Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Treatment of Scedosporium and Lomentospora infections

Sylvia F Costa, MD
Barbara D Alexander, MD, MHS
Section Editor
Carol A Kauffman, MD
Deputy Editor
Anna R Thorner, MD


During the past few decades, opportunistic fungal pathogens have become increasingly recognized as a cause of infection in severely ill or immunocompromised patients [1,2]. Although Aspergillus species remain the most common mold to cause invasive infection, other pathogens are becoming more common [1-3]. Two of these, Scedosporium apiospermum (the asexual form of Pseudoallescheria boydii) and Lomentospora prolificans, are considered major human pathogens [4].

This topic will discuss the diagnosis and treatment of Scedosporium and Lomentospora infections. The epidemiology, mycology, and clinical manifestations of Scedosporium and Lomentospora infections are discussed elsewhere (see "Epidemiology, clinical manifestations, and diagnosis of Scedosporium and Lomentospora infections"). Other emerging fungal infections are discussed elsewhere. (See "Epidemiology and clinical manifestations of Talaromyces (Penicillium) marneffei infection" and "Mycology, pathogenesis, and epidemiology of Fusarium infection".)


Given the varying in vitro activity of antifungal agents against S. apiospermum and especially L. prolificans, we typically ask for susceptibility testing of isolates from patients with infections caused by these pathogens.

Definitions — The term "MIC" refers to the minimum inhibitory concentration of an antifungal agent required to inhibit growth of an organism. MIC50 refers to 50 percent inhibition; MIC90 refers to 90 percent inhibition.

The term "MEC" refers to the lowest concentration of an antifungal agent that leads to aberrant growth, which is the growth of small, rounded, compact hyphal forms as compared with the hyphal growth seen in the growth control well [5]. MECs are used only for the echinocandins. MEC50 is the concentration at which 50 percent of isolates showed aberrant growth, and MEC90 is the concentration at which 90 percent of isolates showed aberrant growth.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Ascioglu S, Rex JH, de Pauw B, et al. Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis 2002; 34:7.
  2. Tarrand JJ, Lichterfeld M, Warraich I, et al. Diagnosis of invasive septate mold infections. A correlation of microbiological culture and histologic or cytologic examination. Am J Clin Pathol 2003; 119:854.
  3. Walsh TJ, Groll A, Hiemenz J, et al. Infections due to emerging and uncommon medically important fungal pathogens. Clin Microbiol Infect 2004; 10 Suppl 1:48.
  4. Perfect JR, Schell WA. The new fungal opportunists are coming. Clin Infect Dis 1996; 22 Suppl 2:S112.
  5. Clinical and Laboratory Standards Institute. Reference method for broth dilution antifungal susceptibility testing of filamentous fungi; Approved standard, 2nd ed, CLSI document M38-A2, Clinical and Laboratory Standards Institute, Wayne, PA 2008.
  6. Espinel-Ingroff A, Fothergill A, Ghannoum M, et al. Quality control and reference guidelines for CLSI broth microdilution susceptibility method (M 38-A document) for amphotericin B, itraconazole, posaconazole, and voriconazole. J Clin Microbiol 2005; 43:5243.
  7. Cuenca-Estrella M, Gomez-Lopez A, Mellado E, et al. Head-to-head comparison of the activities of currently available antifungal agents against 3,378 Spanish clinical isolates of yeasts and filamentous fungi. Antimicrob Agents Chemother 2006; 50:917.
  8. Cuenca-Estrella M, Ruiz-Díez B, Martínez-Suárez JV, et al. Comparative in-vitro activity of voriconazole (UK-109,496) and six other antifungal agents against clinical isolates of Scedosporium prolificans and Scedosporium apiospermum. J Antimicrob Chemother 1999; 43:149.
  9. Johnson EM, Szekely A, Warnock DW. In-vitro activity of voriconazole, itraconazole and amphotericin B against filamentous fungi. J Antimicrob Chemother 1998; 42:741.
  10. Meletiadis J, Meis JF, Mouton JW, et al. In vitro activities of new and conventional antifungal agents against clinical Scedosporium isolates. Antimicrob Agents Chemother 2002; 46:62.
  11. Cortez KJ, Roilides E, Quiroz-Telles F, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev 2008; 21:157.
  12. Thompson GR 3rd, Wiederhold NP. Isavuconazole: a comprehensive review of spectrum of activity of a new triazole. Mycopathologia 2010; 170:291.
