Evaluation of hospital environment for presence of Mucorales during COVID-19-associated mucormycosis outbreak in India – a multi-centre study

Abstract

Introduction – An unprecedented rise in number of COVID-19 associated mucormycosis (CAM) cases has been reported in India. Myriad hyptheses are proposed for the outbreak. We recently reported uncontrolled diabetes and inappropriate steroid therapy as significant risk factors for the outbreak. However, Mucorales contamination of hospital environment was not studied. We, therefore, planned this multi-centre study across India to determine possible Mucorales contamination of hospital environment during the outbreak. Methods Eleven hospitals from four zones of India representing high to low incidence for mucormycosis cases were included in the study. Samples from a variety of equipment used by the patients and ambient air were collected during May 19, 2021 through August 25, 2021. Results None of the hospital equipment sampled was contaminated with Mucorales. However, Mucorales were isolated from 11.1% air-conditioning vents and 1.7% of patients’ used masks. Other fungi were isolated from 18% hospital equipment and surfaces, and 8.1% used masks. Mucorales grew from 21.7% indoor and 53.8% outdoor air samples. Spore counts of Mucorales in air were significantly higher in the hospitals of North and South zones compared to West and East zones ( P < 0.0001). Among Mucorales isolated from the environment Rhizopus spp. were the commonest genus. Conclusion – We found contamination of air-conditioning vents and hospital air by Mucorales. Presence of Mucorales in these areas demands regular surveillance and improvement of hospital environment, as contamination may contribute to healthcare associated mucormycosis outbreaks, especially among immunocompromised patients.

Are Unique Regional Factors the Missing Link in India’s COVID-19-Associated Mucormycosis Crisis?

“…This raises the question of whether excessive environmental exposure to Mucorales spores is the unacknowledged factor in India’s CAM epidemic. One recent multicenter study from India showed that the Mucorales burden in the outdoor hospital environments in India is as high as 51.8% ( 11 ). Herein, we posit that important but overlooked cultural, religious, and social factors specific to India might be responsible for the excessive burden of fungal spores, including Mucorales spores, in the Indian environment.…”

Histomorphological features of mucormycosis with rise and fall of COVID-19 pandemic

“…India, during the month of May to July 2021 saw unexpectedly high reports of mucormycosis from all states, with a close to 50,000 cases just in a span of 3 months. [8] , [9] The highest incidence of mucormycosis came from West of India followed by South India. [9] …”

Novel Secreted Peptides From Rhizopus arrhizus var. delemar With Immunomodulatory Effects That Enhance Fungal Pathogenesis

“…Rhizopus species are responsible for ~70% of all mucormycosis cases, a disease with high mortality rates in immunocompromised patients ( Ibrahim et al, 2012 ). Recently, an outbreak of COVID-19 associated mucormycosis has been reported in India ( Biswal et al, 2022 ). The mortality rate due to COVID-19 increased from 31 to 53% due to fungal infection including mucormycosis ( Mehta and Pandey, 2020 ).…”

“…The mortality rate due to COVID-19 increased from 31 to 53% due to fungal infection including mucormycosis ( Mehta and Pandey, 2020 ). Mucorales contamination of the hospital environment is among the significant risk factors for the outbreak ( Biswal et al, 2022 ). Rhizopus spp.…”

“…Rhizopus spp. were the most common contaminates representing 67% from air-conditioning vents and masks, and 78% from the air ( Biswal et al, 2022 ). Furthermore, successful management of mucormycosis requires early detection and aggressive treatment with antifungal drugs and often disfiguring surgery ( Grant et al, 2006 ; Mohammadi et al, 2014 ).…”