अखिल भारतीय आय ु विान संथान, एस ऋिके श All India Institute of Medical Sciences Rishikesh, Uttarakhand, India, 249203 @Multidisciplinary Mucor management team_Version 1.0_16.05.2021 (AIIMS Rishikesh) 1 Management Protocol For Mucormycosis A diagnosis we cannot afford to miss Institutional Strategies: 1. A multidisciplinary team is constituted for managing mucormycosis cases with following responsibilities: Assessing time to time situations Providing guidelines for prevention and treatment Managing patients admitted at AIIMS Rishikesh To give public-oriented messages for awareness 2. All mucormycosis cases will be admitted in a separate Mucor ward (having CCU beds, HDU, general beds) and it will be managed by multidisciplinary team comprising department of ENT, Medicine, Oral and maxillofacial surgery, Ophthalmology, Neurosurgery, Pediatrics, Paediatric surgery, Microbiology, Pharmacology, Community and Family Medicine, and other departments as per organ involvement. 4. Separate ward, OT, or extra OT are to be arranged as per clinical load. 5. Multidisciplinary team will facilitate steps for prevention and early diagnosis with rapid initiation of antifungal therapy and aggressive early surgical debridement with optimal correction of co- morbidities.
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अखिल भारतीय आयरु्विज्ञान ससं्थान, एम्स ऋर्िकेश
All India Institute of Medical Sciences Rishikesh, Uttarakhand, India, 249203
Sample collection according to the site of Mucormycosis
Specimen Collection Unacceptable specimen
ROCM Scraping or exudate from nares, hard palatal lesions, sinus material, biopsy from extracted tooth socket area. Endoscopic collection of debrided tissue/biopsy
Nasal dry swabs
Cutaneous Aspirations collected with sterile needle and syringe from undrained abscess. Pus expressed from abscess opened with scalpel; transported to laboratory either in sterile container/syringe and needle Tissue should be collected from both centre and edge of the lesion.
Swab or materials from open wound dry swabs
Pulmonary Sputum
Bronchial brush washing/ broncho-alveolar lavage (BAL) Lung biopsy- Collected by bronchoscope, Fluoroscope guided trans-thoracic needle aspiration or open lung biopsy
Second line- AZOLE Derivatives (Step Down or Salvage Therapy) Posaconazole is broad-spectrum azoles available in both parenteral and oral formulations.
Dosage:
- 200 mg four times per day
- Alternatively, posaconazole delayed-release tablets (300 mg every 12 hours on first day, then
300 mg once daily) taken with food.
Amphotericin B administration and monitoring protocol
Drugs Recommended Dose
Duration
Inj Amphotericin B
Deoxycholate (C-
AmB):
1.0-1.5 mg/kg/day
14 to 21 days depending on severity/till clinical resolution and radiological stabilization; after 14days of therapy, shift to oral Posaconazole if clinically stable.
Inj Liposomal
amphotericin B
(LAmB):
5-10mg/kg/day
Inj Amphotericin B
lipid complex (ABLC)
5mg/kg/day
Inj Liposomal amphotericin B (LAmB):
Premedication Complications K + correction
Urea Creatinine Na K Mg
Amphotericin Monitoring Chart(To be filled daily) Patient name : …………………………………..
Serum ElectrolytesCumulative
dose
Dose
givenName of the drug Date
Starting
time
Ending
timeSr. No.
Test dose
•Inj. Liposomal Amphotericin- B 1 vial (50 mg) to be diluted in 12 ml of the diluent and 0.25ml (1 mg) of solution made, to be mixed in 100ml Dextrose and to be infused in 30 minutes.
