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Int J Antimicrob Agents. 2019 Jan 9. pii: S0924-8579(19)30002-0. doi: 10.1016/j.ijantimicag.2019.01.002. [Epub ahead of print]

The contemporary management and clinical outcomes of mucormycosis: a systematic review and meta-analysis of case reports.

Author information

1
Centre for Medicine Use and Safety, Monash University, 381 Royal Pde, Parkville, VIC 3052, Australia.
2
Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology, Westmead Hospital, The University of Sydney, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia; Marie Bashir Institute for Biosecurity and Emerging Infections, The University of Sydney, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia.
3
Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia.
4
National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia.
5
Centre for Medicine Use and Safety, Monash University, 381 Royal Pde, Parkville, VIC 3052, Australia; Pharmacy Department, Ballarat Health Services, 1 Drummon St N, Ballarat Central, VIC 3350, Australia; The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia. Electronic address: david.kong@monash.edu.

Abstract

The optimum treatment of mucormycosis with the advent of newer antifungals remains to be fully elucidated. This study aims to systematically evaluate the contemporary management and outcomes of mucormycosis. Cases of mucormycosis in patients ≥18 years old, published between January 2000 and January 2017 were identified through Ovid MEDLINE and Ovid EMBASE. Of the 3619 articles identified, 600 (851 individual patient cases) were included in the review. Of these 851 patient cases, treatment details were available for 785. Intravenous (IV) amphotericin B formulations remained the most commonly prescribed first-line antifungal (760/785, 97%): 88% (670/760) were initiated as mono-therapy and 12% (90/760) as combination antifungal therapies. Posaconazole oral suspension mono-therapy was prescribed as an initial antifungal in 11 cases. It was also administered as maintenance or salvage therapy in 39 or 25 cases, respectively. Itraconazole capsule mono-therapy (n=10) was prescribed primarily for cutaneous disease in patients not receiving any immunosuppressive therapy. All cause 90-day mortality was 41% (349/851). Initial treatment with combination antifungals did not reduce 90-day mortality, when compared to IV conventional amphotericin B or IV liposomal amphotericin B mono-therapy [35/90 (39%) versus 146/369 (40%) versus 91/258 (35%), respectively; P=0.54]. Concomitant surgical and antifungal therapy was associated with significantly lower 90-day mortality compared to treatment with antifungals alone (OR 0.23, 95%CI 0.13-0.41; P<0.001). Our findings suggested that first-line antifungals with good efficacy remain an urgent unmet need. Whilst surgery is fundamental to improving survival, the clinical utility of combination antifungal therapies or posaconazole mono-therapy requires further investigation.

KEYWORDS:

Mucorales; Outcomes; Systematic review; Treatment; mucormycosis

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