A Patel1, H Kaur2, I Xess3, J S Michael4, J Savio5, S Rudramurthy2, R Singh6, P Shastri7, P Umabala8, R Sardana9, A Kindo10, M R Capoor11, S Mohan12, V Muthu13, R Agarwal13, A Chakrabarti14. 1. Department of Infectious Diseases, Sterling Hospital, Ahmedabad, India; Department of Internal Medicine, University of South Florida, Tampa, FL, USA. 2. Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 3. Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India. 4. Department of Clinical Microbiology, Christian Medical College, Vellore, India. 5. St John's Medical College Hospital, Bangalore, India. 6. Department of Microbiology, JIPMER, Pondicherry, India. 7. Intensive Care Medicine, Sir Ganga Ram Hospital, New Delhi, India. 8. Department of Microbiology, Nizam's Institute of Medical Sciences, Hyderabad, India. 9. Department of Microbiology, Indraprastha Apollo Hospital, New Delhi, India. 10. Department of Microbiology, Sri Ramachandra Medical College, Chennai, India. 11. Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, India. 12. Department of Microbiology, Christian Medical College, Ludhiana, India. 13. Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 14. Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Electronic address: arunaloke@hotmail.com.
Abstract
OBJECTIVES: To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality. METHODS: We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed. RESULTS: We included 465 patients. 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 participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. 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 (versus 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.
OBJECTIVES: To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality. METHODS: We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed. RESULTS: We included 465 patients. 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 participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. 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 (versus 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.