IDSA 2026 Clinical Practice Guideline Update on the Prevention of Invasive Aspergillosis in Adult Solid Organ Transplant Recipients

Background

Invasive aspergillosis (IA) remains a significant cause of morbidity and mortality in immunocompromised patients. The previous Infectious Disease Society of America (IDSA) Practice Guideline for the Diagnosis and Management of Aspergillosis was published in 2016 [1]. The purpose of these updated guidelines is to provide evidence-based reviews and guidance for practitioners managing adult patients at-risk for or with suspected or documented Aspergillus spp. infections. 

This first section addresses antifungal prophylaxis for IA in adult SOT recipients (liver, kidney, pancreas, lung or heart transplant). While antifungal prophylaxis against Candida and Candida-like infections is common post-transplant, these guidelines focus specifically on anti-mold prophylaxis to prevent IA. We examine several strategies including universal prophylaxis, preemptive therapy and targeted prophylaxis (see Table 1 for Definitions), as well as the antifungal agents used for prophylaxis.

Table 1. Definitions of the Different Types of Antifungal Prophylaxis in Solid Organ Transplant Recipients

Abbreviations: IA, invasive aspergillosis

Methods

The panel included adult and pediatric infectious disease specialists, pharmacology experts, and one microbiologist with expertise in patients at risk for Aspergillus infections. It included members with expertise in hematologic malignancy (HM), hematopoietic cell transplantation (HCT), and solid organ transplantation (SOT). Four expert panelists were partner representatives from the following stakeholder organizations: the American Academy of Pediatrics (AAP), American Society of Clinical Oncology (ASCO), American Society of Transplantation (AST), and the Pediatric Infectious Disease Society (PIDS). 

As per the prioritization process, clinical questions for liver and lung transplant populations were selected to be addressed using IDSA guideline methodology to formulate recommendations. For each clinical question, a systematic review was performed to identify relevant studies, and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was followed for assessing the certainty of evidence and strength of recommendation (Figure 1).

Additionally, the incidence of IA in the SOT populations not receiving anti-Aspergillus prophylaxis was addressed using a standardized approach to formulate conclusions. For each incidence of IA in a specific subpopulation, a mapping review was performed to identify relevant studies. Details of the literature review and guideline development processes are available in the Methods section and Supplementary materials for each subpopulation. 

Figure 1. Approach and Implications to Rating the Quality of Evidence and Strength of Recommendations Using GRADE Methodology (unrestricted use of figure granted by the U.S. GRADE Network)

Recommendations and Conclusions

Liver Transplant Recipients Recommendation 1

In liver transplant recipients, we suggest against using universal anti-Aspergillus prophylaxis (conditional recommendation, low certainty of evidence).

Remarks

• Universal prophylaxis is defined as the administration of prophylaxis to all liver transplant recipients.
• In the included studies, universal anti-Aspergillus prophylaxis (agents examined were anidulafungin, micafungin, itraconazole, and liposomal amphotericin B) was compared with either fluconazole or no antifungal prophylaxis.
• This recommendation places a high value on avoiding adverse events and unnecessary costs, given the lack of clear clinically significant benefits.

Liver Transplant Recipients Recommendation 2

In liver transplant recipients, we suggest targeted anti-Aspergillus prophylaxis for individuals at high risk of invasive aspergillosis (conditional recommendation, very low certainty of evidence).

Remarks

• Targeted prophylaxis refers to antifungal prophylaxis given only to patients who are at high risk for invasive aspergillosis. In the evidence reviewed, the most common risk factors for IA included: 1) renal replacement therapy in the peri-transplantation period, 2) re-transplantation, and 3) transplantation for fulminant hepatic failure.
• In the included study, voriconazole was evaluated as a prophylactic agent in both targeted and universal strategies.
• The duration of anti-Aspergillus prophylaxis in the included evidence was typically until discharge from the initial transplant hospitalization through 28 days post-transplant.
• This recommendation places a high value on balancing potential benefits while improving stewardship and reducing costs.

Liver Transplant Recipients Recommendation 3

In liver transplant recipients requiring anti-Aspergillus prophylaxis, we suggest using an echinocandin or a newer anti-mold triazole (voriconazole, posaconazole or isavuconazole) rather than amphotericin B formulations or itraconazole (conditional recommendation, very low certainty of evidence).

Remarks

• This recommendation prioritizes reducing adverse events (e.g., nephrotoxicity and hepatotoxicity), minimizing drug-drug interactions (especially with cyclosporine, tacrolimus, sirolimus and everolimus), and optimizing bioavailability.
• Among the anti-mold triazoles, the available evidence is derived primarily from studies evaluating voriconazole. To date, no peer-reviewed studies have specifically assessed posaconazole or isavuconazole for prophylaxis in liver transplant recipients. Based on indirect evidence from other transplant populations, these anti-mold triazoles (voriconazole, posaconazole and isavuconazole) are expected to provide comparable benefits.

Kidney Transplant Recipients Conclusion

Given the low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is expected to provide limited benefits and thus a less favorable balance of benefits and harms. The current available evidence does not support the use of universal IA prophylaxis in kidney transplant recipients.

Pancreas Transplant Recipients Conclusion

Given the low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is expected to provide limited benefits and thus a less favorable balance of benefits and harms. The current available evidence does not support the use of universal IA prophylaxis in pancreas transplant recipients.

Lung Transplant Recipients Recommendation 1

In lung transplant recipients, we make no recommendation for or against universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Remarks

• The panel concluded that the potential benefits of the universal as compared to no anti-Aspergillus prophylaxis remain unclear. There are critical risks of bias in existing studies, unexplored sources of heterogeneity between studies, and serious concerns regarding their lack of generalizability to current clinical practice. Further studies are needed to evaluate the effectiveness and safety of antifungal agents particularly in respect to potential harms such as serious adverse events, drug-drug interactions, costs and challenges related to antimicrobial stewardship.
• The role of antifungal prophylaxis in lung transplantation remains complex due to the lack of high-quality evidence supporting a standardized approach, leading to significant variability in practice. Please refer to the “Considerations When Implementing a Prophylactic Strategy” section.

