The impact of azole resistance on aspergillosis guidelines

Azole resistance in Aspergillus speciesmay be on the rise, with significant potential implications for the management of invasive aspergillosis. The main mechanism of azole resistance in Aspergillus fumigatus is via alterations of the target enzyme CYP51A. Such azole resistance is either primary or secondary (in the setting of prior azole exposure) and can be derived either from single or multiple mutations. Irrespective of the amino acid substitution type in CYP51A, azole-resistant Aspergillus isolates are always itraconazole resistant. There is significant variability among studies and centers in the prevalence of azole resistance, and this is a multifactorial issue. Nevertheless, the exact frequency of azole resistance is unknown, in part because of the low culturability of the fungus in patients with aspergillosis. This work aims to provide an overview of the current knowledge in Aspergillus azole resistance and raises questions for future research and practical implications in the management of aspergillosis.