key: cord-0831150-qsmcuawa
authors: Buil, Jochem B.; Schouten, Jeroen A.; Wauters, Joost; van de Hoeven, Hans; Verweij, Paul E.
title: Absence of candidemia in critically ill patients with COVID-19 receiving selective digestive decontamination
date: 2022-03-22
journal: Intensive Care Med
DOI: 10.1007/s00134-022-06651-y
sha: 10f420949ba56af50ea2694cf25f3e6328878e9c
doc_id: 831150
cord_uid: qsmcuawa

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100 mg polymyxin B and 80 mg tobramycin into the gastric tube, in combination with four days of intravenous cefuroxime. This strategy aims to prevent Gram-negative bacteremia and ventilator-associated pneumonia and has been proven effective in the Dutch low-resistance setting [4] . Amphotericin B is aimed to prevent intestinal yeast overgrowth. Bacterial and yeast colonization is monitored twice weekly through oropharyngeal, sputum and rectal cultures.

Over a 30-month period (March 2020-November 2021), 378 patients were admitted to our ICU with COVID-19 confirmed by polymerase chain reaction. Review of medical and laboratory records showed no cases of CAC, which corresponds with an incidence of 0% (95% confidence interval 0-0.97%). The cohort involves patients with recognized risk factors for invasive candidiasis including long term ICU stay, presence of central vascular catheter and glucocorticoid therapy. During ICU stay, 53% of patients were colonized by Candida and median time to decolonization was 7 days (Table 1/supplementary Fig. 1 ) [1] . The frequency of CAC was compared with that in a cohort of 569 COVID-19 ICU patients not receiving SDD at University Hospitals Leuven, Belgium, since March 2020. Eight CAC cases were observed (1.4%), which represents a low prevalence compared with the literature, but is significantly higher than observed in our SDD cohort (95% CI 0.19-2.7%; p = 0.0207).

SDD has previously been shown to be associated with a low incidence of candidemia in critically ill patients. Between 1994 and 2013, only 51 candidemia cases were observed among 12,491 ICU patients receiving SDD [5] . Of these, only 10 cases were observed after yeast decolonization was achieved and were considered SDD failures, which corresponds with an incidence of 0.08% [5] . A meta-analysis of 54 observational studies of ICU patients found a mean candidemia incidence of 1.5% (95% 1.2-1.9), which is similar to the 1.4% rate in COVID-19 ICU patients not receiving SDD at University Hospitals Leuven [6] . The observed proportion among our cohort (0%; 95% CI 0.0-0.97%) of SDD recipients is substantially lower than the mean proportion among 43 cohorts of SDD recipients in ICU (2.4%; 1.6-3.1%)" [6] . A limitation of our study was that we did not assess the impact of SDD on multi-drug-resistant bacterial infection, COVID-19 associated pulmonary aspergillosis and mortality. A clinical trial evaluating empiric micafungin in ICU-patients prevented invasive candidiasis but failed to show an impact on survival [7] . Our observation suggests that SDD is effective to decolonize yeast from COVID-19 patients in the ICU, and may help to prevent candidemia in this patient group.

Fungal infections in mechanically ventilated patients with COVID-19 during the first wave: the French multicentre MYCOVID study

Coronavirus disease 2019-associated invasive fungal infection

SARS-CoV-2 productively infects human gut enterocytes

Decontamination of the digestive tract and oropharynx in ICU patients

ICU-acquired candidemia within SDD: low incidence in a 20-year longitudinal database

ICU-acquired candidemia within selective digestive decontamination studies: a meta-analysis

Empirical micafungin treatment and survival without invasive fungal infection in adults with ICU-acquired sepsis, candida colonization, and multiple organ failure: the EMPIRICUS randomized clinical trial