What is the recommended treatment for a non-immunosuppressed patient with Sarocladium kiliense isolated from a lung fungal culture?

Treatment of Sarocladium kiliense Pulmonary Infection in Non-Immunosuppressed Patients

Voriconazole is the recommended first-line antifungal therapy for Sarocladium kiliense lung infection, and surgical resection should be strongly considered for localized progressive lesions. 1

Primary Antifungal Therapy

• Initiate voriconazole immediately once Sarocladium kiliense is identified from lung culture, without waiting for susceptibility testing results 1
• The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) specifically recommend voriconazole as the preferred agent for Sarocladium kiliense infections 1
• Voriconazole has demonstrated clinical efficacy in treating Sarocladium kiliense (formerly Acremonium kiliense) pulmonary infections, with documented mycological cure and clinical improvement 2

Dosing regimen:

• Loading dose: 6 mg/kg IV every 12 hours for 24 hours 3
• Maintenance: 4 mg/kg IV every 12 hours, then transition to oral 200 mg twice daily when clinically stable 3

Alternative Antifungal Options

If voriconazole is contraindicated or not tolerated:

• Liposomal amphotericin B 3-5 mg/kg IV daily is the recommended second-line therapy 1
• Posaconazole serves as an additional alternative azole option 1

Critical Role of Surgical Intervention

Surgical resection is critical for optimal outcomes in non-immunosuppressed patients with Sarocladium kiliense lung infection 1. Consider surgery in the following scenarios:

• Hemoptysis from a single cavitary lung lesion 1
• Progressive cavitary lung lesions despite antifungal therapy 1
• Infiltration into pericardium, great vessels, bone, or thoracic soft tissue 1
• Before initiating any planned immunosuppressive therapy 1

Always obtain CT chest imaging before surgical intervention to identify all lesions and ensure complete resection planning 4

Treatment Duration and Monitoring

• Minimum treatment duration: 6-12 weeks, with actual duration determined by extent of disease, clinical improvement, and immune status 1
• Therapeutic drug monitoring for voriconazole is strongly recommended to ensure adequate levels (target trough 1-5.5 mcg/mL) and minimize toxicity 1
• Serial CT chest imaging should be performed to assess treatment response and guide duration decisions 1

Essential Diagnostic Considerations

• Ensure proper identification to species level, as Sarocladium can be misidentified as other hyalohyphomycetes 1
• Save the isolate for antifungal susceptibility testing 1
• In vitro susceptibility data showed that Sarocladium kiliense isolates were sensitive to voriconazole but resistant to amphotericin B, fluconazole, and itraconazole 2

Management of Treatment Failure

If the patient fails to respond to initial voriconazole therapy:

• Review antifungal susceptibility testing results 1
• Check for drug interactions that may reduce voriconazole levels 1
• Perform therapeutic drug monitoring to ensure adequate serum concentrations 1
• Consider switching to amphotericin B or combination therapy 1
• Reassess for surgical candidacy if not previously performed 1

Common Pitfalls to Avoid

• Do not delay antifungal therapy while awaiting susceptibility testing; initiate voriconazole empirically once Sarocladium is identified 1
• Do not use amphotericin B as first-line therapy, as clinical isolates have demonstrated resistance 2
• Do not rely solely on medical therapy for localized lesions amenable to resection, as combined medical-surgical approach yields superior outcomes 1
• Do not discontinue therapy prematurely based on clinical improvement alone; continue until radiographic resolution or stabilization is documented 1