Incidence of Fungal Infections Including Mucormycosis in Respiratory Intensive Care

doi:10.21203/rs.3.rs-2191641/v1

Background

Recent improvements in the use of wide-spectrum antibiotics for the treatment of life-threatening illnesses have led to an upsurge in fungus infections in critical care units. An invasive fungal illness called Mucormycosis is becoming more common among seriously unwell individuals. Due to its strong invasive power and inherently low susceptibility to antifungal treatments, its prognosis is bleak. Our study aimed to determine the incidence of fungi, especially Mucormycosis, in respiratory intensive care units.

Methods

Patients hospitalized at Menoufia University Hospitals' general and respiratory intensive care units between June 2021 and June 2022 were included in this study. On Sabouraud dextrose agars, bronchial secretions were cultured and evaluated for fungus susceptibility.

Results

Regarding mechanical ventilation and APACHE II score, there was a substantial difference between fungus growth and absence of fungus growth. Regarding Fate, the presence of bilateral lung consolidation associated with cavitations on CT chest, and APACHE II score, there was a significant difference between negative and positive Mucormycosis development. The most susceptible antifungal agent was Caspofungin.

Conclusion

In patients in the pulmonary intensive care unit (ICU) who have a high resistance rate, fungus infections are a big issue. The danger of a fungal infection rises with mechanical ventilation. For quick treatment, isolating and diagnosing the fungus is essential.

Mucormycosis

fungal infection

Respiratory ICU

Due to the widespread use of broad-spectrum antibiotics, prolonged use of immunosuppressive drugs, and rising numbers of chronically sick patients with indwelling catheters, fungus infection has become a serious healthcare issue in recent years. (1)

These risk factors frequently coexist among ICU patients, which raises the risk of opportunistic fungal infections. Another well-known risk factor for invasive fungal infections in critically sick patients is multiple-site Candida spp. colonization. (2)

It was underlined that infections brought on by drug-resistant bacteria and fungi were statistically linked with an increase in death rates. In patients admitted to ICUs, the mortality rate from fungus infections approaches 67%. (3)

Pulmonary fungal infections frequently appear radiologically as pneumonic shadows that are readily mistaken for bacterial infections since the clinical signs of fungus infection are vague. This diagnostic difficulty delays the initiation of antifungal medication, increasing death rates, particularly in the ICU environment. (4)

The widespread filamentous fungi of the Mucorales class are the cause of Mucormycosis, an invasive fungal illness. (5) Allogenic hematopoietic stem cell transplantation, chemotherapy, diabetes, long-term steroid or immunosuppressive medication, and solid organ transplantation are the primary recognized risk factors for Mucormycosis (6)

Other disorders that increase the incidence of Mucormycosis include repeated trauma, severe burns, and some medical procedures. (7)

The purpose of the current research was to study the incidence of fungal infection, including Mucormycosis, in respiratory critical care units.

Between June 2021 and June 2022, patients hospitalized in Menoufia University Hospitals' respiratory intensive care units and those admitted to general intensive care units with respiratory problems were included in this prospective observational study.

Patients with active COVID infection, patients who received any of the antifungal agents for at least 1 week before ICU admission, patients less than 18 years old, and patients or their representatives who refused participation were excluded from the study.

Each patient, or a representative of that patient, provided written informed consent, and the research was approved by the Menoufia University Hospital's Research Ethical Committee (8/2022CHES11).

All patients' demographic information, such as age, sex, chronic illnesses, and smoking, was gathered. Enzymatic techniques were used on an automated autoanalyzer to determine the results of routine laboratory tests such as liver enzymes, creatinine, arterial blood gases, and complete blood count. radiological examination, which may include a chest X-ray, a chest Computerized Tomography (CT), and, if necessary, a CT pulmonary angiography.

Acute physiology and chronic health assessment II (APACHE II), a technique for classifying diseases according to their severity, is used within 24 hours of ICU admission as a disease severity indicator. Higher scores are indicative of more severe illness and a higher probability of mortality, with an integer score range of 0 to 71. (8)

Sputum samples, bronchial lavages, or tracheal aspirates were collected aseptically from patients, and they were promptly sent to the National Liver Institute's microbiology section for mycological research. Prior to the collection of secretions, the same patients' serum samples were also taken and preserved for serological examination at -20°C.

