Risk Factors for Pneumocystis jirovecii Pneumonia in Non-HIV Patients Hospitalized for COVID-19: A Case-Control Study

Abstract

Background: Very few cases of Pneumocystis jirovecii pneumonia (PJP) have been reported in COVID-19 so far, and mostly in patients with concomitant HIV infection or in solid-organ transplant recipients. Despite COVID-19 being associated with lymphopenia and the use of steroids, there are no studies specifically aimed at investigating the risk factors for PJP in COVID-19. Methods: A retrospective case-control study was performed. We matched PJP cases with controls with a 1:2 ratio, based on age ± 10 years, solid-organ transplantation (SOT), hematological malignancies, and in the setting of PJP development (ICU vs. non-ICU). A direct immunofluorescence assay on bronchoalveolar lavage fluid was used to diagnose PJP. Results: We enrolled 54 patients. Among 18 cases of PJP, 16 were diagnosed as “proven”. Seven of the eighteen cases were immunocompromised, while the other patients had no previous immunological impairment. Patients with PJP had significantly lower median lymphocyte values (p = 0.033), longer COVID-19 duration (p = 0.014), a higher dose of steroid received (p = 0.026), higher CRP values (p = 0.005), and a lower SARS-CoV-2 vaccination rate than the controls (p = 0.029). Cumulative steroid dose is the independent risk factor for PJP development (OR = 1.004, 95%CI = 1–1.008, p = 0.042). Conclusions: PJP develops in COVID-19 patients regardless of immunosuppressive conditions and the severity of disease, and it is correlated to the corticosteroid dose received.

Targeted next-generation sequencing of pathogens reveals the profile of secondary infections in COVID-19 patients

“…Kang [38] analysed the incidence of P. jirovecii pneumonia in non-HIV patients between 2016 and 2022, and the results con rmed that the incidence of P. jirovecii pneumonia was signi cantly higher during the COVID-19 epidemic than before the epidemic. Signi cantly decreased lymphocyte count and glucocorticoid use are the principal risk factors for P. jirovecii infection, and the risk of P. jirovecii infection increases with higher doses of glucocorticoid treatment [39]. P. jirovecii pneumonia can be distinguished from the clinical symptoms and imaging features of COVID-19; thus, when the condition of a COVID-19 patient deteriorates, the possibility of P. jirovecii infection should also be considered, and early identi cation and treatment of secondary fungal infections is essential for improving patient outcomes.…”

Candent issues in pneumonia. Reflections from the Fifth Annual Meeting of Spanish Experts 2023

“…Its prevalence is rising because there is a growing number of vulnerable patients each year, diagnosis is usually delayed because of low grade of suspicion and, therefore, mortality is higher than in patients with HIV infection [233]. Risk factors for developing PJP are [119,[234][235][236][237] support to patients with ARDS [212]. In fact, a great variability in mortality between different ICU services was observed during COVID-19 pandemic.…”

Prevalence of Pneumocystis jirovecii Colonization in Non-Critical Immunocompetent COVID-19 Patients: A Single-Center Prospective Study (JiroCOVID Study)

“…At our university hospital, we observed and reported an unexplainable high prevalence of PJP as a complication of COVID-19, even in patients who were immunocompetent before SARS-CoV-2 infection. On the other hand, other published studies reported PJP mostly in HIV or transplant individuals with COVID-19 [11][12][13]. Therefore, we conducted a study to evaluate the prevalence and features of P. jirovecii colonization with PCR on oral wash samples among non-immunocompromised and non-critical patients admitted with COVID-19 pneumonia at our institution.…”