1
|
Zuniga-Moya JC, Papadopoulos B, Mansoor AER, Mazi PB, Rauseo AM, Spec A. Incidence and Mortality of COVID-19-Associated Invasive Fungal Infections Among Critically Ill Intubated Patients: A Multicenter Retrospective Cohort Analysis. Open Forum Infect Dis 2024; 11:ofae108. [PMID: 38567199 PMCID: PMC10986750 DOI: 10.1093/ofid/ofae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
Background An association between coronavirus disease 2019 (COVID-19)-associated invasive fungal infections (CAIFIs) and high mortality among intubated patients has been suggested in previous research. However, some of the current evidence was derived from small case series and multicenter studies conducted during different waves of the COVID-19 pandemic. We examined the incidence of CAIFIs and their associated mortality using a large, multicenter COVID-19 database built throughout the pandemic. Methods We conducted a retrospective analysis of the National COVID Cohort Collaborative (N3C) database collected from 76 medical centers in the United States between January 2020 and August 2022. Patients were 18 years or older and intubated after severe acute respiratory syndrome coronavirus 2 infection. The primary outcomes were incidence and all-cause mortality at 90 days. To assess all-cause mortality, we fitted Cox proportional hazard models after adjusting for confounders via inverse probability weighting. Results Out of the 4 916 229 patients with COVID-19 diagnosed during the study period, 68 383 (1.4%) met our cohort definition. The overall incidence of CAIFI was 2.80% (n = 1934/68 383). Aspergillus (48.2%; n = 933/1934) and Candida (41.0%; n = 793/1934) were the most common causative organisms. The incidence of CAIFIs associated with Aspergillus among patients who underwent BAL was 6.2% (n = 83/1328). Following inverse probability weighting, CAIFIs caused by Aspergillus (hazard ratio [HR], 2.0; 95% CI, 1.8-2.2) and Candida (HR, 1.7; 95% CI, 1.5-1.9) were associated with increased all-cause mortality. Systemic antifungals reduced mortality in 17% of patients with CAIFI with Aspergillus and 24% of patients with CAIFI with Candida. Conclusions The incidence of CAIFI was modest but associated with higher 90-day all-cause mortality among intubated patients. Systemic antifungals modified mortality.
Collapse
Affiliation(s)
| | | | | | - Patrick B Mazi
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
| | - Adriana M Rauseo
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
| | - Andrej Spec
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
| |
Collapse
|
2
|
Heylen J, Vanbiervliet Y, Maertens J, Rijnders B, Wauters J. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024; 45:69-87. [PMID: 38211628 DOI: 10.1055/s-0043-1777769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.
Collapse
Affiliation(s)
- Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yuri Vanbiervliet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Koulenti D, Papathanakos G, Blot S. Invasive pulmonary aspergillosis in the ICU: tale of a broadening risk profile. Curr Opin Crit Care 2023; 29:463-469. [PMID: 37641513 DOI: 10.1097/mcc.0000000000001070] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW In the absence of histopathological proof, the diagnosis of invasive pulmonary aspergillosis (IPA) is usually based on mycology (not on tissue), medical imaging, and the patient's risk profile for acquiring invasive fungal disease. Here, we review the changes in risk profile for IPA that took place over the past decades. RECENT FINDINGS In the early 2000s IPA was considered exclusively a disease of immunocompromised patients. Particularly in the context of critical illness, the risk profile has been broadened steadily. Acute viral infection by influenza or SARS-Cov-2 are now well recognized risk factors for IPA. SUMMARY The classic risk profile ('host factors') reflecting an immunocompromised status was first enlarged by a spectrum of chronic conditions such as AIDS, cirrhosis, and chronic obstructive pulmonary disease. In the presence of critical illness, especially characterized by sepsis and/or severe respiratory distress, any chronic condition could add to the risk profile. Recently, acute viral infections have been associated with IPA leading to the concepts of influenza-associated IPA and COVID-19-associated IPA. These viral infections may affect patients without underlying disease. Hence, the risk for IPA is now a reality for ICU patients, even in the absence of any chronic conditions.
