Ryan Rivosecchi, BCCCP, PharmD
Critical Care Pharmacist
UPMC-Presbyterian Hospital
Pittsburgh, Pennsylvania
Disclosure information not submitted.
Maya Tsvetkova, n/a
Pharmacy Student
UPMC Presbyterian Hospital, United States
Disclosure information not submitted.
Holt Murray, MD
Medical Director
University of Pittsburgh Medical Center Presbyterian Hospital, United States
Disclosure information not submitted.
Christina Thorngren, MD
Attending Physician
UPMC Prespyterian, United States
Disclosure information not submitted.
Veronica Garvia Bianchini, MD
Attending Physician
UPMC Presbyterian, United States
Disclosure information not submitted.
Cornelius Clancy, MD
Attending Physician
University of Pittsburgh, United States
Disclosure information not submitted.
Palash Samanta, MD
Attending Physician
University of Pittsburgh Medical Center Presbyterian Hospital, United States
Disclosure information not submitted.
M. Hong Nguyen, MD
Attending Physician
UPMC Presbyterian Hospital, United States
Disclosure information not submitted.
Title: High rates of invasive fungal infection in COVID-19 patients on extracorporeal membrane oxygenation
Introduction/Hypothesis: COVID-19 patients (pts) in the ICU are vulnerable to invasive fungal infections (IFIs), especially invasive aspergillosis (IA) and candidiasis (IC). Extracorporeal membrane oxygenation (ECMO) is recommended in COVID-19 pts with severe ARDS, but may predispose them to IFIs.
Methods: We conducted a retrospective study of COVID-19 pts requiring ECMO from April '20 – April '21. A weekly IFI screening algorithm was implemented in December '20, which utilized yeast colonization score, serum β-d-Glucan (BDG), serum and respiratory galactomannan (GM) and T2 Candida® (T2C). Fisher’s exact and Mann-Whitney tests were performed to identify risk factors for IFI and death.
Results: Fifty-one patients were included with 1283 days of ECMO support. Median age and BMI were 53 years and 37, respectively. Corticosteroids, remdesivir and tocilizumab were prescribed to 90% (46), 69% (35) and 10% (5) of pts, respectively. Twenty-one pts (41%) were included after screening implementation. Rectal candida colonization and serum BDG were positive during screening in 66% and 62% of pts, respectively. While respiratory and serum GM were positive in only 2%. There were no positive T2C. IFI was diagnosed in 11 (22%) pts: 1 case of IA and 10 cases of IC. Of 10 pts with IC, 8 had BDG screening and 75% of these pts had BDG > 80. Six pts had an autopsy, with IFIs identified in 5 (83%): 3 candida lung abscess and 1 case of each pulmonary IA and small bowel necrosis with IC. Diagnosis of IFI was made post-mortem in 3 pts who were not diagnosed antemortem (2 candida lung abscess, 1 bowel IC). Antifungals were given >2 days in only 45% of IFI pts. At least 2 positive screening tests was significantly associated with IFI (p=0.04). The mortality rate of the entire cohort and pts with IFI were 53% and 55%, respectively. Positive BDG (p=0.01) and higher percentage of positive BDG tests (p=0.02) were risk factors for death.
Conclusion: Incidence of IFI, particularly IC, in COVID pts requiring ECMO was high, and included IC that were present at autopsy but not recognized antemortem. The incidence of IFI may be underdiagnosed, given the scarcity of autopsy studies in COVID-19. Combined biomarker and yeast colonization screening may help identifying pts at risk for IFI. COVID-19 should be added as a predisposing risk of pulmonary IFI.