Opportunistic Fungal Infection
Opportunistic infections from bacteria or fungi are common in patients grappling with Covid-19 infection especially those treated in the intensive care units. According to the Centre for Disease Control and Prevention (CDC), the most common fungal infections in patients with COVID-19 include aspergillosis and invasive candidiasis. (1)
Incidence of invasive fungal disease (IFD) in Covid-19
The Welsh study “A National Strategy to Diagnose Coronavirus Disease 2019–Associated Invasive Fungal Disease in the Intensive Care Unit” found (2):
51 of the 135 (37.8%) screened for IFD had 1 or more positive mycological tests.
30 patients (22.2%) had 1 or more positive tests of Aspergillus infection.
17 patients (12.6%) had invasive yeast infections, mainly a Candida species.
Another 4 patients were found to have unspecified IFD.
Mucormyosis
Another uncommon but fatal fungal infection in Covid-19 patients is mucormyosis. It is caused by inhalation of the spores of the mould fungi of the genus Rhizopus, Mucor, Rhizomucor, Cunninghamella and Absidia of Order- Mucorales, Class- Zygomycetes.
A systematic review of mucormyosis cases reported worldwide and in India suggested (3):
Most cases (81.2%) found in India
Predominantly (78.9%) seen in males
83.3% had hyperglycemia at presentation (due to pre-existing DM or new-onset hyperglycemia or new-onset diabetes or diabetic ketoacidosis [DKA])
76.3% of the cases had a history of corticosteroid treatment
Overall mortality was 30.7%
Antifungal agents
The recommended antifungals by CDC are:
Invasive Aspergillosis: voriconazole, lipid amphotericin formulations, posaconazole, isavuconazole, itraconazole, caspofungin, and micafungin. (4)
Invasive Candidiasis: echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein (intravenous or IV). Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations. (5)
Invasive Mucormyosis: aggressive surgical intervention and amphotericin B, posaconazole, or isavuconazole. (1)
Amphotericin B
The diagnosis of specific fungal species in some of the hospital settings that depends on fungal C&S results can take some time. Hence, empirical antifungal is often prescribed if invasive fungal infection is diagnosed clinically. The most common empirically used antifungal is amphotericin B.
The recommended dose of Amphotericin B (conventional) for invasive aspergillosis, candidiasis and mucormyosis: 0.25 to 1 mg/kg/day IV over 2 to 6 hours; MAX of 1.5 mg/kg when given on alternate days. Renal impairment with CrCl less than 10 mL/min: usual IV dose (20 to 50 mg) every 24 to 36 hours. If the patient is undergoing hemodialysis, no specific dose adjustment is required. (6)
References
Fungal diseases and covid-19. Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/covid-fungal.html. Published June 3, 2021. Accessed August 2021
White PL, Dhillon R, Cordey A, et al. A national strategy to diagnose coronavirus disease 2019–associated invasive fungal disease in the intensive care unit. Clinical Infectious Diseases. 2020. doi:10.1093/cid/ciaa1298
Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021;15(4):102146. doi:10.1016/j.dsx.2021.05.019
Treatment for aspergillosis. Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/diseases/aspergillosis/treatment.html. Published January 8, 2021. Accessed August 20, 2021.
Treatment for invasive candidiasis. Centers for Disease Control and Prevention. https://www.cdc.gov/fungal/diseases/candidiasis/invasive/treatment.html. Published November 18, 2020. Accessed August 20, 2021.
MIMS gateway. https://online1.mimsgateway.com.my/Malaysia/MicroMedex/GetMicroMedexHL7?mainSearchCriteria.v.cs=2.16.840.1.113883.6.69&holder.assignedEntity.n=UBMMA&holder.assignedEntity.certificateText=+myMIMSGW2019&mainSearchCriteria.v.c=39822-1055-05&portal=y. Accessed August 20, 2021.
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