Which medications are used in the treatment of mucormycosis (zygomycosis)?

Updated: Jul 06, 2021
  • Author: Avnish Sandhu, DO; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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The 2 main classes of antifungal medications used to treat mucormycosis are the polyenes (amphotericin formulations) and triazoles (isavuconazole and posaconazole). Amphotericin B and isavuconazole are the 2 agents currently FDA approved for the primary therapy of mucormycosis. Posaconazole can be used off-label for salvage treatment in patients intolerant to amphotericin B. It has also been used as step-down therapy after initial control of the disease with amphotericin. [95, 96]

In patients with hematologic malignancy, posaconazole is superior to other triazoles as prophylaxis for invasive mold infection. Isavuconazole is a novel triazole antifungal agent with many advantages, including excellent oral bioavailability, linear and predictable pharmacokinetics, and minimal CYP450 interactions. [89]  Owing to its safety, tolerability, and comparable efficacy to amphotericin B, [86]  isavuconazole is promising as a primary and salvage therapy. Further study is needed prior to its use as primary mold prophylaxis in the setting of prolonged neutropenia.

Echinocandin agents, including anidulafungin, caspofungin, and micafungin, competitively inhibit the beta-1,3-D-glucan synthase enzyme complex. In Candida species, beta-glucan depletion causes cell lysis via loss of resistance to osmotic force; in Aspergillus, it is fungistatic owing to impaired growth at hyphal branching points. Echinocandins have minimal activity against the Mucorales, which contain little or no beta-1,3-D-glucan. Some studies have suggested combination therapy with amphotericin and an echinocandin may improve survival; however, a more recent retrospective study showed no such mortality benefit. There is no current evidence-based recommendation for the addition of an echinocandin to amphotericin B or isavuconazole for the treatment of mucormycosis.

The benefit of combination therapy with different classes of antifungals (including echinocandins) is uncertain. Despite advances in medical management, surgical evaluation is essential in the management of mucormycosis, and overall mortality rates remain high.

See the Treatment section for further discussion of individual antifungal agents.

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