S econdary infections are known to complicate the clinical course of coronavirus disease . Bacterial infections are the most common secondary infections, but increasing reports of systemic fungal infections are causing concern. In the early part of the COVID-19 pandemic, <1% of secondary infections reported in COVID-19 patients were fungal (1,2). Preexisting conditions, indiscriminate use of antimicrobial and glucocorticoid drugs, and lapses in infection control practices are putative factors contributing to the emergence of systemic fungal infections in severe COVID-19 cases (3). After incidence of candidemia and invasive aspergillosis in COVID-19 patients increased (4,5), awareness of possible fungal co-infections increased among clinicians and microbiologists. One study reported invasive fungal infections in ≈6% of hospitalized COVID-19 patients (6). Occasional reports of COVID-19-associated mucormycosis (CAM) from various centers (7,8) and a series of 18 cases from a city in South India increased our concerns about CAM (9). India has a high burden of mucormycosis among patients with uncontrolled diabetes mellitus, and many severe COVID-19 patients have diabetes (8,10). India also is one of the countries worst affected by the COVID-19 pandemic. Thus, we would expect India to have many CAM cases. We conducted a nationwide multicenter study to evaluate the epidemiology and outcomes of CAM and compare the results with cases of mucormycosis unrelated to COVID-19 (non-CAM). Methods Study Design and SettingWe conducted a retrospective observational study involving 16 healthcare centers across India (Figure 1).

The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

Although C. auris infection has been observed across India, the number of cases is higher in public-sector hospitals in the north of the country. Longer stay in ICU, underlying respiratory illness, vascular surgery, medical intervention and antifungal exposure are the major risk factors for acquiring C. auris infection even among patients showing lower levels of morbidity.

The epidemiology of candidaemia varies between hospitals and geographic regions. Although there are many studies from Asia, a large-scale cross-sectional study across Asia has not been performed. We conducted a 12-month, laboratory-based surveillance of candidaemia at 25 hospitals from China, Hong Kong, India, Singapore, Taiwan and Thailand. The incidence and species distribution of candidaemia were determined. There were 1601 episodes of candidaemia among 1.2 million discharges. The overall incidence was 1.22 episodes per 1000 discharges and varied among the hospitals (range 0.16-4.53 per 1000 discharges) and countries (range 0.25-2.93 per 1000 discharges). The number of Candida blood isolates and the total number of fungal isolates were highly correlated among the six countries (R² = 0.87) and 25 hospitals (R² = 0.77). There was a moderate correlation between incidence of candidaemia and the intensive care unit (ICU)/total bed ratio (R² = 0.47), although ICUs contributed to only 23% of candidaemia cases. Of 1910 blood isolates evaluated, Candida albicans was most frequently isolated (41.3%), followed by Candida tropicalis (25.4%), Candida glabrata (13.9%) and Candida parapsilosis (12.1%). The proportion of C. tropicalis among blood isolates was higher in haemato-oncology wards than others wards (33.7% versus 24.5%, p 0.0058) and was more likely to be isolated from tropical countries than other Asian countries (46.2% versus 18.9%, p 0.04). In conclusion, the ICU settings contribute, at least in part, to the incidence variation among hospitals. The species distribution is different from Western countries. Both geographic and healthcare factors contribute to the variation of species distribution.

Introduction: Oropharyngeal candidiasis (OPC) is the most common opportunistic fungal infection reported in human immunodeficiency virus (HIV) positive patients worldwide. This prospective study was undertaken to investigate OPC and Candida colonization (CC) and their correlation with CD4+ cell counts and antiretroviral therapy (ART) in HIV-positive patients. Methodology: In total, 190 HIV-positive patients were enrolled for study in three groups as follows: Group A, 90 patients without ART; Group B, 100 patients undergoing treatment with ART; and Group C, 75 HIV-negative control patients. All HIV patients underwent clinical examination and were subjected to CD4+ cell counts. Swabs were collected from the oral cavity of all individuals and plated on Sabouraud’s dextrose agar. Identification of Candida species was performed by conventional methods. Results: Candida species were isolated in 84/190 (44.2%) and 20/75 (26.6%) of the HIV-positive subjects and controls respectively (p<0.01). OPC was noted in 21/190 (11%) of the HIV-positive patients. Candida albicans was the most frequently isolated species. Patients with CD4+ cell counts ≤ 200 cells/mm3 were significantly (p<0.001) more frequently colonized (37/63; 58.7%) and infected (18/21; 85.7 %) with Candida species. Candida species was seen in patients with CC and OPC with CD4+cell counts between 201 and 500 (21/63; 33.4% vs 3/21; 14.3%) and > 500 cell/mm3 (5/63; 7.9% versus 0/21 0%) respectively. Conclusion: OPC and Candida colonization occur more frequently in HIV-positive patients with CD4+ cell counts ≤200 cell/mm3. ART significantly reduces OPC. C. albicans is the most frequently isolated species in both OPC and colonization, suggesting endogenous infection.