  13. Guinea J, Peláez T, Recio S, et al. In vitro antifungal activities of isavuconazole (BAL4815), voriconazole, and fluconazole against 1,007 isolates of zygomycete, Candida, Aspergillus, Fusarium, and Scedosporium species. Antimicrob Agents Chemother 2008; 52:1396.
  14. Lackner M, de Hoog GS, Verweij PE, et al. Species-specific antifungal susceptibility patterns of Scedosporium and Pseudallescheria species. Antimicrob Agents Chemother 2012; 56:2635.
  15. Garcia-Effron G, Gomez-Lopez A, Mellado E, et al. In vitro activity of terbinafine against medically important non-dermatophyte species of filamentous fungi. J Antimicrob Chemother 2004; 53:1086.
  16. Carrillo AJ, Guarro J. In vitro activities of four novel triazoles against Scedosporium spp. Antimicrob Agents Chemother 2001; 45:2151.
  17. Lamoth F, Alexander BD. Antifungal activities of SCY-078 (MK-3118) and standard antifungal agents against clinical non-Aspergillus mold isolates. Antimicrob Agents Chemother 2015; 59:4308.
  18. Meletiadis J, Mouton JW, Rodriguez-Tudela JL, et al. In vitro interaction of terbinafine with itraconazole against clinical isolates of Scedosporium prolificans. Antimicrob Agents Chemother 2000; 44:470.
  19. Meletiadis J, Mouton JW, Meis JF, Verweij PE. In vitro drug interaction modeling of combinations of azoles with terbinafine against clinical Scedosporium prolificans isolates. Antimicrob Agents Chemother 2003; 47:106.
  20. Biswas C, Sorrell TC, Djordjevic JT, et al. In vitro activity of miltefosine as a single agent and in combination with voriconazole or posaconazole against uncommon filamentous fungal pathogens. J Antimicrob Chemother 2013; 68:2842.
  21. Heyn K, Tredup A, Salvenmoser S, Müller FM. Effect of voriconazole combined with micafungin against Candida, Aspergillus, and Scedosporium spp. and Fusarium solani. Antimicrob Agents Chemother 2005; 49:5157.
  22. Husain S, Muñoz P, Forrest G, et al. Infections due to Scedosporium apiospermum and Scedosporium prolificans in transplant recipients: clinical characteristics and impact of antifungal agent therapy on outcome. Clin Infect Dis 2005; 40:89.
  23. Husain S, Alexander BD, Munoz P, et al. Opportunistic mycelial fungal infections in organ transplant recipients: emerging importance of non-Aspergillus mycelial fungi. Clin Infect Dis 2003; 37:221.
  24. Marr KA, Carter RA, Crippa F, et al. Epidemiology and outcome of mould infections in hematopoietic stem cell transplant recipients. Clin Infect Dis 2002; 34:909.
  25. Troke P, Aguirrebengoa K, Arteaga C, et al. Treatment of scedosporiosis with voriconazole: clinical experience with 107 patients. Antimicrob Agents Chemother 2008; 52:1743.
  26. Pfizer. Package insert VFEND (Voriconazole).New York, NY 10017: Pfizer Inc., 2006:1-42.
  27. Perfect JR, Marr KA, Walsh TJ, et al. Voriconazole treatment for less-common, emerging, or refractory fungal infections. Clin Infect Dis 2003; 36:1122.
  28. Girmenia C, Luzi G, Monaco M, Martino P. Use of voriconazole in treatment of Scedosporium apiospermum infection: case report. J Clin Microbiol 1998; 36:1436.
  29. Muñoz P, Marín M, Tornero P, et al. Successful outcome of Scedosporium apiospermum disseminated infection treated with voriconazole in a patient receiving corticosteroid therapy. Clin Infect Dis 2000; 31:1499.
  30. Jabado N, Casanova JL, Haddad E, et al. Invasive pulmonary infection due to Scedosporium apiospermum in two children with chronic granulomatous disease. Clin Infect Dis 1998; 27:1437.
  31. Klopfenstein KJ, Rosselet R, Termuhlen A, Powell D. Successful treatment of Scedosporium pneumonia with voriconazole during AML therapy and bone marrow transplantation. Med Pediatr Oncol 2003; 41:494.
  32. Perlroth MG, Miller J. Pseudoallescheria boydii pneumonia and empyema: a rare complication of heart transplantation cured with voriconazole. J Heart Lung Transplant 2004; 23:647.
