Fungal Infections More Deadly When COVID's Involved, CDC Finds

Mortality rates among patients hospitalized for COVID-associated fungal infections were significantly higher compared with pandemic-era fungal infections not linked with the virus, according to data from the CDC.

From 2020 to 2021, the mortality rate for in-hospital COVID-associated fungal infections was 48.5% compared with 12.3% for non-COVID-associated fungal infections (P<0.01), reported Jeremy Gold, MD, MS, of the CDC in Atlanta, and colleagues.

COVID-associated fungal infections with the highest mortality rates involved aspergillosis (57.6%), invasive candidiasis (55.4%), mucormycosis (44.7%), and unspecified mycoses (59.0%), they noted in Emerging Infectious Diseases.

This was consistent with previously reported data that showed COVID-associated deaths from fungal infections versus non-COVID-associated fungal infection deaths more frequently involved Candida (27.1% vs 23.7%) and Aspergillus (23.3% vs 14.5%).

"Our findings emphasize the importance of maintaining a high index of clinical suspicion for fungal infections in patients at high risk, including those with COVID-19, and the need for increased fungal disease surveillance to detect and evaluate emerging trends," Gold and colleagues wrote.

Among 59,212 fungal infection hospitalizations from 2019 to 2021, rates per 10,000 hospitalizations increased from 22.3 in 2019 to 25.0 in 2020 and 26.8 in 2021 (P<0.01) -- an average annual percentage change of 8.5%, Gold and team said.

From 2020 through 2021, 13.4% of 39,423 fungal hospitalizations were linked to COVID. Rates of COVID-associated fungal hospitalizations per 10,000 COVID hospitalizations increased by 24.9% (P<0.01).

Hospitalizations for COVID-associated fungal infections involved longer stays, with a median of 21 days versus 9 days (P<0.01), and were more likely to involve intensive care (70.0% vs 35.5%, P<0.01). Use of invasive mechanical ventilation was also more likely for patients with COVID-associated fungal infections (64.4% vs 22.5%, P<0.01).

The researchers also highlighted that COVID-associated fungal infections were more likely than non-COVID-associated infections to occur in men (59.9% vs 57.5%, P<0.01) and Hispanic/Latino individuals (18.8% vs 11.7%, P<0.01). They were also more likely to occur in western states (29.1% vs 27.5%, P<0.01).

"Racial or ethnic disparities observed for fungal infection-associated hospitalization rates might relate to longstanding inequities in social health determinants, such as lack of access to medical care or occupational exposures, and prevalence of underlying conditions, such as diabetes, that might increase fungal and COVID-19 infection risk among certain minority groups," Gold and colleagues wrote.

Therapies involving the immune system may also have played a role, they noted. "COVID-19 infection is a substantial risk factor for certain fungal infections, particularly those caused by invasive molds, likely because of COVID-19-related immune system dysregulation and immunosuppressive therapies, such as corticosteroids or other immunomodulatory medications."

For this study, the researchers used the Premier Healthcare Database, Special COVID-19 Release, a hospital-based, all-payer database used by the CDC to inform COVID response activities. They identified hospitalizations involving fungal infections and COVID from January 2019 through December 2021.

Median patient age was 63 for those with COVID-associated fungal infection hospitalizations and 61 for those with non-COVID-associated fungal infection hospitalizations.

Gold and colleagues noted that fungal diagnosis codes might be associated with underreporting, misclassification, and nonspecific coding of pathogenic fungi, which was a limitation to their study.

"Data on fungal infections during the pandemic, including hospitalization rates and healthcare utilization, are lacking because many fungal diseases are not reportable in the United States," they explained.

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