Sputum samples were centrifuged after being diluted with sterile saline and combined by the vortex. Additionally, BAL and tracheal aspirate samples were also centrifugated and examined for deposits. After letting the samples dissolve in a solution of KOH 10%, they were directly examined under a microscope for fungal components. The presence of pseudohyphae was associated with yeasts; broad, atypical, ribbon-like, aseptate hyphae were tentatively identified as Mucorales, and the presence of septate, hyaline hyphae that displayed dichotomous branching with Aspergillus spp. All samples were cultured on Sabouraud Dextrose Agar (SDA) (Himedia, India) and incubated for 2–5 days at 25°C and 37°C. The rate of growth, the shape of the colonies, and lactophenol cotton blue mounts were used to further identify any growth that was achieved. (9)

Based on colony color on chromogenic assays, Candida isolates were identified down to the species level. (10) Brilliance Candida Agar medium (Oxoid, Italy), germ tube formation, and other biochemical reactions.

Growth rate, colony shape, and reproductive structures were used to phenotypically identify the several species of the Mucorales genus. Mucorales are characterized by their accelerated development and their mycelial components, which spread out to cover the entire plate. The coloring of the colonies' sporulating surfaces might vary in intensity. (Fig. 1). Then, corals were classed as either "unclassified Mucorales" or by genus. (11)

The disc diffusion assay was used to examine the susceptibility to various antifungal agents (Fluconazole, Itraconazole, Ketoconazole, Voriconazole, Nystatin, Flucytosine, Amphotericin B, and caspofungin). In the dis,c diffusion process, the zone diameters were measured to the closest whole millimeter at the point where there was an 80% reduction in growth for zygomycetes after 16 to 24 h and for the other species after 24, 48, and 72 h. (candida, aspergillus).(12)

Statistical analysis of the data

With the aid of the IBM SPSS software package version 20.0, data were fed into the computer and evaluated. (IBM Corp, Armonk, NY). Categorical data were shown as percentages and numbers. To compare the two groups, the Chi-square test was used. Alternatively, when more than 20% of the cells had an anticipated count below 5, Fisher Exact or Monte Carlo correction test was used. The Shapiro-Wilk test was used to determine the normality of continuous data. Range (minimum and maximum), mean, standard deviation, and median were used to convey quantitative data. For quantitative variables that were regularly distributed, the student t-test was employed to compare two groups. The Mann-Whitney test, on the other hand, was employed to compare two groups for quantitative characteristics that were not regularly distributed. The 5% threshold of significance was used to determine the results' significance.

This study included 37 patients (mean age 55.73 ± 14.86 years, 23 Males (62.2%), and 14 Females (37.8%) admitted to respiratory and general ICU in Menoufia University Hospitals. The Socio-demographic, clinical data, and laboratory investigations of the patients are shown in (table 1).

Table 2 shows the CT finding, final diagnosis, and fate of the studied patients. Nine of the patients died and 28 patients were cured and discharged.

Fungal culture results were positive in 19 specimens (51.4%), where Mucormycosis was found in 5 specimens (13.5%), Candida spp. were found in 8 specimens (42.1) where Candida albicans (C. Albicans) was in 6 specimens (16.2%), C. Glabrata was in 1 specimen (2.7%) and C. kruzei was in 1 specimen (2.7%). Aspergillus was in 4 specimens (10.8%) and mixed C. Albicans with aspergillus were found in 2 specimens (5.4%). (Fig. 3)

The relation between Fungal culture results and different parameters is shown in Tables 3 and 4 where there were statistically significant differences regarding the mechanical ventilation, and APACHE II score (p = 0.029 and, 0.04 respectively). Furthermore, there were statistically significant differences between positive and negative specimens for Mucormycosis regarding the presence of bilateral lung consolidations with cavitations in CT (p = 0.001), higher APACHE II score (p = 0.027), and fate (p = 0.008) (Table 5).