Lung Transplant Recipients Recommendation 2

In lung transplant recipients, we make no recommendation for or against any targeted anti-Aspergillus prophylaxis or preemptive therapy rather than universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Remarks

• The panel concluded that the potential benefits of the different anti-Aspergillus prophylactic strategies (universal prophylaxis, targeted prophylaxis, and preemptive therapy) remain unclear. There are critical risks of bias in existing studies, unexplored sources of heterogeneity between studies, and serious concerns regarding their lack of generalizability to current clinical practice. Further studies are needed to evaluate the effectiveness and safety of antifungal agents in this setting, particularly in respect to potential harms such as serious adverse events, drug-drug interactions, costs and challenges related to antimicrobial stewardship.
• The role of antifungal prophylaxis in lung transplantation remains complex due to the lack of high-quality evidence supporting a standardized approach, leading to significant variability in practice. Please refer to the “Considerations When Implementing a Prophylactic Strategy” section.

Lung Transplant Recipients Recommendation 3

In lung transplant recipients in whom anti-Aspergillus prophylaxis or preemptive therapy is being considered, clinicians should select agent(s) based on the following factors: adverse events profile, drug-drug interactions, ease of administration and tolerability, associated costs and resources, availability, as well as local epidemiology (good practice statement).

Remarks

• In the absence of direct comparisons between different classes of agents in the reviewed evidence, the panel judged that an individualized approach for selecting anti-Aspergillus prophylaxis (if considered) is preferable.
• Comparison between triazoles is presented in the Table “Comparison of Characteristics, Tolerability and Cost of Anti-Mold Triazoles” and between different formulations of aerosolized amphotericin B in the Table “Comparison of Characteristics, Tolerability and Cost of Three Amphotericin B Formulations Adapted for Aerosolized Administration”. 

Heart Transplant Recipients Conclusion

Given the relatively low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is likely to offer limited benefits and a less favorable balance of benefits and harms. The current evidence does not support routine universal prophylaxis against IA in heart transplant recipients. 

Recommendation

Clinical Question

In liver transplant recipients, what is the optimal anti-Aspergillus prophylaxis strategy (universal versus targeted versus no prophylaxis)?

Recommendation 1

In liver transplant recipients, we suggest against using universal anti-Aspergillus prophylaxis (conditional recommendation, low certainty of evidence).

Remarks

• Universal prophylaxis is defined as the administration of prophylaxis to all liver transplant recipients.
• In the included studies, universal anti-Aspergillus prophylaxis (agents examined were anidulafungin, micafungin, itraconazole, and liposomal amphotericin B) was compared with either fluconazole or no antifungal prophylaxis.
• This recommendation places a high value on avoiding adverse events and unnecessary costs, given the lack of clear clinically significant benefits.

Recommendation 2

In liver transplant recipients, we suggest targeted anti-Aspergillus prophylaxis for individuals at high risk of invasive aspergillosis (conditional recommendation, very low certainty of evidence).

Remarks

• Targeted prophylaxis refers to antifungal prophylaxis given only to patients who are at high risk for invasive aspergillosis. In the evidence reviewed, the most common risk factors for IA included: 1) renal replacement therapy in the peri-transplantation period, 2) re-transplantation, and 3) transplantation for fulminant hepatic failure.
• In the included study, voriconazole was evaluated as a prophylactic agent in both targeted and universal strategies.
• The duration of anti-Aspergillus prophylaxis in the included evidence was typically until discharge from the initial transplant hospitalization through 28 days post-transplant.
• This recommendation places a high value on balancing potential benefits while improving stewardship and reducing costs.

Clinical Question

In liver transplant recipients for whom anti-Aspergillus prophylaxis is indicated, what is the optimal choice of agent(s)?

Recommendation 

In liver transplant recipients requiring anti-Aspergillus prophylaxis, we suggest using an echinocandin or a newer anti-mold triazole (voriconazole, posaconazole or isavuconazole) rather than amphotericin B formulations or itraconazole (conditional recommendation, very low certainty of evidence).

Remarks

• This recommendation prioritizes reducing adverse events (e.g., nephrotoxicity and hepatotoxicity), minimizing drug-drug interactions (especially with cyclosporine, tacrolimus, sirolimus and everolimus), and optimizing bioavailability.
• Among the anti-mold triazoles, the available evidence is derived primarily from studies evaluating voriconazole. To date, no peer-reviewed studies have specifically assessed posaconazole or isavuconazole for prophylaxis in liver transplant recipients. Based on indirect evidence from other transplant populations, these anti-mold triazoles (voriconazole, posaconazole and isavuconazole) are expected to provide comparable benefits.

Results

Recommendation 1

In liver transplant recipients, we suggest against using universal anti-Aspergillus prophylaxis (conditional recommendation, low certainty of evidence). 

Universal anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified six randomized, controlled trials (RCTs) comparing the use of universal anti-Aspergillus prophylaxis (either anidulafungin, micafungin, itraconazole, or liposomal amphotericin B) with not using anti-Aspergillus prophylaxis (fluconazole or no antifungal prophylaxis) [7-12]. Additionally, to better understand the true burden of IA in liver transplant recipients, a mapping review across 40 observational studies published from 2000 to 2025 was performed to determine the incidence of IA in liver transplant recipients not receiving anti-Aspergillus prophylaxis [8, 11, 12, 15-52]. 

Table 2. Summary of Findings: Universal Anti-Aspergillus Prophylaxis Versus No Anti-Aspergillus Prophylaxis in Liver Transplant Recipients

Recommendation 2

In liver transplant recipients, we suggest targeted anti-Aspergillus prophylaxis for individuals at high risk of invasive aspergillosis (conditional recommendation, very low certainty of evidence). 

Targeted anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis in individuals at high risk of invasive aspergillosis 

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified three non-randomized studies comparing the use of targeted anti-Aspergillus prophylaxis (either caspofungin, liposomal amphotericin B, and amphotericin B lipid complex) to not using anti-Aspergillus prophylaxis (no antifungal prophylaxis) in individuals at high risk of IA [19, 28, 49].

Table 3. Summary of Findings: Targeted Anti-Aspergillus Prophylaxis Versus No Anti-Aspergillus Prophylaxis in Liver Transplant Recipients

Targeted anti-aspergillus prophylaxis in individuals at high risk of invasive aspergillosis versus Universal anti-aspergillus prophylaxis

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified a single non-randomized retrospective study that directly compared targeted anti-Aspergillus prophylaxis with universal prophylaxis, in which both groups received voriconazole [23].

