Abstract
Management of Coronavirus 2019 (COVID-19) with high-dose corticosteroids and interleukin-2 inhibitors has potential benefits, but is associated with immunosuppression and risk of secondary infections. This single-center, retrospective, cohort study evaluated the incidence of candidemia and associated risk factors in hospitalized COVID-19 patients. Twenty-three patients developed candidemia and were matched to 77 non-candidemic COVID-19 controls. The primary outcome was incidence of candidemia. Secondary outcomes included time to first positive fungal blood culture and antifungal initiation, antifungal treatment duration, fungal isolate identification, candidemia risk factors, in-hospital mortality, Intensive Care Unit (ICU) and hospital Length of Stay (LOS) and mechanical ventilation duration. Candidemia incidence was 0.7% (23/3101). Mean time from hospital admission to first positive fungal blood culture was 26.2±14.3 days, with systemic antifungal therapy initiated in 19 patients; seven started antifungal therapy the same day cultures were drawn and 12 within 24 h of preliminary culture results positive for yeast. The remaining four patients expired prior to culture results. Mean duration of antifungal therapy was 9.7±6.6 days. Candida albicans was the most frequently identified isolate. Candidemic patients were more likely to be admitted to the ICU, receive high-dose corticosteroid, renal replacement therapy, mechanical ventilation, central line, tocilizumab and broad-spectrum antimicrobials. They also had higher mortality (82% vs. 22%, p<0.0001) and longer ICU LOS (25 vs 0 days, p<0.0001), hospital LOS (39 vs 10 days, p<0.0001) and mechanical ventilation days (19 vs 0 days, p<0.0001). Candidemia occurrence is rare in COVID-19 patients, but can result in worse clinical outcomes such as high mortality and longer hospital stay. Clinicians should attempt to minimize risk factors and perform routine workup for systemic candida infections in COVID-19 patients in the ICU, on mechanical ventilation and with multiple risk factors.
Highlights
Coronavirus 2019 (COVID-19) is an acute respiratory disease caused by the Severe Acute Respiratory Syndrome (SARS)-CoV-2 virus and is spread primarily through respiratory droplets during close face-to-face contact
The pathophysiology of COVID-19 involves multisystem inflammation associated with an increased production of inflammatory markers (e.g., elevated erythrocyte sedimentation rate, C-reactive protein, ferritin, tumor necrosis factor-α, interleukin (IL)-1, interleukin 6 (IL-6)) and coagulopathy (Wiersinga et al, 2020)
Non-candidemic COVID-19 patients admitted during the study period were listed in chronological order of admission date; every 30th to 40th admission with similar baseline characteristics to a COVID-19 candidemic patient was selected to be in the control group
Summary
Coronavirus 2019 (COVID-19) is an acute respiratory disease caused by the SARS-CoV-2 virus and is spread primarily through respiratory droplets during close face-to-face contact. Proposed COVID-19 treatments targeted towards the underlying disease pathophysiology include tocilizumab and high-dose corticosteroids. Tocilizumab is a recombinant humanized anti-interleukin 6 (IL-6) monoclonal antibody that is proposed to block the cytokine storm, a severe immune reaction in which the body quickly releases an excess amount of cytokines into the blood, associated with COVID-19 (Antinori et al, 2020; Bhimraj et al, 2020). Current Infectious Diseases Society of America (IDSA) guidelines recommend its use as an adjunct to standard of care in hospitalized COVID-19 adults with progressive severe or critical illness and elevated markers of systemic inflammation (Bhimraj et al, 2020). Corticosteroids are recommended by the IDSA in hospitalized COVID-19 patients with severe or critical illness (Bhimraj et al, 2020). Corticosteroids carry a risk for immunosuppression and predisposition to secondary infections (Coutinho and Chapman, 2011; Ahmadikia et al, 2021)
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