Global prevalence, mortality, and main risk factors for COVID-19 associated pneumocystosis: A systematic review and meta-analysis
Hossein Khodadadi1, Ehsan Ahmadpour2, Sanam Nami3, Rasoul Mohammadi4, Hanieh Hosseini5, Mahsa Behravan5, Hamid Morovati6
1 Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
2 Drug Applied Research Center; Department of Medical Mycology and Parasitology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Medical Mycology and Parasitology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
5 Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
6 Department of Parasitology and Mycology, School of Medicine; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
Department of Parasitology and Mycology, School of Medicine; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
Source of Support: This study has received financial support from the Vice Chancellor for Research & Technology Affairs, Shiraz University of Medical Sciences (Grant number: 26817), Conflict of Interest: None
Objective: Pneumocystis pneumonia (PcP) is a life-threatening infection caused by the opportunistic fungi Pneumocystis jirovecii. The emergence of the COVID-19 pandemic forced the focus of attention of health policymakers on these two infections due to their clinical and paraclinical similarities, which cause diagnostic dilemmas. This study was undertaken to evaluate and estimate the global prevalence and main leading risk factors of coronavirus-associated pneumocystosis (CAP).
Methods: We searched related databases between December 2019 and May 2022 for studies reporting CAP. Meta-analysis was performed using StatsDirect software (version 2.7.9) according to the DerSimonian and Laird method applying the random-effects model. We evaluated heterogeneity using the χ2-based Q statistic (significant for P<0.05) and the I2 statistic (>75% indicative of “notable” heterogeneity). Moreover, an odds ratio (OR) analysis was performed for eligible data.
Results: Our meta-analysis included eight studies with 923 patients hospitalized with COVID-19; among them, 92 were PcP cases. The overall pooled prevalence of CAP was estimated at 11.5%. The mortality among CAP patients was lower than that of non-PcP patients (OR 1.93; 95% CI 0.86-4.31). Long-term corticosteroid therapy (OR 28.22; 95% CI 0.54-1 480.84) was the most predisposing factor for PcP among COVID-19 patients, followed by pulmonary diseases (OR 1.46; 95% CI 0.43-4.98), kidney diseases (OR 1.26; 95% CI 0.21-7.49), and acute respiratory destruction syndrome (OR1.22; 95% CI 0.05-29.28).
Conclusions: The prevalence of PcP among the COVID-19 population is almost similar to the pre-COVID era. However, PcP-related mortality was decreased by the emergence of the COVID-19 pandemic. Women with COVID-19 are more susceptible to PcP than men. Acute respiratory distress syndrome, kidney diseases, pulmonary diseases, and long-term corticosteroid therapy increased the risk of PcP; however, transplantation and malignancy decreased the risk for PcP among COVID-19 patients. Further retrospective, case-control, prospective, and more precisely systematic review and meta-analysis studies are needed in this field.