ABSTRACT
Background The global pandemic caused by severe acute respiratory syndrome coronavirus 2 resulted in a large burden of critically ill patients, a population with an increased risk of both developing and dying from secondary infections. We investigated the clinical characteristics, risk factors, and outcomes associated with developing bloodstream infections (BSIs) among those admitted to the intensive care unit (ICU) for coronavirus disease 2019 (COVID-19) during the peak of the first surge in New York City, before the standardization of treatment regimens limited the ability to analyze differences. Methods We performed a retrospective case-control study including all patients 18 years or older who were admitted to the ICU because of COVID-19 in April 2020 in New York City. Demographic characteristics, risk factors, and outcomes were analyzed between cases, those who developed BSI during ICU admission, and matched controls who did not develop BSI, using a logistic regression. Results Thirty-two cases and 64 controls, all with COVID-19, were matched on sex, age, and the length of ICU stay before BSI. Cases who developed BSI had higher odds of longer corticosteroid use and a preexisting diagnosis of hypertension at the time of hospital admission than controls without BSI. Conclusions We found a positive association between the duration of corticosteroids and the development of BSI. Considering immunosuppression is now the cornerstone of guidelines for COVID-19 treatment, further studies are needed to evaluate risks and mitigation strategies for these therapies.
ABSTRACT
Background. Candidemia is a rare but serious complication of SARS-CoV-2 hospitalization. Combining non-culture and culture-based diagnostics allows earlier identification of candidemia. Given higher reported incidence during COVID-19 surges, we investigated the use of (1-3)-β-D-glucan (BDG) assay at our institution in those who did and did not develop candidemia. Methods. Retrospective study of adults admitted to The Mount Sinai Hospital between March 15-June 30 2020 for SARS-CoV-2 infection, with either ≥1 BDG assay or positive fungal blood culture. Data was collected with the electronic medical record and Vigilanz. A BDG value ≥ 80 was used as a positivity cutoff. Differences in mortality were assessed by univariate logistic regression using R (version 4.0.0). Statistical significance was measured by P value < .05. Results. There were 75 patients with ≥1 BDG assay resulted and 28 patients with candidemia, with an overlap of 9 between the cohorts. Among the 75 who had BDG assay, 23 resulted positive and 52 negative. Nine of 75 patients developed candidemia. Of the 23 with a positive assay, 5 developed candidemia and 18 did not. Seventeen of the 18 had blood cultures drawn within 7 days +/- of BDG assay. Four patients with candidemia had persistently negative BDG;2 had cultures collected within 7 days +/- of BDG assay. With a cut-off of >80, the negative predictive value (NPV) was 0.92. When the cut-off increased to >200, NPV was 0.97 and positive predictive value (PPV) was 0.42. Average antifungal days in patients with negative BDG was 2.6 vs. 4.2 in those with a positive. Mortality was 74% in those with ≥1 positive BDG vs. 50% in those with persistently negative BDGs. There was a trend towards higher odds of death in those with positive BDG (OR = 2.83, 95% CI: 1.00-8.90, p < 0.06). Conclusion. There was substantial use of BDG to diagnose candidemia at the peak of the COVID-19 pandemic. Blood cultures were often drawn at time of suspected candidemia but not routinely. When cultures and BDG were drawn together, BDG had a high NPV but low PPV. High NPV of BDG likely contributed to discontinuation of empiric antifungals. The candidemic COVID-19 patients had high mortality, so further investigation of algorithms for the timely diagnosis of candidemia are needed to optimize use of antifungals while improving mortality rates.