  33. García-Arata MI, Otero MJ, Zomeño M, et al. Scedosporium apiospermum pneumonia after autologous bone marrow transplantation. Eur J Clin Microbiol Infect Dis 1996; 15:600.
  34. Nomdedéu J, Brunet S, Martino R, et al. Successful treatment of pneumonia due to Scedosporium apiospermum with itraconazole: case report. Clin Infect Dis 1993; 16:731.
  35. Goldberg SL, Geha DJ, Marshall WF, et al. Successful treatment of simultaneous pulmonary Pseudallescheria boydii and Aspergillus terreus infection with oral itraconazole. Clin Infect Dis 1993; 16:803.
  36. Schaenman JM, DiGiulio DB, Mirels LF, et al. Scedosporium apiospermum soft tissue infection successfully treated with voriconazole: potential pitfalls in the transition from intravenous to oral therapy. J Clin Microbiol 2005; 43:973.
  37. Talbot TR, Hatcher J, Davis SF, et al. Scedosporium apiospermum pneumonia and sternal wound infection in a heart transplant recipient. Transplantation 2002; 74:1645.
  38. German JW, Kellie SM, Pai MP, Turner PT. Treatment of a chronic Scedosporium apiospermum vertebral osteomyelitis. Case report. Neurosurg Focus 2004; 17:E9.
  39. O'Doherty M, Hannan M, Fulcher T. Voriconazole in the treatment of fungal osteomyelitis of the orbit in the immunocompromised host. Orbit 2005; 24:285.
  40. Karaarslan A, Arikan S, Karaarslan F, Cetin ES. Skin infection caused by Scedosporium apiospermum. Mycoses 2003; 46:524.
  41. Mellinghoff IK, Winston DJ, Mukwaya G, Schiller GJ. Treatment of Scedosporium apiospermum brain abscesses with posaconazole. Clin Infect Dis 2002; 34:1648.
  42. Capilla J, Serena C, Pastor FJ, et al. Efficacy of voriconazole in treatment of systemic scedosporiosis in neutropenic mice. Antimicrob Agents Chemother 2003; 47:3976.
  43. Capilla J, Guarro J. Correlation between in vitro susceptibility of Scedosporium apiospermum to voriconazole and in vivo outcome of scedosporiosis in guinea pigs. Antimicrob Agents Chemother 2004; 48:4009.
  44. González GM, Tijerina R, Najvar LK, et al. Activity of posaconazole against Pseudallescheria boydii: in vitro and in vivo assays. Antimicrob Agents Chemother 2003; 47:1436.
  45. Maertens JA, Raad II, Marr KA, et al. Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomised-controlled, non-inferiority trial. Lancet 2016; 387:760.
  46. Cornely OA. Outcomes in patients with invasive mould disease caused by Fusarium or Scedosporium spp treated with isavuconazole: Experience from the VITAL and SECURE trials. 54th Interscience Conference on Antimicrobial Agents and Chemotherapy [ICAAC]; Washington, DC September 5–9, 2014; M-1760.
  47. Perfect JR. Treatment of non-Aspergillus moulds in immunocompromised patients, with amphotericin B lipid complex. Clin Infect Dis 2005; 40 Suppl 6:S401.
  48. Capilla J, Mayayo E, Serena C, et al. A novel murine model of cerebral scedosporiosis: lack of efficacy of amphotericin B. J Antimicrob Chemother 2004; 54:1092.
  49. Sullivan LJ, Snibson G, Joseph C, Taylor HR. Scedosporium prolificans sclerokeratitis. Aust N Z J Ophthalmol 1994; 22:207.
  50. Taylor A, Wiffen SJ, Kennedy CJ. Post-traumatic Scedosporium inflatum endophthalmitis. Clin Exp Ophthalmol 2002; 30:47.
  51. Vagefi MR, Kim ET, Alvarado RG, et al. Bilateral endogenous Scedosporium prolificans endophthalmitis after lung transplantation. Am J Ophthalmol 2005; 139:370.
  52. Wilson CM, O'Rourke EJ, McGinnis MR, Salkin IF. Scedosporium inflatum: clinical spectrum of a newly recognized pathogen. J Infect Dis 1990; 161:102.
  53. Wood GM, McCormack JG, Muir DB, et al. Clinical features of human infection with Scedosporium inflatum. Clin Infect Dis 1992; 14:1027.
  54. Pickles RW, Pacey DE, Muir DB, Merrell WH. Experience with infection by Scedosporium prolificans including apparent cure with fluconazole therapy. J Infect 1996; 33:193.
