pharmacokinetics and pharmacodynamics in a real-life cohort. JAC Antimicrobial Resistance. 2026;8(3):dlag071. PMID: 42088097
- Joisten CS, Mellinghoff SC, Seidel D, Müller C, Müller-Ohrem C, Kreuzer K-A, Frenzel LP, Simon F, Hallek M, Koehler P, Cornely OA, Stemler J. Clinical impact of potential drug-drug interactions between midostaurin and posaconazole in FLT3-mutated AML. Antimicrobial Agents and Chemotherapy. 2026;70(6):e01951-25. PMID: 42118097
- Vahedi-Shahandashti R, Nickel A-S, Eisele D, Lass-Flörl C; ISHAM Working Group Member of Intrinsic Antifungal Resistance. Can voriconazole gradient diffusion testing results be extrapolated to isavuconazole and posaconazole in Aspergillus spp.? Comparative analysis with CLSI broth microdilution and cyp51A gene sequencing. Antimicrobial Agents and Chemotherapy. 2026;70(6):e01813-25. PMID: 42138696
- Athni TS, Strauch CB, Kovac V, Arbona-Haddad E, Villa IP, Gupta S, Aleissa MM, Liakos AD, Tong A, Vedula RS, Maxfield AZ, Bergmark RW, Sherman AC. Invasive fungal sinusitis in patients with hematological malignancies: a 20-year study from a tertiary academic US hospital system. Open Forum Infectious Diseases. 2026;13(6):ofag304. PMID: 42238379
- Sudhaharan S, Pamidimukkala U, Bojja S, Raju DSB, Kk R, Gopal PSS. Invasive mold infections among transplant recipients: a single-center observational study. Journal de Mycologie Médicale / Journal of Medical Mycology. 2026;36(2):101629. DOI: 10.1016/j.mycmed.2026.101629
- Hollomon JM, Dahlstrom KM. CRISPR-Cas9-mediated targeted gene deletion in Aspergillus calidoustus, a non-model environmental mold. Microbiology Spectrum. 2026;14(6):e03899-25. PMID: 42112836
- Ing SK, Lee YH, Tan YY, Aziz MBA, Chang AKW. Primary traumatic cutaneous aspergillosis of the hand caused by Aspergillus terreus following a mould-contaminated penetrating injury. Medical Mycology Case Reports. 2026;52:100798. PMID: 42237979
Article information
Prepared for: aspergillosis.org professionals section
Intended audience: healthcare professionals and researchers
Article type: monthly professional literature update
Coverage period: May 2026
Last reviewed: June 2026
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