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Liu A, Xiong L, Wang L, Zhuang H, Gan X, Zou M, Wang X. Compare the efficacy of antifungal agents as primary therapy for invasive aspergillosis: a network meta-analysis. BMC Infect Dis 2024; 24:581. [PMID: 38867163 PMCID: PMC11170913 DOI: 10.1186/s12879-024-09477-9] [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: 08/18/2023] [Accepted: 06/04/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Several antifungal agents are available for primary therapy in patients with invasive aspergillosis (IA). Although a few studies have compared the effectiveness of different antifungal agents in treating IA, there has yet to be a definitive agreement on the best choice. Herein, we perform a network meta-analysis comparing the efficacy of different antifungal agents in IA. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Clinical Trials databases to find studies (both randomized controlled trials [RCTs] and observational) that reported on treatment outcomes with antifungal agents for patients with IA. The study quality was assessed using the revised tool for risk of bias and the Newcastle Ottawa scale, respectively. We performed a network meta-analysis (NMA) to summarize the evidence on antifungal agents' efficacy (favourable response and mortality). RESULTS We found 12 studies (2428 patients) investigating 11 antifungal agents in the primary therapy of IA. There were 5 RCTs and 7 observational studies. When treated with monotherapy, isavuconazole was associated with the best probability of favourable response (SUCRA, 77.9%; mean rank, 3.2) and the best reduction mortality against IA (SUCRA, 69.1%; mean rank, 4.1), followed by voriconazole and posaconazole. When treated with combination therapy, Liposomal amphotericin B plus caspofungin was the therapy associated with the best probability of favourable response (SUCRA, 84.1%; mean rank, 2.6) and the best reduction mortality (SUCRA, 88.2%; mean rank, 2.2) against IA. CONCLUSION These findings suggest that isavuconazole, voriconazole, and posaconazole may be the best antifungal agents as the primary therapy for IA. Liposomal amphotericin B plus caspofungin could be an alternative option.
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Affiliation(s)
- Ao Liu
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China.
| | - Liubo Xiong
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
| | - Lian Wang
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
| | - Han Zhuang
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
| | - Xiao Gan
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
| | - Mengying Zou
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
| | - Xiaoming Wang
- Department of Respiratory Medicine, Chengdu BOE hospital, Chengdu, Sichuan Province, 610000, China
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Elkayal O, Mertens B, Wauters J, Debaveye Y, Rijnders B, Verweij PE, Brüggemann RJ, Spriet I, Dreesen E. Dosing of IV posaconazole to treat critically ill patients with invasive pulmonary aspergillosis: a population pharmacokinetics modelling and simulation study. J Antimicrob Chemother 2024:dkae160. [PMID: 38828958 DOI: 10.1093/jac/dkae160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Posaconazole is used for the prophylaxis and treatment of invasive fungal infections in critically ill patients. Standard dosing was shown to result in adequate attainment of the prophylaxis Cmin target (0.7 mg/L) but not of the treatment Cmin target (1.0 mg/L). OBJECTIVES To provide an optimized posaconazole dosing regimen for IV treatment of patients with invasive pulmonary aspergillosis in the ICU. METHODS A population pharmacokinetics (popPK) model was developed using data from the POSA-FLU PK substudy (NCT03378479). Monte Carlo simulations were performed to assess treatment Cmin and AUC0-24 PTA. PTA ≥90% was deemed clinically acceptable. PopPK modelling and simulation were performed using NONMEM 7.5. RESULTS Thirty-one patients with intensive PK sampling were included in the PK substudy, contributing 532 posaconazole plasma concentrations. The popPK of IV posaconazole was best described by a two-compartment model with linear elimination. Interindividual variability was estimated on clearance and volume of distribution in central and peripheral compartments. Posaconazole peripheral volume of distribution increased with bodyweight. An optimized loading regimen of 300 mg q12h and 300 mg q8h in the first two treatment days achieved acceptable PTA by Day 3 in patients <100 kg and ≥100 kg, respectively. A maintenance regimen of 400 mg q24h ensured ≥90% Cmin PTA, whereas the standard 300 mg q24h was sufficient to achieve the AUC0-24 target throughout 14 days, irrespective of bodyweight. CONCLUSIONS We have defined a convenient, optimized IV posaconazole dosing regimen that was predicted to attain the treatment target in critically ill patients with invasive aspergillosis.
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Affiliation(s)
- Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Beatrijs Mertens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, UZ Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology and Radboudumc, CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy and Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen and Radboudumc, CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Gerber V, Boehn L, Sabou M, Studer A, Ursenbach A, Hansmann Y, Herbrecht R, Lefebvre N, Letscher-Bru V, Danion F. Is there an interest in systematic serum screening for aspergillosis in COVID-19 patients in a medical ward? Infect Dis Now 2024; 54:104918. [PMID: 38636842 DOI: 10.1016/j.idnow.2024.104918] [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: 02/25/2024] [Revised: 04/06/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE We evaluated the interest of systematic screening of serum fungal markers in patients hospitalized in a medical ward. METHODS We retrospectively analyzed all patients hospitalized in our infectious disease department from October 1st to October 31st, 2020 for COVID-19 without prior ICU admission, and for whom systematic screening of serum fungal markers was performed. RESULTS Thirty patients were included. The majority of patients received corticosteroids (96.7%). The galactomannan antigen assay was positive for 1/30 patients at D0, and 0/24, 0/16, 0/13 and 0/2 at D4, D7, D10 and D14 respectively. 1,3-ß-D-glucan was positive for 0/30, 1/24, 1/12, 0/12, 0/2 at D0, D4, D7, D10 and D14 respectively. No Aspergillus fumigatus PCR was positive. No cases of aspergillosis were retained. CONCLUSION Our study does not support the interest of systematic screening of fungal markers in immunocompetent patients with COVID-19 in a conventional unit.