  55. Steinbach WJ, Schell WA, Miller JL, Perfect JR. Scedosporium prolificans osteomyelitis in an immunocompetent child treated with voriconazole and caspofungin, as well as locally applied polyhexamethylene biguanide. J Clin Microbiol 2003; 41:3981.
  56. Gosbell IB, Toumasatos V, Yong J, et al. Cure of orthopaedic infection with Scedosporium prolificans, using voriconazole plus terbinafine, without the need for radical surgery. Mycoses 2003; 46:233.
  57. Rodríguez MM, Calvo E, Serena C, et al. Effects of double and triple combinations of antifungal drugs in a murine model of disseminated infection by Scedosporium prolificans. Antimicrob Agents Chemother 2009; 53:2153.
  58. Bocanegra R, Najvar LK, Hernandez S, et al. Caspofungin and liposomal amphotericin B therapy of experimental murine scedosporiosis. Antimicrob Agents Chemother 2005; 49:5139.
  59. Capilla J, Yustes C, Mayayo E, et al. Efficacy of albaconazole (UR-9825) in treatment of disseminated Scedosporium prolificans infection in rabbits. Antimicrob Agents Chemother 2003; 47:1948.
  60. Heath CH, Slavin MA, Sorrell TC, et al. Population-based surveillance for scedosporiosis in Australia: epidemiology, disease manifestations and emergence of Scedosporium aurantiacum infection. Clin Microbiol Infect 2009; 15:689.
  61. Lackner M, Hagen F, Meis JF, et al. Susceptibility and diversity in the therapy-refractory genus scedosporium. Antimicrob Agents Chemother 2014; 58:5877.
  62. Araujo R, Oliveira M, Amorim A, Sampaio-Maia B. Unpredictable susceptibility of emerging clinical moulds to tri-azoles: review of the literature and upcoming challenges for mould identification. Eur J Clin Microbiol Infect Dis 2015; 34:1289.
  63. Sedlacek L, Graf B, Schwarz C, et al. Prevalence of Scedosporium species and Lomentospora prolificans in patients with cystic fibrosis in a multicenter trial by use of a selective medium. J Cyst Fibros 2015; 14:237.
  64. Gilgado F, Serena C, Cano J, et al. Antifungal susceptibilities of the species of the Pseudallescheria boydii complex. Antimicrob Agents Chemother 2006; 50:4211.
  65. Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002; 347:408.
  66. Schwartz S, Ruhnke M, Ribaud P, et al. Improved outcome in central nervous system aspergillosis, using voriconazole treatment. Blood 2005; 106:2641.
  67. Imhof A, Balajee SA, Fredricks DN, et al. Breakthrough fungal infections in stem cell transplant recipients receiving voriconazole. Clin Infect Dis 2004; 39:743.
  68. Pascual A, Calandra T, Bolay S, et al. Voriconazole therapeutic drug monitoring in patients with invasive mycoses improves efficacy and safety outcomes. Clin Infect Dis 2008; 46:201.
  69. Vfend® package insert. Roerig, a Division of Pfizer, Inc. New York, NY, 2008. http://media.pfizer.com/files/products/uspi_vfend.pdf (Accessed on November 12, 2008).
  70. Howard A, Hoffman J, Sheth A. Clinical application of voriconazole concentrations in the treatment of invasive aspergillosis. Ann Pharmacother 2008; 42:1859.
  71. Johnson LB, Kauffman CA. Voriconazole: a new triazole antifungal agent. Clin Infect Dis 2003; 36:630.
  72. Dodds Ashley ES, Lewis R, Lewis JS, et al. Pharmacology of Systemic Antifungal Agents. Clin Infect Dis 2006; 43 Suppl 1:S28.
  73. Rodriguez-Tudela JL, Berenguer J, Guarro J, et al. Epidemiology and outcome of Scedosporium prolificans infection, a review of 162 cases. Med Mycol 2009; 47:359.
  74. Chakraborty A, Workman MR, Bullock PR. Scedosporium apiospermum brain abscess treated with surgery and voriconazole. Case report. J Neurosurg 2005; 103:83.
  75. Mursch K, Trnovec S, Ratz H, et al. Successful treatment of multiple Pseudallescheria boydii brain abscesses and ventriculitis/ependymitis in a 2-year-old child after a near-drowning episode. Childs Nerv Syst 2006; 22:189.
