Continuous Infusion of Amphotericin B Deoxycholate: A Cost‐Effective Gold Standard for Therapy of Invasive Fungal Infections?

Sir—The most compelling argument for replacing amphotericin B deoxycholate (AmBD) with lipid formulations of amphotericin B (LFABs), as proposed by Ostrosky-Zeisner et al. [1], is that it would lead to avoidance of AmBD-associated toxicities, among which nephrotoxicity is the most costly and is associated with the greatest morbidity. However, aggressive hydration and electrolyte correction (as noted by Ostrosky-Zeisner et al. [1] and others [2]), as well as administration via continuous infusion (which is not mentioned by Ostrosky-Zeisner et al. [1], but which has been discussed elsewhere [3, 4]), may significantly reduce the nephrotoxicity associated AmBD. These measures were not systematically used in the comparative trials that showed a reduction in nephrotoxicity with use of LFABs instead of AmBD [1]. Before the much more costly LFABs are adopted for routine use instead of AmBD, it would seem prudent to directly compare the nephrotoxicity of LFABs with that of AmBD administered in a maximally nephroprotective fashion. With respect to the various LFABs, Ostrosky-Zeisner et al. [1] advocate “more head-to-head clinical trials with standardized protocols of infusion and toxicity management...to clearly define which formulation is superior, if any” (p. 423). Perhaps AmBD should be included in such studies.