key: cord-0774516-wkd60yip
authors: Nucci, Marcio; Barreiros, Gloria; Guimarães, Luiz Felipe; Deriquehem, Vitor A.S.; Castiñeiras, Anna Carla; Nouér, Simone A.
title: Increased incidence of candidemia in a tertiary care hospital with the COVID‐19 pandemic
date: 2020-12-10
journal: Mycoses
DOI: 10.1111/myc.13225
sha: fda5d13a23b240cd62b47674521d67b12c787c46
doc_id: 774516
cord_uid: wkd60yip

BACKGROUND: The incidence of candidemia in our hospital has been stable over an 18‐year period (1.3 episodes per 1000 admissions). Since March 2020, we have observed an increase in cases of candidemia. METHODS: In March 2020, the hospital was prepared to receive patients with COVID‐19, with cancellation of elective procedures, discharge of less sick patients and the activation of beds for COVID‐19. We compared the incidence of candidemia in 2 periods: from January 2019 to February 2020 (period 1) and from March to September 2020 (period 2). RESULTS: We diagnosed 41 episodes of candidemia, 16 in period 1 and 25 in period 2 (9 COVID‐19 patients). Compared with non‐COVID‐19 patients, COVID‐19 patients with candidemia were more likely to be under mechanical ventilation (100% vs. 34.4%, P < .001). The median number of monthly admissions in period 1 and 2 was 723 (interquartile range 655‐836) and 523 (interquartile range 389‐574), respectively. The incidence of candidemia (per 1000 admissions) was 1.54 in period 1 and 7.44 in period 2 (P < .001). In period 2, the incidence of candidemia (per 1000 admissions) was 4.76 if we consider only cases of candidemia in non‐COVID‐19 patients, 2.68 if we consider only cases of candidemia in COVID‐19 patients and 14.80 considering only admissions of patients with COVID‐19. CONCLUSIONS: The increase in the incidence of candidemia in our hospital may be attributed to 2 factors: a reduction in the number of admissions (denominator) and the occurrence of candidemia in COVID‐19 patients.

The emergence of the COVID-19 pandemic brought new challenges for healthcare workers worldwide. 6, 7 Among patients with COVID-19 who require hospitalisation, many develop severe acute respiratory distress syndrome, are admitted to an ICU and are exposed to various factors associated with candidemia. 3 Therefore, candidemia could be a potential complication of patients with COVID-19 cared in ICUs. A series of 989 patients with COVID-19

admitted to a hospital in Spain reported four cases of candidemia among 88 coinfections and superinfections. 8 Another series from Italy reported 21 cases of candidemia in patients with COVID-19 and found a higher incidence of candidemia in COVID-19 patients compared with a historical cohort. 9 In Brazil, the first case of COVID-19 was diagnosed in February 2020, 10 and the incidence increased exponentially since March. 11 Accordingly, hospitals in the large cities in Brazil started to implement changes in their routine to be prepared for the increased need of hospital beds for patients with COVID-19.

The incidence of candidemia in our hospital has been stable over a 21-year period, with an overall incidence of 1.3 episodes per 1000 admissions. 12 In March 2020, the hospital was prepared to receive patients with COVID-19, with the discharge of stable patients, cancellation of medical and surgical elective procedures, the deactivation of regular beds and activation of additional beds for COVID-19, including ICU beds. In this study, we report an increase in the incidence of candidemia since March 2020.

The study was conducted in Hospital Universitário Clementino Fraga Filho, a tertiary care university-affiliated public hospital located in the city of Rio de Janeiro. In February 2020, the hospital had 280 active beds (16 of ICU), distributed to different medical and surgical specialties, taking care of patients with complex diseases such as cancer, hematopoietic and solid organ transplantation, autoimmune diseases and chronic degenerative diseases. The present study is part of an active study that characterises the epidemiology of candidemia in the hospital, approved by the Hospital Ethical Committee (number 30/03).

In early March, the hospital administration implemented changes in the routine work to adapt for the upcoming increase in cases of COVID-19 requiring hospitalisation and intensive care. The changes comprised cancellation of all surgical and medical procedures that were not considered urgent, discharge of stable patients, deactivation of 50 regular beds and cancellation of routine outpatient visits.

In addition, two new areas for patients with COVID-19 were created, with 100 additional beds, including 25 for intensive care.

An episode of candidemia (see definition below) was identified by looking at the records of the microbiology laboratory. Once an episode was identified, patients were followed for 30 days from the date of the incident candidemia. We used a standardised case report form and a dictionary of terms to collect information about the episode of candidemia, including demographics, medical ward, underlying medical condition, co-morbidities, coexisting exposures (antibiotics, immunosuppressive agents, parenteral nutrition, mechanical ventilation, surgery), treatment and the outcome (30-day mortality).

An episode of candidemia was defined as the first isolation In order to evaluate changes in the incidence of candidemia, we compared the incidence from January 2019 to February 2020 (period 1) with the incidence from March to September 2020 (period 2) using the chi-square test. We also compared the clinical char- 

During the study period, we observed 41 episodes of candidemia in 41 patients: 16 in period 1 and 25 in period 2. The median age of the 41 patients was 62 years (interquartile range 54-71), and 51.2%

were male. Twenty patients (48.8%) were in the ICU at diagnosis of candidemia. Candida albicans (41.5%) was the most frequent agent of candidemia (Table 1 ). Ten patients did not receive treatment because they died before the diagnosis of candidemia. Treatment was anidulafungin in 28 and fluconazole in three patients. The 30-day mortality rate in the entire cohort was 61.0% (51.6% in patients who received treatment).

March 2020 was 608. Among the 25 episodes of candidemia in period 2, nine occurred in patients with COVID-19 (1.5% of patients admitted with COVID-19). All patients with COVID-19-associated candidemia were under mechanical ventilation, compared with 34.4% of non-COVID-19 patients (P < .001). In addition, although non-significant, COVID-19 patients were more likely to be in an ICU (77.8% vs. 40.6%, P = .07) and to be hypotensive at diagnosis of candidemia (88.9% vs. 50.0%, P = .06) and less likely to have surgery within 30 days before candidemia (no patient vs. 31.2%, P = .08). The 30-day mortality rate was high in both groups (66.7% in COVID-19 and 59.4% in non-COVID-19 patients, Table 1 ). Candida species. 18 The overall incidence varied from 0.7% to 23.5%, and the majority of patients with candidemia were in an ICU and had been exposed to various factors associated with candidemia, including central venous catheter, broad-spectrum antibiotics, corticosteroids and parenteral nutrition. Remarkably, surgery was reported in only one case (vascular surgery, which is not a classical predisposing factor for candidemia). 19 In our study, baseline characteristics of patients with COVID-

While non-COVID-19 cases resembled our usual patient profile, 

Dr Nucci reports personal fees from Pfizer, personal fees from MSD, personal fees from Basilea, personal fees from Biotoscana, personal fees from Astellas, personal fees from Abbvie, personal fees from Amgen, personal fees from Janssen, outside the submitted work;

Other authors: nothing to disclose. 

https://orcid.org/0000-0003-4867-0014

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