What is the recommended treatment for Sarocladium kiliense isolated from a lung fungal culture?

Treatment of Sarocladium kiliense Pulmonary Infection

For Sarocladium kiliense isolated from lung fungal culture, voriconazole is the recommended first-line antifungal therapy, with amphotericin B and posaconazole as alternative options, and surgical resection should be strongly considered for localized progressive lesions. 1

Primary Antifungal Therapy

Voriconazole is the preferred agent based on ESCMID/ECMM joint guidelines that specifically address Sarocladium kiliense (formerly Acremonium kiliense) infections 1. This recommendation is supported by:

• Clinical case evidence demonstrating voriconazole efficacy: A documented case of S. kiliense fungemia with proven lung involvement in a stem cell transplant patient showed complete resolution after 10 days of voriconazole therapy, with the patient remaining symptom-free at one year 2
• In vitro susceptibility data: While S. kiliense shows high MICs to amphotericin B, fluconazole, and itraconazole, it demonstrates sensitivity to voriconazole 2, 3

Dosing for Voriconazole

• Loading dose: 400 mg (6 mg/kg) IV every 12 hours for two doses on day 1 1
• Maintenance dose: 200 mg (4 mg/kg) every 12 hours, with therapeutic drug monitoring recommended 1

Alternative Antifungal Options

When voriconazole cannot be used due to intolerance, drug interactions, or treatment failure:

• Amphotericin B formulations (preferably liposomal amphotericin B 3-5 mg/kg IV daily) are recommended as second-line therapy 1
• Posaconazole is an additional alternative azole option 1

Surgical Intervention

Surgical resection is critical for optimal outcomes and should be considered in the following scenarios 1:

• Hemoptysis from a single cavitary lung lesion (always perform CT chest to exclude additional lesions) 1
• Progressive cavitary lung lesions despite antifungal therapy 1
• Infiltration into pericardium, great vessels, bone, or thoracic soft tissue 1
• Before initiating immunosuppressive therapy to prevent dissemination 1

Treatment Duration and Monitoring

• Minimum treatment duration: 6-12 weeks, varying by extent of disease, clinical improvement, and degree of immunosuppression 1
• Therapeutic drug monitoring for voriconazole is strongly recommended to ensure adequate levels and minimize toxicity 1
• Serial imaging with CT chest to assess treatment response 1

Special Considerations for Immunocompromised Patients

For patients with underlying immunosuppression:

• Reduction of immunosuppression should be attempted if feasible without risking graft rejection or graft-versus-host disease 1
• Secondary prophylaxis with azole therapy should be continued if subsequent immunosuppression is required 1
• Recovery of immune function is a major determinant of successful outcome 1

Critical Pitfalls to Avoid

• Do not delay antifungal therapy while awaiting susceptibility testing; initiate voriconazole empirically once Sarocladium is identified 1
• Do not use fluconazole or standard itraconazole as these agents show poor activity against Sarocladium species 2, 3
• Do not overlook surgical evaluation for localized pulmonary lesions, as medical therapy alone often fails without source control 1
• Ensure proper identification to species level and save the isolate for antifungal susceptibility testing, as Sarocladium species can be misidentified as other hyalohyphomycetes 1

Treatment Failure Management

If the patient fails to respond to initial voriconazole therapy 1:

• Review antifungal susceptibility testing results 1
• Check for drug interactions that may reduce voriconazole levels 1
• Perform therapeutic drug monitoring to ensure adequate voriconazole concentrations 1
• Consider switching to amphotericin B or combination therapy 1
• Re-evaluate for surgical debridement of infected tissue 1