A multicenter observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India

Abstract Objectives To describe the epidemiology, management, and outcome of subjects with mucormycosis; and, to evaluate the risk factors associated with mortality. Methods We conducted a prospective observational study involving consecutive subjects with proven mucormycosis across 12 centers from India. The demographic profile, microbiology, predisposing factors, management, and 90-day mortality were recorded; risk factors for mortality were analyzed. Results We included 465 subjects. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the subjects. Amphotericin B was the primary therapy in 81.9% (381/465), while posaconazole was used as combination therapy in 53 (11.4%) subjects. Antifungal therapy was inappropriate in 7.6% (30/394) of the subjects. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (vs. liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival. Conclusions Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.