The antifungal susceptibly pattern of all isolated fungi (n = 19) is shown in Fig. 4 where the most resistance among the isolated fungal growth was the ketoconazole (89.5%) and the most susceptible among the fungal growth was caspofungin. (94.7%). Table 6 showed the antifungal susceptibly pattern of each isolated fungus with various antifungal agents.

The study demographic data (as shown in Table 1) of the 37 patients showed that most patients were males presenting 62.2% while females 37.8%. The age was 55.73 ± 14.86 (mean ± SD) years. Also, 48.6% of them had a smoking history, 51.4% were diabetic and 75.7% were immunocompromised. Ten (27%) patients were mechanically ventilated and the APACHE II score was 13.49 ± 11.83 (mean ± SD). Furthermore, 24.3% of the patients died while 76.7% are discharged.

The fungal cultures obtained from the patients showed no growth in 18 samples (48.6%), and positive in 19 samples (51.4%) in which C. Albicans was found in 16.2%, Aspergillus spp. was found in 10.8%, Mucormycosis in 13.5%, mixed C. Albicans and Aspergillus spp. in 5.4%, C. Glabrata in 2.7% and C. kruzei in 2.7%. (Fig. 3)

Our study was in accordance with the study of Ahmed et al in which 66.67% of the participants associated with respiratory problems had fungal culture positive while 33.33% were negative. The species were Candida in 57.5%, and Aspergillus in 42.5% of the cases. C. Albicans occurred in 23.33%, Aspergillus non-fumigatus in 18.33%, C. non-Albicans in 15% and Aspergillus fumigatus in 10% of the participants. (13)

The most frequently encountered fungi were Aspergillus species (57%), followed by Cryptococcus species (21%) and Candida species (14%). There were 72 patients with an acute invasive fungal infection, with a mortality rate of 67%. (14)

The study by Biswas et al. was done on 60 patients with pulmonary diseases and it showed positive fungal culture was found in 28 patients (46.7%) that showed Aspergillus sp. in 13 patients (including A. flavus in 6 patients, A. fumigatus in 4 patients and A. niger in 3 patients) and Candida sp. in 14 (C. Albicans and C. Tropicalis being isolated from 12 and 2 patients respectively). One sample showed Cryptococcus neoformans growth in a patient with chronic interstitial lung disease. (15)

In the current study, patients with positive fungal culture were diabetic in 57.9% (11/19), immunocompromised in 78.9% (15/19), and mechanically ventilated in 44% (8/19).

This agreed with the study of Ahmed et al, in which positive fungal cultures were found more with DM (11 out of 16 diabetic patients) and there was a significant association of DM with Candida infection (P = 0.03), while the other comorbidities including cardiovascular, liver, renal diseases, and malignancies showed insignificant association with either Candida or Aspergillus infection. (13)

In the study of Biswas et al.; it was found that diabetes mellitus (DM) was the commonest risk factor associated with Candida albicans (71.4% of patients). However, there was no significant association between positive culture and any risk factor. (15)

There were insignificant statistical differences between negative and positive fungal cultures regarding all demographic, clinical, laboratory, and radiological data except for mechanical ventilation and APACHE II score (p = 0.029 and 0.040 respectively) (Tables 3 & 4).

Fraser et al. (16) reported that mechanical ventilation is a significant risk factor for invasive fungal infection. Furthermore, there was a significant statistical difference (P = 0.001) between sputum fungal culture results regarding the duration of invasive mechanical ventilation. This result was compatible with another study by Alp et al. (17) which showed that longer mechanical ventilation may increase the risk of infection

Chakraborti et al. studied people in a tertiary care hospital's respiratory ICU for about a year. All of the patients had been on mechanical ventilation for more than 7 days. On day 1 and day 7, blood, urine, and endotracheal aspirate samples from these patients were sent to a lab for fungal culture. They found that having mechanical ventilation for more than 7 days was strongly linked to the growth of fungi in the respiratory and urinary tracts. With practises for preventing infections, the colonization of fungi can be reduced by giving the right preventive antifungals. (1)

In a systemic review done to study the risk factors for invasive fungal infection, it was found that mechanical ventilation, DM, APACHE II or III scores, surgery, total parenteral nutrition, fungal colonization, renal replacement therapy, sepsis, and infection are risk factors that were found to be associated significantly with invasive fungal diseases. (18)

There were significant differences between the presence and absence of mucormycosis growth regards the presence of bilateral lung consolidation with lung cavitations in CT, APACHE II score, and the fate of the patients. Furthermore, all cases in our study with bilateral lung consolidations with cavitations were positive for mucormycosis (Fig. 2).