•Observe for fever and reactions
Pre-hydration
•500 mL NS over 30 minutes
•To reduce the risk of renal toxicity and hypokalaemia :- 500ml Normal Saline + 1 Amp (20mmol) KCL
Therapeutic dose
•5mg-10 mg /kg/day Amphotericin B in 500 mL D5 with 10 Units HIR over 3 hrs (To be covered in black sheet)
Post Hydration
•500 mL NS over 30 minutes
Post dose
•KFT with Serum electrolytes after Every dose of Amphotericin B
•Fill Amphotericin monitoring chart
अखिल भारतीय आयरु्विज्ञान ससं्थान, एम्स ऋर्िकेश
All India Institute of Medical Sciences Rishikesh, Uttarakhand, India, 249203
Fill up to about 10 mm below the maximum fill line
Do not let the water level pass below the maximum fill line
Water level should be checked twice daily and topped up when required
Water in the humidifier should be changed daily
Humidifier should be washed in mild soapy water, rinsed with clean water and dried in air
before reuse
Once a week (for the same patient) and in between patients, all the components of the
humidifier should be soaked in mild antiseptic solution for 30 minutes, rinsed with clean
water and dried in air.
Enviromental cleanliness to have NO exposure to decaying organic matters like breads/fruits/vegetables/soil/compost/excreta/etc
Control hyperglycemia
Glucose monitoring in COVID-19 patients requiring steroid therapy
Optimally steroid usage - right timing of initiation, right dose, and right duration
Use clean distilled water for humidifiers during oxygen therapy
Use antibiotics/antifungals only and only when indicated
Do not consider all the cases with blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators
Simple tests like pupillary reaction, ocular motility, sinus tenderness and palatal examination should be a part of routine physical evaluation of a COVID-19 patient.
अखिल भारतीय आयरु्विज्ञान ससं्थान, एम्स ऋर्िकेश
All India Institute of Medical Sciences Rishikesh, Uttarakhand, India, 249203
1. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases - 9th Edition. 2020. E-Book
2. Oliver A Cornely, Ana Alastruey-Izquierdo, Dorothee Arenz, Sharon C A Chen, Eric Dannaoui, Bruno Hochhegger et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.The Lancet Infectious Diseases. 2019;19 (12):e405-e421. Available from: https://doi.org/10.1016/S1473-3099(19)30312-3.
3. Mucormycosis (zygomycosis): Available from: https://www.uptodate.com/contents/mucormycosis-zygomycosis?source=history_widget.
4. Evidence Based Advisory In The Time Of Covid-19: Available from: https://www.icmr.gov.in/pdf/covid/techdoc/Mucormycosis_ADVISORY_FROM_ICMR_In_COVID19_time.pdf
5. Honavar SG. Code Mucor: Guidelines for the Diagnosis, Staging and Management of Rhino-Orbito-Cerebral Mucormycosis in the Setting of COVID-19. Indian J Ophthalmol 2021;69:1361-5.
6. Treatment Protocol For Mucormycosis In Adult Patients- By Expert Committee of Civil Hospital, Ahmedabad
ACKNOWLEDGMENT
I would like to thank Director and CEO Padmashri Prof Ravi Kant for providing me opportunity to be part of
institute MUCOR management team as Team leader. I would like to thank MS Prof Binaya Kumar Bastiya
DHA Prof U.B.Mishra, and Dean (A) Prof Manoj Gupta for their invaluable support. I would like to thank Dr
PK Panda, COVID nodal officer, Department of internal medicine for his invaluable support. I would like to
thank my faculty colleagues in various departments. I would like to thank the Senior Residents and Junior
Residents of Department of ENT and other departments and Nursing officers, ward attendants, Guards, and
housekeeping staffs posted in MUCOR ward for their role in management of the patients. Last I would like
to acknowledge the role of the following departments in preparing the institute protocol for MUCOR
management at present:
1. Department of ENT, AIIMS Rishikesh 2. Department of Internal Medicine, AIIMS Rishikesh 3. Department of Ophthalmology, AIIMS Rishikesh 4. Department of Maxillofacial Surgery, AIIMS Rishikesh 5. Department of Neurosurgery, AIIMS Rishikesh 6. Department of Microbiology, AIIMS Rishikesh 7. Department of Anaesthesia, AIIMS Rishikesh 8. Department of Pediatrics, AIIMS Rishikesh 9. Department of Pediatric Surgery, AIIMS Rishikesh 10. Department of Pharmacology, AIIMS Rishikesh 11. Department of CFM, AIIMS Rishikesh