Collapse
Affiliation(s)
- Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, Athens, Greece
- UQCCR, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Georgios Papathanakos
- Department of Intensive Care Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - Stijn Blot
- UQCCR, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| |
Collapse
|
4
|
Li C, Sun L, Liu Y, Zhou H, Chen J, She M, Wang Y. Diagnostic value of bronchoalveolar lavage fluid galactomannan assay for invasive pulmonary aspergillosis in adults: A meta-analysis. J Clin Pharm Ther 2022; 47:1913-1922. [PMID: 36324286 DOI: 10.1111/jcpt.13792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/31/2022] [Accepted: 09/18/2022] [Indexed: 11/06/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE To analyse the diagnostic accuracy of bronchoalveolar lavage fluid galactomannan (BALF-GM) assay for invasive pulmonary aspergillosis (IPA) in adults to determine the optimal diagnostic cut-off by meta-analysis. METHODS PubMed, Embase, Web of Science, Cochrane Library, China national knowledge infrastructure (CNKI), and China Wanfang databases were searched to collect relevant studies on the diagnostic value of BALF-GM for IPA from inception to March 2022. The summary receiver operating characteristic (SROC) curve was drawn to determine the optimal diagnostic cut-off. RESULTS AND DISCUSSION Nineteen articles (56 data sets) were included. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were 0.79 (95% CI: 0.72-0.84), 0.92 (95% CI: 0.88-0.94), 9.25 (95% CI: 6.84-12.52), 0.23 (95% CI: 0.18-0.30), 39.44 (95% CI: 29.55-52.65), and 0.92 (95% CI: 0.90-0.94), respectively. The area under the curves (AUCs) were 0.92, 0.86, 0.93, 0.89, 0.88, and 0.94 when the cut-off values were 0.5, 0.8, 1.0, 1.5, 2.0, and 3.0, respectively. Sixteen studies were included in the combined analysis when the cut-off value was 0.5. The results showed that the pooled sensitivity, specificity, PLR, NLR and DOR of BALF-GM (cut-off 0.5) for the diagnosis of IPA were 0.89 (95% CI: 0.83-0.93), 0.79 (95% CI: 0.71-0.86), 4.33 (95% CI: 3.04-6.16), 0.14 (95% CI: 0.09-0.22), and 31.51 (95% CI: 17.43-56.98). The AUC was 0.92 (95% CI: 0.89-0.94). WHAT IS NEW AND CONCLUSIONS BALF-GM has excellent diagnostic accuracy for adult IPA, which can be diagnosed early and treated early to reduce the mortality rate. Considering the sensitivity, specificity, PLR and NLR, the recommended diagnostic cut-off of BALF-GM for adult IPA is 0.5.
Collapse
Affiliation(s)
- Chang Li
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Lin Sun
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Yin Liu
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Hongbing Zhou
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Jianguo Chen
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Min She
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Yong Wang
- Department of Pulmonary and Critical Care Medicine, Chongzhou People's Hospital, Chengdu, Sichuan, China
| |
Collapse
|
5
|
Clinical Characteristics and Risk Factors for Pulmonary Infection in Emergency ICU Patients. DISEASE MARKERS 2022; 2022:7711724. [PMID: 35531476 PMCID: PMC9076290 DOI: 10.1155/2022/7711724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
Background Pulmonary infection in the emergency ICUs increases patient morbidity, hospital stay, treatment costs, and the risk of related adverse events. Methods This study included 695 patients admitted to our emergency ICU between December 2019 and March 2021. Medical records of emergency ICU patients were reviewed to collect their clinical data, including antibiotic use, history of tracheostomy, history of mechanical ventilation, presence or absence of underlying disease, history of smoking, alcohol consumption, age, gender, and history of shock. Bacterial cultures were performed. The incidence, main clinical features, main pathogens, and risk factors of pulmonary infection in emergency ICU were analyzed. Results In this study, 69 of the 695 emergency ICU patients (9.93%) developed pulmonary infection. The main clinical features of patients with pulmonary infection included cough and expectoration (97.10%), shortness of breath and chest tightness (95.65%), leukocyte elevation (69.57%), confusion (31.88%), drowsiness (28.99%), persistent fever (27.54%), and nausea and vomiting (10.14%). The main pathogenic bacteria in those with pulmonary infection included Klebsiella pneumoniae (62.32%), Pseudomonas aeruginosa (49.28%), Streptococcus pneumoniae (21.74%), Staphylococcus aureus (39.13%), Candida albicans (7.25%), Pneumococcus pneumoniae (15.95%), Pseudomonas aeruginosa (24.64%), and lung diplococcus inflammatory (13.04%). Univariate analysis showed that there were no significant differences in the occurrence of pulmonary infection with regard to sex, smoking, and alcohol consumption, but there were significant differences with regard to age, basic disease, invasive surgery, and shock. Logistic regression analysis confirmed that age ≥ 80 years, invasive surgery, shock, and basic diseases ≥ 2 were important risk factors for pulmonary infection in emergency ICU patients. Conclusion Considering the clinical features and risk factors for pulmonary infection in the emergency ICU, preventive and control measures are required to minimize its occurrence and ensure good outcomes.
Collapse
|
6
|
Kluge S, Strauß R, Kochanek M, Weigand MA, Rohde H, Lahmer T. Aspergillosis: Emerging risk groups in critically ill patients. Med Mycol 2021; 60:6408468. [PMID: 34677613 DOI: 10.1093/mmy/myab064] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023] Open
Abstract
Information on invasive aspergillosis (IA) and other invasive filamentous fungal infections is limited in non-neutropenic patients admitted to the intensive care unit (ICU) and presenting with no classic IA risk factors. This review is based on the critical appraisal of relevant literature, on the authors' own experience and on discussions that took place at a consensus conference. It aims to review risk factors favoring aspergillosis in ICU patients, with a special emphasis on often overlooked or neglected conditions. In the ICU patients, corticosteroid use to treat underlying conditions such as chronic obstructive pulmonary disease (COPD), sepsis, or severe COVID-19, represents a cardinal risk factor for IA. Important additional host risk factors are COPD, decompensated cirrhosis, liver failure, and severe viral pneumonia (influenza, COVID-19). Clinical observations indicate that patients admitted to the ICU because of sepsis or acute respiratory distress syndrome are more likely to develop probable or proven IA, suggesting that sepsis could also be a possible direct risk factor for IA, as could small molecule inhibitors used in oncology. There are no recommendations for prophylaxis in ICU patients; posaconazole mold-active primary prophylaxis is used in some centers according to guidelines for other patient populations and IA treatment in critically ill patients is basically the same as in other patient populations. A combined evaluation of clinical signs and imaging, classical biomarkers such as the GM assay, and fungal cultures examination, remain the best option to assess response to treatment. LAY SUMMARY The use of corticosteroids and the presence of co-morbidities such as chronic obstructive pulmonary disease, acute or chronic advanced liver disease, or severe viral pneumonia caused by influenza or Covid-19, may increase the risk of invasive aspergillosis in intensive care unit patients.