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Affiliation(s)
- Victor Gerber
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Louis Boehn
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Marcela Sabou
- Laboratoire de Parasitologie et de Mycologie Médicale, Plateau Technique de Microbiologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Antoine Studer
- Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires, Strasbourg, France
| | - Axel Ursenbach
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; Service du Trait d'Union, Hôpitaux Universitaires, Université de Strasbourg, Strasbourg, France
| | - Yves Hansmann
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Raoul Herbrecht
- Department of hematology, Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Nicolas Lefebvre
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et de Mycologie Médicale, Plateau Technique de Microbiologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - François Danion
- Service de maladies infectieuses et tropicales, Fédération de Médecine Translationnelle de Strasbourg, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; Inserm UMR_S 1109, Laboratoire d'ImmunoRhumatologie Moléculaire, Strasbourg, France
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4
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Hurraß J, Heinzow B, Walser-Reichenbach S, Aurbach U, Becker S, Bellmann R, Bergmann KC, Cornely OA, Engelhart S, Fischer G, Gabrio T, Herr CE, Joest M, Karagiannidis C, Klimek L, Köberle M, Kolk A, Lichtnecker H, Lob-Corzilius T, Mülleneisen N, Nowak D, Rabe U, Raulf M, Steinmann J, Steiß JO, Stemler J, Umpfenbach U, Valtanen K, Werchan B, Willinger B, Wiesmüller GA. AWMF mold guideline "Medical clinical diagnostics for indoor mold exposure" - Update 2023 AWMF Register No. 161/001. Allergol Select 2024; 8:90-198. [PMID: 38756207 PMCID: PMC11097193 DOI: 10.5414/alx02444e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/04/2024] [Indexed: 05/18/2024] Open
Affiliation(s)
- Julia Hurraß
- Section for Hygiene in Healthcare Facilities, Division of Infection Control and Environmental Hygiene, Cologne Health Department, Cologne
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Birger Heinzow
- Formerly: State Agency for Social Services (LAsD) Schleswig-Holstein, Kiel
- Co-author
| | - Sandra Walser-Reichenbach
- Formerly: State Agency for Social Services (LAsD) Schleswig-Holstein, Kiel
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Ute Aurbach
- Laboratory Dr. Wisplinghoff
- ZfMK – Center for Environment, Hygiene and Mycology Cologne, Cologne
- Co-author
| | - Sven Becker
- Department for Otorhinolaryngology, Head and Neck Surgery, University Medical Center Tübingen, Tübingen, Germany
- Co-author
| | - Romuald Bellmann
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
- Co-author
| | - Karl-Christian Bergmann
- Institute of Allergology Charité, Charité – University Medicine Berlin, Berlin
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Oliver A. Cornely
- Institute for Translational Research, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany and Department I for Internal Medicine, Cologne University Hospital, Cologne
- Co-author
| | - Steffen Engelhart
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Guido Fischer
- Baden-Württemberg State Health Office in the Stuttgart Regional Council, Stuttgart
- Co-author
| | - Thomas Gabrio
- Formerly: Baden-Württemberg State Health Office in the Stuttgart Regional Council, Stuttgart
- Co-author
| | - Caroline E.W. Herr
- Bavarian Health and Food Safety Authority, Munich
- Environmental Health and Prevention, Institute and Polyclinic for Occupational, Social and Environmental Medicine, University of Munich Hospital Ludwig-Maximilians-University, Munich
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Marcus Joest
- Allergological-Immunological Laboratory, Helios Lung and Allergy Center Bonn, Bonn
- Co-author
| | - Christian Karagiannidis
- Faculty of Health, Professorship for Extracorporeal Lung Replacement Procedures, University of Witten/Herdecke, Witten/Herdecke
- Lung Clinic Cologne Merheim, Clinics of the City of Cologne, Cologne
- Co-author
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Martin Köberle
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Annette Kolk
- Institute for Occupational Safety and Health (IFA) of the German Social Accident Insurance (DGUV), Unit Biological Agents, Sankt Augustin
- Co-author
| | - Herbert Lichtnecker
- Medical Institute for Environmental and Occupational Medicine MIU GmbH Erkrath, Erkrath
- Co-author
| | - Thomas Lob-Corzilius
- Scientific working group of environmental medicine of the German Society of Pediatric Allergology (GPAU)
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Norbert Mülleneisen
- Asthma and Allergy Center Leverkusen, Leverkusen
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Dennis Nowak
- Institute and Polyclinic for Occupational, Social and Environmental Medicine, member of the German Center for Lung Research, Hospital of the University of Munich, Munich
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Uta Rabe
- Center for Allergology and Asthma, Johanniter Hospital Treuenbrietzen, Treuenbrietzen
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Monika Raulf
- Institute for Prevention and Occupational Medicine of the German Statutory Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Jörg Steinmann
- Center for Pediatrics and Adolescent Medicine, University Hospital Giessen and Marburg GmbH, Giessen
- Co-author
| | - Jens-Oliver Steiß
- Specialized Practice in Allergology and Pediatric Pulmonology in Fulda, Fulda
- Institute for Clinical Hygiene, Medical Microbiology and Clinical Infectiology, Paracelsus Private Medical University Nuremberg Clinic, Nuremberg
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Jannik Stemler
- Institute for Translational Research, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany and Department I for Internal Medicine, Cologne University Hospital, Cologne
- Co-author
| | - Ulli Umpfenbach
- Doctor for Pediatrics and Adolescent Medicine, Pediatric Pulmonology, Environmental Medicine, Classical Homeopathy, Asthma Trainer, Neurodermatitis Trainer, Viersen
- Co-author
| | - Kerttu Valtanen
- FG II 1.4 Microbiological Risks, German Environment Agency, Berlin
- Co-author
| | - Barbora Werchan
- German Pollen Information Service Foundation (PID), Berlin, Germany
- Co-author
| | - Birgit Willinger
- Department of Laboratory Medicine, Division of Clinical Microbiology – Medical University of Vienna, Vienna, Austria, and
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
| | - Gerhard A. Wiesmüller
- Laboratory Dr. Wisplinghoff
