Combination therapy in invasive mucormycosis

Objectives: Mucormycosis is a rare and aggressive mold infection with an all-cause mortality of 54%. Treatment has historically been high-dose liposomal amphotericin B (LAmB) monotherapy. Recent data on combination therapies are conflicting, and their benefit remains unclear. This case series explores different combination therapies for mucormycosis and their effects on mortality. Materials and Methods: We report 17 cases of probable or proven mucormycosis managed with combination therapy for at least 48 h at University Hospital between March 2020 and November 2022. Results: The median age of patients was 60 years old (range 21–74), 11 patients were male (64.7%), and the median body mass index was 27.8 kg/m 2 . Of the 17 patients, all patients (100%) were Hispanic, nine patients (53%) had diabetes, and two patients (12%) were lung transplant recipients. The most common infection site was rhino-orbital (6/17; 35%), and surgery was performed on 11 patients (64.7%) after a median of 2 days after hospital admission. All 17 patients received LAmB with an average initial dose of 5.13 mg/kg/day (range 2.9– 6.4 mg/kg/day). All patients received combination therapy with either posaconazole (6/17; 35.2%), micafungin (4/17; 23.5%), or triple therapy (7/17; 41.2%). The duration of combination therapy was a median 6 days (range 2–21 days). Five of the 17 patients (29%) died of mucormycosis-related complications. Mortality observed in patients receiving combination therapy is as follows: micafungin combination (4/4; 100%), posaconazole combination (5/6; 83%), and triple therapy (0/7; 0%). Conclusion: Mucormycosis is an aggressive fungal infection with high morbidity and mortality requiring immediate recognition and medical intervention with an appropriate antifungal dosing regimen. Combination therapy with micafungin may be associated with higher mortality than posaconazole or triple therapy. In this cohort, combination therapy may have lower mortality than previously documented, but further investigation is needed to determine the optimal treatment for invasive mucormycosis.