Even though Mucormycosis is rare, it is becoming more common in patients with uncontrolled diabetes, weakened immune systems, or open wounds that have been contaminated by Mucorales. Most of these patients are diagnosed in the intensive care unit (ICU). Necrotizing lesions that spread quickly in the nose, skin, and soft tissues, as well as the lungs, are a sign of the disease. (19)

The usual radiographic findings of pulmonary mucormycosis include infiltration, consolidation, nodules, cavitations, atelectasis, effusion, and hilar or mediastinal lymphadenopathy. Computed tomography scan results of multiple lung nodules (≥ 10), pleural effusion, and reversed halo signs are found to be better predictors of pulmonary mucormycosis than invasive aspergillosis in patients with hematological malignancy. (20)

Hammer et al, studied the CT features in pulmonary mucormycosis, where cavitations in 3 out of 30 patients on initial imaging and with subsequent CT studies, increased to 37% (11 out of 30 patients), and the reverse halo sign was seen in 7 of these 11 patients. Also, the initial CT finding in 2 patients (7%), was extensive bilateral consolidations like that of multifocal bacterial pneumonia then additional 3 patients developed multifocal pneumonia on subsequent CT studies for a total of 5 patients (17%). (21)

In this current study, 4 patients with Mucormycosis positive samples died out of the 5 patients, this was similar to multiple previous studies that indicated that mucormycosis is associated with high mortality. (21–24)

Chakrabarti et al reported that Mucorales were detected in 14.4% of participants and Aspergillus spp. were the commonest isolates (82.1%), A high APACHE II score and mucormycosis infection were significant mortality predictors. (25)

In this current study, the antifungal agent susceptibility for the isolated fungi was done. (Figs. 3 & 4) The most susceptibility was for caspofungin and amphotericin B while the most resistance was for ketoconazole and voriconazole.

Sani et al studied the antifungal susceptibly against isolated fungi using 3 agents voriconazole, nystatin, and fluconazole. The 3 fungal isolated species Penicillium citrinum, Mucor spp., and Aspergillus flavus are more susceptible to voriconazole while C. albicans was more susceptible to Nystatin. While fluconazole showed the lowest antifungal activity and most isolated fungi were resistant to fluconazole. (26)

Balajee et al. reported the presence of a poorly sporulating variant of Aspergillus fumigatus which was associated with lower susceptibilities to multiple antifungals, including itraconazole. And Amphotericin B but voriconazole had potent in-vitro activity against these isolates. (27)

There are some limitations of this current study. The participants were small in number which needs to be increased in future research. Also, the duration of the study was short. Further studies are needed to investigate the relationship between species that have antifungal drug resistance with risk factors and the clinical outcome.

Fungal infections are a big worry for people in the pulmonary ICU. The danger of a fungal infection rises with mechanical ventilation. For quick treatment, it is important to find and isolate the fungus that is causing the infection. Mucormycosis is associated with high mortality.

APACHE

Acute physiology and chronic health assessment

C. Albicans spp.

Candida Albicans species

CT

computed Tomography

DM

Diabetes mellitus

ICU

intensive care unit

Ethics approval and Consent to participate:

The study was approved by the Ethics Committee of Menoufia University Hospital (IRB: 8/2022CHES11 and informed consent from all participants was obtained in accordance with the local ethical committee at Menoufia University Hospital.

Consent for publication:

The authors affirm that the participant of the image in figure 2 was provided informed consent for the publication

Competing interests:

Not applicable

Authors Contributions:

Study design: M.M. Data collection: M.M, B.B, M.T and S.A. Data analysis: S.A and A.E. Interpretation of results: A.E, M.M, B.B. Initial draft: A.E, S.A, and M.T. final review of the manuscript content: all authors.