- ZfMK – Center for Environment, Hygiene and Mycology Cologne, Cologne
- Institute for Occupational, Social and Environmental Medicine, Uniclinic RWTH Aachen, Aachen, Germany
- Co-author
- Member of a scientific medical society, a society or a medical association with voting rights
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5
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Mikulska M, Melchio M, Signori A, Ullah N, Miletich F, Sepulcri C, Limongelli A, Giacobbe DR, Balletto E, Russo C, Magnasco L, Vena A, Di Grazia C, Raiola AM, Portunato F, Dentone C, Battaglini D, Ball L, Robba C, Angelucci E, Brunetti I, Bassetti M. Lower blood levels of isavuconazole in critically ill patients compared with other populations: possible need for therapeutic drug monitoring. J Antimicrob Chemother 2024; 79:835-845. [PMID: 38366368 DOI: 10.1093/jac/dkae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/25/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Isavuconazole is first-line treatment of invasive aspergillosis. Therapeutic drug monitoring (TDM) is deemed not necessary, since most patients reached therapeutic levels (>1 mg/L) in large studies. Low levels were reported in some critically ill patients admitted to the ICU. The aim was to compare isavuconazole levels between critically ill and non-critically ill patients. MATERIALS AND METHODS Retrospective analysis of data from all patients treated with standard-dose isavuconazole between 1 January 2019 and 26 October 2022 was performed. The following data were collected: TDM results from the first 30 days of therapy; ward of admission; demographic and clinical characteristics; continuous renal replacement therapy; extracorporeal membrane oxygenation; and co-administered drugs. RESULTS Seventy-two patients (median age 65 years) and 188 TDM measurements (mean number of samples per patient 2.6 ± 1.7) were included; 33 (45.8%) were ICU patients (3 also had haematological disorders); 39 (54.2%) were non-ICU patients, of whom 31 had haematological disorders. In all patients, the mean isavuconazole blood level was 3.33 ± 2.26 mg/L. Significantly lower levels were observed in the ICU versus the non-ICU population: mean 2.02 ± 1.22 versus 4.15 ± 2.31 mg/L (P < 0.001). Significantly higher rates of subtherapeutic levels were observed in ICU patients compared with the non-ICU population: all determinations <2 mg/L in 33.3% versus 7.7%, and all determinations <1 mg/L in 12.1% versus 0%, respectively. Predictors of lower isavuconazole levels were admission to the ICU, BMI > 25 kg/m2, bilirubin > 1.2 mg/dL and the absence of haematological disorder. CONCLUSIONS ICU patients had significantly lower isavuconazole blood levels compared to non-ICU population. The TDM of isavuconazole for efficacy should be performed in ICU.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Monica Melchio
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, Genova, Italy
| | - Nadir Ullah
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
| | - Franca Miletich
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Sepulcri
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
| | - Alessandro Limongelli
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniele Roberto Giacobbe
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Balletto
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Russo
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Laura Magnasco
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Di Grazia
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Anna Maria Raiola
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federica Portunato
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Dentone
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Emanuele Angelucci
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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6
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Zhao J, Zhuo X, Pu D, Fan G, Lu B, Cao B. Comparison of influenza- and COVID-19-associated pulmonary aspergillosis in China. Eur J Clin Microbiol Infect Dis 2024; 43:683-692. [PMID: 38326545 DOI: 10.1007/s10096-024-04772-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE We conducted a monocentric retrospective study using the latest definitions to compare the demographic, clinical, and biological characteristics of influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA). METHODS The study retrospectively enrolled 180 patients, including 70 influenza/IPA patients (with positive influenza A/B and Aspergillus) and 110 COVID-19/IPA patients (with positive SARS-CoV-2 and Aspergillus). Among them, 42 (60%) and 30 (27.3%) patients fulfilled the definitions of IAPA and CAPA, respectively. RESULTS The CAPA patients had significantly higher in-hospital mortality (13/31, 41.9%) than IAPA patients (8/42, 19%) with a P-value of 0.033. Kaplan-Meier survival curve also showed significantly higher 30-day mortality for CAPA patients (P = 0.025). Additionally, the CAPA patients were older, though insignificantly, than IAPA patients (70 (60-80) vs. 62 (52-72), P = 0.075). A lower percentage of chronic pulmonary disease (12.9 vs. 40.5%, P = 0.01) but higher corticosteroids use 7 days before and after ICU admission (22.6% vs. 0%, P = 0.002) were found in CAPA patients. Notably, there were no significant differences in the percentage of ICU admission or ICU mortality between the two groups. In addition, the time from observation to Aspergillus diagnosis was significantly longer in CAPA patients than in IAPA patients (7 (2-13) vs. 0 (0-4.5), P = 0.048). CONCLUSION Patients infected with SARS-CoV-2 and Aspergillus during the concentrated outbreak of COVID-19 in China had generally higher in-hospital mortality but a lower percentage of chronic pulmonary disease than those infected with influenza and Aspergillus. For influenza-infected patients who require hospitalization, close attention should be paid to the risk of invasive aspergillosis upfront.
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Affiliation(s)
- Jiankang Zhao
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Xianxia Zhuo
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Department of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Danni Pu
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Guohui Fan
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Binghuai Lu
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
| | - Bin Cao
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
- Department of Respiratory Medicine, Capital Medical University, Beijing, China.
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
- Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China.
