best method to control Mucor mycosis at a ICU set up especially is cases of COVID19 patients?
1. early initiation of therapy: IV Liposomal
Amphotericin B ,5-10mg/kg ( less nephrotoxic and better CNS penetration. Still daily monitoring of renal function is needed.
(Or)
Second line agents like 200 mg of isavuconazole, PO , load q8h × 6 followed by once-daily dosing
2. surgical debridement, when possible reduces the fungal load
3. rapid reversal of underlying predisposing risk factors, like in case of covid judicious administration of steroids and proper glycemic control in diabetic patients.
Prophylaxis
Use distilled water in O2 humidifiers
Do not over fill humidifiers
Strict control of the blood sugars
Steroids should be used judiciously
There are various strategies that need to be adopted to control mucor in ICU patients-
1. First is treatment with amphotericin B, followed by posaconazole in amphotericin resistant or intolerant patients.
2. Cautious potassium levels and RFT monitoring to watch for associated hypokalemia and timely correction of the same.
3. Using well-sterilized HME filters and distilled water use in humidifiers as these can be a major source of fungal infection in ventilated patients in ICU.
4. Appropriate surgical debridement as soon as possible to contain the progression of infection.
5. Last but not the least, close RBS monitoring and optimum glycemic control in all diabetic patients.
Control blood sugar. Keep target blood sugar 140-180 mg
Maxillary sinuses are usually the source of infection, so early start of amphotericin followed by nasal/sinus surgical debridement is mandatory. Just medical treatment may not be enough... If early control is not achieved, mucor can disseminate and may require more sugical plus antifungals interventions especially luns, brain, orbits etc...
Depends on how early the disease can be been picked up. Mucor in COVID 19 patients develop due to multiple reasons- sudden rise in blood sugar and development of diabetic ketoacidosis , deranged iron metabolism, high dose of steroids comprosing the immune system.
Few studies have shown that mucor are present in improperly cleaned bed linen and has been responsible for mucor outbreaks in the past.
Prophylactically speaking, the use of steroids and monitoring of blood sugars must be done very carefully. Few guidelines have also been formulated for keeping in check the surge of blood sugar.
Many believe that contaminated oxygen masks and humidifiers also act as a source of mucor. Making it a communicable disease amongst immunocompromised patients. In developing countries the use of tap water as humidifying agent may be another source of mucorales. Few have advocated methylene blue dye in the humidifier to stop fungus.
Ideally all high risk patients- diabetic, those with fluctuating blood sugars, chronic debilitated, history of transplant and receiving O2 therapy should be screened for early signs of Mucor on a regular basis.
Once the disease sets in and reaches the orbit its very difficult to manage even with Amphotericin B or posaconazole and most require surgical debridement with or without exenteration.
Use of Ultra pure water ( Genome free) in O2 humidifiers.
Do not over fill humidifiers, and replace water on regular basis.