What is the treatment for mucormycosis?

Treatment of Mucormycosis

Liposomal amphotericin B (L-AmB) at 5-10 mg/kg/day is the first-line treatment for mucormycosis, combined with aggressive surgical debridement whenever feasible and rapid correction of underlying predisposing conditions. 1, 2

First-Line Antifungal Therapy

• Administer the full daily dose of L-AmB (5-10 mg/kg/day) from day one—do not slowly escalate the dose over several days, as delays significantly worsen mortality 1, 2
• For CNS involvement, escalate to L-AmB 10 mg/kg/day immediately based on clinical evidence showing improved CNS penetration at higher doses 1, 2, 3
• Amphotericin B lipid complex (ABLC) at 5 mg/kg/day is an acceptable alternative for patients without CNS involvement 1, 2
• Isavuconazole can be considered as an alternative first-line agent with moderate strength of evidence 2
• Conventional amphotericin B deoxycholate should be avoided due to severe nephrotoxicity and inferior survival rates (39% vs 67% with L-AmB) 1, 3

Surgical Management

• Surgery is mandatory (AII evidence) for rhino-orbito-cerebral mucormycosis, soft tissue infections, and localized pulmonary lesions—antifungal therapy alone is insufficient 1, 2, 3
• Surgical debridement or resection should be performed as early as possible, as delays of 6 or more days double 12-week mortality 2
• For disseminated disease, evaluate surgical options on a case-by-case basis, prioritizing resectable lesions 2

Management of Underlying Conditions (Critical Component)

• Rapidly correct metabolic abnormalities in diabetic patients—uncontrolled hyperglycemia and acidosis fuel fungal growth 4, 1, 2
• Discontinue corticosteroids immediately if feasible, or taper to the lowest possible dose 4, 1, 2
• Reduce other immunosuppressive medications as much as clinically tolerable 4, 2
• Administer G-CSF or GM-CSF if neutropenia is present to enhance immune response 2

Second-Line and Salvage Therapy

• Posaconazole 400 mg twice daily (oral or IV) is the recommended salvage therapy (BII evidence) for patients who fail or cannot tolerate amphotericin B 1, 3
• Combination therapy options include:
  • L-AmB plus caspofungin (BII evidence) 1, 2
  • L-AmB plus posaconazole (CIII evidence) 1, 2
• Do NOT use deferasirox in combination (AI evidence against)—despite theoretical benefits of iron chelation, clinical trials showed no benefit 1

Treatment Duration and Monitoring

• Continue antifungal therapy until complete clinical and radiological resolution of infection, which typically requires months of treatment 1, 3
• Maintenance therapy with posaconazole is recommended after initial treatment (BIII evidence) to prevent relapse, especially in persistently immunosuppressed patients 1, 2
• For patients with previous mucormycosis, surgical resection and continuation of the last effective antifungal is strongly recommended for secondary prophylaxis 2

Critical Pitfalls to Avoid

• Never delay treatment initiation while awaiting diagnostic confirmation—start L-AmB immediately in any immunocompromised patient with suspected mucormycosis, as even a 6-day delay doubles mortality 2
• Do not underdose amphotericin B—inadequate dosing (below 5 mg/kg/day) leads to treatment failure 2
• Blood cultures are almost always negative in mucormycosis; their positivity should raise suspicion for contamination rather than reassure you of the diagnosis 4
• While renal toxicity may occur with high-dose L-AmB (10 mg/kg/day), it is mostly reversible and should not prompt dose reduction below 5 mg/kg/day unless absolutely necessary 2
• Diagnostic procedures should never delay therapy initiation—begin treatment based on clinical suspicion and adjust if cultures or histopathology reveal an alternative diagnosis 2