To the Editor—We read the article by White et al [1] with great interest. The proposed strategy will probably elucidate the true role of coronavirus disease 2019 (COVID-19)–associated invasive fungal infections, especially COVID-19–associated pulmonary aspergillosis (CAPA). We have not found the same incidence of CAPA, probably due to the absence of an active search. However, we detected an increase in the number of fungemias in critically ill COVID-19 patients. We report 20 cases of fungemia in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in 4 institutions in the northern region of Colombia from June to September 2020. We reviewed medical records and evaluated microbiological, demographic, and clinical variables. Mortality was evaluated at 30 days after isolation of the yeast. Pathogen identification was performed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (Bruker Daltonik, Bremen, Germany). SARS-CoV-2 infection was confirmed by reverse-transcription polymerase chain reaction for SARS-CoV-2. The epidemiological and demographic characteristics, underlying conditions, treatments, and outcomes of the 20 patients are shown in Table 1. All patients received β-lactam antibiotics at the time of admission, and 5 patients received prophylactic antifungal therapy before the development of fungemia (3 with fluconazole and 2 with caspofungin). Nineteen of the 20 patients received steroids as part of the COVID-19 treatment. The mean number of days from admission to the time of diagnosis of fungemia was 17.7 (range, 6–35 days). Epidemiological and Demographic Characteristics, Underlying Conditions, Treatments, and Outcomes of Patients With Coronavirus Disease 2019 and Fungemia in 4 Institutions in Northern Colombia Data are presented as No. (%) unless otherwise indicated. Abbreviations: COVID-19, coronavirus disease 2019; ICU, intensive care unit. Epidemiological and Demographic Characteristics, Underlying Conditions, Treatments, and Outcomes of Patients With Coronavirus Disease 2019 and Fungemia in 4 Institutions in Northern Colombia Data are presented as No. (%) unless otherwise indicated. Abbreviations: COVID-19, coronavirus disease 2019; ICU, intensive care unit. The mean number of days from blood culture to antifungal treatment initiation was 3.9. Fifteen patients received antifungal treatment, 12 (60%) patients died, and the mean number of days from the diagnosis of fungemia to the time of death was 6.1 (range, 0–24 days). Six patients had fungemia caused by Candida auris, 4 by Candida albicans, 4 by Candida tropicalis, 3 by Candida parapsilosis, 1 by Candida orthopsilosis, 1 by Candida glabrata, and 1 by Trichosporon asahii. The association between COVID-19 and fungemia can be multifactorial as a consequence of the severity of the disease (most patients required ventilatory support, invasive hemodynamic monitoring, and a prolonged stay in the intensive care unit) and previous use of antibiotics and steroids. Currently, the use of steroids is part of the standard of care in managing patients with COVID-19 and hypoxemia. Although bacterial coinfection is low, the use of antimicrobials is common; therefore, the antimicrobial stewardship program must be strengthened for patients with SARS-CoV-2 infection as part of preventive strategies for the development of fungemia [2, 3] In this case series, the time to develop fungemia was more significant than that reported by White et al (17.7 vs 9 days), as was the mortality of this group of patients (60% vs 47.1%). The prevalence of non–albicans Candida fungemia in this group of patients, 15 of 19 (78.94%), is striking. The northern region of Colombia is an endemic zone for C. auris [4]. In places where C. auris is endemic, despite the strict control measures in place in the management of SARS-CoV-2 infection, coinfections by this microorganism continue to occur. Given the multiresistant characteristics of C. auris and the difficulties of eradicating it, we must not let our guard down in the era of COVID-19 in regard to both infection control policies and antimicrobial stewardship, including antifungals. Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.
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Rodríguez et al. (2020) studied this question.