News and Opinions  –  2021

COVID-19: India pays a high price for indiscriminate drug use

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Since early April this year India’s deadly second wave of COVID-19 infections has claimed thousands of lives and devastated families across the country. The impact of the pandemic has however been made even worse by the rampant, irrational prescription of medicines, especially steroids and antibiotics.

Mucor fungi as a cause of sinusitis. Inflammation of maxillary sinuses and close-up view of fungi Mucor. Mucormycosis, Covid-19 complication, sinusitis in immunocompromised patients. Photo: Shutterstock.

By 12 June 2021 India had the second largest number of cases in the world at 29.4 million and total deaths stood at 370,168[i]. At its peak in early May the country recorded over 600,000 new cases and 5,000 deaths a day and even these high numbers are considered a gross underestimation.

Rise of “black fungus” infections in India

Overuse of steroids, for example, has given rise to a parallel epidemic of thousands of cases of “black fungus” infections in India. Also called mucormycosis, the fungal infections, have a 54% mortality rate. It affects patients, initially in the nose, but the fungus can then spread into the brain, and can often only be treated by major surgery removing the eye or part of skull and jaw.

The use of steroids been widespread since a large WHO study showed that steroids reduced the mortality of COVID-19 patients who were receiving oxygen or required mechanical ventilation. However, in many cases even patients who did not have low blood oxygen nor require hospitalization were indiscriminately given steroids.

While the exact reason for India recording so many cases is yet to be identified, some experts believe the black fungus infections are spreading due to excessive steroids being given to COVID-19 patients with diabetes, who already have a weakened immune system. By early June this year India has reported over 28,200 cases of the deadly fungal infection.

Is driver of “black fungus” infections a cocktail of antibiotics?

Another tentative theory is that the driving factor behind these infections could be that many patients receive a cocktail of antibiotics such as azithromycin and doxycycline early in the infection as prophylactics.  This wipes out normal bacteria in the human microbiome, leaving mainly multidrug-resistant bacteria, yeast or fungi.

Antibiotic resistance is already widespread in India[viii] and during the COVID-19 pandemic there have been many reports of indiscriminate prescriptions of antibiotics by doctors around the country. Antibiotics prescribed for COVID-19 patients have included carbapenems, the most potent antibacterial, and colistin, a drug of last resort used to treat the most stubborn antibiotic-resistant strains.

Patients with secondary infections are given antibiotics that should be used very sparingly

A recent study of ten Indian hospitals found 74% of patients with secondary infections during the first wave were given antibiotics, that according to the WHO should only be used very sparingly. Another 9% received antibiotics that were not recommended.

“The practice of empiric antimicrobial prescription, due to limited diagnostic capabilities of many hospitals, has the potential to escalate an already worrisome antimicrobial resistance (AMR) situation in India”

said the study.

The retrospective study of 17,534 patients admitted to Indian hospitals between June and August 2020 found that 3.6% of patients developed secondary bacterial or fungal infections. It found predominance of Gram-negative pathogens in COVID-19 patients coupled with high rates of resistance to higher generation antimicrobials.

“Fear of missing a secondary infection and lack of specific therapy for Covid-19 leads to over-prescription of antibiotics”

Dr Kamini Walia, a microbiologist with the Indian Council of Medical Research was quoted as saying by media reports.

In the case of the black fungus infections treatment options are limited and very expensive, with patients needing 150-300 vials of liposomal amphotericin B (L-AmB). Each vial in the Indian market can cost between USD80 to USD100 and the price, supply, and production of the drug is dominated by a couple of global pharma companies.

Growing antibiotic resistance too is known to cause a steep rise in costs of medicine and fall in access as existing drugs become ineffective and result in treatment failure.

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