Funding:

Not applicable

Data Availability:

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Acknowledgments:

Not applicable

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Table (1): Distribution of the studied cases according to the different parameters (n = 37):

parameters	Results
Sex Male Female	23 (62.2%) 14 (37.8%)
Age (years) Mean ± SD. Median (Min. – Max.)	55.73 ± 14.86 59 (18 – 80)
Smoking	18 (48.6%)
DM	19 (51.4)
HTN	18 (48.6)
Immunocompromised	28 (75.7%)
Other comorbidities	6 (16.2%)
Fever	31 (83.8%)
Mechanical ventilation	10 (27.0%)
PO₂(mmHg) Mean ± SD. Median (Min. – Max.)	61.41 ± 10.76 60 (40 – 80)
PCO₂(mmHg) Mean ± SD. Median (Min. – Max.)	38.51 ± 12.52 38 (20 – 75)
HCO₃(mEq/L) Mean ± SD. Median (Min. – Max.)	22.89 ± 4.96 23 (7 – 33)
TLC (cell/m³) Mean ± SD. Median (Min. – Max.)	14.17 ± 4.52 15 (3 – 25)
APACHE II score Mean ± SD. Median (Min. – Max.)	13.49 ± 11.83 8 (3 – 49)

SD: Standard deviation

Table (2): Distribution of the studied cases according to the CT finding, final diagnosis, and Fate: (n = 37)

	No. (%)
CT chest
Pulmonary infarction Unilateral consolidation Bilateral consolidation Bilateral lung infiltrates +bilateral pleural effusion Unilateral consolidation + pleural effusion Consolidation + lung mass Bilateral lung consolidation + cavitations Lung abscess Bronchiectasis Lung fibrosis Emphysema Lung mass Normal	2(5.4%) 7(18.9) 5(13.5%) 1(2.7%) 1(2.7%) 4(10.8%) 3(8.1%) 4(10.8%) 2(5.4%) 2(5.4%) 3(8.1%) 1(2.7%) 2(5.4%)
Final Diagnosis
Pulmonary embolism Bronchopneumonia with lung cavitations Lung abscess Lobar pneumonia Bronchopneumonia Aspiration pneumonia Unilateral pneumonia with pleural effusion Lung cancer with pneumonia Lung cancer Bronchiectasis COPD exacerbation Lung fibrosis Pulmonary edema Pickwickian with respiratory failure	2 (5.4%) 3 (8.1%) 4(10.8%) 5(13.5%) 4(10.8%) 3(8.1%) 1(2.7%) 4(10.8%) 1(2.7%) 2(5.4%) 3(8.1%) 2(5.4%) 1(2.7%) 2(5.4%)
Fate:
Died Discharged	9 (24.3%) 28 (75.7%)

Table (3): Relation between culture results and different parameters (n = 37)

	Culture results		Test of Sig.	p
	No fungal growth (n = 18)	Fungal Growth (n = 19)	Test of Sig.	p
Sex Male Female	11 (61.1%) 7 (38.9%)	12 (63.2%) 7 (36.8%)	χ²= 0.016	0.898
Age (years) Mean ± SD. Median (Min. –Max.)	56.33 ± 16.36 63 (18 – 80)	55.16 ± 13.71 58 (23 – 77)	t= 0.237	0.814
Smoking	9 (50.0%)	9 (47.4%)	χ²=0.026	0.873
DM	8 (44.4%)	11 (57.9%)	χ²=0.669	0.413
HTN	9 (50.0%)	9 (47.4%)	χ²=0.026	0.873
Other comorbidities	2 (11.1%)	4 (21.1%)	χ²=0.672	^FEp=0.660
Immunocompromised	13 (72.2%)	15 (78.9%)	χ²=0.227	^FEp=0.714
Fever	13 (72.2%)	18 (94.7%)	χ²=3.449	^FEp=0.090
Mechanical ventilation	2 (10.5%)	8 (44.4%)	χ²=5.392^*	^FEp=0.029^*
PO₂(mmHg) Mean ± SD. Median (Min. – Max.)	62.44 ± 8.78 60 (50 – 77)	60.42 ± 12.51 63 (40 – 80)	t= 0.566	0.575
PCO₂(mmHg) Mean ± SD. Median (Min. – Max.)	38.17 ± 12.93 36 (20 – 65)	38.84 ± 12.47 38 (23 – 75)	t= 0.162	0.872
HCO₃(mEq/L) Mean ± SD. Median (Min. – Max.)	21.77 ± 6.11 22.5 (7 – 31)	23.95 ± 3.39 24.0 (19 – 33)	t= 1.332	0.194
TLC (cell/cm³) Mean ± SD. Median (Min. – Max.)	13.07 ± 4.61 14 (3 – 20)	15.21 ± 4.30 15 (4 – 25)	t= 1.464	0.152
APACHE II score Mean ± SD. Median (Min. – Max.)	10.5 ± 9.78 5 (3 – 30)	16.31 ± 13.13 10 (5 – 49)	U= 103.0	0.040*

