Now, a new study published in Frontiers in Health Services has examined how these patients were actually treated and what happened to them after they left the hospital. Researchers led by Ruchi Baghel and Megha Sharma at R. D. Gardi Medical College in Ujjain, Madhya Pradesh, in collaboration with Karolinska Institutet in Stockholm, extracted clinical data from the medical records of 108 biopsy-proven ROCM inpatients admitted between May and July 2021 at two COVID-19-dedicated hospitals, one private and one public, in Central India. Two years later, in early 2023, the team conducted a Mobile-Based Post-Discharge follow-up, telephoning survivors using a structured 27-question instrument drafted in Hindi and validated through pilot testing and back-translation. The ambispective design, reported according to the STROBE statement, integrated retrospective record analysis with prospective patient-reported experiences, aiming to fill a critical gap: post-discharge follow-up is rarely part of mucormycosis treatment strategies, despite the long-term sequelae survivors face, including facial deformities, neurological deficits, and psychological impacts.

The pharmacological picture that emerged from the medical records was dominated by two antifungal agents. Of the 108 patients, 90 received at least one antifungal: 71 percent were prescribed liposomal amphotericin B, the guideline-recommended drug of choice with broad-spectrum activity against Mucorales, and 75 percent received posaconazole, which was often used as an alternative or step-down therapy amid supply shortages and the nephrotoxicity associated with amphotericin formulations. The mean duration of treatment with both agents was 16 days. Notably, 64 percent of patients received a combination of two or more antifungals, even though current global and national guidelines do not recommend concurrent use of two systemic antifungal agents for mucormycosis, because robust clinical data supporting combination therapy are lacking. A propensity score analysis of 106 patients with hematologic malignancies had previously shown that combination therapy did not improve outcomes compared with monotherapy, while unavoidably increasing the incidence of adverse drug reactions. The researchers suggest that the prescribing patterns in their cohort reflected real-world treatment constraints during the pandemic, guided by drug availability, patient tolerance, and evolving consensus rather than evidence-based preference.

Antibiotic prescribing was equally revealing. The study population received an average of two antibiotics per patient, with ceftriaxone and its fixed-dose combination with sulbactam the most frequently prescribed substances. Nearly half of the antibiotics were administered parenterally, reflecting the preference for intravenous therapy in severe infections. When the prescriptions were audited against the WHO AWaRe classification, which categorizes antibiotics into Access, Watch, and Reserve groups based on their potential to drive antimicrobial resistance, Access antibiotics constituted only 40 percent of prescriptions, well below the WHO target of at least 60 percent. Watch antibiotics accounted for 39 percent and Reserve antibiotics 8 percent, while 13 percent of prescriptions were WHO Not Recommended fixed-dose combinations that lack evidence-based indications in international guidelines. The authors attribute this pattern to the exceptional circumstances of the pandemic, including diagnostic uncertainty, high patient burden, and empiric treatment of suspected secondary bacterial infections, and call for pandemic-specific antimicrobial stewardship policies to promote rational antibiotic use during future public health emergencies.

Adverse drug reactions were identified through active surveillance of deranged laboratory parameters, as no spontaneous reports reached the ADR Monitoring Center during the study period. Among the 108 inpatients, 68 percent had deranged laboratory values, with hyponatremia in 46 percent and hypokalemia in 44 percent. Overall, 97 ADRs were observed in 73 patients, an average of 1.3 per patient. All were categorized as possible on the WHO causality assessment scale, since limited clinical information and concomitant polypharmacy made it difficult to establish definite causal relationships with individual drugs. On the modified Hartwig and Siegel severity scale, 72 percent of the reactions were mild and 28 percent moderate. Hypokalemia is a well-recognized effect of liposomal amphotericin B and has also been reported with posaconazole, along with hepatic enzyme elevations. Because both antifungals were often administered concomitantly, the laboratory abnormalities could not be attributed to either drug individually, underscoring the importance of daily monitoring of electrolytes, renal function, and liver enzymes during therapy, which the study hospitals did perform.

The comorbidity profile highlighted the central role of hyperglycemia. Diabetes mellitus, alone or with other conditions, was present in 32 percent of patients, while 42 percent had a history of COVID-19 infection and only 14 percent had documented steroid use before admission. The relatively low steroid prevalence suggests that diabetes, rather than corticosteroid exposure, may have been the dominant driver of mucormycosis pathogenesis in this Central Indian cohort, consistent with multicentric evidence that diabetes prevalence is rising rapidly in the region. Diabetes-related immune dysfunction creates a favorable environment for Mucorales fungi to grow. All 108 patients underwent endoscopic surgical debridement, including Denker’s and Modified Denker’s procedures, with orbital exenteration in 23 percent of cases. The median length of hospital stay was 14 days, shorter than the 22 to 24.5 days reported in other Indian and United States studies, which the authors attribute to the rhino-orbital disease spectrum, timely intervention, and the fact that about a quarter of patients were referred elsewhere to continue treatment.