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Bradbury JD, Chesshyre E, Orenti A, Jung A, Warris A. A multinational report on SARS-CoV-2 infection outcomes in people with CF and Aspergillus infection or ABPA. J Cyst Fibros 2024; 23:354-363. [PMID: 37925255 DOI: 10.1016/j.jcf.2023.10.017] [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: 06/21/2023] [Revised: 09/01/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Aspergillus infection is known to be associated with worse respiratory outcomes in people with CF (pwCF) and is a well-recognised complication of severe SARS-CoV-2 infection. The aim of this observational cross-sectional study was to examine the association of pre-existing Aspergillus infection and/or allergic bronchopulmonary aspergillosis (ABPA) in pwCF and severity of COVID-19. METHODS Data on SARS-CoV-2 infections in pwCF from January 2020 to June 2021 were collected by the European Cystic Fibrosis Society Patient Registry. The primary outcome was COVID-19 severity measured by hospitalisation comparing those with Aspergillus infection and/or ABPA in the 12 months preceding COVID-19 and those without. RESULTS In total, 1095 pwCF were diagnosed with SARS-CoV-2 and information on pre-existing Aspergillus/ABPA status was available from 807. PwCF and SARS-CoV-2 in the Aspergillus/ABPA group (n = 153), in comparison to the non-Aspergillus/ABPA group (n = 654), were more likely to be hospitalised (adjusted OR 1.79 (1.19 to 2.85); p = 0.005) and their disease course was more likely to be complicated by sepsis (adjusted OR 7.78 (1.78 to 49.43); p = 0.008). The association with hospital admission was no longer significant after excluding patients with ABPA. Secondary analysis comparing pwCF who received antifungal treatment (n = 18), versus those who did not (n = 474) during COVID-19, showed a higher rate of hospitalisation (p < 0.001); intensive care unit admission (p < 0.001), and requirement for invasive ventilation (p < 0.001) in the antifungal treated group. CONCLUSION We show that pre-existing Aspergillus/ABPA is associated with increased rates of hospitalisation and sepsis during COVID-19 in pwCF.
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Affiliation(s)
- Jacob D Bradbury
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Pharmacology, University of Oxford, OX1 3QT, UK
| | - Emily Chesshyre
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Paediatrics, Royal Devon University Healthcare NHS Foundation Trust, EX2 5DW, UK
| | - Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology G.A. Maccacaro, University of Milan, Milan 20122, Italy
| | - Andreas Jung
- Paediatric Pulmonology, University Children's Hospital Zurich, Ramistrasse 102, Stadtkreis 7 8006, Zurich, Switzerland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, EX4 4QD, UK; Department of Paediatric Infectious Diseases, Great Ormond Street Hospital, London, WC1N 3JH, UK
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8
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Feys S, Lagrou K, Lauwers HM, Haenen K, Jacobs C, Brusselmans M, Debaveye Y, Hermans G, Hoenigl M, Maertens J, Meersseman P, Peetermans M, Spriet I, Vandenbriele C, Vanderbeke L, Vos R, Van Wijngaerden E, Wilmer A, Wauters J. High Burden of COVID-19-Associated Pulmonary Aspergillosis in Severely Immunocompromised Patients Requiring Mechanical Ventilation. Clin Infect Dis 2024; 78:361-370. [PMID: 37691392 PMCID: PMC10874259 DOI: 10.1093/cid/ciad546] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a frequent superinfection in critically ill patients with COVID-19 and is associated with increased mortality rates. The increasing proportion of severely immunocompromised patients with COVID-19 who require mechanical ventilation warrants research into the incidence and impact of CAPA during the vaccination era. METHODS We performed a retrospective, monocentric, observational study. We collected data from adult patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit (ICU) of University Hospitals Leuven, a tertiary referral center, between 1 March 2020 and 14 November 2022. Probable or proven CAPA was diagnosed according to the 2020 European Confederation for Medical Mycology/International Society for Human and Animal Mycology (ECMM/ISHAM) criteria. RESULTS We included 335 patients. Bronchoalveolar lavage sampling was performed in 300 (90%), and CAPA was diagnosed in 112 (33%). The incidence of CAPA was 62% (50 of 81 patients) in European Organisation for Research and Treatment of Cancer (EORTC)/Mycosis Study Group Education and Research Consortium (MSGERC) host factor-positive patients, compared with 24% (62 of 254) in host factor-negative patients. The incidence of CAPA was significantly higher in the vaccination era, increasing from 24% (57 of 241) in patients admitted to the ICU before October 2021 to 59% (55 of 94) in those admitted since then. Both EORTC/MSGERC host factors and ICU admission in the vaccination era were independently associated with CAPA development. CAPA remained an independent risk factor associated with mortality risk during the vaccination era. CONCLUSIONS The presence of EORTC/MSGERC host factors for invasive mold disease is associated with increased CAPA incidence and worse outcome parameters, and it is the main driver for the significantly higher incidence of CAPA in the vaccination era. Our findings warrant investigation of antifungal prophylaxis in critically ill patients with COVID-19.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Moon Lauwers
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Koen Haenen
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Cato Jacobs
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Marius Brusselmans
- Leuven Biostatistics and Statistical Bioinformatics Center (L-BioStat), KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Bio TechMed, Graz, Austria
- Translational Medical Mycology Research Group, Medical University of Graz, Graz, Austria
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Marijke Peetermans
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lore Vanderbeke
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Eric Van Wijngaerden
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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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.
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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
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Aerts R, Feys S, Mercier T, Lagrou K. Microbiological Diagnosis of Pulmonary Aspergillus Infections. Semin Respir Crit Care Med 2024; 45:21-31. [PMID: 38228164 DOI: 10.1055/s-0043-1776777] [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: 01/18/2024]
Abstract
As microbiological tests play an important role in our diagnostic algorithms and clinical approach towards patients at-risk for pulmonary aspergillosis, a good knowledge of the diagnostic possibilities and especially their limitations is extremely important. In this review, we aim to reflect critically on the available microbiological diagnostic modalities for diagnosis of pulmonary aspergillosis and formulate some future prospects. Timely start of adequate antifungal treatment leads to a better patient outcome, but overuse of antifungals should be avoided. Current diagnostic possibilities are expanding, and are mainly driven by enzyme immunoassays and lateral flow device tests for the detection of Aspergillus antigens. Most of these tests are directed towards similar antigens, but new antibodies towards different targets are under development. For chronic forms of pulmonary aspergillosis, anti-Aspergillus IgG antibodies and precipitins remain the cornerstone. More studies on the possibilities and limitations of molecular testing including targeting resistance markers are ongoing. Also, metagenomic next-generation sequencing is expanding our future possibilities. It remains important to combine different test results and interpret them in the appropriate clinical context to improve performance. Test performances may differ according to the patient population and test results may be influenced by timing, the tested matrix, and prophylactic and empiric antifungal therapy. Despite the increasing armamentarium, a simple blood or urine test for the diagnosis of aspergillosis in all patient populations at-risk is still lacking. Research on diagnostic tools is broadening from a pathogen focus on biomarkers related to the patient and its immune system.
