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1.
Open Forum Infectious Diseases ; 9(Supplement 2):S272, 2022.
Article in English | EMBASE | ID: covidwho-2189654

ABSTRACT

Background. COVID-19 can cause serious illness requiring multimodal treatment of the viral infection and its associated complications, including the potential for secondary infections. Studies have suggested an increased risk of fungal infections, including candidemia following severe COVID-19 though understanding of risk factors and clinical outcomes remains unclear. Methods. A multi-center, case-control study of patients with severe COVID-19 was conducted to evaluate risk factors and clinical outcomes in patients who developed candidemia between August 2020 to August 2021. Risk factors associated with candidemia and mortality were characterized using multivariate analyses. Results. A total of 275 patients were enrolled in the study, including 91 patients with severe COVID-19 and subsequent candidemia and 184 patients with severe COVID-19 without candidemia. Most patients received antibiotics prior to candidemia episode (93%), while approximately one-quarter of all patients received biologic for COVID-19. In-hospital mortality was significantly higher in the case group compared to the control group (68% vs 40%, P < 0.01). Multivariable logistic regression revealed that the use of central lines, biologic and paralytic therapy were independent risk factors for candidemia. The presence of candidemia, older age, central line use, and intensive care unit admission were significantly associated with mortality. Demographics and Baseline Characteristics of Study Patients with SARS-CoV-2 Positive With or Without Candidemia Hospitalization Details and Outcomes Conclusion. Clinicians should be aware of the possibility of development of candidemia in hospitalized older patients with severe COVID-19 and should closely monitor those patients at risk. Risk factors for developing candidemia in the setting of COVID-19 are largely consistent with classic risk factors previously identified.

2.
Open Forum Infectious Diseases ; 9(Supplement 2):S226, 2022.
Article in English | EMBASE | ID: covidwho-2189639

ABSTRACT

Background. Invasive fungal diseases (IFD) have been described in patients (pts) with severe coronavirus disease 2019 (COVID), albeit with geographic variability in rates. Methods. We performed a retrospective study to determine rates of & risk factors for IFD occurring within 30 days (d) of COVID diagnosis (dx) in adults requiring critical care for severe COVID between 5/11/20 & 2/7/21. Mortality was assessed at 90 d following COVID dx and at 84 d after IFD dx, if applicable. ECMM/ISHAM criteria were used for COVID-associated pulmonary aspergillosis (CAPA) and EORTC/ MSGERC criteria were used for other IFD and treatment response. Results. 218 pts were included;median age was 62 (19 - 91) & 63% were men. Underlying conditions included solid organ transplant (Tx) (16;7%), allogenic stem cell Tx (3;1%), malignancy (21;10%), & exposure to either high-dose steroids (HDS) (11;5%) or T- or B-cell suppressants (29;13%) within 90 d prior to COVID dx. 209 (96%) pts had respiratory failure & 127 (58%) required mechanical ventilation. 15 (7%) required extracorporeal membrane oxygenation. COVID treatment consisted of corticosteroids in 205 (96%) & tocilizumab in 10 (5%). 12 (6%) pts developed IFD. 6 pts had CAPA (2 probable, 4 possible);50% were men, median age 64.5 (48 - 83). Mean time to CAPA dx from COVID dx was 17 d (+/- 14d). All pts had received corticosteroids for COVID but only 1 pt received > 30d of HDS by the time of IFD dx. Mortality at 84 d from CAPA dx was 67%. 5 (2%) pts had central venous catheter associated candidemia;80% were men & median age 61 (55 - 77). Mean time from COVID to candidemia dx was 29 d (+/-12 d). All pts with Candida infection had received steroids for COVID. Mortality at 84 d from candidemia dx was 60%. A 35-year-old man with prolonged exposure to HDS had Paecilomyces pneumonia;he was alive at 84 d after IFD dx. No cases of mucormycosis were identified. All-cause mortality in the entire cohort was 38% at 90 d after COVID dx. Mortality among pts who developed IFD was 58% at the same time point. Conclusion. Rates of IFD in pts with severe COVID were low and most pts with IFD after COVID had CAPA or catheter-associated candidemia. All but one pt with CAPA had no risk factors for IFD. In pts with severe COVID, mortality was higher among pts who developed IFD than those who did not.

