To the Editor—Even as India is struggling to recover from an annihilating second wave of the coronavirus disease 2019 (COVID-19) pandemic, a rare yet lethal fungal infection mucormycosis caused by Mucormycetes, colloquially called the “black fungus,” is wreaking new havoc at alarming rates. This opportunistic disease is infecting patients that have recovered or are recovering from COVID-19. ^{Reference Rocha, Hasan and Goyal1,Reference Ghosh, Patelia, Hasan, Ghosh, Jain and Patel2}

More concerning than the infection itself is the shortage of the antifungal drug used for its treatment, amphotericin B. The pandemic has disrupted entire global supply and manufacture chains, causing a dire shortage of this essential drug. As the country witnesses a 2-fold increase in the number of mucormycosis cases, the government is scrambling to provide treatment for the increasing in-flow of patients. The central government is working to provide free treatment in public hospitals, incentivizing import by exempting custom duty on import of the drug, redistributing the drug based on urgency and need, and creating new facilities for treatment. Very little improvement has followed, however, and access to the antifungal amphotericin B remains inadequate. ^{Reference Gowda3}

Manufacturing volumes have been low in India due to previously low occurrence rates. Following the sudden increase in cases, the current volumes of manufacture by Bharat Serums & Vaccines, BDR Pharmaceuticals, Sun Pharma, Cipla, and Life Care Innovations (companies that currently produce the drugs) are not sufficient to meet the needs of the country. Hence, India is more likely to become dependent on imports from companies like the major US pharmaceutical producer Gilead Sciences, which could be significantly delayed. ^4,5

An added burden amid the distressing situation is the emergence of other invasive fungal infections, such as candidiasis, also referred to as “white fungus,” alongside aspergillosis. Candida auris, one of the organisms implicated in candidemia, is known to cause serious multidrug-resistant nosocomial infections. In a recent study, nearly all cases of Candida auris were fluconazole resistant, and close to 40% were resistant to amphotericin-B. ^{Reference Ghosh, Patelia, Hasan, Ghosh, Jain and Patel2} Further increases in drug-resistant fungal infections would prove disastrous in India, where the health system has already been stressed to its maximum capacity by the COVID-19 pandemic. ^{Reference Ghosh, Moledina, Hasan, Jain and Ghosh6}

The drug resistance that is increasingly occurring in a variety of pathogens especially in the Indian context can be attributed to the widespread and injudicious use of medications prescribed by physicians as well as self-medication among the public. With drug-resistant fungi surfacing, research is urgently needed to identify effective drugs and alternative treatment modalities to curb the negative health outcomes related to these deadly and invasive infections. Just as urgently, antibiotic stewardship must be promoted and practiced throughout the healthcare system. ^{Reference Rajendran, Kulirankal, Rakesh and George7}

With the pandemic still looming, local pharmaceutical production must be undertaken to meet these demands and to simultaneously reduce dependency on expensive imports. Better policies related to drug manufacture, contingency, import, and distribution should be developed and enforced. In-house production must be encouraged to combat the pandemic and to prepare for future outbreaks. Apart from all this, the ancient field of herbal and indigenous medicine in India, such as Ayurveda and Unani, should be re-examined and probed in the hope of finding replacements and/or cheaper, safe treatment options. ^{Reference Mishra, Bentur, Thakral, Garg and Duggal8}