The Last of Fungus? Recent Developments in Fungal Infections in the German Hospital Setting

OBJECTIVES: Invasive fungal diseases are rising, particularly among immunocompromised populations. However, fungal infections receive limited attention and resources, leading to a lack of data on disease distribution and antifungal resistance patterns. In 2022, the World Health Organization (WHO) released the first fungal priority pathogens list, which systematically prioritizes fungal pathogens. This study aims to provide an overview of fungal infections and antifungal resistances in the inpatient setting in Germany.

METHODS: This retrospective data analysis was based on German hospital data from the Institute for the Hospital Remuneration System (InEK) from 2019 to 2023. Fungal infections and antifungal resistance were identified by ICD-10-GM codes. Due to coding limitations preventing exact species identification, this assessment focused on the three fungal genus classifications from the WHO critical priority group (Cryptococcus, Candida, Aspergillus). Antifungal applications were identified by operation and procedure keys (OPS codes). Hospitalization rates with 95% confidence intervals (CI) were calculated.

RESULTS: Between 2019 and 2023, n=39,199 patients (52.9% men; 68.7% ≥60 years) were hospitalized due to infections with fungal pathogens of critical priority. Most hospitalizations were due to Candida infections (75.8%; CI: 74.9-76.6%). However, the share of hospitalizations with Candida decreased from 2019 (77.4%; CI: 75.7-79.2%) to 2023 (74.8%; CI: 72.9-76.7%). In contrast, hospitalizations due to Cryptococcus infections increased between 2019 (0.6%; CI: 0.5-0.8%) and 2023 (0.9%; CI: 0.7-1.1%). A significant trend was observed for hospitalizations due to infections with Aspergillus from 2019 (21.9%; CI: 21.0-22.9%) to 2023 (24.3%; CI: 23.2-25.4%). Between 2019 and 2023, n=7,183 hospitalized patients were diagnosed with antifungal resistance. Among these patients, the most frequently applied antifungal drug was caspofungin.

CONCLUSIONS: The increase in hospitalization rates due to fungal infections with Cryptococcus and Aspergillus affirms the WHO concerns. Further observation and research are necessary to estimate the burden and future risks of invasive fungal diseases.