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Affiliation(s)
- Robina Aerts
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Toine Mercier
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Oncology-Hematology, AZ Sint-Maarten, Mechelen, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
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11
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Desmedt L, Raymond M, Le Thuaut A, Asfar P, Darreau C, Reizine F, Colin G, Auchabie J, Lorber J, La Combe B, Kergoat P, Hourmant B, Delbove A, Frérou A, Morin J, Ergreteau PY, Seguin P, Martin M, Reignier J, Lascarrou JB, Canet E. Covid-19-associated pulmonary aspergillosis in mechanically ventilated patients: incidence and outcome in a French multicenter observational cohort (APICOVID). Ann Intensive Care 2024; 14:17. [PMID: 38285382 PMCID: PMC10825096 DOI: 10.1186/s13613-023-01229-3] [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: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Recent studies identified coronavirus disease 2019 (COVID-19) as a risk factor for invasive pulmonary aspergillosis (IPA) but produced conflicting data on IPA incidence and impact on patient outcomes. We aimed to determine the incidence and outcomes of COVID-19-associated pulmonary aspergillosis (CAPA) in mechanically ventilated patients. METHODS We performed a multicenter retrospective observational cohort study in consecutive adults admitted to 15 French intensive care units (ICUs) in 2020 for COVID-19 requiring mechanical ventilation. CAPA was diagnosed and graded according to 2020 ECMM/ISHAM consensus criteria. The primary objective was to determine the incidence of proven/probable CAPA, and the secondary objectives were to identify risk factors for proven/probable CAPA and to assess associations between proven/probable CAPA and patient outcomes. RESULTS The 708 included patients (522 [73.7%] men) had a mean age of 65.2 ± 10.8 years, a median mechanical ventilation duration of 15.0 [8.0-27.0] days, and a day-90 mortality rate of 28.5%. Underlying immunosuppression was present in 113 (16.0%) patients. Corticosteroids were used in 348 (63.1%) patients. Criteria for probable CAPA were met by 18 (2.5%) patients; no patient had histologically proven CAPA. Older age was the only factor significantly associated with probable CAPA (hazard ratio [HR], 1.04; 95% CI 1.00-1.09; P = 0.04). Probable CAPA was associated with significantly higher day-90 mortality (HR, 2.07; 95% CI 1.32-3.25; P = 0.001) but not with longer mechanical ventilation or ICU length of stay. CONCLUSION Probable CAPA is a rare but serious complication of severe COVID-19 requiring mechanical ventilation and is associated with higher day-90 mortality.
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Affiliation(s)
- Luc Desmedt
- Service de Médecine Intensive Réanimation, CHU Nantes, Nantes Université, 30 Bd. Jean Monnet, 44000, Nantes, France.
| | - Matthieu Raymond
- Service de Médecine Intensive Réanimation, CHU Nantes, Nantes Université, 30 Bd. Jean Monnet, 44000, Nantes, France
| | - Aurélie Le Thuaut
- Direction de la recherche, Plateforme de Méthodologie et Biostatistique, CHU de Nantes, Nantes, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, CHU d'Angers, Angers, France
| | - Cédric Darreau
- Service de Réanimation polyvalente, CH du Mans, Le Mans, France
| | - Florian Reizine
- Service de Médecine Intensive Réanimation, CHU de Rennes, Rennes, France
| | - Gwenhaël Colin
- Service de Réanimation polyvalente, CHD de La Roche sur Yon, La Roche-sur-Yon, France
| | - Johann Auchabie
- Service de Réanimation polyvalente, CH de Cholet, Cholet, France
| | - Julien Lorber
- Service de Réanimation polyvalente, CH de Saint Nazaire, Saint-Nazaire, France
| | - Béatrice La Combe
- Service de Réanimation Polyvalente, Groupe Hospitalier Bretagne Sud, Lorient, France
| | - Pierre Kergoat
- Service de Réanimation polyvalente, Cornouille General Hospital, Quimper, France
| | - Baptiste Hourmant
- Service de Médecine Intensive Réanimation, CHU de Brest, Brest, France
| | - Agathe Delbove
- Service de Réanimation polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Aurélien Frérou
- Service de Réanimation polyvalente, CH de Saint Malo, Saint-Malo, France
| | - Jean Morin
- Unité de soins intensifs de Pneumologie, CHU de Nantes, Nantes, France
| | | | - Philippe Seguin
- Service de Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, CHU Nantes, Nantes Université, 30 Bd. Jean Monnet, 44000, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Movement-Interactions-Performance, MIP, UR 4334, CHU Nantes, Nantes Université, 44000, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Movement-Interactions-Performance, MIP, UR 4334, CHU Nantes, Nantes Université, 44000, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, CHU Nantes, Nantes Université, 30 Bd. Jean Monnet, 44000, Nantes, France.
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Sharma A, Sharma A, Soubani AO. Incidence and inhospital outcomes of coronavirus disease 2019-associated pulmonary aspergillosis in the United States. Ann Thorac Med 2024; 19:87-95. [PMID: 38444990 PMCID: PMC10911242 DOI: 10.4103/atm.atm_190_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE The aim of this study was to estimate the predictors, associations, and outcomes of COVID-19-associated pulmonary disease (CAPA) in the United States. STUDY DESIGN AND METHODS This retrospective cohort study was performed by using the National Inpatient Sample Database 2020 to identify coronavirus disease 2019 (COVID-19) and CAPA hospitalizations. Baseline variables and outcomes were compared between COVID-19 hospitalizations without aspergillosis and those with aspergillosis. These variables were then used to perform an adjusted analysis for obtaining predictors and factors associated with CAPA and its inhospital mortality. RESULTS Of the 1,020,880 hospitalizations identified with the principal diagnosis of COVID-19, CAPA was identified in 1510 (0.1%) hospitalizations. The CAPA cohort consisted of a higher proportion of males (58%) as well as racial and ethnic minorities (Hispanics, Blacks, and others [including Asian or Pacific islanders, native Americans]). Inhospital mortality was significantly higher (47.35% vs. 10.87%, P < 0.001), the average length of stay was longer (27.61 vs. 7.29 days, P < 0.001), and the mean cost per hospitalization was higher ($121,560 vs. $18,423, P < 0.001) in the CAPA group compared to COVID-19 without aspergillosis. History of solid organ transplant, chronic obstructive pulmonary disease, and venous thromboembolism were associated with higher odds of CAPA among other factors. The use of invasive mechanical ventilation (adjusted odds ratio [aOR] 6.24, P < 0.001), acute kidney injury (aOR 2.02, P = 0.028), and septic shock (aOR 2.07, P = 0.018) were associated with higher inhospital mortality in the CAPA cohort. CONCLUSION While CAPA is an infrequent complication during hospitalizations for COVID-19, it significantly increases all-cause mortality, prolongs hospital stays, and leads to higher hospital expenses compared to COVID-19 cases without aspergillosis.
