Skip to main content Accessibility help
×
Home
Hostname: page-component-dc8c957cd-qr7d4 Total loading time: 0.363 Render date: 2022-01-27T06:12:08.778Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Bacterial and fungal infections in COVID-19 patients: A matter of concern

Published online by Cambridge University Press:  22 April 2020

Pengcheng Zhou
Affiliation:
Xiangya Hospital, Central South University, Changsha, China The Third Xiangya Hospital, Central South University, Changsha, China
Zhenguo Liu
Affiliation:
The Third Xiangya Hospital, Central South University, Changsha, China
Yuhua Chen
Affiliation:
Xiangya Hospital, Central South University, Changsha, China
Yinzong Xiao
Affiliation:
Xiangya Hospital, Central South University, Changsha, China Burnet Institute, St Vincent’s Hospital Melbourne, and University of Melbourne, Melbourne, Australia
Xun Huang*
Affiliation:
Xiangya Hospital, Central South University, Changsha, China
Xue-Gong Fan*
Affiliation:
Xiangya Hospital, Central South University, Changsha, China
*
Author for correspondence: Xue-Gong Fan MD Or Xun Huang MD, E-mail: xgfan@hotmail.com or huangxun224@126.com.
Author for correspondence: Xue-Gong Fan MD Or Xun Huang MD, E-mail: xgfan@hotmail.com or huangxun224@126.com.
Rights & Permissions[Opens in a new window]

Abstract

Type
Letter to the Editor
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

To the Editor—Coronavirus disease 2019 (COVID-19) has become a pandemic. As of April 2, 2020, a total of 896,450 laboratory-confirmed cases have been reported. The death toll from COVID-19 has soared quickly: 45,526 deaths have been reported globally, including 24,692 deaths in only a week (March 26, 2020, through April 2, 2020).1 Age, sequential organ failure assessment (SOFA) score, and D-dimer are the main prognostic factors of COVID-19 patients.Reference Zhou, Yu and Du2 The presence of bacterial and/or fungal secondary infection or coinfection is likely another important factor affecting mortality, and it has received inadequate attention.

Bacterial and fungal infections are common complications of viral pneumonia, especially in critically ill patients. They lead to increased need for intensive care and increased mortality. In influenza patients, bacterial coinfection occurs in ~0.5% of healthy young individuals and at least 2.5% of older individuals.Reference Chertow and Memoli3 A systematic review revealed that ~1 in 4 H1N1 patients during the 2009 pandemic had a bacterial or fungi infection infection.Reference MacIntyre, Chughtai and Barnes4 Data regarding the bacterial or fungi infection in viral pneumonia led by coronavirus are limited. According to the cohort study report by Zhong Nanshan et al,Reference Zheng, Chen and Li5 20 of 90 severe acute respiratory syndrome (SARS) patients had secondary lower respiratory tract infections in 2003, which accounted for 70.6% of those critical SARS patients who underwent an invasive operation. The pathogens causing secondary infections in SARS patients were diverse: negative bacilli were the most common but Candida was also common.Reference Zheng, Chen and Li5 Invasive pulmonary aspergillosis was another common complication secondary to influenza.Reference Rijnders, Schauwvlieghe and Wauters6

Bacterial and fungal infections in COVID-19 patients have been inadequately investigated and reported thus far. Among the hundreds of articles published with clinical data, only a few have reported secondary infection, mostly without detailed pathogens (Table 1). Even in studies for which secondary infection data are available, the antibiotics use rate (94%–100%) was much higher than the reported incidence of secondary infection (10%–15%).Reference Zhou, Yu and Du2,Reference Huang, Wang, Li, Ren and Zhao7,Reference Yang, Yu, Xu, Shu and Xia8 In addition, the complication of bacterial or fungal infection was not included in the prognosis analysis in most published papers. Moreover, most of the current infection control protocols aim to prevent the transmission and cross infection by SARS-CoV-2, missing the prevention of bacterial or fungal secondary infection. In fact, secondary infection was found in 50% of nonsurviving COVID-19 patients.Reference Zhou, Yu and Du2

Table 1. Secondary Infection or Coinfection in COVID-19 Patients

Note. Patients were classified in to ICU and non-ICU patients instead of nonsurvivors and survivors in the study by Huang et al.Reference Huang, Wang, Li, Ren and Zhao7