Collapse
Affiliation(s)
- Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg - Eppendorf, Hamburg, D-20246, Germany
| | - Richard Strauß
- Department of Medicine 1, Medizinische Klinik 1, University Hospital Erlangen, Erlangen, D-91054, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, D-50937, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, D-69120, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, D-20246, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität Munich, Munich, D-81675, Germany
| |
Collapse
|
7
|
Klein J, Rello J, Dimopoulos G, Bulpa P, Blot K, Vogelaers D, Blot S. Invasive pulmonary aspergillosis in solid-organ transplant patients in the intensive care unit. Transpl Infect Dis 2021; 24:e13746. [PMID: 34843161 DOI: 10.1111/tid.13746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/01/2021] [Accepted: 10/08/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Solid-organ transplantation (SOT) is a well-known risk factor for invasive pulmonary aspergillosis (IPA). We report on the epidemiology and outcome of SOT patients with IPA in an intensive care unit (ICU) setting. METHODS This is a secondary study based on a subset of SOT patients from a prospective observational multicenter cohort (the AspICU project) including ICU patients with at least one Aspergillus spp. positive culture. Cases were classified as proven, probable, or putative IPA, or as Aspergillus-colonized. Mortality was reported at 12 weeks. RESULTS The study included 52 SOT patients (of which 18 lung, 17 liver, 12 kidney, and five heart transplants). Sixteen patients had proven IPA, 28 were categorized as putative IPA (of which only five reached a probable IPA diagnosis according to the European Organization for Research and Treatment of Cancer/Mycosis Study Group and Research Consortium criteria), and eight as Aspergillus-colonization. Among patients with IPA, 20 (45.5%) developed IPA during their ICU stay following transplantation whereas 24 patients (54.5%) had a medical ICU admission. Regarding medical imaging, nearly all IPA cases presented with non-specific findings as only nine demonstrated robust findings suggestive for invasive fungal disease. Overall, severity of the disease was reflected by a high prevalence of underlying conditions and acute organ derangements. Mortality among patients with IPA was 68%. Lung transplantation was associated with better survival (50%). CONCLUSION IPA in SOT patients in the ICU develops in the presence of overall high severity of the disease. It rarely presents with suggestive medical imaging thereby hampering diagnosis. IPA in ICU patients with SOT carries a grim prognosis.
Collapse
Affiliation(s)
- Joachim Klein
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis, Vall d'Hebron Institute of Research, Barcelona, Spain.,Clinical Research, CHRU Nimes, Nimes, France
| | - George Dimopoulos
- Department of Critical Care, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Pierre Bulpa
- Department of Intensive Care Unit, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - Koen Blot
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Dirk Vogelaers
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of General Internal Medicine and Infectious Diseases, AZ Delta, Roeselare, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Burns, Trauma and Critical Care Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| |
Collapse
|
8
|
Gu Y, Ye X, Liu Y, Wang Y, Shen K, Zhong J, Chen B, Su X. A risk-predictive model for invasive pulmonary aspergillosis in patients with acute exacerbation of chronic obstructive pulmonary disease. Respir Res 2021; 22:176. [PMID: 34107968 PMCID: PMC8188951 DOI: 10.1186/s12931-021-01771-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/06/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives Invasive pulmonary aspergillosis (IPA) is increasingly reported in chronic obstructive pulmonary disease (COPD) patients. These patients often have poor clinical outcomes. Early recognition of IPA in COPD is always challenging. We aimed to develop and validate a risk model using readily available clinical parameters to predict IPA for acute exacerbation of COPD (AECOPD) patients. Methods We performed a retrospective cohort study. AECOPD patients who were admitted to Jinling Hospital between January 2012 and December 2017 were included. 880 AECOPD patients were randomly divided into the training set (70%, n = 616) and validation set (30%, n = 264). A nomogram model was developed using multivariate logistic regression from training set. The discrimination and calibration of model were validated internally. Decision curve analyses assessed the clinical utility of the nomogram. Results The incidence of IPA in hospitalized AECOPD patients was 9.6% in the training set (59 cases of IPA) and 9.1% in the validation set (24 cases of IPA), respectively. The nomogram model consisted of independent factors associated with IPA included lung function GOLD III–IV, use of broad-spectrum antibiotic over 10 days in the last month, oral or intravenous corticosteroids (prednisone) over 265 mg in the last 3 months and serum albumin < 30 g/L. The model performed good discrimination and calibration in validation set (c-statistic, 0.79 [95%CI 0.68–0.90]). The 95%CI region of calibration belt did not cross the 45-degree diagonal bisector line (P = 0.887). Conclusion The simple risk predictive model for earlier recognition of IPA is useful in hospitalized AECOPD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01771-3.
