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Post COVID-19 Patient information pack

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COVID Associated Mucormycosis Infection Control

The aim of this Advisory is not to cause panic but to reiterate certain points

Mucormycosis:It is a form of invasive fungal infection commonly seen in immunocompromised population, the principal forms of these diseases include rhinocerebral, cutaneous, pulmonary and disseminated infections.

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Predisposing Factors (Net state of Immunosuppression of the patient)

Host factors have a major role:
• Uncontrolled diabetes mellitus(Requires Glucovigilance)
• Treatment with long duration high-dose corticosteroids
• Immunosuppressed state in COVID and on immunomodulators
• Increased Ferriitin levels
• Underlying Co-morbidities –post transplant/malignancy
• Voriconazole therapy (Breakthrough infections)
• Prolonged ICU stay on long-standing supplemental oxygen


Patient Placement
This is not a contagious disease –Requires Standard Precautions:


• Standard Precautions to be followed strictly by all the staff in these areas.
• Hand-hygiene to be performed meticulously –as and when indicated.
• Use of Personal Protective Equipment (PPE):COVID patient areas: Wearcomplete PPE as per protocol.Non COVID patient areas: Wear PPE: 3 Gs and an M(Gloves, Gowns, Goggles/face shieldand mask). Wear N95 mask during aerosol-generating procedures.
• In case of patients with open woundsor thoserequiring dressings, barrier precautions to be followed by all staff.
• Maintain Oxygen flow meter humidifiers and Ventilator humidifier chambers using sterile water, keeping dry when not in use and properly disinfecting in between patients (Please see Annexure 1.0 for details on cleaning and disinfection).
• Environmental decontamination after patient shifting,as per protocol.
• Maintain Personal hygieneat all times.



Warning Signs
Any of the warning signs mentioned below, if observed by the nursing /doctor-on-duty /CCC, should be escalated to the treating team immediately:


• Unilateral swelling over eyelids, proptosis(abnormal protrusion of eye)and conjunctival suffusion
• Blackish discoloration over bridge of nose/palate
• Nasal discharge (blackish/bloody)
• Persistent nasal blockage or congestion suggestive of new-onset Sinusitis
• Blurred or double vision with pain
• Local pain on the cheek bone
• Unilateral facial pain, numbness or swelling or deviation
• Toothache, loosening of teeth, jaw involvement
• Skin lesion; thrombosis and necrosis
• Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms



Diagnosis
Maintain a high clinical suspicion in the presence of above predisposing factors


i.Radiological:MRI Brain +/-sinus / orbits with/without MR Angiography
ii.Lab Diagnosis:Microbiology plus Histopathology

Direct microscopy / Fungal smear (KOH) of the affected site, Fungal culture, Histopathology of the affected tissue.


Management
Surgical Intervention / Debridement along with early initiation of appropriate antifungals and control of predisposing factors


Comprehensive approach is required for appropriate management:
▪ Physician / Infectious Disease - Initiation of appropriate antifungals in an appropriate dosage.
▪ ENT/Head & Neck Surgery: Collection of appropriate sample - deep tissue biopsy from sino-nasal
crust (and send sample for fungal smear, fungal culture and histopathology)
▪ Neurology: To assess the degree of focal neurological deficit if any.
▪ Ophthalmology/Oculoplastics: To look for visual acuity as well as assessment of eyeball
involvement (ophthalmoplegia) and in case enucleation is required so as to contain local spread to CNS.
▪ Neurosurgery: To assess CNS involvement (with or without cavernous sinus involvement)



Oxygen Flow Meter Humidifier Container: Cleaning and Decontamination
For the same patient


• The humidifiers would be changed every morning if in use.
• The water would be discarded, down the drain in the cleaning area.
• Wash with detergent and water followed by rinsing with running tap water • Spray with 1% Hypochlorite.

• Let this stand for 20 minutes.
• Rinse well with water.
• Let dry and store dry till further use.
• When in use, only sterile water is to be used.
• The humidifier should never be topped up.

In between patients • After the discharge/transfer out of the patient, the humidifier water would be discarded.
• The humidifier is washed with detergent and water, rinsed and then sprayed with 1% Hypochlorite.
• Let it stand for 20 minutes.
• Rinse well with water.
• It is dried and stored dry till further use.
• When in use, only sterile water is to be used.
• The humidifier should never be topped up.
Alternatively disposable humidifiers are used for a single patient for not exceeding 5 days. These are discarded as per Biomedical Waste Management Rules


New Humidifier
If the humidifier is new, then before using:
• The humidifier is washed with soap/detergent and water, rinsed and then sprayed with 1% Hypochlorite. Let it stand for 20 minutes. Rinse well with water.
• It is dried and stored dry till further use.
• When in use, only sterile water is to be used.
• The humidifier should never be topped up.

Note: For long period (more than one week) non usage treat as if new

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