Trichosporon Infections Treatment & Management

Updated: Jan 16, 2015
  • Author: Ryan C Maves, MD, FACP, FCCP, FIDSA; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Treatment

Medical Care

Voriconazole and posaconazole show excellent in vitro activity against Trichosporon. [16, 24, 26, 39] In particular, voriconazole seems to have better in vitro activity than amphotericin B. [24, 40, 41] Indeed, successful clearance of fungemia with voriconazole has been reported when liposomal amphotericin B treatment was failing. [26] Posaconazole is approved by the US Food and Drug Administration for prophylaxis of invasive Aspergillus and Candida infections in patients at high risk because of severe immunosuppression and has activity against Trichosporon, although human clinical data are both limited and mixed in terms of results. [42, 43]

High-dose amphotericin B deoxycholate (1-1.5 mg/kg/d) historically has been the most common treatment for invasive trichosporonosis, but many breakthrough cases have occurred on this therapy. [22, 44] Because of high rates of resistance to amphotericin B [40] and the toxicity of this regimen, alternate therapies are often necessary. Lipid preparations of amphotericin B (eg, liposomal amphotericin B, 5 mg/kg/d) are commonly used in place of amphotericin B deoxycholate, although treatment failures have also been reported with these agents. [20] Bcapitatus infections appear to respond better to amphotericin B than those due to Trichosporon species. [22]

The echinocandins caspofungin and micafungin have poor in vitro activity against Trichosporon when used alone. [19] One report describes successful treatment of T inkin peritoneal catheter–associated peritonitis using caspofungin monotherapy. [8] However, cases of breakthrough T asahii infections have been reported in patients with hematologic malignancies receiving micafungin [19] and caspofungin [32] for empiric treatment of neutropenic fever. Combination therapy with caspofungin and liposomal amphotericin B may be effective, [20] and micafungin and amphotericin B appear synergistic against Trichosporon in vitro. One in vivo murine model of trichosporonosis showed a significant reduction in fungal burden in multiple infected organ systems when amphotericin B was combined with micafungin.

Combination therapy should be the cornerstone of treatment for trichosporonosis. The combination of high-dose amphotericin B (deoxycholate or liposomal) with either or both 5-flucytosine or voriconazole is commonly prescribed, although failure rates remain high. Amphotericin B plus an echinocandin is a potentially promising regimen, and synergy has been suggested in vitro [45] and in a murine model, [46] with a small number of successful reports of salvage therapy in the current literature. [47, 48]

Regardless of the therapeutic options, patients’ clinical responses may not be optimal until they recover from their predisposing immunocompromised states. Possible strategies include the addition of granulocyte colony-stimulating factor (G-CSF) in patients with neutropenia [7] and the reduction of glucocorticoid doses as much as possible in patients receiving these agents. Persistence of positive blood culture findings on amphotericin B monotherapy suggests resistance, and modification of the regimen is indicated. Catheter-associated infections, such as peritonitis in patients undergoing peritoneal dialysis, generally require removal of the catheter.

In patients who do not respond to high-dose amphotericin B, an azole or flucytosine (5-FC) should be added. Unfortunately, all of these therapies have significant failure rates in patients with neutropenia. levels of 5-FC must be carefully monitored. Do not use 5-FC if levels cannot be measured expeditiously. Liposomal amphotericin has been successfully used in trichosporonosis but may not necessarily offer greater efficacy over standard therapy. Miconazole has significant in vitro activity; however, this does not translate to useful in vivo results, and it should not be used.

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Consultations

Patients with trichosporonosis are often critically ill because of their infection and their frequent underlying illnesses. ICU admission is warranted in most cases.

Proper management should include input from an infectious disease specialist.

Consultation with an ophthalmologist is generally advised for diagnostic purposes and to evaluate for fungal retinitis.

Because of the many organ systems involved, input from a number of other specialists may be required. Pulmonologists, intensivists, gastroenterologists, dermatologists, and general surgeons commonly assist in the diagnosis and management of patients with trichosporonosis.

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