Collapse
Affiliation(s)
- Yu Gu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210002, China
| | - Xianping Ye
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210002, China
| | - Yuxiu Liu
- Department of Medical Statistics, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, China
| | - Yu Wang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Kunlu Shen
- Department of Respiratory and Critical Care Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, China
| | - Jinjin Zhong
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Bilin Chen
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Xin Su
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, 210002, China. .,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China. .,Department of Respiratory and Critical Care Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, China.
| |
Collapse
|
9
|
Rogers TR. Defining Invasive Fungal Diseases for Clinical Research: A Work in Progress. Clin Infect Dis 2021; 71:1377-1378. [PMID: 31802113 DOI: 10.1093/cid/ciz1013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/08/2019] [Indexed: 01/22/2023] Open
Affiliation(s)
- Thomas R Rogers
- Department of Clinical Microbiology, Trinity College Dublin, St James's Hospital Campus, Dublin, Ireland
| |
Collapse
|
10
|
Is the COVID-19 Pandemic a Good Time to Include Aspergillus Molecular Detection to Categorize Aspergillosis in ICU Patients? A Monocentric Experience. J Fungi (Basel) 2020; 6:jof6030105. [PMID: 32664423 PMCID: PMC7558333 DOI: 10.3390/jof6030105] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022] Open
Abstract
(1) Background: The diagnosis of invasive aspergillosis (IA) in an intensive care unit (ICU) remains a challenge and the COVID-19 epidemic makes it even harder. Here, we evaluated Aspergillus PCR input to help classifying IA in SARS-CoV-2-infected patients. (2) Methods: 45 COVID-19 patients were prospectively monitored twice weekly for Aspergillus markers and anti-Aspergillus serology. We evaluated the concordance between (I) Aspergillus PCR and culture in respiratory samples, and (II) blood PCR and serum galactomannan. Patients were classified as putative/proven/colonized using AspICU algorithm and two other methods. (3) Results: The concordance of techniques applied on respiratory and blood samples was moderate (kappa = 0.58 and kappa = 0.63, respectively), with a higher sensitivity of PCR. According to AspICU, 9/45 patients were classified as putative IA. When incorporating PCR results, 15 were putative IA because they met all criteria, probably with a lack of specificity in the context of COVID-19. Using a modified AspICU algorithm, eight patients were classified as colonized and seven as putative IA. (4) Conclusion: An appreciation of the fungal burden using PCR and Aspergillus serology was added to propose a modified AspICU algorithm. This proof of concept seemed relevant, as it was in agreement with the outcome of patients, but will need validation in larger cohorts.
Collapse
|
11
|
Bulpa P, Duplaquet F, Dimopoulos G, Vogelaers D, Blot S. Invasive Pulmonary Aspergillosis in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:851-861. [PMID: 32599634 DOI: 10.1055/s-0040-1702210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nowadays, reports in the literature support that patients with severe chronic obstructive pulmonary disease (COPD) are at higher risk to develop invasive pulmonary aspergillosis (IPA). However, the interpretation of Aspergillus-positive cultures from the airways in critically ill COPD is still a challenge. Indeed, as the patient could be merely colonized, tissue samples are required to ascertain IPA diagnosis but they are rarely obtained before death. Consequently, diagnosis is often only suspected on the basis of a combination of three elements: clinical characteristics, radiological images (mostly thoracic CT scan), and microbiological, and occasionally serological, results. To facilitate the analysis of these data, several algorithms have been developed, and the best effectiveness has been demonstrated by the Clinical algorithm. This is of importance as IPA prognosis in these patients remains presently very poor and using such an algorithm could promote prompter diagnosis, early initiation of treatment, and subsequently improved outcome.While the most classical presentation of IPA in critically ill COPD patients features a combination of obstructive respiratory failure, antibiotic-resistant pneumonia, recent or chronic corticosteroid therapy, and positive Aspergillus cultures from the lower respiratory tract, the present article will also address less typical presentations and discuss the most appropriate treatments which could alter prognosis.
