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Introduction: SARSCoV2 infection increases the risk of secondary bacterial and fungal infections and contributes to adverse outcomes. The present study was undertaken to get better insights into the extent of secondary bacterial and fungal infections in Indian hospitalized patients and to assess how these alter the course of COVID19 so that the control measures can be suggested. Methods: This is a retrospective multicentre study where data of all RTPCR positive COVID19 patients was accessed from Electronic Health Records (EHR) of a network of 10 hospitals across 5 North Indian states admitted during the period from March 2020 to July 2021.The data included demographic profile of patients, clinical characteristics, laboratory parameters treatment modalities and outcome in those with secondary infections (SIs) and those without SIs. Spectrum of SIS was also studied in detail. Results: Of 19852 RTPCR positive SARSCO2 patients admitted during the study period, 1940 (9.8%) patients developed SIs. Patients with SIs were 8 years older on average (median age 62.6 years versus 54.3 years P<0.001) than those without SIs. The risk of SIs was significantly (p < 0.001) associated with age, severity of disease at admission, diabetes, ICU admission, and ventilator use. The most common site of infection was urinary tract infection (UTI) (41.7%), followed by blood stream infection (BSI) (30.8%), sputum/BAL/ET fluid (24.8%), and the least was pus/wound discharge (2.6%). As many as 13.4% had infections with more than organism and 34.1% patients had positive cultures from more than one site. Gram negative bacilli (GNB) were the commonest organisms (63.2%), followed by Gram positive cocci (GPC) (19.6%) and fungus (17.3%). Most of the patients with SIs were on multiple antimicrobials the most commonly used were the BL BLI for GNBs (76.9%) followed by carbapenems (57.7%), cephalosporins (53.9%) and antibiotics carbapenem resistant entreobacteriace (47.1%). The usage of emperical antibiotics for GPCs was in 58.9% and of antifungals in 56.9% of cases, and substantially more than the results obtained by culture. The average stay in hospital for patients with SIs was twice than those without SIs (median 13 days versus 7 days). The overall mortality in the group with SIs (40.3%) was more than 8 times of that in those without SIs (4.6%). Only 1.2% of SI patients with mild COVID 19 at presentation died, while 17.5% of those with moderate disease and 58.5% of those with severe COVID 19 died (P< 0.001). The mortality was highest in those with BSI (49.8%), closely followed by those with HAP (47.9%), and then UTI and SSTI (29.4% each). The mortality rate where only one microorganism was identified was 37.8% and rose to 56.3% in those with more than one microorganism. The mortality in cases with only one site of infection was 28.8%, which steeply rose to 62.5% in cases with multiple sites of infection. The mortality in diabetic patients with SIs was 45.2% while in non-diabetics it was 34.3% (p < 0.001). Conclusions: Secondary bacterial and fungal infections can complicate the course of almost 10% of COVID19 hospitalised patients. These patients tend to not only have a much longer stay in hospital, but also a higher requirement for oxygen and ICU care. The mortality in this group rises steeply by as much as 8 times. The group most vulnerable to this complication are those with more severe COVID19 illness, elderly, and diabetic patients. Varying results in different studies suggest that a region or country specific guideline be developed for appropriate use of antibiotics and antifungals to prevent their overuse in such cases. Judicious empiric use of combination antimicrobials in this set of vulnerable COVID19 patients can save lives.

Pulmonary alveolar proteinosis (PAP) is a rare disorder, in which lipoproteinaceous material accumulates within the alveoli. We report a case of a 27-year-old male patient with acute worsening of breathlessness over the last 7-8 months and cough with desaturation up to 79% on room air. Contrast-enhanced computerized tomography of the thorax revealed unilateral diffuse crazy-paving pattern likely PAP. Transbronchial lung biopsy confirmed the diagnosis of PAP. The present case highlights the unusual presentation of PAP with unilateral involvement. To the best of our knowledge, this is the first reported case of unilateral PAP from India with a biopsy diagnosis and resolution with whole lung lavage.

Lung cancer is among the most frequently diagnosed cancers and the world’s leading cause of cancer-related death. Radiology remains the mainstay for timely diagnosis; however, atypical radiologic patterns are known, and these may be misdiagnosed as infectious or inflammatory pathology, particularly in the absence of smoking history. We report herein an account of an older male nonsmoker who presented radiologically with bilateral diffuse pulmonary infiltrates, simulating pneumonia, but was eventually diagnosed with adenosquamous lung carcinoma. The delay in diagnosis and subsequent unfortunate rapid deterioration of our patient serves as a reminder for clinicians to consider lung cancer in patients with clinical/radiologic findings suggestive of pneumonia, especially in nonsmokers or cases refractory to antibiotic therapy.