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Acetic acid to prevent mucormycosis – Dr. Puneet Wadhwani (OMFS)

By Dr. Puneet Wadhwani
May 25, 2021

The Covid-19 pandemic has unleashed a flood of Mucormycosis cases in India. All specialists - the ENT/ ophthalmic/ maxillofacial surgeons, physicians, and radiologists are working on its early diagnosis, early radical surgical debridement, and medical management with Liposomal Amphotericin B. However, it is equally critical to explore the other end of the spectrum, i.e., the site of initial fungal spore invasion-the nostrils. Dr. Puneet Wadhwani (OMFS) suggests the use of acetic acid as a simple, readily available, and inexpensive measure - worth exploring further for the prevention of mucormycosis.

The Rhino Orbital Cerebral Mucormycosis (ROCM) form comprises about 90% of the total cases, with inhalation of fungal spore being the mode of contamination.

Regarding its etiology, several speculations are making rounds - hyperglycemia, acidic medium due to diabetic ketoacidosis, high iron levels, decreased phagocytic activity due to immunosuppression, indiscriminately high doses of steroids, contaminated oxygen, and water contamination, etc.

Let us discuss the potential role of acetic acid that can help us in preventing mucormycosis.

In 2015, Wioleta J. Trzaska published a study demonstrating acetic acid's antifungal efficacy against all the tested Mucorale species.

The authors also discovered that acetic acid strongly suppressed fungal germination at a very low concentration (0.3%) and was potently fungicidal at concentrations above 2.5%.

Inhibition of spore germination was based on lowering intracellular pH levels because of stronger dissociation of ions within the fungal cytoplasm.

Inhibition of fungal growth involved both pH-dependent and pH-independent but acetate-dependent mechanisms.

It was also effective against spores that were already germinated.

The antifungal activity of acetic acid is due to both hydrogen ion concentration and undissociated acid or free acetate. An undissociated acid molecule diffuses through the cell membrane and dissociates within the fungal cytoplasm.

Acetic acid has been used as a wound dressing for thousands of years, including the American civil war.

Gauze soaked in 1% acetic acid solution was used on 100 patients with infected wounds.

Acetic acid lowers the pH level of the wound, consequently affecting the healing process of the wound by several mechanisms.

Studies have shown that acetic acid was effective against various microorganisms and inhibited fungal growth.

Acetic acid is readily available, inexpensive, and non-toxic compared to other topical agents and systemic antibiotics.

Acetic acid can be used for the management of mucormycosis in two ways
A) Prophylactic topical application at the potential site of entry (nostrils) of fungal spores to inhibit spore germination.
B) As a wound dressing agent on freshly debrided tissues to promote wound healing and inhibit fungal growth.

References:

1. Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, Puri GD, Chakrabarti A, Agarwal R. Coronavirus Disease (Covid-19) Associated Mucormycosis (CAM): Case Report and Systematic Review of Literature. Mycopathologia. 2021 May;186(2):289-298. doi: 10.1007/s11046-021-00528-2. Epub 2021 Feb 5. PMID: 33544266; PMCID: PMC7862973.
2. Trzaska WJ, Correia JN, Villegas MT, May RC, Voelz K. pH manipulation as a novel strategy for treating mucormycosis. Antimicrob Agents Chemother. 2015 Nov;59(11):6968-74. doi: 10.1128/AAC.01366-15. Epub 2015 Aug 31. PMID: 26324263; PMCID: PMC4604374.
3. Agrawal KS, Sarda AV, Shrotriya R, Bachhav M, Puri V, Nataraj G. Acetic acid dressings: Finding the Holy Grail for infected wound management. Indian J Plast Surg. 2017 Sep-Dec;50(3):273-280. doi: 10.4103/ijps.IJPS_245_16. PMID: 29618862; PMCID: PMC5868106.

Dr. Puneet Wadhwani
Professor
Oral and Maxillofacial Sugery
Career postgraduate institute of dental sciences and hospital
Lucknow, U.P

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