Mumbai: Doctors flag indiscriminate use of steroids, antibiotics in Covid-19 treatment

A 43-year-old man from Andheri was prescribed a cocktail of antibiotics, antiviral, and steroids on his first consultation with a local physician when he developed symptoms and was suspected of Covid-19. At first, he got better but within days he developed a persistent high-grade fever and his oxygen saturation levels dropped, following which he had to be hospitalized last month.

In another instance, a 13-year-old girl with Covid-19 was prescribed a heavy dosage of steroids by her family physician on the fifth day of her illness, even as her symptoms had diminished. Her physician made the prescription based on a chest CT scan that showed a slight abnormality in her lungs. On the 10th day, she developed a full-blown fever and was rushed to a hospital where the doctors had to take her off steroids and work with other medicines.

These are not one-off cases. City’s top medical experts have flagged a trend of patients being prescribed steroids in the first few days of symptoms. Even antibiotics that have no role in treating Covid-19 -- a viral infection-- and antiviral drugs that have little evidence backing them are being indiscriminately used, they said.

“The Recovery Trial carried out in the UK has established that a 6mg dose of dexamethasone once daily has shown reduced mortality,” said Dr Sujeet K Rajan, city-based respiratory medicine specialist. “But what you see in practice is disturbing. Patients are given two to three times more steroids than what they should be given,” he said.

The Recovery Trial conducted in the United Kingdom – preliminary results came out in June 2020 --found that a 6mg dose of dexamethasone, an inexpensive steroid drug, once daily for up to 10 days decreased mortality in patients on respiratory support. The trial also showed that patients not requiring oxygen did not benefit from the drug.

Steroids like dexamethasone are widely used to fight against inflammation, one of the effects of the coronavirus disease. However, most doctors label steroids as “double edged swords” in Covid-19 treatment if they are not used judiciously.

In fact, the unwarranted use of steroids began soon after the trial results became public. Given that the number of Covid-19 cases is higher in absolute numbers, the problem is more pronounced in the second wave. “This has the potential to be nothing short of a disaster,” said Rajan, who practices at Bombay Hospital.

Indiscriminate use

“Starting patients on steroids early is harmful for them,” said infectious disease expert Dr Tanu Singhal from Kokilaben Dhirubhai Ambani Hospital where the 43-year-old man and the teenager mentioned above are undergoing treatment. “Steroids lower the body’s immunity and can also cause viral replication. Their unindicated and early use worsen the outcome of patients. The right time to use steroids is when the oxygen saturation is low,” she said.

The treatment protocol released by the Maharashtra Covid-19 task force in April 2021 allows the use of steroid- injection dexamethasone in moderate patients with pneumonia and oxygen saturation below 94%.

Put simply, viral replication is a process of multiplication of the virus in the body. As steroids mask symptoms and reduce the body’s immunity, patients are at the risk of developing a severe infection. Dr Randeep Guleria, a member of the national Covid-19 task force and director of All India Institute of Medical Sciences (AIIMS), Delhi has also recently cautioned against an early use of steroids and said that it leads to “faster viral replication and severe viral pneumonia.”

According to Rajan, unwarranted high doses of steroids, often coupled with unnecessary high-generation antibiotics, present the perfect soil for invasive and life-threatening fungal infections, which can be independently a major risk factor for mortality. Cases of mucormycosis, a stubborn fungal infection are now widely being reported from the city. Also referred to as black fungus, it commonly affects sinuses or the lungs. While the disease is tackled with medication at a very early stage, cutting away the infected tissue is the only option when it spreads. Doctors in the city have had to operate out tissues of the eyes, nose and jaw in many patients.

“We currently have 21 patients with mucormycosis and 15 of them are in an inoperable stage,” said Dr Hemant Deshmukh, dean of civic-run KEM Hospital. “The number of patients coming with these infections has doubled,” he said.

Doctors said that post-Covid-19 we are staring at a wave of threatening antimicrobial resistance. “Antibiotics like doxycycline, azithromycin, and others are crucial in treating illnesses and infections like typhoid, scrub typhus, pneumonia, etc,” said Singhal. “With their unnecessary use, we are leading to a serious drug resistance,” she said. Singhal has also stopped using ivermectin and another antiviral called favipiravir as they don’t play any role in treating Covid-19 contrary to popular belief.

Many doctors in the city have questioned the inclusion of antibiotic doxycycline for off-label use and antiviral drug ivermectin in the Covid-19 treatment protocol framed by the state task force. “The task force has simply encouraged the grassroots level physicians to use antibiotics and antivirals without any great evidence backing these drugs,” said a senior doctor who did not wish to be named.

Anti-microbial resistance

Antibiotics, antivirals, antifungals and antiparasitic drugs are known as antimicrobial drugs. Misuse and overuse of antimicrobial drugs is one of the main factors for antimicrobial resistance. The World Health Organization has declared antimicrobial resistance as one of the top 10 global public health threats facing humanity.

“For mild patients, we immediately start doxycycline, ivermectin, and paracetamol,” said Dr. Akhtar Shaikh, general secretary of the Dharavi AYUSH Doctors Association- a body of nearly 180 alternative medicine practitioners in Dharavi, who are also now treating Covid-19 patients with allopathic drugs.

“Additionally, we also prescribe some AYUSH remedies for symptom relief,” Shaikh said that antibiotics are crucial because patients may have an underlying bacterial infection developed along with Covid-19 when the body’s immunity is low. “We avoid steroids before seven days of symptoms unless it is extremely necessary,” he added.

Due to a shortage of healthcare staff, mainly allopathy doctors, the state government has also deployed a large number of AYUSH practitioners on Covid-19 duty. On the grassroots, however, many other alternative medicine practitioners prescribe allopathic medications, even when they are not allowed to do so.

“Except Ayurveda and Unani practitioners, no other alternative medicine practitioners are allowed to prescribe allopathic medicines in Maharashtra,” said Dr Jayesh Lele, general secretary of the Indian Medical Association (IMA). “But the government rule that allows these practitioners to prescribe allopathic medicines has been challenged in court by the IMA. This is a huge problem and often leads to unwarranted use of drugs,” he said.