Diversity in Fungal Infections in the Initial Waves of COVID-19: An Occurrence Based Systematic Review

Abstract

Background: Fungal coinfections have been part of the complications in coronavirus disease (COVID-19) patients. While systematic reviews on individual fungus was available, comprehensive data on the occurrence of various fungal infections was limited. Methodology: A systematic search in the databases ‘PubMed’ and ‘Global Research Database on COVID-19 by the World Health Organization (WHO) was made using relevant search terms. Only fungal coinfections/superinfections in confirmed COVID-19 cases were considered. All observational studies, case series, and case reports in English were included. Overall, the occurrence of the fungal infections and the associated factors was noted. Chi-square and Fisher’s exact tests compared epidemiological factors between survived and dead. Results: Data from 126 eligible studies reporting 870 cases showed that mucormycosis was the most common infection (42.5%), followed by aspergillosis (32.41%) and candidiasis (22.87%). The majority of the infections were seen in severe COVID-19 (94.01%), in ICU (67.25%), and with mechanical ventilation (73.61%). Prior steroid therapy was seen in 81.3% in mucormycosis. In aspergillosis, mechanical ventilation, infection due to Aspergillus fumigatus and administration of steroids at more than the recommended dose were significantly associated with those who died (p<0.05). Conclusion: Mucormycosis, followed by invasive pulmonary aspergillosis and invasive candidiasis, has been the most common coinfections/superinfections in COVID-19 patients. Early diagnosis led to better survival in Covid associated mucormycosis (CAM); however, in COVID-19-associated pulmonary aspergillosis (CAPA), mechanical ventilation, larger doses of corticosteroids than recommended and infection with A. fumigatus were significant associations among those who succumbed to the condition.