key: cord-0851798-3lvc4nj9 authors: Zalona Fernandes, Henry Marcel; Mastrobuono, Gabriela; Conceição, Emilyn Costa; da Silva Dias, Rubens Clayton; Alviano, Daniela Sales; Duarte, Rafael Silva title: Coronavirus disease 2019 (COVID-19) treatment versus mycobacterial infections: Better safe than sorry? date: 2021-03-19 journal: Infection control and hospital epidemiology DOI: 10.1017/ice.2021.124 sha: 5db3f8b5132fa6913f5b148620b9ecee0a08f35a doc_id: 851798 cord_uid: 3lvc4nj9 nan To the Editor-More than 1 year after the onset of the coronavirus disease 2019 (COVID-19) pandemic, severe acute respiratory coronavirus virus 2 (SARS-CoV-2) has infected ∼113 million people and has caused ∼2.5 million deaths, according to the World Health Organization (WHO). Vaccination campaigns have been implemented in several countries worldwide as a prevention strategy for preventing new cases, preventing overcrowding of health facilities and decreasing COVID-19-associated deaths. Nevertheless, the total number of vaccines produced is still not sufficient to address the world population, especially developing countries, and many people continue to be infected daily, requiring hospitalization and health care. 1 Currently, there is no effective treatment for COVID-19. However, some drugs and immunomodulators agents have been suggested to prevent the aggravation of clinical conditions: azithromycin, hydroxychloroquine, remdesivir, lopinavir, ritonavir, dexamethasone, tocilizumab, and others. 2 Previous studies have also alluded to the importance of differential diagnosis to facilitate adequate treatment because other infectious lung diseases, such as tuberculosis (TB) and nontuberculous mycobacteria (NTM) pulmonary diseases, may present similar symptoms and result in increased disease severity if they are not correctly identified early. 3 Furthermore, TB-COVID-19 and NTM-COVID-19 coinfections have also been described. 3, 4 Some medications used in COVID-19 therapy can cause drugdrug interactions with first-line anti-TB drugs, such as antivirals and corticosteroids with rifampicin, 5, 6 or they can increase the risk of latent TB reactivation and NTM pulmonary diseases, such as antirheumatic and immunomodulatory agents. 7, 8 In addition, azithromycin, which has been adopted in the medication management of COVID-19 patients based on its anti-inflammatory and antiviral properties, may result in the development of macrolide-resistant mycobacterial strains (Table 1) . 9 Therefore, when COVID-19 is suspected, differential diagnoses should be performed to prevent risk factors for mycobacterial disease due to inadequate patient treatment. On the other hand, patients with concomitant mycobacterial and COVID-19 etiology require simultaneous treatment, but coadministration of rifampicin with antiviral drugs (eg, remdesivir, lopinavir and ritonavir) should be avoided due to the gastrointestinal and liver toxicity risk in addition to the reduction of antivirals drugs to subtherapeutic concentrations. 6 In a related study, high cortisol levels have been proposed as a possible prognostic marker for COVID-19 associated with adverse outcomes. However, concomitant use of rifampicin with dexamethasone can result in increased dexamethasone metabolism and altered cortisol levels. 5, 10 Under these circumstances, an antimycobacterial protocol should be maintained to reduce the selection of resistant mycobacterial strains, and drug therapy for COVID-19 should be limited to severe cases. 3 During the COVID-19 pandemic, TB surveillance programs have also been affected by social isolation and limited patient access to health services, resulting in delayed diagnosis and treatment failure. Moreover, COVID-19 and TB share socioeconomic determinants and comorbidities, so TB-COVID-19 coinfection should be considered, especially in endemic regions, because it can result in potentiated pathogenesis of both diseases and consequent worsening of the patient's condition. Some measures that may be used in pandemic management to improve TB monitoring include assessing patient and family exposure history and implementing digital health-assistive technologies. 3 Due to the absence of specific treatment of COVID-19, only ongoing drug trials have been used to improve the outcomes of hospitalized patients. Nevertheless, drug therapy protocols for COVID-19 can increase susceptibility to mycobacterial infections. 3, 4 Thus, further studies analyzing the therapeutic agents used for COVID-19 and their influence on mycobacterial viability and virulence are needed. Their findings will contribute to clinical decision making regarding the best treatment strategy while preventing the development of mycobacterial infections or serious complications in TB-COVID-19 and NTM-COVID-19 coinfections, especially in elderly patients with comorbidities and in TB-endemic countries, such as Brazil and India, which are among the 3 countries with the highest burden of COVID-19 worldwide. 1, 3 World Health Organization website COVID-19: review on latest available drugs and therapies against SARS-CoV-2. Coagulation and inflammation cross-talking Tuberculosis and COVID-19: lessons from the past viral outbreaks and possible future outcomes. Can Respire J 2020 COVID-19 coinfection with Mycobacterium abscessus in a patient with multiple myeloma. Case Rep Infect Dis Abnormal dexamethasone suppression tests in a rifampicin-treated patient with suspected Cushing's syndrome Potential drug-drug interactions associated with drugs currently proposed for COVID-19 treatment in patients receiving other treatments Increased risk of mycobacterial infections associated with anti-rheumatic medications Prevention strategies to minimize the infection risk associated with biologic and targeted immunomodulators Clinical characteristics and treatment outcomes of patients with macrolide-resistant Mycobacterium massiliense lung disease Cortisol concentrations and mortality from COVID-19-authors' reply Acknowledgments. The authors acknowledge support from Foundation for Research Support of the State of Rio de Janeiro (FAPERJ) and National Council for Scientific and Technological Development (CNPq). Financial support. This study was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brazil (CAPES, finance code 001). All authors report no conflicts of interest relevant to this article.