key: cord-0740995-m0qkha3h authors: Salehi, Mohammadreza; Ahmadikia, Kazem; Mahmoudi, Shahram; Kalantari, Saeed; Jamalimoghadam Siahkali, Saeidreza; Izadi, Alireza; Kord, Mohammad; Dehghan Manshadi, Seyed Ali; Seifi, Arash; Ghiasvand, Fereshteh; Khajavirad, Nasim; Ebrahimi, Saeedeh; Koohfar, Amirhossein; Boekhout, Teun; Khodavaisy, Sadegh title: Oropharyngeal candidiasis in hospitalized COVID‐19 Patients from Iran: Species identification and antifungal susceptibility pattern date: 2020-07-01 journal: Mycoses DOI: 10.1111/myc.13137 sha: 751f195a759e74a7987bb7e243b04f1a5d9ef264 doc_id: 740995 cord_uid: m0qkha3h BACKGROUND: Emergence of coronavirus disease 2019 (COVID‐19) is a major healthcare threat. Apparently, the novel coronavirus (SARS‐CoV‐2) is armed by special abilities to spread and dysregulate the immune mechanisms. The likelihood of oropharyngeal candidiasis (OPC) development in COVID‐19 patients with a list of attributable risk factors for oral infections has not yet been investigated. OBJECTIVES: We here aim to investigate the prevalence, causative agents, and antifungal susceptibility pattern of OPC in Iranian COVID‐19 patients. PATIENTS AND METHODS: A total of 53 hospitalized COVID‐19 patients with OPC were studied. Relevant clinical data were mined. Strain identification was performed by 21‐plex PCR and sequencing of the internal transcribed spacer region (ITS1‐5.8S‐ITS2). Antifungal susceptibility testing to fluconazole, itraconazole, voriconazole, amphotericin B, caspofungin, micafungin and anidulafungin was performed according to the CLSI broth dilution method. RESULTS: In 53 COVID‐19 patients with OPC, cardiovascular diseases (52.83 %), and diabetes (37.7 %) were the principal underlying conditions. The most common risk factor was lymphopenia (71%). In total, 65 Candida isolates causing OPC were recovered. C. albicans (70.7%) was the most common, followed by C. glabrata (10.7%), C. dubliniensis (9.2%), C. parapsilosis sensu stricto (4.6%), C. tropicalis (3%), and Pichia kudriavzevii (=C. krusei, 1.5%). Majority of the Candida isolates were susceptible to all three classes of antifungal drugs. CONCLUSION: Our data clarified some concerns regarding the occurrence of OPC in Iranian COVID‐19 patients. Further studies should be conducted to design an appropriate prophylaxis program and improve management of OPC in critically ill COVID‐19 patients. Since December 2019, an unprecedented outbreak of viral pneumonia caused by an initially unknown viral pathogen linked to a seafood associated wholesale market emerged in Wuhan, Hubei Province, China 1, 2 . The pathogen of the disease was soon identified as a novel coronavirus (SARS-CoV-2), and the disease was named coronavirus disease-19 (COVID-19) 3 . Despite global containment and quarantine attempts, the incidence continued to increase, spread to many other countries and caused a pandemic with a great number of deaths 4 . The mortality rate differs greatly from country to country 5 . Among various factors leading to morbidity and mortality in COVID-19 patients, the prevalence and role of bacterial and fungal co-infections has not yet been discussed, particularly in patients suffering from acute respiratory distress syndrome (ARDS). So far, inadequate attention has been given to the prevalence of fungal infections in patients suffering from COVID-19 that may experience lymphocytopenia, hospitalization in intensive care unit (ICU), broad-spectrum antibiotics and corticosteroid usage, intubation, cytokine storms, and having underlying diseases which make them severely immunocompromised [5] [6] [7] [8] [9] . Due to undefined pharmacological treatment for COVID -19, indirect complex effect, invasive therapeutic methods and multi-drug treatment, some pathological oral conditions can be expected to be aggravated by SARS-CoV-2, particularly in those patients with a compromised immune mechanism, or that take long-term pharmacotherapies 10 . For these reasons they are at substantial risk for developing mucosal candidiasis. Based on our centers experiences in the management of severely COVID-19 patients, oropharyngeal candidiasis (OPC) might be a probable cause of morbidity in these patients that begins with colonization of the Candida species on the oral mucosa. Consequently, local discomfort, an altered taste sensation, oral burning, glossodynia, dysphagia and difficulty in breathing may be felt by the patients 11 . In the majority of cases this opportunistic yeast infection is endogenously acquired and develops when local host defenses