3.
Open Forum Infectious Diseases ; 9(Supplement 2):S224, 2022.
Article in English | EMBASE | ID: covidwho-2189638

ABSTRACT

287 IDWeek 2021). We reinstated mitigation strategies including staff education, line insertion check list and antimicrobial stewardship. 1041 patients with acute COVID-19 were admitted to our hospital in 2021 (January to December) and 6 out 12 cases (50%) of Nosocomial Candidemia were seen in patients with acute COVID-19 infection. We re-evaluated the risk factors and mortality of hospitalized COVID-19 patients with Candidemia. Methods. We performed a retrospective chart review of the 6 patients with Candidemia and confirmed COVID-19 infection at our 292-bed community teaching hospital in Chicago, Illinois from January through December 2021. We report a descriptive analysis of the demographic characteristics, comorbidities, complications, and outcomes of these patients comparing both years. Results. The average age of our study population was 71 years (older);67% were male. The average hospital length of stay (LOS) was shorter 28 days. The mean time from admission to the development of Candidemia was slightly longer 18 days. Associated co-morbidities included cardiovascular diseases (CVD) in 83%, diabetes mellitus (DM), in 50%, and obesity in 50%. Treatments for COVID-19 included Steroids (100%), Remdesivir (50%) and Baricitinib (33%). All patients were managed in the intensive care unit (ICU) and 67% had a central in place at the time of Candidemia. Half of the patients (50%) required hemodialysis (HD);all patients were treated with multiple antibiotics. The average LOS in the ICU was 18 days (shorter). Despite antifungal treatment, 80% expired. Conclusion. Incidence of Candidemia in acute COVID-19 infections decreased by 56% in one year after reinstating mitigation strategies in our hospital. However, Candidemia remains a menace in hospitalized patients with acute COVID-19 infection. Associated risk factors remain history of CVD, DM, obesity, prolonged hospital LOS, requirement for multiple CL, HD, treatment with multiple antibiotics, treatment with steroids (100%) and a long stay in the ICU. The mortality of COVID-19 patients with Candidemia remains very high.

4.
Medical Mycology ; 60(Supplement 1):182, 2022.
Article in English | EMBASE | ID: covidwho-2189370

ABSTRACT

Introduction: Isolation of Candida spp. from a blood sample in patients is known as candidemia. Candida albicans is the most common causative agent of candidemia globally while C.tropicalis is the most common causative agent in India.Candida parapsilosis complex, C.glabrata, and C.krusei are the other three common causative agents of candidemia.Candida auris was described in 2009 and is a public health treatment. It is multidrug-resistant and causes localized hospital outbreaks. Objective(s): To determine the fungal profile of candidemia in a tertiary care hospital. Method(s): Institute ethics approval was taken. All patients admitted to the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India from January 2020 to January 2021, whose blood culture samples yielded yeast were included in the study. The patient's demographic details were recorded. Yeast isolates were identified by Matrix-Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry (MALDI-T OF MS) as per the manufacture's instruc-tion. The antifungal susceptibility testing (AFST) was performed by microbroth dilution method for fluconazole, voriconazole, amphotericin B, and casp ofungin as per Clinical and Laboratory Standards Institute (CLSI) M27 and interpreted by CLSI M59 and M60 document.AFST of C.auris was interpreted as per Centers for Disease Control and Prevention (CDC) criteria.Results were expressed in percentages. Result(s): A total of 248 blood culture samples yielded yeast cells during the study period. Approximately 63% of samples were obtained from male patients, while 37% were obtained from female patients. Most of the patients were between 41 to 60 years or under 10 years of age. A total of 52/240 (15.8%) were diabetic, and 30 (15.2%) were positive for severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2). Candida tropicalis (34.7%) was the most common causative agent. It was followed by C. parapsilosis complex (20.2%). Candida auris (16.5%), C. albicans (13.3%), C. glabrata (6.5%), and other C. spp. (8.9%). Candida krusei is no longer observed as one of the top five agents of candidemia and it is replaced by C. auris. The rise of candidemia due to C.auris is a cause of concern, and its prevalence is observed more than that of C.albicans in our tertiary care hospital.The antifungal resistant pattern of the top four candidemia isolates is depicted in Figure 1.The antifungal resistance was maximum in C.auris isolates, followed by C.parapsilosis complex isolates.A total of 12.2% of C.auris isolates were resistant to amphotericin B, and azoles and 4.9% of C. auris isolates were multidrug-resistant. Conclusion(s): Candida tropicalis was the most common causative agent of candidemia. But the increased prevalence of C. auris over C. albicans is a cause of concern as 4.9% of C. auris isolates were multidrug-resistant.