Collapse
Affiliation(s)
- Pierre Bulpa
- Department of Intensive Care Unit, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - Fabrice Duplaquet
- Department of Pneumology, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - George Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, Haidari, Greece
| | - Dirk Vogelaers
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| |
Collapse
|
12
|
|
13
|
Ehret N, Carlier N, Marey J, Rabbat A, Burgel PR, Roche N. [Aspergillus-related respiratory conditions and COPD: Diagnostic challenges]. Rev Mal Respir 2020; 37:308-319. [PMID: 32284206 DOI: 10.1016/j.rmr.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/11/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The relations between chronic obstructive pulmonary disease (COPD) and respiratory diseases due to Aspergillus spp. are not well understood. METHODS We analysed a retrospective series of patients hospitalized with a diagnosis of COPD and respiratory disease due to Aspergillus. Patients were identified between 2010 and 2015 from the medico-administrative database of Cochin hospital, Paris. Historical, clinical, biological, microbiological and imaging data were collected and described. Diagnoses were reclassified based on reference definitions and classifications from the literature. Patients were classified according to the type of Aspergillus-related diseases and risk factors were described. RESULTS Forty patients were identified. Classifiable Aspergillus-related respiratory conditions were confirmed in 26 of them including 12 allergic bronchopulmonary aspergillosis (ABPA), 8 chronic pulmonary aspergillosis (CPA), 1 invasive pulmonary aspergillosis (IPA) and 3 diagnostic associations ABPA/CPA. Other respiratory comorbidities were present in all cases of CPA and immunodepression was recorded for semi-invasive and invasive forms. Finally, 16 patients could not be classified, among whom Aspergillus related lung disease was considered as likely in one-half. CONCLUSION The complexity of the diagnosis of pulmonary aspergillosis is related to its multiple types with sometimes unclear distinctions. Any type of pulmonary aspergillosis can be observed in patients with COPD, depending on associated risks factors. It would be helpful to establish specific classifications adapted to patients with COPD. This will require larger, prospective, multicentre studies.
Collapse
Affiliation(s)
- N Ehret
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - N Carlier
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - J Marey
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - A Rabbat
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P-R Burgel
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - N Roche
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| |
Collapse
|
14
|
|
15
|
Bassetti M, Scudeller L, Giacobbe DR, Lamoth F, Righi E, Zuccaro V, Grecchi C, Rebuffi C, Akova M, Alastruey-Izquierdo A, Arikan-Akdagli S, Azoulay E, Blot SI, Cornely OA, Lass-Flörl C, Koehler P, Cuenca-Estrella M, de Lange DW, De Rosa FG, De Waele JJ, Dimopoulos G, Garnacho-Montero J, Hoenigl M, Kanj SS, Maertens J, Martin-Loeches I, Muñoz P, Kullberg BJ, Agvald-Ohman C, Poulakou G, Rello J, Sanguinetti M, Taccone FS, Timsit JF, Torres A, Vazquez JA, Calandra T. Developing definitions for invasive fungal diseases in critically ill adult patients in intensive care units. Protocol of the FUNgal infections Definitions in ICU patients (FUNDICU) project. Mycoses 2019; 62:310-319. [PMID: 30426598 DOI: 10.1111/myc.12869] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 10/21/2018] [Accepted: 11/05/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The reliability of diagnostic criteria for invasive fungal diseases (IFD) developed for severely immunocompromised patients is questionable in critically ill adult patients in intensive care units (ICU). OBJECTIVES To develop a standard set of definitions for IFD in critically ill adult patients in ICU. METHODS Based on a systematic literature review, a list of potential definitions to be applied to ICU patients will be developed by the ESCMID Study Group for Infections in Critically Ill Patients (ESGCIP) and the ESCMID Fungal Infection Study Group (EFISG) chairpersons. The proposed definitions will be evaluated by a panel of 30 experts using the RAND/UCLA appropriateness methods. The panel will rank each of the proposed definitions on a 1-9 scale trough a dedicated questionnaire, in two rounds: one remote and one face-to-face. Based on their median rank and the level of agreement across panel members, selected definitions will be organised in a main consensus document and in an executive summary. The executive summary will be made available online for public comments. CONCLUSIONS The present consensus project will seek to provide standard definitions for IFD in critically ill adult patients in ICU, with the ultimate aims of improving their clinical outcome and facilitating the comparison and generalizability of research findings.
