Pulmonary Mucormycosis with Pre-existing Renal Failure: What to Do When Initial Azole Therapy Achieves Only Partial or Stable Response
This protocol addresses pulmonary mucormycosis occurring in patients with pre-existing renal compromise or renal failure. In this population, azole-based antifungals are the preferred first-line approach. When that initial azole course does not produce an adequate imaging response, a structured salvage approach is required.
The previous treatment step combined early complete surgical debridement with first-line azole antifungal therapy (isavuconazole or posaconazole), chosen to avoid nephrotoxic alternatives in the setting of renal compromise. The goal of that line was an adequate response on imaging. The escalation trigger to this protocol is achieving only stable disease or a partial response at imaging reassessment — not the complete response required.
The aim is resolution of signs and symptoms of infection together with a complete response on imaging.
- In case of renal failure, posaconazole or isavuconazole were shown to be effective.
- Isavuconazole is strongly supported as salvage treatment.
- Posaconazole delayed release tablets or infusions are strongly supported for salvage treatment, and when available should be preferred over posaconazole oral suspension, which in turn is marginally supported for salvage treatment.
- The guideline group strongly supports treatment until permanent reversal of immunosuppression and complete response on imaging, which might be difficult to determine because of scarring and postoperative changes.