5.
Medical Mycology ; 60(Supplement 1):121, 2022.
Article in English | EMBASE | ID: covidwho-2189366

ABSTRACT

Introduction: Candida spp.accounts for 70%-80% of invasive bloodstream fungal infections.It is most commonly spread in long-term care facilities, caring for people with severe medical conditions. Patients hospitalized for COVID-19 are at risk for healthcare-associated infections like candidemia. Candida auris is an emerging, multidrug-resistant, healthcare-associated fungal pathogen. Candida auris is currently one of the most common clinical fungal pathogens, causing nosocomial infections. Due to its higher drug-resistance rate, C. auris is more difficult to treat, requires longer hospitalization periods, and results in higher morbidity and mortality than other Candida species. Aim and Objectives: To analyze the risk factors associated with C. auris candidemia in COVID-19 and post-COVID-19 patients at tertiary care center. Material(s) and Method(s): We prospectively analyzed all positive blood samples which were received in the Microbiology department at SGPGI, Lucknow for a period of 1 year (March 2020-March 2021).Blood samples were inoculated and cultured in BACTECBottles (BD) andincubated for 5days at 37degreeC.The bottles whichflagged positive, aGram's stain wasperformed and were sub-cultured on SDA for isolation of yeast colonies. Isolated yeasts were identified by phenotypic method and confirmed by MALDI-T OF MS. Demographics details of the patients were collected and recorded. The significant associated risk factors with C. auris candidemia were analyzed. Result(s): A total of 13 000 blood samples were received during the 1-year study period from different departments of the hospital.1.25% (n = 163) of the blood culture samples were positive for candidemia. Out of 163 Candida culture-positive blood samples, 27.61% (n = 45) were C. auris. A total of 64% (n = 29) C. auris candidemia was seen in non-COVID-19 patients, 31.1% (n = 14) in COVID-19patients, and twopatients had ahistory ofpost-COVID-19 infection.Theassociated risk factors included the use of broad-spectrum antibiotics, intravenous catheterization, underlying respiratory illness, mechanical ventilation, use of steroids, and dialysis. A total of 46.6% (n = 21) mortality was seen with C. auris candidemia. Conclusion(s): Candida auris candidemia continues to be a threat in hospitalized patients. This study shows prevalence of C. auris candidemia in COVID-19 and post-COVID-19 patients with 47% mortality. Candida auris is continuously reported from different departments in our institute, especially from intensive care units with high morbidity and mortality.An alertness, awareness and infection control practices by the healthcare personnel will help in early diagnosis and appropriate antifungal therapy and control the spread of C. auris.

6.
Medical Mycology ; 60(Supplement 1):98, 2022.
Article in English | EMBASE | ID: covidwho-2189362

ABSTRACT

Background: Candida is responsible for roughly 96% of all opportunistic mycoses and is a major cause of bloodstream infections (BSIs). The potential for nosocomial spread of Candidemia infections is a new concern concurrent with the rapid expansion of intensive care facilities for COVID-19 patients. With the pandemic of COVID-19 now moving into 2022, it is understood that critically ill COVID-infected patients in the ICUs are commonly infected with highly resistant bacterial and fungal infections. Objective(s): To estimate the incidence rates and compare the epidemiology of candidemia in COVID infected and non-infected patients requiring ICU care. Methodology: In this 2-year retrospective multicentric study, we present the findings on candidemia from the Healthcare-Associated Infections (HAI) surveillance network which includes 40 hospitals across India and with special emphasis on differ-ences in the epidemiology of Candidemia in COVID infected and non-infected patients in the pre-COVID (April 2019 to April 2020) and COVID times (April 2020 to April 2021) across this network. We compared the incidence of candidemia between COVID infected and non-infected patients using Poisson regression analysis. Chi-squared (<=2) test was used to test for differ-ences in variables such as gender and 14-day mortality between the patients and Wilcoxon rank-sum (Mann-Whitney) test was used to compare median between the patients. Result(s): A total of 628 patients with candidemia were screened from HAI Surveillance Database where 68 patients are COVID infected and 560 non-infected patients from both pre-COVID and COVID periods. Incidence of Candida-associated BSI increased significantly from 1.47 (95% CI, 1.35-1.60) to 3.08 (95% CI, 2.38-3.92) in non-infected and COVID-infected patients respectively, while in CLABSI the rates increased from 2.62 (95% CI, 2.34-2.92) in non-infected to 5.99 (95% CI, 4.30-8.12) in COVID-infected patients.COVID infected patients in the age group (> 60 years) were significantly more prone to candidemia compared to non-infected patients.During the COVID period, the maximum time for candidemia to develop (from the time of ICU admission) in COVID-infected patients was shorter (< 65 days) than in non-infected patients (> 90 days). Conclusion(s): We observed an increased incidence of candidemia in hospitalized patients during the COVIDperiod compared with the same during the pre-COVID period.

7.
Medical Mycology ; 60(Supplement 1):62, 2022.
Article in English | EMBASE | ID: covidwho-2189358

ABSTRACT

Objective: The incidence of bloodstream fungal infection is on the rise and Candida species remains responsible for the majority of the cases. Candidemia is frequently associated with a high rate of mortality and morbidity. The purpose of this study was to characterize Candidemia, its epidemiology, species distribution, and antifungal susceptibility pattern in a tertiary care hospital. Methods and Material: Candida species isolated from the blood culture of 51 patients in a tertiary care hospital during the period from 2016 to 2021 were included in the study. The growth on SDA was confirmed by Gram staining and speciation and antifungal susceptibility were performed with Automated system VITEK 2.0. Result(s): Out of51 isolates, Candida auris wasthe most common speciesaccounting for about 37.2% followedby C.albicans 19.7%, C. tropicalis 17.6%, and C. famata 9.8%. Candida auris has emerged as the predominant species during severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) pandemic.The incidence has risen from 22% to 60% during the pandemi C. Candida specieswere foundto be96.08% sensitiveto flucytosine, 94.12% tovoricanazole, 90.19%to casp ofungin/micafungin, 60.78% to amphoterecin B, and 56.86% to fluconazole. Conclusion(s): Candida auris has emerged as the predominant species in ICU setup and during SARS-CoV-2 pandemi C. Empirical treatment with echinocandines would be appropriate in high-risk patients with suspected Candidemia.