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Affiliation(s)
- Aditya Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Aditi Sharma
- Department of Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ayman O. Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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Dhaliwal M, Muthu V, Sharma A, Raj K, Rudramurthy SM, Agarwal R, Kaur H, Rawat A, Singh S, Chakrabarti A. Immune and metabolic perturbations in COVID-19-associated pulmonary mucormycosis: A transcriptome analysis of innate immune cells. Mycoses 2024; 67:e13679. [PMID: 38214399 DOI: 10.1111/myc.13679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/23/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND AND OBJECTIVES The mechanisms underlying COVID-19-associated pulmonary mucormycosis (CAPM) remain unclear. We use a transcriptomic analysis of the innate immune cells to investigate the host immune and metabolic response pathways in patients with CAPM. PATIENTS AND METHODS We enrolled subjects with CAPM (n = 5), pulmonary mucormycosis (PM) without COVID-19 (n = 5), COVID-19 (without mucormycosis, n = 5), healthy controls (n = 5) without comorbid illness and negative for SARS-CoV-2. Peripheral blood samples from cases were collected before initiating antifungal therapy, and neutrophils and monocytes were isolated. RNA sequencing was performed using Illumina HiSeqX from monocytes and neutrophils. Raw reads were aligned with HISAT-2 pipeline and DESeq2 was used for differential gene expression. Gene ontology (GO) and metabolic pathway analysis were performed using Shiny GO application and R packages (ggplot2, Pathview). RESULTS The derangement of core immune and metabolic responses in CAPM patients was noted. Pattern recognition receptors, dectin-2, MCL, FcRγ receptors and CLEC-2, were upregulated, but signalling pathways such as JAK-STAT, IL-17 and CARD-9 were downregulated; mTOR and MAP-kinase signalling were elevated in monocytes from CAPM patients. The complement receptors, NETosis, and pro-inflammatory responses, such as S100A8/A9, lipocalin and MMP9, were elevated. The major metabolic pathways of glucose metabolism-glycolysis/gluconeogenesis, pentose phosphate pathway, HIF signalling and iron metabolism-ferroptosis were also upregulated in CAPM. CONCLUSIONS We identified significant alterations in the metabolic pathways possibly leading to cellular iron overload and a hyperglycaemic state. Immune responses revealed altered recognition, signalling, effector functions and a pro-inflammatory state in monocytes and neutrophils from CAPM patients.
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Affiliation(s)
- Manpreet Dhaliwal
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunima Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Khem Raj
- Department of Microbiology, Panjab University, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kelty MT, Beattie SR. Development of a murine model to study the cerebral pathogenesis of Aspergillus fumigatus. mSphere 2023; 8:e0046823. [PMID: 38010145 PMCID: PMC10732035 DOI: 10.1128/msphere.00468-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023] Open
Abstract
IMPORTANCE Molds are environmental fungi that can cause disease in immunocompromised individuals. The most common pathogenic mold is Aspergillus fumigatus, which is typically inhaled into the lungs and causes invasive pulmonary disease. In a subset of these patients, this infection can spread from the lungs to other organs including the brain, resulting in cerebral aspergillosis. How A. fumigatus causes brain disease is not well understood and these infections are associated with extremely high mortality rates. Thus, we developed an animal model to study the pathogenesis of cerebral aspergillosis to better understand this disease and develop better treatments for these life-threatening infections.
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Affiliation(s)
- Martin T. Kelty
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Sarah R. Beattie
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Kosmidis C, Hoenigl M. COVID-19-associated pulmonary aspergillosis in mechanically ventilated patients: a deadly complication. Thorax 2023; 79:9-10. [PMID: 37940199 DOI: 10.1136/thorax-2023-220621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Chris Kosmidis
- National Aspergillosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Translational Medical Mycology Research Group, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
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16
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Hurt W, Youngs J, Ball J, Edgeworth J, Hopkins P, Jenkins DR, Leaver S, Mazzella A, Molloy SF, Schelenz S, Wise MP, White PL, Yusuff H, Wyncoll D, Bicanic T. COVID-19-associated pulmonary aspergillosis in mechanically ventilated patients: a prospective, multicentre UK study. Thorax 2023; 79:75-82. [PMID: 37657925 PMCID: PMC10804023 DOI: 10.1136/thorax-2023-220002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/22/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Invasive pulmonary aspergillosis is a complication of severe COVID-19, with regional variation in reported incidence and mortality. We describe the incidence, risk factors and mortality associated with COVID-19-associated pulmonary aspergillosis (CAPA) in a prospective, multicentre UK cohort. METHODS From March 2020 to March 2021, 266 mechanically ventilated adults with COVID-19 were enrolled across 5 UK hospital intensive care units (ICUs). CAPA was defined using European Confederation for Medical Mycology and the International Society for Human and Animal Mycology criteria and fungal diagnostics performed on respiratory and serum samples. RESULTS Twenty-nine of 266 patients (10.9%) had probable CAPA, 14 (5.2%) possible CAPA and none proven CAPA. Probable CAPA was diagnosed a median of 9 (IQR 7-16) days after ICU admission. Factors associated with probable CAPA after multivariable logistic regression were cumulative steroid dose given within 28 days prior to ICU admission (adjusted OR (aOR) 1.16; 95% CI 1.01 to 1.43 per 100 mg prednisolone-equivalent), receipt of an interleukin (IL)-6 inhibitor (aOR 2.79; 95% CI 1.22 to 6.48) and chronic obstructive pulmonary disease (COPD) (aOR 4.78; 95% CI 1.13 to 18.13). Mortality in patients with probable CAPA was 55%, vs 46% in those without. After adjustment for immortal time bias, CAPA was associated with an increased risk of 90-day mortality (HR 1.85; 95% CI 1.07 to 3.19); however, this association did not remain statistically significant after further adjustment for confounders (adjusted HR 1.57; 95% CI 0.88 to 2.80). There was no difference in mortality between patients with CAPA prescribed antifungals (9 of 17; 53%) and those who were not (7 of 12; 58%) (p=0.77). INTERPRETATION In this first prospective UK study, probable CAPA was associated with corticosteroid use, receipt of IL-6 inhibitors and pre-existing COPD. CAPA did not impact mortality following adjustment for prognostic variables.
