ICMR study found no black fungus cases after first wave

A study by the Indian Council of Medical Research, released on Monday, said that there were no instances of mucormycosis (black fungus disease), in 10 hospitals where researchers tracked secondary bacterial and fungal infections in Covid-19 patients during the first wave of the pandemic.

The study was conducted between June and August last year, on 17,534 patients in 10 hospitals (Two in Delhi, two in Mumbai, one each in Vellore, Jodhpur, Bhopal, Pondicherry, Chennai, and Kolkata) and its findings are interesting at a time India is combating an unprecedented spate of black fungus cases. The Union government said last week that there were 5,000 cases of the disease, which has a fatality of at least 50%, around the country.

According to the study, secondary bacterial and fungal infections affected around 3.6% (ranging from 1.7% to 28% between hospitals) of patients hospitalised with Covid-19 . And the mortality in patients with these secondary infections was 56.7% as against 10.6% among other hospitalised patients. The mortality in those with secondary infections was as high as 78.9% in one of the hospitals, the data showed.

“What we found was that most of these secondary infections, 78% of them, were acquired at the hospital; the indication for infections started two days after hospitalisation and most of the samples had gram negative bacteria showing that they were hospital-based infection. This could be because infection control policies at the hospitals went for a toss amid the pandemic. Hand hygiene wasn’t as good because of double gloving and use of PPE kits in the hot weather also added to that,” said Dr Kamini Walia, corresponding author of the paper and a scientist with the epidemiology and communicable diseases department at ICMR.

She added, “The most common pathogens causing the infection were klebsiella pneumoniae and acinetobacter baumannii; usually E coli is the most common pathogen found as per previous ICMR reports. Both the infections are very difficult to treat because they have acquired lot of resistant genes over time. The treatment will further become difficult post-Covid. Hospitals must invest in infection control and rationalise antimicrobial prescriptions.”

The study cautions about the increase in antimicrobial resistance due to excessive use of stronger medicines. Around 74.4% of the total antimicrobials prescribed in the hospitals were from the Watch and Reserve category of the World Health Organization (WHO).

WHO classifies all antibiotics in three categories – Access drugs that can treat commonly encountered pathogens and have lower resistance potential, Watch drugs that have higher resistance potential and are critical for treatment, and Reserve drugs that need to be saved as last resort for drug-resistant microbes and given only once an infection is confirmed.

“Around 47% of the infections were found to be multi-drug resistant; but more than 74% of the antimicrobials prescribed were from the Watch and Reserve category. And the 10 hospitals from where we have collected data are in the ICMR network; they have been trained in infection control and antimicrobial stewardship. We can only imagine what is happening in other hospitals,” said Dr Walia.

Even in the case of mucormycosis, the overuse (and misuse) of steroids is blamed by many experts.

“[This is] a double whammy; Covid-19, along with the secondary infections, increases mortality significantly... Mucormycosis cases reported after the second wave are largely [related] with the overuse of steroids. At the peak [of the second wave], steroids had vanished from the market. This has never happened before; It is one of the most common medicines available,” said Dr Chand Wattal, head of the department of microbiology at Sir Ganga Ram hospital, one of the 10 hospitals that participated in the study.

Sampling was low, though, he added.

Only 7,163 samples were sent for microbial culture , with multiple samples belonging to the same patients. The low sampling was because of the practical problems; not many healthcare workers wanted to collect them during the first wave when not much was known about the disease.

“The sample size decreased considerably because people were scared to take the samples; especially those that generate aerosols such as lavage (a procedure where lower respiratory tract is flushed with fluid which is collected for diagnosis). The sampling has increased now that people are aware of how to protect themselves,” said Dr Wattal.