Thus far, many diagnostic and prevention approaches to targeting complications in COVID-19 patients have been outlined in clinical guidelines in China. However, little attention has been given to secondary bacterial and fungal infections, and a standardized diagnostic process remains unavailable. A few challenges exist in diagnosing secondary infection in COVID-19 patients. Although it can be difficult to distinguish bacterial or fungal infection and existing viral pneumonia based on clinical and radiological appearance, microbiological examination can add great value to diagnoses, especially sputum culture. However, this approach can pose significant risks to biosample collectors and laboratory technicians processing samples from COVID-19 patients because the virus is transmitted via virus-laden aerosols in addition to respiratory droplets and direct contact.9 Thus far, no standardized personal protection equipment (PPE) has been recommended in the guidelines in China for healthcare workers who process bacterial and fungal cultures.10 Other problems include insufficient laboratory biosafety conditions and PPE shortages. These conditions have led to most hospitals to decide not to carry out routine microbiological examination in COVID-19 patients, which undermines the diagnosis and treatment of secondary infection.

Clinical data regarding bacterial and fungal infections are valuable in guiding evidence-based treatment of COVID-19. Thus, we call for strengthening the investigation of secondary infection and/or coinfection in COVID-19 patients without risking laboratory staff safety. Health authorities and academic organizations need to include a practical diagnostic process for determining bacterial and fungal infection in COVID-19 patients. Furthermore, the biosafety requirements for COVID-19 microbiological laboratory staff should be issued, and personal protection guidelines for microbiological laboratory staff should be clear. Qualified medical institutions need to be encouraged to carry out necessary microbiological examinations. Thus, we will be able to study bacterial or fungal infections in COVID-19 patients in the following aspects: epidemiology (eg, infection sites, incidence rates, epidemic characteristics, risk factors, etc); pathogens and their drug sensitivity results, thus providing the theoretical and factual evidence for precise treatment; accurate prevention and control of infection complications; and effective reduction of the mortality of COVID-19 patients.

Acknowledgments

Financial support

This study was funded by the Emergency Project of Prevention and Control for COVID-19 of Central South University (grant no. 160260003).

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References

COVID-19 situation report-73. World Health Organization website. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-19.pdf?sfvrsn=5ae25bc7_2. Published 2020. Accessed April 7, 2020.Google Scholar
Zhou, F, Yu, T, Du, R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020. doi: 10.1016/S0140-6736(20)30566-3.CrossRefGoogle Scholar
Chertow, DS, Memoli, MJ. Bacterial coinfection in influenza: a grand rounds review. JAMA 2013;309:275282.CrossRefGoogle ScholarPubMed
MacIntyre, CR, Chughtai, AA, Barnes, M, et al.The role of pneumonia and secondary bacterial infection in fatal and serious outcomes of pandemic influenza a(H1N1)pdm09. BMC Infect Dis 2018;18:637.CrossRefGoogle ScholarPubMed
Zheng, Z, Chen, R, Li, Y, et al.The clinical characteristics of secondary infection of lower respiratory in severe acute respiratory syndrome. Chin J Respir Crit Care Med 2003;2:270274.Google Scholar
Rijnders, B, Schauwvlieghe, A, Wauters, J. Influenza-associated pulmonary aspergillosis: a local or global lethal combination? Clin Infect Dis 2020. doi: 2020.10.1093/cid/ciaa010.CrossRefGoogle Scholar
Huang, C, Wang, Y, Li, X, Ren, L, Zhao, J, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020. doi: 10.1016/S0140-6736(20)30183-5.CrossRefGoogle Scholar
Yang, X, Yu, Y, Xu, J, Shu, H, Xia, J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020. doi: 10.1016/S2213-2600(20)30079-5.CrossRefGoogle Scholar
Prevention and control program of the novel coronavirus pneumonia, sixth edition. National Health Commission of the People’s Republic of China website. http://www.nhc.gov.cn/jkj/s3577/202003/4856d5b0458141fa9f376853224d41d7/files/4132bf035bc242478a6eaf157eb0d979.pdf. Published 2020. Accessed April 7, 2020.Google Scholar
Laboratory biological safety guidelines for novel coronavirus. National Health Commission of the People’s Republic of China website. http://www.nhc.gov.cn/xcs/zhengcwj/202001/0909555408d842a58828611dde2e6a26.shtml. Published 2020. Accessed April 7, 2020.Google Scholar
Figure 0

Table 1. Secondary Infection or Coinfection in COVID-19 Patients

You have Access
Open access
56
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Bacterial and fungal infections in COVID-19 patients: A matter of concern
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Bacterial and fungal infections in COVID-19 patients: A matter of concern
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Bacterial and fungal infections in COVID-19 patients: A matter of concern
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *