Mortality in invasive aspergillosis remains high, and triazole resistance is rising. A randomised trial of voriconazole plus anidulafungin against voriconazole alone found the combination safe and associated with a reduction in all-cause mortality that missed conventional statistical significance by a small margin. In this Personal View, the authors argue against reading that as a negative result and contend that laboratory and clinical evidence together favour a triazole-echinocandin combination in immunocompromised patients with proven or probable invasive aspergillosis.
The methodological point is legitimate and general: a p-value marginally above 0.05 in a trial powered for a large effect does not demonstrate absence of benefit, and treating the threshold as a verdict discards information. Where an opinion piece cannot substitute for evidence is in the decision itself — the same reasoning would justify almost any intervention whose trial came close, and the reader has to weigh the argument rather than the authors' conclusion.
What makes this worth reading in Indian practice is the resistance context underneath it. Azole-resistant Aspergillus is a documented and growing problem here, environmental azole use is part of the reason, and the combination question is therefore less academic than it is in settings where triazole monotherapy still reliably works. Nothing here changes a guideline. It does argue for a considered discussion in the individual immunocompromised patient rather than an automatic monotherapy default.
- This is a Personal View, not new data — weigh the argument, not the conclusion
- A p-value just above 0.05 is not evidence of no effect, but neither is it evidence of one
- Consider susceptibility testing and local azole resistance rates before committing to monotherapy
- Combination therapy adds cost and toxicity; the case is strongest in proven or probable disease in immunocompromised patients
- Environmental azole resistance is a real and rising problem in India, which sharpens the question
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