What is the treatment for mucormycosis?

Treatment of Mucormycosis

The treatment of mucormycosis requires a multimodal approach including antifungal therapy with liposomal amphotericin B at 5-10 mg/kg/day as first-line treatment, surgical debridement when possible, and correction of underlying predisposing conditions. 1, 2

First-Line Antifungal Therapy

Amphotericin B Formulations

• Liposomal amphotericin B (L-AmB) at 5-10 mg/kg/day is strongly recommended as the first-line treatment for all forms of mucormycosis 1, 2
• The full daily dose should be administered from the first treatment day rather than slowly increasing over several days 1
• For CNS involvement, L-AmB at 10 mg/kg/day is recommended based on animal models and clinical observations 1
• Amphotericin B lipid complex (ABLC) at 5 mg/kg/day can be used as an alternative for patients without CNS involvement 1, 2
• Conventional amphotericin B deoxycholate is discouraged due to substantial toxicity, especially at the doses needed for mucormycosis 1, 2

Alternative First-Line Options

• Isavuconazole is recommended with moderate strength as an alternative first-line treatment for mucormycosis 1, 2
• Posaconazole delayed release tablets and infusion are moderately supported for first-line treatment, while oral suspension is marginally supported 1

Surgical Management

• Surgical debridement or resection should be combined with antifungal therapy whenever possible 1
• Surgery is strongly recommended (AII evidence) for rhino-orbito-cerebral, soft tissue, and localized pulmonary lesions 1
• For disseminated disease, surgical intervention should be considered on a case-by-case basis (BII evidence) 1
• A multidisciplinary approach is recommended when considering surgical options 1

Management of Underlying Conditions

• Control of underlying conditions is critical and strongly recommended (AII evidence) 1
• Rapid correction of metabolic abnormalities is mandatory in uncontrolled diabetes 1
• Discontinuation or tapering of corticosteroids when feasible 1
• Reduction of immunosuppressive therapy when possible 1
• Use of hematopoietic growth factors (G-CSF, GM-CSF) if neutropenia is present 1
• Discontinuation of deferroxamine if applicable 1

Second-Line and Salvage Treatment

• Posaconazole 400 mg twice daily is recommended (BII evidence) for patients with treatment failure or intolerance to first-line therapy 1, 3
• Combination therapy with lipid formulation of amphotericin B and caspofungin is supported (BII evidence) 1
• Combination of lipid formulation of amphotericin B and posaconazole can be considered (CIII evidence) 1, 4
• Combination with deferasirox is NOT recommended (AI evidence) 1

Treatment Duration and Monitoring

• Treatment should continue until clinical and radiological resolution of infection 2
• For maintenance therapy, posaconazole is recommended (BIII evidence) 1
• Monitoring of serum drug levels might be indicated, especially for posaconazole 1
• When transitioning from amphotericin B to posaconazole, an overlap of at least 5 days is recommended to obtain appropriate serum levels 1

Special Considerations

• Immediate treatment initiation is strongly recommended in any immunocompromised patient with suspected mucormycosis 1
• Diagnostic procedures should not delay therapy initiation 1
• In patients with renal impairment, L-AmB is preferred over conventional amphotericin B formulations 2
• For patients with previous mucormycosis, surgical resection and continuation or restart of the last effective antifungal is strongly recommended for secondary prophylaxis 1

Common Pitfalls and Caveats

• Delaying treatment initiation significantly increases mortality - studies show a two-fold increase in 12-week mortality when treatment is delayed for 6 or more days 1
• Underdosing amphotericin B formulations may lead to treatment failure - ensure adequate dosing from the start 1, 2
• Renal toxicity may occur with high-dose L-AmB (10 mg/kg/day), but is mostly reversible; doses should not be reduced below 5 mg/kg/day unless absolutely necessary 1, 2
• Conventional amphotericin B deoxycholate has significant toxicity limitations and should only be used when no other options are available 1, 2, 5
• Fever of unknown origin alone is not sufficient to initiate treatment for mucormycosis 1