Treatment of Acremonium citrinum Infection in Immunocompromised Patients

Primary Antifungal Therapy

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) recommend voriconazole as the preferred first-line agent for Acremonium species infection, based on superior clinical outcomes and favorable CNS penetration 1, 2
Voriconazole dosing strategy includes a loading dose of 6 mg/kg IV every 12 hours for 2 doses, followed by maintenance of 4 mg/kg IV every 12 hours, then transition to oral 200 mg twice daily when clinically stable 3, 2
Therapeutic drug monitoring is mandatory to maintain trough levels between 1-5.5 mcg/mL, due to significant pharmacokinetic variability 2

Amphotericin B lipid formulations are recommended as second-line therapy, at a dose of 3-5 mg/kg IV daily 1, 2
Posaconazole serves as salvage therapy, at a dose of 300 mg twice daily on day 1, then 300 mg daily 1, 2

Surgical debridement is a critical component of successful management, and is not optional 1, 5, 6, 2
Absolute indications for surgery include progressive cavitary lung lesions, hemoptysis, infiltration into pericardium or great vessels, osteomyelitis, and septic arthritis 1, 2

Reversal of immunosuppression is the single most important determinant of survival, and must be attempted whenever feasible 1, 5, 6, 2
Reduce corticosteroid doses if possible, and consider granulocyte colony-stimulating factor (G-CSF) to shorten neutropenia duration 2, 7

Minimum treatment duration is 6-12 weeks, depending on extent of disease, immune status, and clinical response 2
Obtain serial CT imaging every 2-4 weeks to assess treatment response, and continue therapy until radiographic resolution and immune reconstitution 2
Secondary prophylaxis with voriconazole or posaconazole is required if ongoing immunosuppression continues, due to substantial relapse risk 5, 6, 2

Do not misidentify the organism, as Acremonium species grow slowly and require at least 2 weeks of culture incubation 1, 2
Do not rely on blood cultures alone, as diagnosis requires isolation from infected tissue sites 1
Do not use fluconazole or itraconazole, as these agents demonstrate poor in vitro activity against Acremonium species and are associated with treatment failures 1
Do not ignore occult sources, such as onychomycosis, which can be a source of subsequent disseminated infection in immunocompromised patients 5, 6