8.
Medical Mycology ; 60(Supplement 1):48-49, 2022.
Article in English | EMBASE | ID: covidwho-2189357

ABSTRACT

Objectives: To study the susceptibility patterns in blood isolates of Candida parapsilosis at a tertiary care center. Method(s): This was a retrospective observational study of nine cases of candidemia due to C. Parapsilosis over a period of 1 year. Data were collected using the hospital's electronic health records. Species identification was done using Matrix-Assisted Laser Desorption and Ionization-Time of Flight Mass Spectrometry (MALDI-T OF-MS) (Bruker Biotyper Sirius-Bruker Dalton-ics, Bremen, Germany). Antifungal susceptibility was performed by broth microdilution method using Sensititre TM YeastOne TM YO1O AST Plates (Therm ofisher Scientific, USA). Result(s): All patients with C. parapsilosis bloodstream infection had central venous access and all patients had received broad-spectrum antibiotics atthe time of developing candidemia.Fourpatients developed C.parapsilosis candidemiain the post coronavirus disease 2019 (COVID 19) setting.Out of the 9 isolates, 7 (77.7%) were resistant to fluconazole, 2 were resistant to voriconazole and posaconazole, and 1 isolate was resistant to amphotericin.A total of 4/9 patients were started on fluconazole prior to antifungal susceptibility testing;3 of these needed to be switched to an echinocandin due to fluconazole resistance. Conclusion(s): Fluconazole resistance in this study was seen in 7/9 (77.7%) isolates which is more than what has been previously described for C. parapsilosis. This makes fluconazole a poor choice for the treatment of C. parapsilosis in our institute. These findings may have an implication in the selection or de-escalation of antifungal treatment for C. parapsilosis.

9.
Jac-Antimicrobial Resistance ; 4(6), 2022.
Article in English | Web of Science | ID: covidwho-2161069

ABSTRACT

Introduction The primary outcome of the study was to evaluate the effect on 30 day mortality of the combination ceftazidime/avibactam + fosfomycin in the treatment of bloodstream infections (BSIs) caused by KPC-producing Klebsiella pneumoniae (KPC-Kp). Materials and methods From October 2018 to March 2021, a retrospective, two-centre study was performed on patients with KPC-Kp BSI hospitalized at Sapienza University (Rome) and ISMETT-IRCCS (Palermo) and treated with ceftazidime/avibactam-containing regimens. A matched cohort (1:1) analysis was performed. Cases were patients receiving ceftazidime/avibactam + fosfomycin and controls were patients receiving ceftazidime/avibactam alone or in combination with in vitro non-active drugs different from fosfomycin (ceftazidime/avibactam +/- other). Patients were matched for age, Charlson comorbidity index, ward of isolation (ICU or non-ICU), source of infection and severity of BSI, expressed as INCREMENT carbapenemase-producing Enterobacteriaceae (CPE) score. Results Overall, 221 patients were included in the study. Following the 1:1 match, 122 subjects were retrieved: 61 cases (ceftazidime/avibactam + fosfomycin) and 61 controls (ceftazidime/avibactam +/- other). No difference in overall mortality emerged between cases and controls, whereas controls had more non-BSI KPC-Kp infections and a higher number of deaths attributable to secondary infections. Almost half of ceftazidime/avibactam + fosfomycin patients were prescribed fosfomycin without MIC fosfomycin availability. No difference in the outcome emerged after stratification for fosfomycin susceptibility availability and dosage. SARS-CoV-2 infection and ICS >= 8 independently predicted 30 day mortality, whereas an appropriate definitive therapy was protective. Conclusions Our data show that fosfomycin was used in the treatment of KPC-Kp BSI independently from having its susceptibility testing available. Although no difference was found in 30 day overall mortality, ceftazidime/avibactam + fosfomycin was associated with a lower rate of subsequent KPC-Kp infections and secondary infections than other ceftazidime/avibactam-based regimens.