Table 4. Summary of Findings: Targeted Anti-Aspergillus Prophylaxis Versus Universal Anti-Aspergillus Prophylaxis in Liver Transplant Recipients

Recommendation

In liver transplant recipients requiring anti-Aspergillus prophylaxis, we suggest using an echinocandin or a newer anti-mold triazole (voriconazole, posaconazole or isavuconazole) rather than amphotericin B formulations or itraconazole (conditional recommendation, very low certainty of evidence). 

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified two network meta-analysis reporting on the efficacy of universal antifungal prophylaxis for the prevention of invasive fungal infections (IFIs) [57, 58], although neither assessed differences in safety among antifungal agents. No RCTs comparing different antifungal agents used for targeted prophylaxis were identified. Our systematic review identified two non-randomized studies reporting on the use of either echinocandins or amphotericin B formulations as targeted prophylaxis in liver transplant recipients considered at high risk of IFIs [44, 59].

Rationale for Recommendations

Recommendation 1

In liver transplant recipients, we suggest against using universal anti-Aspergillus prophylaxis (conditional recommendation, low certainty of evidence).

Universal anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis

Rationale for Recommendation

The use of universal anti-Aspergillus prophylaxis in liver transplant recipients results in comparable desirable and undesirable outcomes to those observed without anti-Aspergillus prophylaxis. The panel agreed that the overall certainty of the evidence for using universal anti-Aspergillus prophylaxis in liver transplant recipients is low. Concerns include potential risks of bias and imprecision due to the low number of reported events. In the absence of demonstrable clinical benefits, the panel concluded that additional harms or drug interactions, together with resource use and cost, weigh against the use of universal anti-Aspergillus prophylaxis in liver transplant recipients. The guideline panel suggested against the use of universal anti-Aspergillus prophylaxis for liver transplant recipients following transplantation.

Recommendation 2

In liver transplant recipients, we suggest targeted anti-Aspergillus prophylaxis for individuals at high risk of invasive aspergillosis (conditional recommendation, very low certainty of evidence).

Targeted anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis in individuals at high risk of invasive aspergillosis 

Rationale for Recommendation

When targeted prophylaxis was compared with no prophylaxis, the panel judged that the balance of benefits and harms favored targeted anti-Aspergillus prophylaxis in liver transplant recipients. Specifically, targeted prophylaxis is anticipated to provide a moderate reduction in IA incidence and IA attributable mortality, without evidence of excess harm compared to no prophylaxis although potential harms may vary depending on the antifungal class used. The panel agreed that the overall certainty of the evidence was very low due to risk of bias and imprecision related to small sample size and number of events. 

The panel acknowledges that targeted anti-Aspergillus would increase direct costs related to drug acquisition, administration, and laboratory monitoring. Although cost-effectiveness could not be determined, the panel judged that the use of targeted anti-Aspergillus prophylaxis was acceptable for stakeholders. The panel assumed that patients would generally value an intervention that offers a favorable balance of benefits and harms. Because prophylaxis is usually provided in the inpatient setting for a limited duration, inequities are unlikely to be significant. 

The guideline panel suggested using targeted anti-Aspergillus prophylaxis for liver transplant recipients considered at high risk of IA following transplantation (renal replacement therapy [RRT] in the peri-transplantation period, re-transplantation, or transplantation for fulminant hepatic failure), rather than no anti-Aspergillus prophylaxis. 

Targeted anti-aspergillus prophylaxis in individuals at high risk of invasive aspergillosis versus universal anti-aspergillus prophylaxis

Rationale for Recommendation

The panel judged that the balance of benefits and harms does not clearly favor either strategy. Specifically, the evidence showed that targeted prophylaxis was anticipated to provide trivial undesirable effects (small to no increase in IA and attributable mortality) with trivial desirable effects (small to no reduction in adverse events [AEs]) as compared to universal prophylaxis. The panel agreed that the certainty in the evidence was very low due to the risk of bias associated with the study design as well as the imprecision.

The panel judged that restricting anti-Aspergillus prophylaxis to a targeted group of individuals was acceptable to stakeholders, largely because of stewardship benefits. The panel acknowledged that restricting anti-Aspergillus prophylaxis to target individuals at high risk of invasive disease would reduce drug-drug interactions, toxicities, and selective pressure for resistance, while also lowering direct drug acquisition and monitoring costs. Cost-effectiveness was not formally evaluated, but targeted prophylaxis was expected to be more resource-efficient than universal use. Patients are likely to value avoiding unnecessary antifungal exposure while still receiving protection when the risk is elevated. Restricting prophylaxis to high-risk groups was not expected to introduce inequity, as all patients meeting defined criteria would remain eligible. The panel also recognized that some centers may have local protocols for yeast prophylaxis that overlap with anti-Aspergillus prophylaxis, suggesting that the latter may not always represent a major incremental cost or use of additional resources. Overall, the panel assumed that most patients would support this targeted approach, though some variability in how stewardship considerations would be valued may exist.

The guideline panel suggested using targeted anti-Aspergillus prophylaxis in liver transplant recipients at high risk of IA following transplantation (RRT in the peri-transplantation period, re-transplantation, or transplantation for fulminant hepatic failure), rather than universal prophylaxis in all liver transplant recipients.

Recommendation 

In liver transplant recipients requiring anti-Aspergillus prophylaxis, we suggest using an echinocandin or a newer anti-mold triazole (voriconazole, posaconazole or isavuconazole) rather than amphotericin B formulations or itraconazole (conditional recommendation, very low certainty of evidence).

Rationale for Recommendation

When comparing anti-Aspergillus prophylaxis options in liver transplant recipients, the panel judged that the balance of benefits and harms generally favored echinocandins and the newer anti-mold triazoles (voriconazole, posaconazole and isavuconazole), primarily due to their more favorable side effect profile as compared to amphotericin B formulations (infusion-related reaction and nephrotoxicity) and itraconazole (gastrointestinal side effects and variable absorption). However, direct evidence in liver transplant recipients remains limited. To date, posaconazole has not been formally studied for prophylaxis in this population. Although isavuconazole use has been reported in a study that included liver transplant recipients, data specific to its effectiveness for prophylaxis have not yet been published. As a result, recommendations regarding posaconazole and isavuconazole are extrapolated from trial data in other transplant populations. Overall, the certainty in the evidence remains very low due to the paucity of head-to-head comparative studies and the small sample size of available cohort studies.