SD: Standard deviation t: Student t-test U: Mann Whitney test

c²: Chi-square test MC: Monte Carlo FE: Fisher Exact

p: p-value for comparison between the studied categories

*: Statistically significant at p ≤ 0.05

Table (4): Relation between culture results and different parameter (n = 37)

	Culture results		Test of Sig.	p
	No fungal growth (n = 18)	Fungal Growth (n = 19)	Test of Sig.	p
CT chest finding:
Pulmonary infarction	2 (11.1%)	0 (0.0%)	χ²=2.231	^FEp=0.230
Unilateral consolidation	4 (22.2%)	3 (15.8%)	χ²=0.249	^FEp=0.693
Bilateral consolidation	3 (16.7%)	2 (10.5%)	χ²=0.298	^FEp=0.660
Bilateral lung infiltrates +bilateral pleural effusion	1 (5.6%)	0 (0.0%)	χ²=1.085	^FEp=0.486
Unilateral consolidation + pleural effusion	1 (5.6%)	0 (0.0%)	χ²=1.085	^FEp=0.486
Consolidation + lung mass	2 (11.1%)	2 (10.5%)	χ²=0.003	^FEp=1.00
Bilateral lung Consolidation + cavitation	0 (0.0%)	3 (15.8%)	χ²=3.093	^FEp=0.230
Lung abscess	1 (5.6%)	3 (15.8%)	χ²=1.004	^FEp=0.604
Bronchiectasis	0 (0.0%)	2 (10.5%)	χ²=2.003	^FEp=0.486
Lung fibrosis	0 (0.0%)	2 (10.5%)	χ²=2.003	^FEp=0.486
Emphysema	2 (11.1%)	1 (5.3%)	χ²=0.424	^FEp=0.604
Lung mass	1 (5.6%)	0 (0.0%)	χ²=1.085	^FEp=0.486
Normal	1 (5.6%)	1 (5.3%)	χ²=0.002	^FEp=1.00
Fate:
Discharge Died	14 (77.8%) 4 (22.2%)	14 (73.7%) 5 (26.3%)	χ²= 0.084	^FEp= 1.000

SD: Standard deviation U: Mann Whitney test

c²: Chi-square test FE: Fisher Exact

p: p-value for comparison between No growth and growth of culture results

Table (5): Relation between mucormycosis and different parameter (n = 37)

