Triazoles Versus Echinocandins for the First-Line Treatment of Invasive Pulmonary Aspergillosis: A Propensity Score-Weighted Multicenter Study.

Background: Triazoles (eg, isavuconazole, posaconazole, voriconazole) are the first-line treatment for invasive pulmonary aspergillosis (IPA), but their use can be limited by drug interactions, hepatotoxicity, and emerging azole resistance. Recent guidelines recommend echinocandins as a safe and well-tolerated first-line alternative. Methods: In this multicenter observational study across 9 treatment centers, we included all consecutive patients with IPA from 1 January 2014 to 1 June 2024. We compared 30-day overall survival (OS) as the primary outcome and 90-day OS as the secondary outcome between patients receiving triazoles versus echinocandins as first-line therapy. Propensity score adjustment was applied to address baseline characteristic imbalances. Results: We included 177 patients, of whom 153 (86%) received triazoles as first-line therapy (69 voriconazole, 54 isavuconazole, 30 posaconazole). Before propensity score adjustment, patients treated with echinocandins were significantly sicker, with higher rates of intensive care treatment (95% vs 75%, Conclusions: Using echinocandins as alternative first-line treatment for IPA may result in poorer survival outcomes and should be approached with caution until further trials confirm our findings.