10.
Journal of Microbiology, Immunology and Infection ; 2022.
Article in English | ScienceDirect | ID: covidwho-2159306

ABSTRACT

The incidence of COVID-19-associated candidiasis (CAC) is increasing, resulting in a grave outcome among hospitalized patients with COVID-19. The most alarming condition is the increasing incidence of multi-drug resistant Candida auris infections among patients with COVID-19 worldwide. The therapeutic strategy towards CAC caused by common Candida species, such as C. albicans, C. tropicalis, and C. glabrata, is similar to the pre-pandemic era. For non-critically ill patients or those with a low risk of azole resistance, fluconazole remains the drug of choice for candidemia. For critically ill patients, those with a history of recent azole exposure or with a high risk of fluconazole resistance, echinocandins are recommended as the first-line therapy. Several novel therapeutic agents alone or in combination with traditional antifungal agents for candidiasis are potential options in the future. However, for multidrug-resistant C. auris infection, only echinocandins are effective. Infection prevention and control policies, including strict isolation of the patients carrying C. auris and regular screening of non-affected patients, are suggested to prevent the spread of C. auris among patients with COVID-19. Whole-genome sequencing may be used to understand the epidemiology of healthcare-associated candidiasis and to better control and prevent these infections.

11.
Chest ; 162(4):A1012-A1013, 2022.
Article in English | EMBASE | ID: covidwho-2060751

ABSTRACT

SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: With the development of resistant organisms, additional therapies are needed to effectively treat patients with severe infections. The Seraph®-100 Microbind Affinity Blood Filter utilizes immobilized heparinized microbeads, acting similar as the human glycocalyx, to bind and remove these substrates. In vitro and pre-clinical studies have shown up to 99% clearance of Enterococcus faecalis exposed to the Seraph®-100 blood filter. This novel extracorporeal blood purification system could assist with infection source control and reduction of vasopressor requirements. CASE PRESENTATION: A 30-year-old male with no significant past medical history was admitted due to severe ARDS secondary to COVID-19 infection and required extracorporeal membrane oxygenation (ECMO) after an unsuccessful trial of conventional supportive therapies. The patient's hospital course was complicated by multiple infections, including bacteremia from methicillin susceptible Staphylococcus aureus, candidemia and Enterobacter ventilator associated pneumonia. These infections initially improved with use of appropriate intravenous antimicrobials. However, the patient experienced an acute hemodynamic decompensation requiring multiple vasoactive medications. He was empirically started on broad spectrum anti-microbials including meropenem, vancomycin, and isavuconazole. Blood cultures revealed Enterococcus faecalis, susceptible to broad-spectrum antibiotics. After 24 hours of broad-spectrum antimicrobials without improvements in vasopressor requirements, the Seraph-100® blood filter was used in-parallel with the ECMO circuit. Immediate improvement in vasopressors was noted with discontinuation of vasopressin and decrease in norepinephrine by 75%. The patient finished a 2-week course of intravenous ampicillin/sulbactam. His respiratory status subsequently improved and he was able to be removed from ECMO 24 days later. DISCUSSION: Initial studies have shown the Seraph-100 is capable of clearing the SARS-Cov-2 virus and use has been associated with decreased mortality in patients with SARS-Cov-2. The ability to remove additional pathogens including bacteria, fungi and viruses would aid in obtaining source control and augment the effects of intravenous antibiotics. This case not only illustrates the benefits with the use of the Seraph ®-100 blood filter along with broad spectrum antibiotics, but also the ability to use this extracorporeal blood purification system in-line with ECMO. CONCLUSIONS: With the emergence of multi-drug resistant pathogens, additional treatment options are urgently needed. The Seraph®-100 may be a useful adjunct to broad spectrum antimicrobials and may improve hemodynamics in patients with vasopressor-dependent septic shock. Further prospective studies are needed to assess clinical improvements with the use of the Seraph-100 Microbind blood filter in patients with bacteremia and those requiring ECMO. Reference #1: Olson SW, Oliver JD, Collen J, et al. Treatment for Severe Coronavirus Disease 2019 With the Seraph 100 Microbind Affinity Blood Filter. Critical Care Explor. 2020;2(8):e0180. Reference #2: Chitty, Stephen, Mobbs, Sarah, Chung, Kevin et al., for the PURIFY INVESTIGATORS. A Multicenter Evaluation of Blood Purification with Seraph 100 Microbind Affinity Blood Filter for the Treatment of Severe COVID-19: A Preliminary Report. medRxiv 2021.04.20.21255810;doi: https://doi.org/10.1101/2021.04.20.21255810 Reference #3: Seffer, Malin-Theres, et al. "Heparin 2.0: a new approach to the infection crisis.” Blood Purification 50.1 (2021): 28-34. DISCLOSURES: No relevant relationships by Joshua Boster No relevant relationships by Henry Danchi Speaker/Speaker's Bureau relationship with Janssen Please note: $1001 - $5000 by Michael Morris, value=Honoraria Speaker/Speaker's Bureau relationship with GSK Please note: $1001 - $5000 by Michael Morris, value=Honoraria Removed 03/29/2022 by Michael Morris No releva t relationships by Mai Nguyen No relevant relationships by Melissa Rosas No relevant relationships by Steven Stoffel No relevant relationships by Robert Walter

