What is the treatment for mucormycosis?

Treatment of Mucormycosis

The first-line treatment for mucormycosis is liposomal amphotericin B (L-AmB) at a dose of 5-10 mg/kg/day, combined with surgical debridement whenever possible and control of underlying conditions. 1

First-Line Antifungal Therapy

• Liposomal amphotericin B (L-AmB) at 5-10 mg/kg/day is the recommended 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 clinical evidence 1, 2
• Amphotericin B lipid complex (ABLC) at 5 mg/kg/day can be used as an alternative for patients without CNS involvement 1, 3
• Conventional amphotericin B deoxycholate is less preferred due to its toxicity profile but is still effective against Mucorales 4, 3

Surgical Management

• Surgical debridement or resection should be combined with antifungal therapy whenever possible 1, 3
• Surgery is strongly recommended (AII evidence) for:
  • Rhino-orbito-cerebral mucormycosis 3, 1
  • Soft tissue infections 3, 1
  • Localized pulmonary lesions 3, 1
• For disseminated disease, surgical intervention should be considered on a case-by-case basis (BII evidence) 3, 1

Management of Underlying Conditions

• Control of underlying conditions is critical (AII evidence) and must be addressed alongside antifungal therapy 3, 1
• Rapid correction of metabolic abnormalities is mandatory in uncontrolled diabetes 3, 1
• Corticosteroids should be discontinued if feasible, and other immunosuppressive drugs should be tapered 3, 1
• Use of hematopoietic growth factors (G-CSF, GM-CSF) if neutropenia is present 1, 3

Second-Line and Salvage Therapy

• Posaconazole 400 mg twice daily is recommended for second-line treatment (BII evidence) 3, 5
• Combination therapy options include:
  • Lipid amphotericin B plus caspofungin (BII evidence) 3, 1
  • Lipid amphotericin B plus posaconazole (CIII evidence) 3, 1
• Combination with deferasirox is NOT recommended (AI evidence) 3, 1
• Isavuconazole can be considered as an alternative first-line treatment with moderate strength of recommendation 1, 2

Treatment Duration and Monitoring

• Treatment should continue until clinical and radiological resolution of infection 2, 6
• Maintenance therapy with posaconazole is recommended after initial treatment (BIII evidence) 3, 1
• Monitoring of serum levels might be indicated when using posaconazole 3
• Overlap of at least 5 days between first-line therapy and posaconazole is recommended to obtain appropriate serum levels 3

Common Pitfalls and Caveats

• Delaying treatment initiation significantly increases mortality - studies show a two-fold increase in mortality when treatment is delayed for 6 or more days 1, 7
• 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
• Diagnostic procedures should not delay therapy initiation in suspected cases 1, 7

Efficacy Data

• Amphotericin B has shown excellent activity against Mucorales in vitro, with most strains displaying MICs near the suggested breakpoint of ≤1 mg/mL 3
• In a review of 120 mucormycosis cases in patients with hematological malignancies, the survival rate was 67% in patients treated with L-AmB compared with 39% in those treated with amphotericin B deoxycholate (P=0.02) 3
• In an Italian retrospective study of 59 patients with hematological malignancy and proven or probable mucormycosis, the response rate was 23% in patients who received amphotericin B deoxycholate compared with 58% in those treated with L-AmB 3
• Posaconazole has been successfully used in 96 case reports, with complete response achieved in 64.6% of cases, primarily as combination or second-line therapy 5