The panel judged that either voriconazole, posaconazole, isavuconazole or echinocandins are preferred for antifungal prophylaxis. Itraconazole is limited by unreliable absorption and significant drug-drug interactions. Voriconazole and posaconazole also have notable interactions, requiring careful monitoring. Amphotericin B formulations have limited tolerability at optimal dosing, are only available intravenously, and carry increased costs. Stewardship considerations may influence agent selection and differ across antifungal classes.
The guideline panel suggested using an echinocandin or a newer anti-mold triazole (voriconazole, posaconazole or isavuconazole) rather than amphotericin B formulations or itraconazole for targeted anti-Aspergillus prophylaxis for liver transplant recipients at high risk of IA in the post-transplantation period.

Recommendation

Clinical Question

In kidney transplant recipients, what is the baseline risk of invasive aspergillosis in patients not receiving anti-Aspergillus prophylaxis and which factors increase this risk of IA?

Conclusion

Given the low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is expected to provide limited benefits and thus a less favorable balance of benefits and harms. The current available evidence does not support the use of universal IA prophylaxis in kidney transplant recipients.

Results

Summary of Evidence

To understand the true burden of IA in kidney transplant recipients, a mapping review of the literature published from 2000 to 2025 was performed to determine the incidence of IA in kidney transplant recipients not receiving anti-Aspergillus prophylaxis [30, 34, 78-109]. Among 35,240 kidney transplant recipients from the 34 included observational studies, the pooled incidence of IA was 0.8% (95% CI 0.6 to 1.2%). The one-year all-cause mortality among 124 cases with available survival data was 45%. Two large United States database registry studies that used billing codes to detect cases of IA included a total of 90,608 patients [114, 115] and the pooled incidence for IA 0.4% (95% CI: 0.2% to 0.6%). Factors associated with increased IA risk included low volume transplant centers, older age, preceding bacterial pneumonia, Candida colonization (which may be a surrogate marker for severe immunosuppression), diabetes, chronic lung or heart disease, and leukopenia [80, 115]. Other factors that may increase risk include delayed graft function, acute rejection, and RRT [86, 89].

Recommendation

Clinical Question

In pancreas transplant recipients, what is the baseline risk of invasive aspergillosis in patients not receiving anti-Aspergillus prophylaxis and which factors increase this risk of IA?

Conlcusion

Given the low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is expected to provide limited benefits and thus a less favorable balance of benefits and harms. The current available evidence does not support the use of universal IA prophylaxis in pancreas transplant recipients.

Results

Summary of Evidence

To understand the true burden of IA in pancreas transplant recipients, a mapping review of the literature published from 2000 to 2025 was performed to determine the incidence of IA in patients who did not receive anti-Aspergillus prophylaxis. Among 1,234 pancreas transplant recipients from 11 included observational studies [26, 87, 119-127], the pooled incidence of IA was 0.8% (95% CI 0.3% to 1.7%). The one-year all-cause mortality was 70%, although only three deaths were clearly attributable to IA. Although some reports suggest a higher incidence of IA among patients receiving lymphocyte-depleting agents such as alemtuzumab, available data are insufficient to confirm this association [120, 123, 125].

Recommendation

Clinical Question

In lung transplant recipients, what is the optimal anti-Aspergillus prophylaxis strategy (universal prophylaxis, targeted prophylaxis, or preemptive therapy)?

Recommendation 1

In lung transplant recipients, we make no recommendation for or against universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Remarks

• The panel concluded that the potential benefits of the universal as compared to no anti-Aspergillus prophylaxis remain unclear. There are critical risks of bias in existing studies, unexplored sources of heterogeneity between studies, and serious concerns regarding their lack of generalizability to current clinical practice. Further studies are needed to evaluate the effectiveness and safety of antifungal agents particularly in respect to potential harms such as serious adverse events, drug-drug interactions, costs and challenges related to antimicrobial stewardship.
• The role of antifungal prophylaxis in lung transplantation remains complex due to the lack of high-quality evidence supporting a standardized approach, leading to significant variability in practice. Please refer to the “Considerations When Implementing a Prophylactic Strategy” section.

Recommendation 2

In lung transplant recipients, we make no recommendation for or against any targeted anti-Aspergillus prophylaxis or preemptive therapy rather than universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Remarks

• The panel concluded that the potential benefits of the different anti-Aspergillus prophylactic strategies (universal prophylaxis, targeted prophylaxis, and preemptive therapy) remain unclear. There are critical risks of bias in existing studies, unexplored sources of heterogeneity between studies, and serious concerns regarding their lack of generalizability to current clinical practice. Further studies are needed to evaluate the effectiveness and safety of antifungal agents in this setting, particularly in respect to potential harms such as serious adverse events, drug-drug interactions, costs and challenges related to antimicrobial stewardship.
• The role of antifungal prophylaxis in lung transplantation remains complex due to the lack of high-quality evidence supporting a standardized approach, leading to significant variability in practice. Please refer to the “Considerations When Implementing a Prophylactic Strategy” section.

Clinical Question

In lung transplant recipients in whom anti-Aspergillus prophylaxis or preemptive therapy is considered, is there an optimal choice of antifungal agent(s)?

Recommendation 

In lung transplant recipients in whom anti-Aspergillus prophylaxis or preemptive therapy is being considered, clinicians should select agent(s) based on the following factors: adverse events profile, drug-drug interactions, ease of administration and tolerability, associated costs and resources, availability, as well as local epidemiology (good practice statement).

Remarks

• In the absence of direct comparisons between different classes of agents in the reviewed evidence, the panel judged that an individualized approach for selecting anti-Aspergillus prophylaxis (if considered) is preferable.
• Comparison between triazoles is presented in the Table “Comparison of Characteristics, Tolerability and Cost of Anti-Mold Triazoles” and between different formulations of aerosolized amphotericin B in the Table “Comparison of Characteristics, Tolerability and Cost of Three Amphotericin B Formulations Adapted for Aerosolized Administration”. 