12.
Chest ; 162(4):A432-A433, 2022.
Article in English | EMBASE | ID: covidwho-2060596

ABSTRACT

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: Since its emergence in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has spread across the world, claiming millions of lives. With the publication of RECOVERY trial and REMAP-CAP trial, tocilizumab is recommended as additional therapy in select COVID populations by various professional societies. Although not observed initially in several randomized trials, concerns regarding serious secondary infections have been raised. Hereby, we seek to describe the epidemiology of infectious complications after tocilizumab in COVID patients admitted to a tertiary community hospital and to determine related risk factors for infections. METHODS: A retrospective cohort study was conducted among COVID patients requiring noninvasive or invasive ventilation who received tocilizumab at our hospital between June 2020 to December 2021. We define infectious complications as positive culture grown on a specimen that was also treated with antibiotics by the primary team. Baseline demographics and laboratory values are obtained through electronic medical records. Continuous outcomes are analyzed with parametric and non-parametric testing. Categorical variables are analyzed using the Chi-Square test. Risk factors are identified through Probit regression analysis and stepwise analysis. Statistics are performed using SPSS and STATA. RESULTS: 52 patients are identified with a median age of 63 and 46.2% female sex. Median hospital admission time since COVID diagnosis is 2 days and median tocilizumab administered time is 6.5 days. Common comorbidities include hypertension (63.5%), hyperlipidemia (50%) and diabetes (44.2%). Infectious complications are documented in 30 patients (57.7%), with 29 episodes of pneumonia, 7 episodes of urinary tract infection, and 4 episodes of bacteremia. Common organisms include MSSA (21%), Pseudomonas aeruginosa (19%), Klebsiella species (13%) and MRSA (5%). There are 9 cases of multidrug-resistant bacterial infection and 3 episodes of invasive fungal infection (1 Candidemia and 2 invasive aspergilloses). 22 patients (43.3%) died in the hospital before discharge with a median alive time after tocilizumab of 16.5 days. Hyperglycemia on admission (defined as a random glucose >200 mg/dl), hypertension and antibiotic use before tocilizumab are independent risk factors associated with infectious complications during regression analysis. Age >65 is the single most significant factor associated with death in the hospital. CONCLUSIONS: In real-world experience, infectious complications are not uncommon in COVID patients who receive tocilizumab. Our analyses show that potential risk factors for developing infections include a history of hypertension, hyperglycemia on admission and antibiotic use before tocilizumab. CLINICAL IMPLICATIONS: More rigorous criteria in patient selection and patient monitoring should be explored in future trials involving tocilizumab in COVID patients. DISCLOSURES: No relevant relationships by Zauraiz Anjum No relevant relationships by Ming-Yan Chow No relevant relationships by Ahmed Elkhapery No relevant relationships by Hafsa Faisal No relevant relationships by Lakshmi G Nair No relevant relationships by Charoo Iyer No relevant relationships by Hongli Liu No relevant relationships by Chengu Niu No relevant relationships by Kaiwen Zhu

13.
Kidney International Reports ; 7(9):S527, 2022.
Article in English | EMBASE | ID: covidwho-2041723

ABSTRACT

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

14.
Mycoses ; 2022 Sep 22.
Article in English | MEDLINE | ID: covidwho-2038152

ABSTRACT

BACKGROUND: The development of candidemia is a highly fatal condition in severe COVID-19 infection. OBJECTIVES: This study aimed to develop a candidemia prediction score in COVID-19 patient based on the patient's clinical characteristics, and healthcare-related factors during intensive care units (ICU) follow-up. PATIENTS/METHODS: Severe COVID-19 patients hospitalised in ICU in Ankara City Hospital during the one-year period (August 15, 2020, and August 15, 2021) were included. After univariate analysis, multivariate analysis was applied using variable selection approach to investigate the effects of variables together and to create a score model for candidemia. Statistically significant factors were included in the development process of candida prediction score. RESULTS: Of 1305 COVID-19 ICU patients, 139 had a candidemia episode. According to the final model, four variables, presence of central venous catheter (CVC) (OR 19.07, CI 8.12-44.8, p < .0001), multifocal colonisation (OR 2.28, CI 1.39-3.72, p 0.001), length of ICU stays ≥14 days (OR 3.62, CI 2.42-5.44, p < .0001) and corticosteroids (OR 0.51, CI 0.34-0.76, p 0.0011) were the only statistically significant independent risk factors for candidemia. Score model was demonstrated by a nomogram, and the risk for candidemia was calculated to be high in patients who scored ≥56 points by using the criteria [CVC = 51, multifocal colonisation = 14, prolonged hospitalisation = 23, no steroid use = 12 points]. The AUC of the score is 0.84 (CI 0.81-0.87). CONCLUSION: We developed and validated an easy-to-use clinical prediction score for candidemia in severe COVID-19 infection. In COVID-19 ICU patients, the risk of candidemia is high if one of the other risk factors is present together with CVC.

