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Govt issues guidelines on Mucormycosis/black fungus in children: Details of treatment, medicines

The Directorate General of Health Services (DGHS) under the Union Ministry of Health and Family Welfare has issued guidelines for the management of Mucormycosis/black fungus disease in children below 18 years.

As per the government, Mucormycosis or black fungus is a complication caused by fungal infection. People catch mucormycosis by coming in contact with the fungal spores in the environment. It can also develop on the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma. What is more worrying is that the fungal complication is being detected in several COVID-19 patients.

The government advised that one should now wait for culture results to initiate therapy as mucormycosis is an emergency and early complete surgical debridement is the cornerstone of treatment and may be repeated as required.

Mucormycosis treatment: Here’s what DGHS advises

Conventional Amphotericin B (deoxycholate) as a prolonged IV infusion through a central venous catheter or PICC; closely monitor kidney function and electrolytes during treatment

Reconstitute in water for injection, and dilute in 5% dextrose (do not use normal saline/Ringer’s lactate); start with test dose: 1 mg IV infusion over 20-30 min

Loading dose: 0.25–0.5 mg/kg IV infused over 2-6 hours; gradually increase by 0.25 mg-increments/day to reach maintenance dose: 1–1.5 mg/kg/day

Liposomal Amphotericin B or Amphotericin lipid complex: Prolonged infusion over 2–3 hours through a central venous catheter or PICC and closely monitoring KFT and electrolytes
Reconstitute in water for injection, and dilute in 5% dextrose (do not use normal saline/Ringer’s lactate); start full dose from first day; 5 mg/kg/day (10 mg/kg/day in case of CNS involvement)
Continue till a favourable response is achieved which may take 3-6 weeks following which step down to oral Posaconazole (delayed release tablets, children ≥3 years and adolescents ≤17 years: 5-7 mg/kg/dose twice daily on day 1, followed by 5 to 7 mg/kg/dose daily) or Isavuconazole (not approved below 18 years of age, however if required to be given, the dose for weight >30kg: 200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily, <30kg: half the dose for >30 kg children) may have to be taken for prolonged period as per advice of pediatrician, the DGHS release said.

Posaconazole should be given as salvage therapy in cases who cannot be given Amphotericin B

Injection IV

Children <11 years: Loading dose: 7-12 mg/kg/dose IV twice on the first day and maintenance dose: 7-12 mg/kg IV once a day, starting on second day (max: 300 mg/dose)

Adolescents: 300 mg IV twice on the first day and maintenance dose 300 mg IV once a day, starting on the second day

Oral delayed release tablets (100 mg) and Oral Suspension (for infants and smaller children) to be administered with fatty food:

Oral delayed release tablets: Children 7 to 12 years – Initial dose should be 200 mg/dose thrice daily and maximum dose can be 800 mg/day

Adolescents: 300 mg/dose twice on day 1, followed by 300 mg/dose once daily
Oral suspension (for infants and children) as syrup in a strength of 40 mg/ml. The recommended dose for children with body weight <34 kg is 4.5 to 6 mg/kg/dose 4 times daily.

Maximum dose 800 mg/day: For those children and adolescents with body weights >34 kg the dose is 200 mg/dose 3 times daily (maximum 200 mg 4 times a day).

 

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