OUTCOMES OF FUNGAL INFECTIONS IN COVID-19 ADMISSIONS

ABSTRACT

BACKGROUND: COVID-19 has increased awareness of fungal infections among hospitalized patients. With the use of multiple immune-modulating drugs in COVID-19 along with COVID-19 related immune suppression, the risk of fungal infections is high. We studied fungal infections in COVID-19 to identify patterns to aid in preventive measures. METHODS: We included all COVID-19 positive adult patients (≥18 years) hospitalized between March 1, 2020, to October 1, 2021. Fungal infections were deemed positive if they developed fevers, leukocytosis along with positive cultures (blood, respiratory or urine). Candida albicans was considered to be causative if either blood cultures were positive or positive cultures from 2 sites and antifungals were administered. Outcomes studied were rates, organisms involved, and in-hospital mortality. We used multivariable logistic regression models to examine characteristics associated with the development of fungal infections. Variables used in the model included patient demographics (age, gender, race), comorbidities (congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, end- stage renal disease, cirrhosis, and cancer), medications used to treat COVID-19 (ivermectin, hydroxychloroquine, steroids, tocilizumab, baricitinib), the severity of disease (4C score, use of invasive mechanical ventilation (IMV), acute kidney injury (AKI) requiring hemodialysis), and presence of central venous catheters. RESULTS: Of 7508 admissions with COVID-19, 82 (1.1%) acquired fungal infections. Fungal infections developed in 61(3.7%) of the 1642 intensive care unit (ICU) admissions and 21 (0.4%) of the 5866 non-ICU admissions. Among the fungal infections - 33 were Candida albicans, 28 were non-candida albicans, 19 were molds and 2 were cryptococcus. Fungal infections were associated with the use of IMV (Odds Ratio (OR) 13.3, 95% confidence interval (CI) 6.7-26.3, p<0.001), steroids (OR 2.4, 95%CI 1.6- 3.6, p<0.001), and AKI requiring hemodialysis (OR 2.2, 95%CI 1.2-4.1, p=0.01). Of the 5866 non-ICU admissions, in-hospital mortality was significantly higher in those with fungal infections (65% vs 7.3%, p< 0.001). Similarly, among the 1642 ICU admissions, in-hospitalmortality was significantly higher in those with fungal infections (64% vs 37%, p<0.001). On logistic regression analysis, fungal infections were associated with higher in-hospital mortality (OR 2.0;95%CI 1.1- 3.6, p=0.03). Of the fungal infections, molds were associated with higher in-hospital mortality (OR 4.4, 95%CI 1.2- 16.4) while Candida albicans (OR 2.4, 95%CI 0.9-6.4, p=0.08) and non-albicans candida (OR 1.2, 95%CI 0.5-3.3, p=0.66) did not reach significance. CONCLUSIONS: Fungal infections are rare in hospitalized COVID-19 patients but ten times more common in ICU admission. Fungal infections were associated with IMV, steroids, and AKI requiring hemodialysis. Molds were associated with higher in-hospital mortality.