15.
Journal of the Formosan Medical Association ; 121(9):1617-1621, 2022.
Article in English | Scopus | ID: covidwho-2015654
16.
Emerg Microbes Infect ; 11(1): 2264-2274, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2008478

ABSTRACT

Patients presenting with severe COVID-19 are predisposed to acquire secondary fungal infections such as COVID-19-associated candidemia (CAC), which are associated with poor clinical outcomes despite antifungal treatment. The extreme burden imposed on clinical facilities during the COVID-19 pandemic has provided a permissive environment for the emergence of clonal outbreaks of multiple Candida species, including C. auris and C. parapsilosis. Here we report the largest clonal CAC outbreak to date caused by fluconazole resistant (FLZR) and echinocandin tolerant (ECT) C. parapsilosis. Sixty C. parapsilosis strains were obtained from 57 patients at a tertiary care hospital in Brazil, 90% of them were FLZR and ECT. Although only 35.8% of FLZR isolates contained an ERG11 mutation, all of them contained the TAC1L518F mutation and significantly overexpressed CDR1. Introduction of TAC1L518F into a susceptible background increased the MIC of fluconazole and voriconazole 8-fold and resulted in significant basal overexpression of CDR1. Additionally, FLZR isolates exclusively harboured E1939G outside of Fks1 hotspot-2, which did not confer echinocandin resistance, but significantly increased ECT. Multilocus microsatellite typing showed that 51/60 (85%) of the FLZR isolates belonged to the same cluster, while the susceptible isolates each represented a distinct lineage. Finally, biofilm production in FLZR isolates was significantly lower than in susceptible counterparts Suggesting that it may not be an outbreak determinant. In summary, we show that TAC1L518F and FKS1E1393G confer FLZR and ECT, respectively, in CAC-associated C. parapsilosis. Our study underscores the importance of antifungal stewardship and effective infection control strategies to mitigate clonal C. parapsilosis outbreaks.


Subject(s)
COVID-19 , Candidemia , Antifungal Agents/pharmacology , Antifungal Agents/therapeutic use , Brazil/epidemiology , COVID-19/epidemiology , Candida parapsilosis/genetics , Candidemia/drug therapy , Candidemia/epidemiology , Candidemia/microbiology , Disease Outbreaks , Echinocandins/pharmacology , Echinocandins/therapeutic use , Fluconazole/pharmacology , Fluconazole/therapeutic use , Humans , Intensive Care Units , Microbial Sensitivity Tests , Pandemics , Voriconazole/therapeutic use
17.
Journal of General Internal Medicine ; 37:S425, 2022.
Article in English | EMBASE | ID: covidwho-1995603

ABSTRACT

CASE: A 56-year-old male with a history of asthma was admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure. He was found to have sepsis secondary to pneumococcal pneumonia superinfected by COVID19. Labs showed elevated inflammatory markers. Chest x-ray initially demonstrated left lower lobe pneumonia but throughout the COVID-19 course, worsened to persistent multifocal pneumonia. The patient was intubated and treated with enoxaparin and a ten-day course of dexamethasone as well as antibiotics due to worsening clinical status. After the COVID-19 course resolved and the patient was extubated, he developed sepsis again - this time secondary to Candidemia. Treatment with intravenous micafungin was initiated and HIV antibodies screening returned negative. The patient began to report subacute visual changes including floating spots and blurry vision in the right eye without any other acute ocular symptoms. Upon ophthalmological exam, there were multiple white retinal lesions without vitreous involvement bilaterally on the macula indicating candida retinitis. Antifungal treatment with micafungin was changed to intravenous voriconazole for greater intraocular penetration. After seven days of intravenous voriconazole, two blood cultures came back negative for Candida. At this point, the patient was medically stable and was discharged on a six- week course of oral voriconazole. IMPACT/DISCUSSION: The COVID-19 pandemic changed the landscape of medicine. Not only have healthcare systems worked hard to treat the COVID-19 infections themselves but also the long-term effects that result from an infection. As treatment guidelines have been developed and honed, steroids appear at the forefront of therapy. However, this does not come without consequences as prolonged use of corticosteroids can dampen the body's immune system. This compounds the ability of COVID-19 pneumonia to result in a severely immunocompromised state that can subsequently expose the body to opportunistic infections. Candida albicans is an organism that exists in all humans in the gastrointestinal and genitourinary systems typically without impact. In severely immunocompromised individuals such as the patient in the case, hospital courses involving ICU care can lead to hematogenous spread of Candida. The candidemia leads to sepsis and may also present with rare clinical pictures such as Candida retinitis. For this reason, candidemia should prompt thorough evaluation of patients with an echocardiogram, abdominal computer tomography, and ophthalmologic exam. CONCLUSION: This case displays the ability of COVID-19 infections to provide an opportunity for rare infectious manifestations such as Candida retinitis. As the pandemic prolongs, proper treatment regimens must be reassessed for future use as these presentations may become more common.