Results

Recommendation 1

In lung transplant recipients, we make no recommendation for or against universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Universal anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified four observational studies [15-18] comparing universal anti-Aspergillus prophylaxis (utilizing either voriconazole or aerosolized amphotericin B with or without itraconazole) to the absence of anti-Aspergillus prophylaxis. Additionally, to better understand the true burden of IA in lung transplant recipients, a mapping review across 6 observational studies published from 2000 to 2025 was performed to determine the incidence of IA in lung transplant recipients not receiving anti-Aspergillus prophylaxis. [15-17, 21-23]

Table 5. Summary of Findings: Universal Anti-Aspergillus prophylaxis Versus No Anti-Aspergillus Prophylaxis in Lung Transplant Recipients

Limitations

The overall risk of bias of the identified evidence was judged to be critical, which precludes drawing meaningful conclusions. All three studies were single-center retrospective “before-and-after” cohort studies, a design inherently prone to biases. The inclusion of patients from older studies may compromise the validity of the conclusions, as evolving clinical practice, patient demographics, and healthcare standards could affect the findings’ generalizability to current clinical settings. Small sample sizes (55 to 274 patients) were prone to residual confounding and selection bias, undermining reliability. Moreover, the absence of critical baseline characteristics, such as Aspergillus colonization at transplant and use of anti-lymphocyte therapies, maintenance immunosuppressive regimens precluded meaningful comparisons. Similarly, Tofte 2012 noted significant mortality changes across two time periods, likely driven by shifts in clinical practices or inclusion of higher-risk patients rather than prophylaxis effects [15]. Additional limitations included the absence of surveillance bronchoscopies in two studies [16, 17], lack of therapeutic drug monitoring (TDM) for azoles in one study [15], and incomplete reporting on AE and adherence to the intended prophylaxis. Finally, the very high incidence of IA (>17%) in all four studies raises further concerns about their generalizability to current practice.

Our review revealed significant heterogeneity among the studies, but the small number of studies limited exploration of its sources. Potential contributors include differences in eras (patients enrolled in the 1990s vs later), population IA risk profiles, surveillance protocols (routine surveillance bronchoscopies and newer diagnostic tools), standards of care, prophylaxis types (agents, dosage, route of administration, and duration), or durations of follow-up. Without addressing these factors, the panel could not draw meaningful conclusions about the impact of antifungal prophylactic strategies on IA incidence. Consequently, the panel was unable to draw meaningful or definitive conclusions regarding the impact of antifungal prophylaxis on IA incidence.

Given the critical risk of bias, limited generalizability to current clinical practice, and unresolved sources of heterogeneity between studies, the panel concluded that the potential benefits of universal prophylaxis as compared to no anti-Aspergillus prophylaxis in lung transplant recipients remain uncertain.

Recommendation 2

In lung transplant recipients, we make no recommendation for or against any targeted anti-Aspergillus prophylaxis or preemptive therapy rather than universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Universal anti-Aspergillus prophylaxis versus targeted anti-Aspergillus prophylaxis or pre-emptive therapy

Summary of Evidence

Our systematic review of the literature (spanning from 2000-2025) identified three observational studies reported across four publications [25, 28, 46, 47] that compared universal anti-Aspergillus prophylaxis with targeted anti-Aspergillus prophylaxis or preemptive therapy.

Table 6. Summary of Findings: Universal Anti-Aspergillus Prophylaxis Versus Targeted Anti-Aspergillus Prophylaxis or Preemptive Therapy in Lung Transplant Recipients

Limitations

The overall risk of bias of the identified evidence was judged to be critical, severely limiting the ability to draw meaningful conclusions. All three studies were single-center retrospective “before-and-after” cohort studies, each enrolling a relatively small number of participants. The most important methodological limitation across these studies was the simultaneous alterations of multiple variables, including the antifungal prophylactic strategy, the agent used, and the duration of prophylaxis. These concurrent changes precluded valid comparisons and attribution of outcomes to any one intervention component.

Additional limitations included: 1) the incomplete reporting on AE and adherence to the intended prophylaxis in two studies [25, 28] and significant non-adherence and interruption of prophylaxis in the universal prophylaxis group in Crone 2023 study [46, 47], 2) serious concerns about dose of itraconazole used in Linder 2021 study [25], 3) the lack of TDM for azoles in the three studies, and 4) missing data on pertinent baseline clinical characteristics in two studies [25, 28], precluded any meaningful comparison between the before-and-after periods.

Our review of the literature highlighted the large heterogeneity between the different studies identified. Sources of heterogeneity could not be explored due to the small number of studies identified, but may have been caused by a multitude of factors such as difference in eras (patients enrolled in the 2000s vs 2020s), included populations, baseline risk of IA, surveillance protocols (timing of surveillance newer diagnostic tools), standards of care, types of prophylaxis use (class of agents, dosage, route of administration, and duration), or durations of follow-up. Without further exploration of the potential sources of heterogeneity, the panel could not come to a meaningful conclusion on the potential effect of any type of antifungal prophylactic strategies on the incidence of IA.

Due to critical risk of bias of the studies identified and unexplorable sources of heterogeneity between studies, the panel concluded that no reliable inferences could be made regarding the relative effectiveness of the different prophylactic strategies and thus the potential benefits and harms of the different prophylactic strategies (universal or targeted prophylaxis) and preemptive therapy remain unknown.

Considerations When Implementing a Prophylactic Strategy

The role of antifungal prophylaxis in lung transplantation remains complex due to the lack of high-quality evidence supporting a standardized approach, leading to significant variability in practice. Four main approaches—universal prophylaxis, targeted prophylaxis, preemptive therapy, and no prophylaxis and no preemptive therapy—are commonly employed, each with distinct advantages and limitations (See Table 7). Transplant centers must carefully balance clinical efficacy, toxicity, drug interactions, cost, and feasibility to determine the most practical prophylaxis strategy for use in their own center.

Table 7. Comparative Antifungal Prophylaxis Strategies in Lung Transplantation

While Table 7 highlights the advantages and limitations of various antifungal prophylaxis strategies, it is important to emphasize that antifungal prophylaxis is not a one-size-fits-all approach. Instead, the choice should be tailored to transplant institutional factors, including local epidemiology, patient characteristics, immunosuppression protocols, diagnostic capabilities and available resources (See Table 8).

Table 8. Summary Table for Selecting Antifungal Prophylaxis Strategies

By carefully weighing these factors, transplant centers can design antifungal prophylaxis protocols that optimize patient outcomes while adapting to local conditions. If a prophylactic strategy is selected, continuous monitoring with regular assessment of IA rates, mortality, drug tolerability, and resistance patterns is essential. Stable IA infection rates and minimal toxicities support maintaining the current strategy. However, increases in breakthrough IA, toxicity, or resistance warrants a strategic evaluation and adjustment. 

