Review
The battle against fungi: lessons in antifungal stewardship from COVID 19 times

https://doi.org/10.1016/j.ijantimicag.2023.106846Get rights and content
Under a Creative Commons license
open access

Highlights

  • Clinical symptoms and radiological findings are not specific for invasive fungal infections (IFI) in critically ill COVID-19 patients.

  • As secondary fungal infections may occur in patients with severe COVID-19, an active diagnostic strategy should be used.

  • Optimal management of secondary fungal infections depends on patient risk profile, SARS-CoV-2 virulence, and use of antivirals and immunosuppressants.

  • Empirical use of combination therapy is generally discouraged but voriconazole plus an echinocandin for aspergillosis might be considered.

  • TDM has potential clinical benefit for azoles but is not recommended for polyenes and echinocandins.

  • Early recognition of high-risk patients is key for prevention, rapid diagnosis, and timely management of IFI.

  • Many patients who received empirical antifungal therapy during COVID-19 did not have fungal infection; AFS should focus on this wastage.

Abstract

The COVID-19 pandemic has highlighted the detrimental effect of secondary pathogens in patients with a primary viral insult. In addition to superinfections with bacterial pathogens, invasive fungal infections were increasingly reported. The diagnosis of pulmonary fungal infections has always been challenging; however, it became even more problematic in the setting of COVID-19, particularly regarding the interpretation of radiological findings and mycology test results in patients with these infections. Moreover, prolonged hospitalization in ICU, coupled with underlying host factors. such as preexisting immunosuppression, use of immunomodulatory agents, and pulmonary compromise, caused additional vulnerability to fungal infections in this patient population. In addition, the heavy workload, redeployment of untrained staff, and inconsistent supply of gloves, gowns, and masks during the COVID-19 outbreak made it harder for healthcare workers to strictly adhere to preventive measures for infection control. Taken together, these factors favored patient-to-patient spread of fungal infections, such as those caused by Candida auris, or environment-to-patient transmission, including nosocomial aspergillosis. As fungal infections were associated with increased morbidity and mortality, empirical treatment was overly used and abused in COVID-19-infected patients, potentially contributing to increased resistance in fungal pathogens. The aim of this paper was to focus on essential elements of antifungal stewardship in COVID-19 for three fungal infections, COVID-19-associated candidemia (CAC), -pulmonary aspergillosis (CAPA), and -mucormycosis (CAM).

Keywords

Antifungal stewardship
COVID-19-associated candidemia (CAC)
COVID-19-associated pulmonary aspergillosis (CAPA)
COVID-19-associated mucormycosis (CAM)

Cited by (0)

A consensus statement on behalf of the International Society of Antimicrobial Chemotherapy, Alliance for the Prudent Use of Antibiotics, European Society of Clinical Microbiology and Infectious Diseases Study Group for Antimicrobial Stewardship, and European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group.

1

Contributed equally.