In order to develop new approaches to treatment of infections due to Pseudallescheria boydii, the in vitro antifungal activity of amphotericin B alone and in combination with miconazole, itraconazole, and fluconazole was studied. Combinations of amphotericin B and antifungal azoles were synergistic, additive, or indifferent in their interaction against P. boydii. Antagonism was not observed.Pseudallescheria boydii causes mycetoma, pneumonia, and disseminated infections, particularly involving the central nervous system, that are frequently refractory to antifungal chemotherapy (1-4, 6, 7, 10-16, 19-23, 25-28). Isolates of P. boydii are often considered to be resistant to amphotericin B; however, the frequency with which such resistance occurs is not well described. Antifungal azoles are often cited as the agents of choice for infections due to P. boydii (7,13,15), yet patients with pneumonia, cerebral abscesses, endophthalmitis, osteomyelitis, or disseminated infections due to P. boydii often fail to respond to single-agent azole therapy. New therapeutic approaches are clearly needed for the treatment of infections due to this organism. The combination of amphotericin B and antifungal azoles may provide an important therapeutic option.Little is known, however, about the combination of amphotericin B and antifungal azoles for P. boydii. The combination of antifungal azoles and amphotericin B in treatment of P. boydii infections may not be considered feasible on the basis of theoretical concern about potential antagonism. We therefore determined the MICs and minimum lethal concentrations (MLCs) of amphotericin B and antifungal azoles in vitro against a large group of clinical isolates of P. boydii and further studied the potential synergistic interaction between these two classes of antifungal compounds against this frequently refractory pathogen.The 22 isolates of P. boydii used in this study were identified at the Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio. Cultures were maintained on the surface of potato dextrose agar slants (Remel, Lenaxa, Kans.) at Ϫ70ЊC.MICs were determined by broth macrodilution methods, as previously described (8,9,18). Briefly, a suspension was adjusted with a spectrophotometer to 68 to 71% transmission at a wavelength of 530 nm and diluted 100-fold to yield an inoculum of 1 ϫ 10 4 to 5 ϫ 10 4 CFU/ml. Amphotericin B, fluconazole, itraconazole, and miconazole were tested in 0.165 M morpholinepropanesulfonic acid (MOPS)-buffered RPMI 1640 (Bio-Whittaker, Walkersville, Md.) at a pH of 7.0. A 100-l quantity of concentrated antifungal compound was diluted 10-fold into 900 l of inoculum suspension and incubated at 35ЊC for 24 and 48 h. The final concentration ranges for amphotericin B (Bristol-Myers Squibb, Princeton, N.J.) and itraconazole and miconazole (both from Janssen Pharmaceutica, Piscataway, N.J.) were 0.03 to 16.0 g/ml, and that for fluconazole (Pfizer Central Research, Groton, Conn.) was 0.125 to 64.0 g/ml. Growth was...