Zygomycosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

If mucormycosis is suspected, prompt amphotericin B therapy should be administered due to the rapid spread and mortality rate of the disease. Amphotericin B (which works by damaging the cell walls of the fungi) is usually administered for a further 4-6 weeks after initial therapy begins to ensure eradication of the infection. Posaconazole has been shown to be effective against mucormycosis, perhaps more so than amphotericin B, but has not yet replaced it as the standard of care. After administration the patient must then be admitted to surgery for removal of the "fungus ball". The disease must be monitored carefully for any signs of reemergence. Treatment for skin lesions is traditionally with potassium iodide,[1] but itraconazole has also been used successfully.[2][3]

Treatment

Antimicrobial Regimen[4]

Treatment include surgical debridement of involved tissues, antifungal therapy, use of growth factors to accelerate recovery from neutropenia, provision of granulocyte transfusions with sustained circulating neutrophils until the patient recovers from neutropenia, and discontinuation or reduction in the dose of glucocorticoids, correction of metabolic acidosis and hyperglycemia.

  • Preferred regimen (1): Amphotericin B Deoxycholate 1.0-1.5 mg/kg/day IV q24h
  • Preferred regimen (2): Lipid Amphotericin B 5-10 mg/kg/day IV q24h
  • Preferred regimen (3): Amphotericin B lipid complex 5-7.5 mg/kg/day IV q24h
  • Alternative regimen (1):Caspofungin 70 mg IV load dose, 50 mg/day for >2 weeks PLUS Lipid Amphotericin B 5-10 mg/kg/day IV q24h
  • Alternative regimen (3): Deferasirox 20 mg/kg PO qd for 2–4 weeks PLUS Lipid Amphotericin B 5-10 mg/kg/day IV q24h
  • Alternative regimen (4): Posaconazole 800 mg/day PO qid or bid
  • Alternative regimen (5): Initial: Isavuconazole 200 mg PO/IV q8h for 6 doses; maintenance: 200 mg PO/IV qd
  • Note (1): start maintenance dose 12 to 24 hours after the last loading dose.
  • Note (2): For salvage therapy: (Posaconazole 800 mg/day PO qid or bid ± Lipid Amphotericin B 5-10 mg/kg/day IV q24h) OR (Deferasirox 20 mg/kg PO qd for 2–4 weeks PLUS Lipid Amphotericin B 5-10 mg/kg/day IV q24h) OR Granulocyte transfusions (for persistently neutropenic patients) ∼10ˆ9 cells/kg OR Recombinant cytokines G-CSF 5 μg/kg/day, GM-CSF 100–250 μg/m², or IFN-g at 50 μg/m² for those with body surface area ≥ 0.5 m² and 1.5 μg/kg for those with body surface area <0.5 m²

References

  1. Nazir Z, Hasan R, Pervaiz S, Alam M, Moazam F (1997). "Invasive retroperitoneal infection due to Basidiobolus ranarum with response to potassium iodide--case report and review of the literature". Ann Trop Paediatr. 17 (2): 161–4. PMID 9230980.
  2. Yusuf NW, Assaf HM, Rotowa N (2003). "Invasive gastrointestinal Basidiobolus ranarum infection in an immunocompetent child (brief report)". Ped Infect Dis J. 22 (3): 281&ndash, 82.
  3. Mathew RM, Kumaravel S, Kuruvilla S; et al. (2005). "Successful treatment of extensive basidiobolomycosis with oral itraconazole in a child". Int J Dermatol. 44 (7): 572&ndash, 75.
  4. Spellberg B, Walsh TJ, Kontoyiannis DP, Edwards J, Ibrahim AS (2009). "Recent advances in the management of mucormycosis: from bench to bedside". Clin. Infect. Dis. 48 (12): 1743–51. doi:10.1086/599105. PMC 2809216. PMID 19435437.



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