Rationale for Recommendations

Recommendation 1

In lung transplant recipients, we make no recommendation for or against universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Universal anti-Aspergillus prophylaxis versus no anti-Aspergillus prophylaxis

Rationale for Recommendation

When comparing the different anti-Aspergillus prophylaxis strategies in lung transplant recipients, the panel judges that the balance of benefits and harms remains unknown. More specifically, potential benefits were not fully evaluable due to critical risk of bias (multiple study limitations), serious inconsistency (i.e. heterogeneity between studies), and indirectness (lack of generalizability).

Furthermore, potential harms are very heterogenous and agent-specific: 1) specific safety profile (toxicities, such as hepatotoxicity, bronchospasm), 2) specific drug interactions with immunosuppressive agents, 3) mode of administration, 4) availability of TDM, 5) total duration of prophylaxis (duration of immediate post-transplantation to life), 6) costs of agents and resources needed for administration, as well as 7) stewardship considerations. See the section on choice of agent(s) for more information.

The guideline panel makes no recommendation for or against anti-Aspergillus prophylactic strategies or for or against any specific anti-Aspergillus preemptive treatment strategies for lung transplant recipients in the post-transplantation period.

Recommendation 2

In lung transplant recipients, we make no recommendation for or against any targeted anti-Aspergillus prophylaxis or preemptive therapy rather than universal anti-Aspergillus prophylaxis (no recommendation, knowledge gap).

Universal anti-Aspergillus prophylaxis versus targeted anti-Aspergillus prophylaxis or pre-emptive therapy

Rationale for Recommendation

When comparing the different anti-Aspergillus prophylaxis strategies in lung transplant recipients, the panel judges that the balance of benefits and harms remains unknown. More specifically, potential benefits were not fully evaluable due to critical risk of bias (multiple study limitations), serious inconsistency (i.e. heterogeneity between studies), and indirectness (lack of generalizability).

Furthermore, potential harms are very heterogenous and agent-specific: 1) specific safety profile (toxicities, such as hepatotoxicity, bronchospasm), 2) specific drug interactions with immunosuppressive agents, 3) mode of administration, 4) availability of TDM, 5) total duration of prophylaxis (duration of immediate post-transplantation to life), 6) costs of agents and resources needed for administration, as well as 7) stewardship considerations. See the section on choice of agent(s) for more information.

The guideline panel makes no recommendation for or against anti-Aspergillus prophylactic strategies or for or against any specific anti-Aspergillus preemptive treatment strategies for lung transplant recipients in the post-transplantation period.

Recommendation

Clinical Question

In heart transplant recipients, what is the baseline risk of invasive aspergillosis in patients not receiving anti-Aspergillus prophylaxis and which factors increase this risk of IA?

Conclusion

Given the relatively low pooled incidence of IA, the use of universal anti-Aspergillus prophylaxis is likely to offer limited benefits and a less favorable balance of benefits and harms. The current evidence does not support routine universal prophylaxis against IA in heart transplant recipients. 

Results

Summary of the Evidence

To understand the true burden of IA in heart transplant recipients, a mapping review of the literature published from 2000 to 2025 was performed to estimate the incidence of IA among patients who did not receive anti-Aspergillus prophylaxis. Among 6,005 heart transplant recipients from the 16 included studies [27, 79-93], the pooled incidence of IA was approximately 3.8% (95% CI 2.5 to 5.7%). Across the included studies, a range of patient-, procedure-, and environment-related factors were associated with the development of IA. The most consistently reported and reproducible risk factors were post-operative RRT, reoperation or redo thoracic surgery, cytomegalovirus infection, and augmented immunosuppression for treatment of rejection [83, 89, 92]. Additional factors reported in individual cohorts included prolonged mechanical ventilation or intubation, extracorporeal membrane oxygenation, hypoalbuminemia, multiple pre-transplant hospitalizations, prior Aspergillus colonization, and environmental or programmatic exposures such as hospital construction, ventilation system failures, or clustering of cases.

References and Notes

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List of Abbreviations

AEs: Adverse events
AAP: The American Academy of Pediatrics
ABLC: Amphotericin B lipid complex
AC: Acquisition cost
AFT: Antifungal therapy
AmB: Amphotericin B
aOR: Adjusted odds ratio
aRR: Adjusted risk ratio
ASCO: The American Society of Clinical Oncology
AST: The American Society of Transplantation
AWP: Average wholesale prices
BD: Twice a day
CAR: Chimeric antigen receptor
CI: Confidence interval
CMV: Cytomegalovirus 
CNI: Calcineurin inhibitor
COE: Certainty of evidence 
COI: Conflict of interest
CRRT: Continuous renal replacement therapy
d-AmB: Amphotericin B deoxycholate 
EORTC/MSG: The European Organization for Research and Treatment of Cancer/Mycoses Study Group 
GGT: Gamma-glutamyl transpeptidase enzyme
GI: Gastrointestinal system
GLMM: Generalized linear mixed-effects model
GRADE: Grading of Recommendations Assessment, Development and Evaluation
HCT: Hematopoietic cell transplant 
HM: Hematologic malignancy
IA: Invasive aspergillosis
IC: Invasive candidiasis
ICD-9: The International Classification of Diseases, Ninth Revision
ICU: Intensive care unit 
IDSA: The Infectious Disease Society of America 
IFIs: Invasive fungal infections
IMIs: Invasive mold infections
IPA: Invasive pulmonary aspergillosis 
IQR: Interquartile range 
ISHLT: The International Society for Heart and Lung Transplantation 
IV: Intravenous route 
KP: Kidney pancreas transplant 
L-AmB: Liposomal amphotericin B
MID: Minimal important difference 
mITT: Modified intent-to-treat
NR: Not reported
OLT: orthotopic liver transplant
OR: Odds ratio
PAK: Pancreas after kidney transplant
PCR: Polymerase chain reaction
PICO: Patient/Population; Intervention/Indicator; Comparator/Control; Outcome
PO: Oral route 
PP: Per protocol
PRISMA: Preferred reporting items for systematic reviews and meta-analyses
PSID: The Pediatric Infectious Disease Society
PTA: Pancreas transplant alone 
RCT: Randomized clinical trials or randomized controlled trials 
RD: Risk difference 
RF: Risk factor
RR: Relative risk 
RRT: Renal replacement therapy
QTc: QT interval corrected 
SEA: Serious adverse events 
SARS-CoV2: severe acute respiratory syndrome coronavirus 2
SOT: Solid organ transplant 
SPGS: The Standards and Practice Guideline Subcommittee
SPK: Simultaneous pancreas kidney transplant
TDA: Three times a day
TDM: Therapeutic drug monitoring 