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Affiliation(s)
- William Hurt
- Institute of Infection and Immunity, St George's University of London, London, UK
- Clinical Infection Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Jonathan Youngs
- Institute of Infection and Immunity, St George's University of London, London, UK
- Clinical Infection Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Ball
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Edgeworth
- Clinical Infection and Microbiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Hopkins
- Adult Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - David R Jenkins
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Susannah Leaver
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrea Mazzella
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Síle F Molloy
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Silke Schelenz
- Medical Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Matt P Wise
- Adult Critical Care, University of Wales Hospital, Cardiff, UK
| | | | - Hakeem Yusuff
- Adult Critical Care, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Duncan Wyncoll
- Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, UK
- Clinical Infection Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
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17
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Yassin Z, Farid A, Ahmadi S, Emamikhah M, Motamedi O, Jafari M, Goodarzi A. Coronavirus disease 2019 (COVID-19)-associated brain abscesses caused by Pseudomonas aeruginosa and Aspergillus fumigatus: two case and a review of the literature. J Med Case Rep 2023; 17:520. [PMID: 38049820 PMCID: PMC10694943 DOI: 10.1186/s13256-023-04206-3] [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: 05/25/2022] [Accepted: 10/09/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Bacterial and fungal superinfections are commonly reported in patients with coronavirus disease 2019. CASE PRESENTATION We report the first case of brain and intramedullary abscesses caused by Pseudomonas aeruginosa and a rare case of brain abscesses caused by Aspergillus fumigatus in two post-coronavirus disease 2019 patients. The first patient-34-year-old Iranian woman-presented with weakness of the left upper limb, headaches, and lower limb paresthesia. She had a history of undiagnosed diabetes and had received corticosteroid therapy. The second patient-45-year-old Iranian man-presented with right-sided weakness and had a history of intensive care unit admission. Both patients passed away despite appropriate medical therapy. CONCLUSION The immune dysregulation induced by coronavirus disease 2019 and its' treatments can predispose patients, especially immunosuppressed ones, to bacterial and fungal infections with unusual and opportunistic pathogens in the central nervous system. Pseudomonas aeruginosa and Aspergillus fumigatus should be considered as potential causes of brain infection in any coronavirus disease 2019 patient presenting with neurological symptoms and evidence of brain abscess in imaging, regardless of sinonasal involvement. These patients should get started on appropriate antimicrobial therapy as soon as possible, as any delay in diagnosis or treatment can be associated with adverse outcomes.
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Affiliation(s)
- Zeynab Yassin
- Antimicrobial Resistance Research Center, Institute of Immunology and Infectious Diseases, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Armita Farid
- School of Medicine, Iran University of Medical Sciences, Bisotun Street, 6.1 Alley, No 56, Tehran, 1431644311, Iran
| | - Sayedali Ahmadi
- Department of Neurosurgery, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Niayesh Street, Sattarkhan Ave, Tehran, 1431644311, Iran
| | - Maziar Emamikhah
- Department of Neurosurgery, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Niayesh Street, Sattarkhan Ave, Tehran, 1431644311, Iran
| | - Omid Motamedi
- Department of Radiology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Niayesh Street, Sattarkhan Avenue, Tehran, 1445613131, Iran
| | - Mohammadamin Jafari
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Niayesh Street, Sattarkhan Avenue, Tehran, 1445613131, Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Niayesh Street, Sattarkhan Avenue, Tehran, 1445613131, Iran.
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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18
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Simmons BC, Rhodes J, Rogers TR, Verweij PE, Abdolrasouli A, Schelenz S, Hemmings SJ, Talento AF, Griffin A, Mansfield M, Sheehan D, Bosch T, Fisher MC. Genomic Epidemiology Identifies Azole Resistance Due to TR 34/L98H in European Aspergillus fumigatus Causing COVID-19-Associated Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:1104. [PMID: 37998909 PMCID: PMC10672581 DOI: 10.3390/jof9111104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Aspergillus fumigatus has been found to coinfect patients with severe SARS-CoV-2 virus infection, leading to COVID-19-associated pulmonary aspergillosis (CAPA). The CAPA all-cause mortality rate is approximately 50% and may be complicated by azole resistance. Genomic epidemiology can help shed light on the genetics of A. fumigatus causing CAPA, including the prevalence of resistance-associated alleles. We present a population genomic analysis of 21 CAPA isolates from four European countries with these isolates compared against 240 non-CAPA A. fumigatus isolates from a wider population. Bioinformatic analysis and antifungal susceptibility testing were performed to quantify resistance and identify possible genetically encoded azole-resistant mechanisms. The phylogenetic analysis of the 21 CAPA isolates showed that they were representative of the wider A. fumigatus population with no obvious clustering. The prevalence of phenotypic azole resistance in CAPA was 14.3% (n = 3/21); all three CAPA isolates contained a known resistance-associated cyp51A polymorphism. The relatively high prevalence of azole resistance alleles that we document poses a probable threat to treatment success rates, warranting the enhanced surveillance of A. fumigatus genotypes in these patients. Furthermore, potential changes to antifungal first-line treatment guidelines may be needed to improve patient outcomes when CAPA is suspected.