are weakened 12, 13 . Candida albicans is the most important species (>80%) that causes OPC 9 . This article is protected by copyright. All rights reserved Nonetheless, non-albicans species, such as C. tropicalis, C. glabrata, C. parapsilosis, Pichia kudriavzevii (=C. krusei) and C. dubliniensis, are also known to contribute to this infection 9 . In case of untreated, ineffective treatment, OPC caused by fluconazole-resistant Candida species or in patients with an immunocompromised status, the infection can regionally spread from the oropharynx to the esophagus or systematically through the bloodstream or upper gastrointestinal tract leading to candidemia with significant morbidity and mortality 11 . Hence, timely detection of OPC and accurate identification of etiological agents in patients suffering from COVID-19 are important to optimize effective therapy and improvement of outcome. So far, the likelihood of OPC development, as the most prevalent mucocutaneous mycosis of the oral cavity in severe COVID-19 patients has not yet been investigated. Therefore, the current study was conducted to investigate the prevalence, causative agents, and antifungal susceptibility pattern of OPC in Iranian COVID-19 patients. This cross-sectional study was undertaken from March 1, 2020 to April 30, 2020 on all patients with clinically and laboratory confirmed COVID-19 infections at three tertiary care training hospitals Sampling was carried out from oral plaques using sterile swabs. OPC was confirmed by the presence of budding yeasts and pseudohyphae in KOH 10% preparation and culture. The swabs were streaked on Sabouraud dextrose agar (Difco Laboratories, Detroit, Mich) plates on bedside. Plates were incubated at 37 °C and checked daily. This article is protected by copyright. All rights reserved For obtaining pure single colonies and preliminary identification, the grown yeast isolates were subcultured on CHROMagar Candida medium (CHROMagar, Paris, France). Accurate identification of isolates was based on a 3-step 21-plex PCR method using primers and conditions described previously 14, 15 . A set of standard strains of common Candida species were included as controls. To identify isolates with inconclusive results in the 21-plex PCR, the ITS1-5.8S rDNA-ITS2 region was amplified using primers ITS1: 5'-TCCGTAGGTGAACCTGCGG-3 and ITS4: 5'-TCCTCCGCTTATTGATATGC-3 using conditions described previously 16 Antifungal susceptibility patterns of isolates to three classes of antifungal drugs, i.e. azoles This article is protected by copyright. All rights reserved M59 supplements 18, 19 . Results of itraconazole against C. albicans, C. dubliniensis, and C. parapsilosis were interpreted according to the values established by Pfaller et al. 20 . All statistical analyses were performed using SPSS v24 (SPSS Inc., Chicago, IL, USA). Descriptive test was performed to describe the demographic characteristics and Chi-Square test was performed on all variables of this study. Statistical significance was assumed with p = 0.05. During the period of this study, 53 (5%) out of 1059 However, these findings need to be verified by a comparative case control study in the future to accurately identify the risk factors for OPC in patients with COVID-19. Broad spectrum antibiotics usage was the most associated risk factors for the development of OPC in COVID-19 patients as it occurred in nearly 92.5 of our subjects. Dysbiosis by bacterial depletion due to the use of broadspectrum antibiotics can alter the local oral flora, creating a favorable environment for Candida to proliferate 35 . In a study from Chinese hospitals, the usage rate of antibiotics and antifungal agents in patients with severe COVID-19 were 100% and 39 %, respectively 36 . It is noteworthy that lymphocyte counts were found to be below the normal range in nearly 63-85% of patients with COVID-19 indicating lymphocytopenia (approximately 63-83%) as the main laboratory finding 6, 7, 22, 31 . The possible reason for the high rate of OPC in lymphocytopenic patients can be attributed to This article is protected by copyright. All rights reserved lymphocytes consumption by the virus; especially T lymphocytes as was also documented in infections caused HIV and SARS-CoV resulting in a substantial decrease of the total number of lymphocytes and, subsequently, result in an immunocompromised status of the patients 10 This article is protected by copyright. All rights reserved This article is protected by copyright. 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