key: cord-1031387-ow2dt7r8 authors: Alanio, A.; Voicu, S.; Delliere, s.; Megarbane, B.; Bretagne, S. title: Do COVID-19 patients admitted to the ICU require anti-Pneumocystis jirovecii prophylaxis? date: 2020-05-22 journal: nan DOI: 10.1101/2020.05.18.20105296 sha: 3e3d92367e7223cd85446f55e953520b270e3c94 doc_id: 1031387 cord_uid: ow2dt7r8 We are currently facing a frightening increase in COVID-19 patients admitted to the ICU. Aiming at screening for secondary pneumonia, we collected the data of our first twelve ICU patients who underwent bronchoalveolar lavage (BAL). Surprisingly, four were detected with Pneumocystis jirovecii (Pj) DNA and RNA, resulting in Pj prevalence of 17%. Pj is a ubiquitous ascomycetes fungus that thrives at the surface of type-I pneumocytes, specifically in human alveoli, leading to pneumocystosis in immunocompromised patients. Interestingly, none of our patients was immunocompromised per se before admission, while all presented the recognized risk factors for life-threatening COVID-19 infection. Observing such high prevalence in COVID-infected patients was unexpected. Almost all patients developed ARDS and received high-dose steroids to prevent worsening, as suggested by reports from China. In Pj-positive patients requiring steroids, prophylaxis was given to avoid the risk of pneumocystosis and increased lung inflammation that may compromise the outcome. We are strongly convinced that testing deep lung specimens for Pj in severe COVID-19 patients should be recommended and Pj-positive patients treated with steroids, and given anti-Pj prophylaxis. This message is important, given the high mortality rate of COVID-19 patients in the ICU. Word count: 1000 words + 10 references + 1 table + 1 Figure 45 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. Three out of five P. jirovecii RTqPCR-positive patients received co-trimoxazole as prophylaxis. To date, 93 one patient has died, one patient is still mechanically ventilated and the three others including the two 94 patients who were not treated with co-trimoxazole have been discharged from the hospital. We found an unexpectedly high proportion of critically ill COVID-19 patients detected with P. jirovecii 98 (17%) as compared to previous findings in influenza patients (~7%) (4). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . https://doi.org/10.1101/2020.05.18.20105296 doi: medRxiv preprint The presence of P. jirovecii in the healthy adult population has been measured using oropharyngeal 100 wash samples obtained by gargling and examined by conventional or nested PCR methods. 5 However, 101 experts agree that the reported prevalence (~20%) has been overestimated due to technical issues such as Our study limitations include the relatively small number of patients, the single-center setting, and the 123 short study period. However, to the best of our knowledge, this is the first study evaluating the prevalence 124 of P. jirovecii in COVID-19 patients. Because we focused on critically ill COVID-19 patients, prevalence 125 of P. jirovecii in less severe patients remains to be determined. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . https://doi.org/10.1101/2020.05.18.20105296 doi: medRxiv preprint 6 In conclusion, based on our findings, we advocate systematically searching for P. jirovecii in deep 127 respiratory specimens in critically ill COVID-19 patients. We believe that this strategy may be useful in 128 limiting enhanced inflammation due to the presence of P. jirovecii in the lung and avoiding inter-patient P. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 22, 2020. . https://doi.org/10.1101/2020.05.18.20105296 doi: medRxiv preprint Clinical features of patients infected with 2019 novel 140 coronavirus in Wuhan, China ECIL guidelines for the 145 diagnosis of Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell 146 transplant recipients Influenza 148 virus and factors that are associated with ICU admission, pulmonary co-infections and ICU mortality Pneumocystis 151 jirovecii in general population Longitudinal characteristics of lymphocyte responses and 153 cytokine profiles in the peripheral blood of SARS-CoV-2 infected patients β-D-glucan testing is important for diagnosis of invasive fungal infections . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . https://doi.org/10.1101/2020.05.18.20105296 doi: medRxiv preprint 10 †Steroid regimen, dexamethasone intravenous dose of 20 mg once daily from day 1 to day 5, followed by 10 mg once daily 69 from day 6 to day 10. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted May 22, 2020. . https://doi.org/10.1101/2020.05.18.20105296 doi: medRxiv preprint