  76. Nesky MA, McDougal EC, Peacock Jr JE. Pseudallescheria boydii brain abscess successfully treated with voriconazole and surgical drainage: case report and literature review of central nervous system pseudallescheriasis. Clin Infect Dis 2000; 31:673.
  77. Casadevall A, Pirofski LA. Adjunctive immune therapy for fungal infections. Clin Infect Dis 2001; 33:1048.
  78. Pappas PG. Immunotherapy for invasive fungal infections: from bench to bedside. Drug Resist Updat 2004; 7:3.
  79. Howden BP, Slavin MA, Schwarer AP, Mijch AM. Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine. Eur J Clin Microbiol Infect Dis 2003; 22:111.
  80. Bouza E, Muñoz P, Vega L, et al. Clinical resolution of Scedosporium prolificans fungemia associated with reversal of neutropenia following administration of granulocyte colony-stimulating factor. Clin Infect Dis 1996; 23:192.
  81. Ortoneda M, Capilla J, Pastor FJ, et al. Interaction of granulocyte colony-stimulating factor and high doses of liposomal amphotericin B in the treatment of systemic murine scedosporiosis. Diagn Microbiol Infect Dis 2004; 50:247.
  82. Simitsopoulou M, Gil-Lamaignere C, Avramidis N, et al. Antifungal activities of posaconazole and granulocyte-macrophage colony-stimulating factor ex vivo and in mice with disseminated infection due to Scedosporium prolificans. Antimicrob Agents Chemother 2004; 48:3801.
  83. Gil-Lamaignere C, Roilides E, Lyman CA, et al. Human phagocytic cell responses to Scedosporium apiospermum (Pseudallescheria boydii): variable susceptibility to oxidative injury. Infect Immun 2003; 71:6472.
  84. Gil-Lamaignere C, Winn RM, Simitsopoulou M, et al. Inteferon gamma and granulocyte-macrophage colony-stimulating factor augment the antifungal activity of human polymorphonuclear leukocytes against Scedosporium spp.: comparison with Aspergillus spp. Med Mycol 2005; 43:253.
  85. Gil-Lamaignere C, Roilides E, Mosquera J, et al. Antifungal triazoles and polymorphonuclear leukocytes synergize to cause increased hyphal damage to Scedosporium prolificans and Scedosporium apiospermum. Antimicrob Agents Chemother 2002; 46:2234.
  86. Farina C, Marchesi G, Passera M, et al. Comparative study of the in vitro activity of various antifungal drugs against Scedosporium spp. in aerobic and hyperbaric atmosphere versus normal atmosphere. J Mycol Med 2012; 22:142.
  87. Johnson LS, Shields RK, Clancy CJ. Epidemiology, clinical manifestations, and outcomes of Scedosporium infections among solid organ transplant recipients. Transpl Infect Dis 2014; 16:578.
  88. Idigoras P, Pérez-Trallero E, Piñeiro L, et al. Disseminated infection and colonization by Scedosporium prolificans: a review of 18 cases, 1990-1999. Clin Infect Dis 2001; 32:E158.
  89. Berenguer J, Rodríguez-Tudela JL, Richard C, et al. Deep infections caused by Scedosporium prolificans. A report on 16 cases in Spain and a review of the literature. Scedosporium Prolificans Spanish Study Group. Medicine (Baltimore) 1997; 76:256.
  90. Madrigal V, Alonso J, Bureo E, et al. Fatal meningoencephalitis caused by Scedosporium inflatum (Scedosporium prolificans) in a child with lymphoblastic leukemia. Eur J Clin Microbiol Infect Dis 1995; 14:601.
  91. Salesa R, Burgos A, Ondiviela R, et al. Fatal disseminated infection by Scedosporium inflatum after bone marrow transplantation. Scand J Infect Dis 1993; 25:389.
  92. de Batlle J, Motjé M, Balanzà R, et al. Disseminated infection caused by Scedosporium prolificans in a patient with acute multilineal leukemia. J Clin Microbiol 2000; 38:1694.
  93. Rabodonirina M, Paulus S, Thevenet F, et al. Disseminated Scedosporium prolificans (S. inflatum) infection after single-lung transplantation. Clin Infect Dis 1994; 19:138.
  94. Spielberger RT, Tegtmeier BR, O'Donnell MR, Ito JI. Fatal Scedosporium prolificans (S. inflatum) fungemia following allogeneic bone marrow transplantation: report of a case in the United States. Clin Infect Dis 1995; 21:1067.