Optimization of Oral Posaconazole Step Down Therapy in Management of Rhino-Orbital-Cerebral Mucormycosis (ROCM): Outcome of an Institutional Protocol

Abstract

All cases of ROCM received antifungal for a prolong period in step down phase. There is no definite guidelines regarding duration. We have formulated and followed an institutional protocol with good results. To determine the outcome of an institutional protocol and required optimum duration of oral posaconazole therapy to cure ROCM in step down phase, 30 ROCM patients were followed up in step down phase. Oral posaconazole tablet was given for minimum 3, 4 & 1/2 and 6 months to stage-II, III & IV cases respectively, with a provision of extension for another 6 weeks in suspected active diseases. Nasal endoscopy, MRI, histopathology /culture of suspected tissue and hematologic investigations were done routinely to identify the residual active disease or recurrences at earliest. Outcome of this protocol proved excellent as all cases of ROCM were cured. Oral posaconazole step down therapy for a duration according to the stages of disease cured 18 cases (60%) of ROCM. Fourteen patients required extended duration of therapy as per provision of our treatment protocol. Only one patient needed re-debridement. The cases with deformities needed extended period of posaconazole therapy. No one needed posaconazole therapy for more than 7and1/2 months.

Mucormycosis: update on clinical presentation, diagnosis, and treatment

“…Posaconazole is often used as step-down therapy after AMB [73]. Posaconazole treatment of CAM has been associated with decreased in-hospital mortality [11 & ].…”

“…No robust studies have been published to inform us regarding the role, if any, of combination therapy or length of therapy. However, Mukherjee et al [73] attempted to answer this question by standardizing step-down and lengths of therapy protocols within their institution [73].…”