What is the first-line antifungal therapy for Aspergillus pneumonia?

• A. Itraconazole
• B. Amphotericin B
• C. Voriconazole
• D. Fluconazole

Answer: (C)

Voriconazole is the preferred initial treatment for invasive pulmonary aspergillosis because randomized evidence shows it improves survival and response more than amphotericin B. It has strong activity against Aspergillus species, good lung penetration, and comes in both IV and oral forms, which allows starting treatment aggressively and then stepping down to oral therapy as the patient improves. Fluconazole doesn’t cover Aspergillus, so it isn’t suitable. Itraconazole is active but has variable absorption and less consistent outcomes in invasive disease, making it a less reliable first choice. Amphotericin B can treat Aspergillus but carries more toxicity and isn’t associated with the same survival benefit in pivotal trials. If voriconazole can’t be used, liposomal amphotericin B is a common alternative, with consideration of combination strategies in certain cases.