	Mucormycosis Positive culture		Test of Sig.	p
	No (n = 32)	Yes (n = 5)	Test of Sig.	p
CT chest finding
Pulmonary infarction	2 (6.3%)	0 (0.0%)	χ²=0.330	^FEp=1.0
Unilateral consolidation	7 (21.9%)	0 (0.0%)	χ²=1.349	^FEp=0.560
Bilateral consolidation	4 (12.5%)	1 (20.0%)	χ²=0.208	^FEp=0.538
Bilateral lung infiltrates +bilateral pleural effusion	1 (3.1%)	0 (0.0%)	χ²=0.161	^FEp=1.000
Unilateral consolidation + pleural effusion	1 (3.1%)	0 (0.0%)	χ²=0.161	^FEp=1.000
Consolidation + lung mass	3 (9.4%)	1 (20.0%)	χ²=0.506	^FEp=0.456
Bilateral lung consolidations + cavitations	0 (0.0%)	3 (60.0%)	χ²=20.89^*	^FEp=0.001^*
Lung abscess	4 (12.5%)	0 (0.0%)	χ²=0.701	^FEp=1.00
Bronchiectasis	2 (6.3%)	0 (0.0%)	χ²=0.330	^FEp=1.00
Lung fibrosis	2 (6.3%)	0 (0.0%)	χ²=0.330	^FEp=1.00
Emphysema	3 (9.4%)	0 (0.0%)	χ²=0.510	^FEp=1.00
Lung mass	1 (3.1%)	0 (0.0%)	χ²=0.161	^FEp=1.000
Normal	2 (6.3%)	0 (0.0%)	χ²=0.330	^FEp=1.00
Fate
Discharge Died	27 (84.4%) 5 (15.6%)	1 (20.0%) 4(80.0%)	χ²= 9.735	^FEp= 0.008^*
APACHE II score
Mean ± SD. Median (Min. – Max.)	11.53 ± 10.30 6.5 (3.0 – 35.0)	26 ± 14.54 22.0 (10.0 – 49.0)	U= 30.0^*	0.027^*

SD: Standard deviation U: Mann Whitney test

c²: Chi-square test FE: Fisher Exact

p: p-value for comparison between negative and positive cultures for mucormycosis

*: Statistically significant at p ≤ 0.05

Table 6: Drug susceptibility for each fungus isolated (S: sensitive, I: intermediate sensitivity, R: resistant)

		Mucormycosis N=5	C.albicans N=6	Aspergillus N=4	Mixed N=2	C. glabrata N=1	C. krusei N=1
Fluconazole N (%)	S	2(40.0)	1(16.7)	2(50.0)	1 (50.0)	0 (0.0)	0 (0.0)
	I	0 (0.0)	1(16.7)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	3 (60.0)	4 (66.6)	2(50.0)	1(50.0)	1 (100)	1 (100)
Itraconazole N (%)	S	2 (40.0)	22 (33.3)	2(50.0)	0 (0.0)	0 (0.0)	0 (0.0)
	I	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	3(60.0)	44 (66.7)	2(50.0)	2 (100)	1 (100)	1 (100)
Ketoconazole N (%)	S	0 (0.0)	2 (33.3)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	I	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	5 (100)	4 (66.7)	4 (100)	2 (100)	1 (100)	1 (100)
Voriconazole N (%)	S	0 (0.0)	2(33.3)	1(25.0)	1 (50.0)	0 (0.0)	0 (0.0)
	I	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	5 (100)	44 (66.7)	3 (75.0)	1(50.0)	1 (100)	1 (100)
Nystatin N (%)	S	2 (40.0)	3(50.0)	1(25.0)	0 (0.0)	1 (100)	1 (100)
	I	1 (20.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	2 (40.0)	3(50.0)	3 (75.0)	2 (100)	0 (0.0)	0 (0.0)
Flucytosine N (%)	S	1 (20.0)	3(50.0)	2(50.0)	2 (100)	1 (100)	0 (0.0)
	I	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	4(80.0)	3(50.0)	2(50.0)	0 (0.0)	0 (0.0)	1 (100)
Amphotericin B. N (%)	S	5 (100)	4 (66.7)	1(25.0)	2 (100)	1 (100)	1 (100)
	I	0 (0.0)	0 (0.0)	1(25.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	0 (0.0)	2 (33.3)	2(50.0)	0 (0.0)	0 (0.0)	0 (0.0)
Caspofungin N (%)	S	4(80.0)	6 (100)	4 (100)	2 (100)	1 (100)	1 (100)
	I	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	R	1 (20.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)

No competing interests reported.

Incidence of Fungal Infections Including Mucormycosis in Respiratory Intensive Care

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Subjects And Methods

Results

Discussion

Conclusion

List Of Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1