Acknowledgments

First, the panel would like to acknowledge the previous panel for their work on the previous iteration of this larger guideline. The panel would like to acknowledge the important contributions of Mary Beth McAteer (librarian supporting systematic and mapping reviews), Loretta Dzanya (IDSA staff assisting with logistics and editorial coordination) and Malavika Tampi (previous IDSA methodologist helping with the development of clinical questions). The panel would also like to acknowledge the following organizations and selected external reviewers for their review of the draft manuscripts: The American Academy of Pediatrics (AAP), The American Society of Clinical Oncology (ASCO), The American Society of Transplantation (AST), The Pediatrics Infectious Diseases Society (PIDS), Drs. Emily Blumberg, Jennifer Saullo, Lianne Singer, Peter Pappas, Shmuel Shoham, and Surabhi (Sara) Vora.

Dr. Mindy G. Schuster is the Chair of the Aspergillosis Guideline Panel, and Dr. C. Orla Morrissey is the Vice Chair of the panel. Drs. Jo-Anne H, M. Hong Nguyen, Nitipong Permpalung, and Shahid M. Husain for their leading role in the development of Adult Solid Organ Transplant Recipients section of the Clinical Practice Guidelines on Prevention of Invasive Aspergillosis. The remaining panelists contributed to the conception and design of the analysis, interpretation of the data, drafting and revision of the recommendations and manuscript, and final approval of the published recommendations and manuscript. Dr. Valéry Lavergne, IDSA clinical practice guidelines senior methodologist, was responsible for overall project management, designing and conducting the systematic review, and leading the panel in accordance with the GRADE process, developing the manuscript and curating the supplementary material.

Conflicts of Disclosure

Possible conflicts of interest. Evaluation of relationships as potential conflicts of interest is determined by a review process. The assessment of disclosed relationships for possible COIs is based on the relative weight of the financial relationship (i.e., monetary amount) and the relevance of the relationship (i.e., the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration).  

The following panelists have reported relationships unrelated to the topic of fungal infections/antifungal therapies since 2021–2025, when the guideline work began, with the indicated companies. S.H. received educational grants and served in advisory roles with Takeda, Xedition, Kamada, Knight Therapeutic, Sanofi, and GSK for unrelated topics; served in editorial roles with the Journal of Heart and Lung Transplantation and Transplant Infectious Diseases. N.P. served in past advisory/consulting roles with ClearView and Alcimed (unrelated); held editorial roles with Medical Mycology and the Journal of Heart and Lung Transplantation Open. M.H.N. received research grants from bioMérieux (target NGS for fungal diagnosis direct from samples) and Melinta (Rezafungin clinical trial). J.H.Y. received research funding for subject enrollment on clinical trials from AlloVir (adoptive T cells) and Ansun (DAS-181 for viral infections); served as Editor-in-Chief for Clinical Microbiology Reviews; serves as an Associate Editor for Transplantation and Cellular Therapy; receives research funding for subject enrollment on clinical trials from AiCuris (HSV infection), GSK (RSV vaccination), Lumen (C diff infection), Pulmotect (respiratory viral infections), SNIPR (phage therapy), Shire/Takeda (CMV infection), and Vedanta (C diff infection). M.S. received funding from the Public Health Agency of Canada for initiatives related to antimicrobial stewardship. D.R.A. served in advisory roles for Roche, Basilea, Cidara, Astellas, Mundipharma, F2G, Amplyx, and Elion; owned stock in Symbiotica; served on the editorial board for Clinical Infectious Diseases/Journal of Infectious Diseases (CID/JID) as editor for Antimicrobial Agents and Chemotherapy (AAC), Journal of Infectious Diseases, mBio, and PLoS Pathogens; served as a member for the Clinical and Laboratory Standards Institute (CLSI). M.I.A. served as a consultant for Karius (application of Karius for fungal diagnostics in immunocompromised children); Miravista (evaluating fungal diagnostics in children with research support paid to institution); received travel reimbursement from St. Jude Children’s Research Hospital (participation in infectious disease research conferences); serves as an editorial board member for Transplant Infectious Disease and the Journal of the Pediatric Infectious Diseases Society; serves on the American Academy of Pediatrics (AAP) Committee on Infectious Diseases). E.J.B. served in advisory roles for Avir Pharma and GSK; participates as a guidelines panel member for the American Society of Clinical Oncology and Infectious Diseases Society of America (neutropenic fevers); received honoraria as Section Editor, Up-to-Date. P.H.C. participated in a speakers bureau for Astellas (isavuconazole); received research funding from Aicuris (recruited patients for HSV Pritelevir study); received other remuneration from Pfizer (data review on Aztreonam-Avibactam study); served as president at Michigan State Infectious Diseases Society; serves as editor at the British Journal of Antimicrobial Agents and Chemotherapy. S.C-A.C. received organizational benefits from MSD Australia (untied educational grants); served as Pathology editor for the Journal of Clinical Microbiology, editor for Microbiology, editor-in-chief for Medical Mycology, and as a board member for the Mycoses Study Group Education and Research Consortium (MSGERC). S.P.H. served in past advisory and consulting roles with Pfizer (advisory roles regarding infections associated with BCMA bispecific antibodies and myeloma therapies), Roche (advisory board regarding infectious complications of therapies for multiple myeloma), Treeline Biosciences (consulting regarding infectious complications of novel targets therapies for lymphoma) and Seres Therapeutics (consulting regarding infectious complications of leukemia therapy and use of live spore products in hematologic malignancy patients)  ;   received research funding from GlaxoSmithKline (GSK) for a study of sotrovimab prophylaxis against COVID-19 infection in immunocompromised individuals; serves in an advisory role (scientific) with Takeda (infection adjudication committee for a clinical trial). S.A.K. reported family relationships (spouse consulting roles or employment) with Boston Scientific, Janssen, Novartis, Myovant, Blue Earth Diagnostics, MDx Health, AIQ, Reversal Therapeutics, Stratagen Bio, and Nanocan; received research funding from GlaxoSmithKline (GSK); serves in an advisory role with Vertex Pharmaceuticals (member of a safety adjudication committee for a clinical trial; unrelated). G.R.T. served in advisory as a consultant for Cidara (clinical trial design). M.G.S. served as associate editor for Annals of Internal Medicine (American College of Physicians). V.L. received funding from Centre de Recherche du Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l’île-de-Montréal (CIUSSS_NIM). 