18.
Curr Med Mycol ; 8(1): 32-38, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1988710

ABSTRACT

Background and Purpose: Candidemia remained important in the intensive care units (ICU) during the COVID-19 pandemic. This study aimed to investigate the clinical and laboratory data on candidemia in COVID-19 patients. Materials and Methods: The baseline characteristics, as well as laboratory and clinical findings of candidemia and non-candidemia patients, were compared. Candidemia was defined as the isolation of Candida spp. from blood cultures. The isolates were identified by VITEK® 2 (bioMérieux, France) commercial method. Antifungal susceptibility was assessed using the E-test method. Univariate and multiple binary logistic regression analyses were performed to compare the variables. Results: In total, 126 patients with the COVID-19 disease were included. Candidemia was diagnosed in 44 (35%) of the patients. The number of patients with diabetes mellitus and chronic renal failure was higher in the candidemia group. In the candidemia group, the duration of ICU stay of patients, the 30-day mortality rate, mechanical ventilation therapy, and systemic corticosteroids (Prednisone) usage were significantly higher in candidemia patients. Moreover, the median white blood cell, neutrophils, and lactate dehydrogenase were higher in the candidemia group.Univariate and multiple binary logistic regression analyses were performed to compare the variables. Isolated species were identified as Candida albicans (n=12, 41%), Candida parapsilosis (n=7, 24%), Candida glabrata (n=6, 21%), Candida tropicalis (n=3, 10%), and Candida dublinensis (n=1, 3%). In total, three isolates of six C. glabrata species had dose-dependent sensitivity to fluconazole, and one C. parapsilosis was determined to be resistant. Conclusion: The COVID-19 patients who are admitted to ICU have many risk factors associated with candidemia. The most common risk factors for the development of candidemia were mechanical ventilation, diabetes mellitus, neutrophilia, and low hemoglobin level. The most frequently isolated species was C. albicans. Moreover, caspofungin was found to be the most effective drug in vitro. No significant resistance pattern was detected against the isolated species. It should be noted that risk-stratified antifungal prophylaxis in the ICU is possible.

19.
Microb Cell ; 9(8): 141-144, 2022 Aug 01.
Article in English | MEDLINE | ID: covidwho-1988633

ABSTRACT

Candida auris is a multidrug resistant (MDR) fungal pathogen with a crude mortality rate of 30-60%. First identified in 2009, C. auris has been rapidly emerging to become a global risk in clinical settings and was declared an urgent health threat by the Centers for Disease Control and Prevention (CDC). A concerted global action is thus needed to successfully tackle the challenges created by this emerging fungal pathogen. In this brief article, we underline the importance of unique virulence traits,including its easy transformation, its persistence outside the host and its resilience against multiple cellular stresses, as well as of environmental factors that have mainly contributed to the rise of this superbug.

20.
J Infect Chemother ; 28(10): 1433-1435, 2022 Oct.
Article in English | MEDLINE | ID: covidwho-1936795

ABSTRACT

Candida dubliniensis phenotypically mimics Candida albicans in its microbiological features; thus, its clinical characteristics have yet to be fully elucidated. Here we report the case of a 68-year-old Japanese man who developed C. dubliniensis fungemia during treatment for severe coronavirus disease 2019 (COVID-19). The patient was intubated and received a combination of immunosuppressants, including high-dose methylprednisolone and two doses of tocilizumab, as well as remdesivir, intravenous heparin, and ceftriaxone. A blood culture on admission day 11 revealed Candida species, which was confirmed as C. dubliniensis by mass spectrometry. An additional sequencing analysis of the 26S rDNA and ITS regions confirmed that the organism was 100% identical to the reference strain of C. dubliniensis (ATCC MYA-646). Considering the simultaneous isolation of C. dubliniensis from a sputum sample, the lower respiratory tract could be an entry point for candidemia. Although treatment with micafungin successfully eradicated the C. dubliniensis fungemia, the patient died of COVID-19 progression. In this case, aggressive immunosuppressive therapy could have caused the C. dubliniensis fungemia. Due to insufficient clinical reports on C. dubliniensis infection based on definitive diagnosis, the whole picture of the cryptic organism is still unknown. Further accumulation of clinical and microbiological data of the pathogen is needed to elucidate their clinical significance.


Subject(s)
COVID-19 , Candidemia , Fungemia , Aged , COVID-19/complications , Candida , Candida albicans , Candidemia/diagnosis , Candidemia/drug therapy , Candidemia/microbiology , Fungemia/diagnosis , Fungemia/drug therapy , Fungemia/microbiology , Humans , Male
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