Collapse
Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Santa Maria Misericordia Hospital, Udine, Italy
| | - Luigia Scudeller
- Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniele R Giacobbe
- Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Elda Righi
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Santa Maria Misericordia Hospital, Udine, Italy
| | - Valentina Zuccaro
- Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cecilia Grecchi
- Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rebuffi
- Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Murat Akova
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University Ankara, Ankara, Turkey
| | | | - Sevtap Arikan-Akdagli
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Elie Azoulay
- AP-HP, Saint-Louis Hospital, Medical Intensive Care Unit, Paris (LZ, EA), ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 INSERM, Paris Diderot, Sorbonne University, Paris, France
| | - Stijn I Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, Ghent, Belgium
| | - Oliver A Cornely
- Department I of Internal Medicine, University Hospital of Cologne and Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University Innsbruck, Innsbruck, Austria
| | - Philipp Koehler
- Department I of Internal Medicine, University Hospital of Cologne and Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | | | - Dylan W de Lange
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | | | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - José Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena and Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Medicine, University of California-San Diego, San Diego, California.,Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Johan Maertens
- Hematology, Department of Immunology and biology, KU Leuven, Leuven, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Patricia Muñoz
- Department of Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, CIBERES, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Bart J Kullberg
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Christina Agvald-Ohman
- Department of Clinical Science, Intervention and Technology, Division of Anaesthesiology and Intensive Care, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Garyphallia Poulakou
- 3rd Department of Medicine, Medical School, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Maurizio Sanguinetti
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Fabio S Taccone
- Department of Intensive Care, CUB - Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jean-François Timsit
- Université Paris Diderot/Hopital Bichat-Réanimation Medicale et Des Maladies Infectieuses, Paris, France.,UMR 1137-IAME Team 5-DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Inserm/Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Antoni Torres
- Department of Pulmonary Medicine, Hospital Clinic of Barcelona, University of Barcelona, CIBERES, IDIBAPS, Barcelona, Spain
| | - Jose A Vazquez
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia/Georgia Regents University, Augusta, Georgia
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University, Lausanne, Switzerland
| | | | | | | | | |
Collapse
|
16
|
Abstract
The number of pharmacological treatments available for COPD has increased markedly in the last years, mostly corresponding to new agents, combinations and devices within know pharmacological classes. Hierarchizing these options is not straightforward since expected effects are limited by the intrinsically fixed character of the underlying lung damage. In addition, all options have not been directly compared face-to-face. Therefore, guidelines derive from some level of subjective interpretation of the available evidence. Determining which magnitude of change can be taken as clinically relevant is complex although crucial to define long-term strategies. Similarly, estimating not only the possible benefits but also the risks of treatments at the individual level is of major importance to guide choices. In the future biomarkers may be of help in that respect. They will hopefully emerge from progresses in systems biology and medicine. Before then, prescriptions should be restricted to the appropriate treatment indications, as established by high level studies and formalized by guidelines.
Collapse
Affiliation(s)
- Nicolas Roche
- a Respiratory and Intensive Care Medicine, Hôpital Cochin (AP-HP) , University Paris Descartes (EA2511) , Paris , France
| |
Collapse
|