Candidemia Among Coronavirus Disease 2019 Patients in Turkey Admitted to Intensive Care Units: A Retrospective Multicenter Study

Amir Arastehfar; Nevzat Ünal; Tuğrul Hoşbul; Muhammed Alper Özarslan; Ayşe Sultan Karakoyun; Furkan Polat; Diego Fuentes; Ramazan Gümral; Tuba Turunç; Farnaz Daneshnia; David S Perlin; Cornelia Lass-Flörl; Toni Gabaldón; Macit Ilkit; M Hong Nguyen

doi:10.1093/ofid/ofac078

Candidemia Among Coronavirus Disease 2019 Patients in Turkey Admitted to Intensive Care Units: A Retrospective Multicenter Study

Open Forum Infect Dis. 2022 Feb 13;9(4):ofac078. doi: 10.1093/ofid/ofac078. eCollection 2022 Apr.

Authors

Amir Arastehfar¹, Nevzat Ünal², Tuğrul Hoşbul³, Muhammed Alper Özarslan⁴, Ayşe Sultan Karakoyun⁵, Furkan Polat⁴, Diego Fuentes^{6

7}, Ramazan Gümral³, Tuba Turunç⁸, Farnaz Daneshnia¹, David S Perlin¹, Cornelia Lass-Flörl⁹, Toni Gabaldón^{6

7

10

11}, Macit Ilkit⁵, M Hong Nguyen¹²

Affiliations

¹ Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA.
² University of Health Sciences, Adana City Training and Research Hospital, Laboratory of Medical Microbiology, Adana, Turkey.
³ Department of Microbiology, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey.
⁴ Department of Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey.
⁵ Division of Mycology, Faculty of Medicine, Çukurova University, Adana, Turkey.
⁶ Life Sciences Programme, Supercomputing Center (BSC-CNS), Barcelona, Spain.
⁷ Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Spain.
⁸ University of Health Sciences, Adana Faculty of Medicine, Adana City Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Adana, Turkey.
⁹ Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁰ Catalan Institution for Research and Advanced Studies, Barcelona, Spain.
¹¹ Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Barcelona, Spain.
¹² Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Abstract

Background: We evaluated the epidemiology of candidemia among coronavirus disease 2019 (COVID-19) patients admitted to intensive care units (ICUs).

Methods: We conducted a retrospective multicenter study in Turkey between April and December 2020.

Results: Twenty-eight of 148 enrolled patients developed candidemia, yielding an incidence of 19% and incidence rate of 14/1000 patient-days. The probability of acquiring candidemia at 10, 20, and 30 days of ICU admission was 6%, 26%, and 50%, respectively. More than 80% of patients received antibiotics, corticosteroid, and mechanical ventilation. Receipt of a carbapenem (odds ratio [OR] = 6.0, 95% confidence interval [CI] = 1.6-22.3, P = .008), central venous catheter (OR = 4.3, 95% CI = 1.3-14.2, P = .02), and bacteremia preceding candidemia (OR = 6.6, 95% CI = 2.1-20.1, P = .001) were independent risk factors for candidemia. The mortality rate did not differ between patients with and without candidemia. Age (OR = 1.05, 95% CI = 1.01-1.09, P = .02) and mechanical ventilation (OR = 61, 95% CI = 15.8-234.9, P < .0001) were independent risk factors for death. Candida albicans was the most prevalent species overall. In Izmir, Candida parapsilosis accounted for 50% (2 of 4) of candidemia. Both C parapsilosis isolates were fluconazole nonsusceptible, harbored Erg11-Y132F mutation, and were clonal based on whole-genome sequencing. The 2 infected patients resided in ICUs with ongoing outbreaks due to fluconazole-resistant C parapsilosis.

Conclusions: Physicians should be aware of the elevated risk for candidemia among patients with COVID-19 who require ICU care. Prolonged ICU exposure and ICU practices rendered to COVID-19 patients are important contributing factors to candidemia. Emphasis should be placed on (1) heightened infection control in the ICU and (2) developing antibiotic stewardship strategies to reduce irrational antimicrobial therapy.

Keywords: COVID-19; bacteremia; candidemia; fluconazole resistance; infection control.