The most striking findings came from the mobile-based follow-up conducted two years after hospitalization. Of the 97 survivors, 17 had incomplete or incorrect phone numbers in their records, and 19 of the remaining 80 never answered despite repeated attempts. Ultimately, 61 of the 80 contacted respondents consented to participate, a 76 percent response rate, with 51 calls answered by patients themselves and 10 by family members. Fifty-two of the 61 respondents reported 123 post-discharge adversities, averaging 2.4 per patient. The most frequent were hypokalemia at 22 percent, vomiting at 13 percent, and nausea at 11 percent. Nine respondents, 7 percent of the cohort, confirmed deaths after discharge, revealing post-discharge mortality that likely would have gone unreported without the follow-up calls. Nine patients also developed new-onset diabetes after receiving mucormycosis treatment, and others reported loss of vision, eye pain, headache, memory loss, and loose teeth. Six respondents described financial burdens from medical expenses, even though the government had supplied antifungal drugs free of cost to both hospitals during the pandemic.

Statistical analysis using multivariable Firth-penalized logistic regression, chosen to handle the modest cohort size and sparse outcome distribution, found that receipt of any antifungal prescription was independently associated with nearly six-fold higher odds of adversity, with an adjusted odds ratio of 5.82 and a 95 percent confidence interval of 1.56 to 21.71, statistically significant at p equals 0.009. This finding is consistent with the pharmacodynamic profile of systemic antifungal agents, including hepatotoxicity, nephrotoxicity, gastrointestinal effects, and drug-drug interactions. Patients older than 60 years showed almost four times the odds of adversity compared with younger adults, a borderline association that is biologically plausible given age-related physiological changes, multimorbidity, and altered pharmacokinetics. The overall model was statistically significant, and the authors recommend a contextual drug-use policy alongside vigilant monitoring and structured follow-up to mitigate these risks.

Perhaps the most human dimension of the study was the response to the follow-up calls themselves. Survivors and grieving family members expressed surprise and gratitude that anyone had called. One respondent who lost her mother said the call felt like someone cared about her, while another patient wrote that he never thought someone would ask how he was feeling now, describing the pandemic period as days of bad dreams. One participant suggested that a government scheme to call and follow up patients with serious illness would give a sense of being cared for and help those unable to visit a doctor. The mean call duration of 7.33 minutes suggests the intervention was operationally feasible and efficient, and the authors argue that such mobile-based follow-up could be regularized to monitor recovery, identify health needs, and provide psychological support, particularly in resource-constrained settings where access to in-person follow-up is limited.

The study is the first comprehensive analysis of mucormycosis cases in Central India, a region scarcely represented in the existing literature despite facing rising diabetes prevalence and resource constraints. The authors acknowledge limitations, including reliance on medical record completeness, the two-year recall gap between hospitalization and follow-up, potential survivor and non-response bias, and the unknown survival status of the 36 non-respondents, which may have produced overly optimistic outcome estimates. Notably, the length of hospital stay reported by respondents was twice that documented in medical records, possibly reflecting referral to other facilities and recall bias. Despite these caveats, the findings provide real-world evidence on mucormycosis management and survivorship, highlight the persistent risk of death and complications after discharge, and demonstrate the feasibility of mobile-based post-discharge follow-up as a scalable surveillance and support strategy. The authors call for survivor-centred care models that extend monitoring beyond one year, encompassing psychosocial well-being, quality of life, functional outcomes, and reconstructive needs, to inform targeted interventions and optimize care pathways for mucormycosis survivors within global public health systems.

Subject of Research: Health

Article Title: Pharmacological treatment, adversities, and mobile-based post-discharge follow-up of mucormycosis survivors in Central India: strengthening patient care

Article References: Baghel, R., Acharya, P., Verma, A., & Sharma, M. (2026). Pharmacological treatment, adversities, and mobile-based post-discharge follow-up of mucormycosis survivors in Central India: strengthening patient care. Frontiers in Health Services, 6, Article 1911647. https://doi.org/10.3389/frhs.2026.1911647

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1911647

Keywords: Pharmacological, treatment, adversities, mobile-based, post-discharge, follow-up, mucormycosis, survivors, Central, India, strengthening, patient