The following panelists have reported relationships related to the topic of fungal infections/antifungal therapies since 2021–2025, when the guideline work began, with the indicated companies. S.H. received educational grants from Merck (posaconazole), Astellas , Avir Pharma, Sanofi, and GlaxoSmithKline (GSK); served in advisory roles with TFF Pharmaceuticals (inhaled voriconazole), Takeda (Maribavir), ITB Med (siplizumab), and TFF Pharmaceuticals; received research funding from the National Institutes of Health, University Health Network, Princess Margaret Hospital Foundation, PSI Foundation (PC945 studies), Scynexis (Ibrexafungerp studies), Pulmocide (opelconazole studies), F2G (olorofim studies), Baselia (Fosmanogepix) and Gilead (immunomodulatory effects of antifungals) (all paid to institution); served in an editorial role as section editor for the Journal of Heart and Lung Transplantation and Transplant Infectious Diseases. N.P. served in advisory roles for Pulmocide (opelconazole) and Basilea (Fosmanogepix); received research funding from Scynexis (candidemia/invasive candidiasis studies), Merck (long-term outcomes of SARS-CoV-2 infections and COVID-19 vaccine breakthrough risk in kidney transplant recipients – clinical burden of RSV and other respiratory viral infections in immunocompromised hosts), CareDx, Inc. (kidney allograft outcomes, Allosure registry), Pulmocide Ltd (opelconazole clinical trials), IMMY Diagnostics (Aspergillus galactomannan assay evaluation), Pearl Diagnostics (urine MycoMEIA), Applied BioCode  (ABC assay), Fujifilm (Beta-d-glucan), Zepto Life Technology (cfDNA) and the Cystic Fibrosis Foundation, National Institutes of Health, Health Systems Research Institute, and Chulalongkorn University (various studies on fungal infections, transplant outcomes, and infectious disease diagnostics). M.H.N. received research funding from NIH/NIAID and CDC/Mycoses Study Group, investigator-initiated research grants from bioMérieux (target NGS for fungal diagnosis direct from samples) and Melinta (Rezafungin clinical trial), clinical trial funding from F2G Ltd UK (olorofim) and Pulmocide (opelconazole); all funds were paid directly to the University of Pittsburgh; serves on the advisory board for Basilea Pharmaceutica International Ltd (Fosmanogepix) and Pulmocide (opelconazole). J.H.Y. received research funding for subject enrollment on clinical trials from Basilea (Fosmanogepix), Cidara/Mundipharma (Rezafungin), F2G (olorofim), and Scynexis (Ibrexafungerp); received industry support from the NIH for studies related to antifungal and infectious disease therapeutics; receives research funding for subject enrollment on clinical trials from Pulmocide (opelconazole) and Zepto (fungal diagnostics); serves on the Aspergillus Guidelines panel with the European Confederation of Medical Mycology. M.I.A. received research funding and remuneration related to antifungal/viral therapeutics from Merck (letermovir), Shire (maribavir), and Miravista (Histoplasma diagnostics); received research funding from NIH (comparison of high dose vs standard dose influenza vaccine in HCT recipients – multicenter prospective study of human adenovirus infection and disease in pediatric HCT recipients and non-invasive diagnosis of pediatric pulmonary invasive mold infection); served as a consultant for Karius (diagnostics). A.C.A. received extensive research funding from Merck, Astellas, Nabriva, Paratek, and Summit Therapeutics for clinical trials involving antifungal and antibacterial agents; received honoraria from Astellas related to isavuconazole and micafungin. S.C-A.C. received research funding from F2G, Pfizer Australia for studies involving fungal infections, and prior funding from PRSP for infectious disease surveillance including mycology. S.P.H. served in advisory roles for F2G (olorofim) and Melinta (Rezafungin); received  research funding from F2G, Scynexis, Mundipharma, Cidara, and Elion related to antifungal  therapeutics (all paid to institution). S.A.K. received research funding from Scynexis and GSK related to antifungal and infectious disease therapeutics; received research funding from the NIH for work related to pneumonia diagnostics. T.F.P. served in advisory and consulting roles for F2G (olorofim and other investigational antifungals), Basilea (isavuconazole and Fosmanogepix), Gilead (amBisome), Pfizer (voriconazole), Scynexis (Ibrexafungerp), and Sfunga (investigational antifungals); received research funding from the National Institutes of Health (including RECOVER, ACTT/ACTIV, U19 Coccidioidomycosis Research Center, STOMP, and preclinical infectious disease studies); received industry sponsorship from F2G (olorofim for resistant molds) and Cidara (Rezafungin). G.R.T. served in advisory roles for Astellas, Basilea, Elion, F2G, GSK, and Cidara related to antifungal agents (e.g., isavuconazole, olorofim, Fosmanogepix, Turletricin, Rezafungin, Ibrexafungerp); receives research funding from F2G (OASIS) and Astellas (Mycoses Study Group; Radiology Study). C.O.M. served in advisory roles for Gilead Sciences (liposomal amphotericin B), Merck Sharp & Dohme, Australia (caspofungin and posaconazole),  Pfizer, Australia (voriconazole and anidulafungin) and Elio Therapeutics (SF001); received honoraria from Gilead Sciences (webinar chair, liposomal amphotericin B), Merck Sharp & Dohme, Australia (fungal diagnostics), and Pfizer, Australia (diagnostic stewardship); received research funding from F2G Ltd UK (F901318), Cidara Therapeutics Inc. (Rezafungin), Gilead Sciences (azole resistance studies), and Merck Sharp & Dohme, Australia (UPPRITE trial and posaconazole use in cystic fibrosis), all funding paid directly to institution. All other authors reported no conflicts of interest during the specified period.

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Update History

As of June 26, 2026, the Infectious Diseases Society of America (IDSA) has released updated recommendations for the diagnosis and management of aspergillosis, replacing the previous guidelines last updated in 2016. The current guidelines are available on the IDSA website and will be published in Clinical Infectious Diseases (CID) at a later date.