Part 2: mucormycosis: focus on therapy

ABSTRACT

Introduction

Mucormycosis (MCR), a rare but life-threatening infection, occurs primarily in immunocompromised hosts. Mortality rates with invasive MCR are high (>30–50%), up to 90% with disseminated disease, but lower (10–30%) with localized cutaneous disease. Due to the rarity of MCR, randomized, controlled therapeutic trials are lacking. Lipid formulations of amphotericin B (LFAB) are the mainstay of therapy, but oral triazoles (posaconazole and isavuconazole) may be effective as step-down therapy or in MCR cases refractory to or intolerant of LFAB. Early surgical debridement or excision plays important adjunctive roles in localized invasive disease. Control of hyperglycemia in diabetic patients, correction of neutropenia, and reduction of immunosuppressive therapy are critical for optimal survival.

Areas covered

The authors discuss various therapeutic options for mucormycosis. A literature search of mucormycosis therapies was performed via PubMed (up to December 2022), using the following keywords: invasive fungal infections; mold; mucormycosis; Mucorales; amphotericin B; isavuconazole; and posaconazole.

Expert opinion

Randomized, controlled therapeutic trials are lacking. Lipid formulations of amphotericin B (LFAB) are the mainstay of therapy, but oral triazoles (posaconazole and isavuconazole) may be effective as step-down therapy, in MCR cases refractory to or intolerant of LFAB. We encourage early surgical debridement or excision as adjunctive measures.

KEYWORDS:

• Invasive fungal infections
• mold
• mucormycosis
• Mucorales
• amphotericin B
• isavuconazole
• posaconazole

Article highlights

• Assessment of optimal therapy for mucormycosis (MCR) is difficult, owing to the retrospective nature of most trials, heterogeneous patient populations, delayed diagnosis, and various treatment regimens.

• Conclusions regarding optimal therapy for MCR are based on clinical experience from numerous large studies that are mostly retrospective.

• A multidisciplinary approach including consultants with expertise in MCR is vital.

• Early initiation of antifungal agent(s) coupled with aggressive resection of necrotic tissue can be sightsaving and lifesaving.

• Lipid formulations of amphotericin B (LFAB) are the mainstay of therapy, but oral triazoles (posaconazole and isavuconazole) may be effective as step-down therapy or in MCR cases refractory to or intolerant of LFAB.

• Currently, insufficient data are available to support combination antifungal therapy in humans.

• Early surgical debridement or excision plays important adjunctive roles in localized invasive disease.

• Prompt reversal of underlying risk factors (e.g. hyperglycemia, acidosis, neutropenia, corticosteroids, or immunosuppressive therapy) is vital for optimal outcome.

Declaration of interest

GG Zhanel has received research funding from Avir, Iterum, Merck & Co, Paladin labs, Pfizer Inc., Sandoz, Venatorx, Verity, and Zambon. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contribution statement

Both authors have substantially contributed to the conception, design of the review article, interpreting the relevant literature, and writing the review article.

Additional information

Funding

This paper was not funded.