A High Frequency of Candida auris Blood Stream Infections in Coronavirus Disease 2019 Patients Admitted to Intensive Care Units, Northwestern India: A Case Control Study

Abstract

Background The ongoing pandemic of COVID-19 has overwhelmed healthcare facilities raising an important novel concern of nosocomial transmission of Candida species in the intensive care units. Methods We evaluated the incidence and risk factors for development of candidemia in 2384 COVID-19 patients admitted during August 2020-January 2021 in ICUs of two hospitals (Delhi and Jaipur), India. A 1:2 case control matching was used to identify COVID-19 patients who did not develop candidemia as controls. Result A total of 33 patients developed candidemia accounting for an overall incidence of 1.4% over a median ICU stay of 24 days. A two-fold increase in the incidence of candidemia in COVID-19 versus non–COVID-19 patients was observed with an incidence rate of 14 and 15/1000 admissions in two ICUs. Candida auris was the predominant species (42%) followed by Candida tropicalis. Multivariable regression analysis revealed the use of tocilizumab, duration of ICU stay (24 vs. 14 days) and raised ferritin level as an independent predictor for the development of candidemia. Azole resistance was observed in C. auris and C. tropicalis harbouring mutations in the azole target ERG11 gene. MLST identified identical genotypes of C. tropicalis in COVID-19 patients raising concern of nosocomial transmission of resistant strains. Conclusion Secondary bacterial infections has been a concern with the use of tocilizumab. In this cohort of critically ill COVID-19 patients tocilizumab was associated with development of candidemia. Surveillance of antifungal resistance is warranted to prevent transmission of MDR strains of nosocomial yeasts in COVID-19 hospitalised patients.

Prevalence, risk factors, treatment and outcome of multidrug resistance Candida auris infections in Coronavirus disease (COVID‐19) patients: A systematic review

“…Thus, the ongoing COVID‐19 pandemic would become a perfect battlefield for outbreaks of C. auris because of the similar underlying diseases and the risk factors, which increases the chance of C. auris infections in COVID‐19 patients. Further, a recent study from India confirmed these findings, that the treatment with interleukin‐6 antagonists such as tocilizumab, prolonged ICU stay, mechanical ventilation and raised ferritin levels were identified as significant risk factors of candidemia (majority of reported cases in the study were due to C. auris ) in COVID‐19 patients 36 …”

Incidence of Candidemia Is Higher in COVID-19 versus Non-COVID-19 Patients, but Not Driven by Intrahospital Transmission

“…Further to this, ours is the first study in which isolates causing candidemia during the COVID-19 pandemic have been genotyped to gain more insight about patient-to-patient transmission not only in patients with COVID-19 but also in patients with candidemia and non-COVID-19. Previous studies in which Candida genotyping was carried out are limited by the fact that the number of isolates was low, they were sourced exclusively from patients with COVID-19, and they were not designed to address the question of clonal spreading as a driver of higher candidemia incidence in COVID-19 patients [ 30 , 31 ]. As a whole, comparison of this population with patients without COVID-19 provides valuable and thorough information not previously described, since comparisons of candidemia episodes including patients with and without COVID-19 have been only occasionally carried out [ 14 , 18 , 19 , 20 , 21 ].…”

COVID-19 and C. auris: A Case-Control Study from a Tertiary Care Center in Lebanon

“…This result was similar to the study performed in Qatar where no association was found between candidemia, including C. auris , and the use of corticosteroids and tocilizumab after matching for the period of LOS in the ICU [ 29 ]. On the contrary, in a study conducted by Rajni et al, the multivariate logistic regression analysis showed that tocilizumab was an independent predictor of candidemia in severe COVID-19 patients [ 10 ].…”

“…In the multivariable logistic regression analysis, only LOS and high qSOFA score were shown to be independent risk factors for C. auris isolation. Longer ICU stay had been shown to be a risk factor for the development of candidemia, including C. auris fungemia in several studies, possibly because of horizontal transmission of C. auris during a prolonged ICU stay [ 10 , 26 , 27 , 28 ]. In a case-control study conducted by Omrani et al to assess risk factors for candidemia, including C. auris in COVID-19 patients, 8 out of 82 cases of candidemia were due to C. auris , and qSOFA score in addition to age were shown to be the only independent risk factors for candidemia in COVID-19 patients admitted to the ICU [ 29 ].…”

“…It has so far been reported from over 30 countries and has constituted a heavy burden to the healthcare system [ 5 ]. Since the beginning of the COVID-19 pandemic, outbreaks of C. auris have been described from many centers in critically-ill patients [ 6 , 7 , 8 , 9 , 10 ]. The first C. auris case ever described in Lebanon occurred during the COVID-19 pandemic at the American University of Beirut Medical Center (AUBMC), a tertiary referral center, where an outbreak with 14 patients with positive cultures for C. auris was initially identified over a period of 13 weeks, starting from October 2020.…”