What is the treatment for mucormicosis?

From the Guidelines

The treatment for mucormycosis involves a multifaceted approach combining aggressive surgical debridement and antifungal therapy, with liposomal amphotericin B at doses of 5-10 mg/kg/day intravenously as the primary antifungal medication, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Surgical debridement of infected and necrotic tissue is crucial and may need to be repeated to ensure complete removal of infected material.
• Antifungal therapy should begin immediately upon diagnosis and typically continues for several weeks.
• Controlling underlying conditions such as diabetes, reducing immunosuppression when possible, and correcting metabolic abnormalities are essential components of treatment.

Antifungal Therapy

• Liposomal amphotericin B is the recommended first-line therapy, with a conventional dose of 5 mg/kg/day and 10 mg/kg/day recommended for those with CNS involvement 1.
• Amphotericin B deoxycholate 1-1.5 mg/kg/day may be used as an alternative to treat mucormycosis.

Duration of Treatment

• Treatment should be continued until both clinical and radiological resolution occurs and should be tailored to each patient, based on the underlying immune status 1.

Additional Considerations

• Nephrotoxicity is the major drawback of amphotericin B deoxycholate and can be reduced by isotonic saline infusion and premedication with diphenhydramine or acetaminophen.
• For patients who need debridement, surgical intervention should not be delayed, and the operation should be performed with appropriate personal protective equipment in a well-established facility to prevent transmission of SARS-CoV-2.

From the FDA Drug Label

For patients with invasive mucormycosis, all-cause mortality through Day 42 and success in overall response at the End‑of-Treatment as assessed by the Independent Data Review Committee is shown in Table 13. These results provide evidence that CRESEMBA is effective for the treatment of mucormycosis, in light of the natural history of untreated mucormycosis Table 13. All-Cause Mortality and Overall Response Success in Mucorales Patients

• Two primary mucormycosis patients were not assessed at End-of-Treatment due to ongoing treatment Primary N=21 Refractory N=11 Intolerant N=5 Total N=37 All-cause Mortality Through Day 42 7 (33%) 5 (46%) 2 (40%) 14 (38%) Overall Response Success Rate at End-of-Treatment 6/19* (32%) 4/11 (36%) 1/5 (20%) 11/35* (31%)

The treatment for mucormycosis is CRESEMBA (isavuconazonium sulfate), with an overall response success rate of 31% at the End-of-Treatment. Key points include:

• All-cause mortality through Day 42: 38%
• Overall response success rate: 31% 2

From the Research

Treatment for Mucormicosis

The treatment for mucormicosis typically involves a combination of antifungal therapy and surgery. The following are some key points to consider:

• First-line therapy: Liposomal amphotericin B (≥5mg/kg) combined with surgery whenever possible is strongly recommended as first-line therapy 3.
• Second-line therapy: Isavuconazole and intravenous or delayed-release tablet forms of posaconazole have remained second-line options 3.
• Efficacy of isavuconazole: Isavuconazole has shown activity against mucormycosis with efficacy similar to amphotericin B 4.
• Combination therapy: Combinations of treatment have failed to demonstrate superiority versus monotherapy 3.
• Adjuvant therapies: Adjuvant therapies are particularly complex to evaluate without prospective randomized controlled studies 3.
• Successful treatment: Successful treatment requires a combination of antifungal therapy, surgical intervention, and reversal of the underlying immunocompromised state 5.

Antifungal Therapy

Some antifungal agents that have been used to treat mucormicosis include:

• Amphotericin B: High-dose intravenous antifungal agents, including amphotericin B, are generally accepted as the first-line medical treatment 6.
• Itraconazole: Itraconazole has been used in combination with amphotericin B to treat mucormycosis 5.
• Isavuconazole: Isavuconazole has been used as a primary treatment for mucormycosis and has shown efficacy similar to amphotericin B 4.
• Posaconazole: Posaconazole has been used as a second-line option for the treatment of mucormycosis 3.

Surgery

Surgery plays a crucial role in the treatment of mucormicosis, particularly in cases where the infection is localized:

• Surgical excision: Surgical excision of affected tissue is often necessary to obtain infection-free margins 7.
• Prompt surgical resection: Prompt surgical resection of lesions is generally accepted as part of the treatment for pulmonary mucormycosis 6.