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Affiliation(s)
- Benjamin C. Simmons
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- UK Health Security Agency, London EP14 4PU, UK
| | - Johanna Rhodes
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
| | - Thomas R. Rogers
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
- Radboudumc-CWZ Center of Expertise for Mycology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Alireza Abdolrasouli
- Department of Infectious Diseases, Imperial College London, London W2 1NY, UK;
- Department of Infectious Diseases, King’s College Hospital, London SE5 9RS, UK
| | - Silke Schelenz
- Infection Sciences, King’s College Hospital, London SE5 9RS, UK;
- School of Immunology & Microbial Sciences, King’s College London, London WC2R 2LS, UK
| | - Samuel J. Hemmings
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
| | - Alida Fe Talento
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
- Department of Microbiology, Our Lady of Lourdes Hospital, A92 VW28 Drogheda, Ireland
- Department of Microbiology, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Auveen Griffin
- Department of Microbiology, St. James’ Hospital, D08 NHY1 Dublin, Ireland;
| | - Mary Mansfield
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - David Sheehan
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Thijs Bosch
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Matthew C. Fisher
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
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19
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Hashim Z, Nath A, Khan A, Gupta M, Kumar A, Chatterjee R, Dhiman RK, Hoenigl M, Tripathy NK. Effect of glucocorticoids on the development of COVID-19-associated pulmonary aspergillosis: A meta-analysis of 21 studies and 5174 patients. Mycoses 2023; 66:941-952. [PMID: 37551043 DOI: 10.1111/myc.13637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
COVID-19-associated pulmonary aspergillosis (CAPA) remains a high mortality mycotic infection throughout the pandemic, and glucocorticoids (GC) may be its root cause. Our aim was to evaluate the effect of systemic GC treatment on the development of CAPA. We systematically searched the PubMed, Google Scholar, Scopus and Embase databases to collect eligible studies published until 31 December 2022. The pooled outcome of CAPA development was calculated as the log odds ratio (LOR) with 95% confidence intervals (CI) using a random effect model. A total of 21 studies with 5174 patients were included. Of these, 20 studies with 4675 patients consisting of 2565 treated with GC but without other immunomodulators (GC group) and 2110 treated without GC or other immunomodulators (controls) were analysed. The pooled LOR of CAPA development was higher for the GC group than for the controls (0.54; 95% CI: 0.22, 0.86; p < .01). In the subgroups, the pooled LOR was higher for high-dose GC (0.90; 95% CI: 0.17, 1.62: p = .01) and dexamethasone (0.71; 95% CI: 0.35, 1.07; p < .01) but had no significant difference for low-dose GC (0.41; 95% CI: -0.07, 0.89; p = .09), and non-dexamethasone GC (0.21; 95% CI: -0.36, 0.79; p = .47), treated patients versus controls. GC treatment increases the risk of CAPA development, and this risk is particularly associated with the use of high-dose GC or dexamethasone treatment.
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Affiliation(s)
- Zia Hashim
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ajmal Khan
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anup Kumar
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Riksoam Chatterjee
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Naresh Kumar Tripathy
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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20
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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.
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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
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21
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Sánchez-Castellano MÁ, Marcelo C, Marco J, Figueira-Iglesias JC, García-Rodríguez J. A Tale of Two Hospitals: Comparing CAPA Infections in Two ICUs During the Spanish Fourth Pandemic Wave. Mycopathologia 2023; 188:335-344. [PMID: 37256502 PMCID: PMC10230482 DOI: 10.1007/s11046-023-00750-0] [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: 02/22/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE COVID-19 associated pulmonary aspergillosis (CAPA) is a new clinical entity linked to SARS-CoV-2 infection that is causing a rise on the risk of complications and mortality, particularly in critical patients. METHODS We compared diagnostic and clinical features in two cohorts of patients with severe COVID-19 admitted in the intensive care units (ICU) of two different hospitals in Madrid, Spain, between February and June 2021. Clinical and microbiological relevant aspects for CAPA diagnosis were collected for further classification. CAPA was classified as colonization, possible, probable, proven, and tracheobronchial aspergillosis according to the ECMM/ISHAM consensus, with some modifications to consider tracheobronchial aspirate as sample comparable to non-bronchoscopic lavages (NBL). RESULTS 56 patients admitted in HULP (Hospital Universitario La Paz) ICU and 61 patients admitted in HEEIZ (Hospital de Emergencias Isabel Zendal) ICU had clinical suspicion of invasive fungal disease in the context of COVID-19 infection. Cultures were positive for Aspergillus spp. in 32 patients. According to 2020 European Confederation of Medical Mycology and the International Society for Human and Animal Mycology (ECMM/ISHAM) consensus, 11 patients were diagnosed with possible CAPA and 10 patients with probable CAPA. Global incidence for CAPA was 6.3%. Global median days between ICU admission and diagnosis was 14 day. Aspergillus fumigatus complex was the main isolated species. Antifungal therapy was used in 75% of patients with CAPA suspicion, with inter-hospital differences in the administered antifungals. Global overall mortality rate for CAPA patients was 66.6% (14/21). All-cause mortality in non-CAPA cohorts were of 26.3% in HULP group (34/129) and 56.8% (104/183) in HEEIZ group. CONCLUSIONS There were no significant differences in incidence between the two hospitals, and differences in antifungal therapy did not correlate with differences in mortality, reflecting that both first-line azoles and Amphotericin B could be effective in treating CAPA infections, according to the current guideline indications.
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Affiliation(s)
| | - Cristina Marcelo
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain
| | - Javier Marco
- Hospital de Emergencias Enfermera Isabel Zendal, Madrid, Spain
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22
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Ouranos K, Tsakiri K, Massa E, Dourliou V, Mouratidou C, Soundoulounaki S, Mouloudi E. COVID-19-associated pulmonary aspergillosis in patients with severe SARS-CoV-2 infection: A single-center observational study from Greece. Ann Thorac Med 2023; 18:116-123. [PMID: 37663880 PMCID: PMC10473063 DOI: 10.4103/atm.atm_14_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION COVID-19-associated pulmonary aspergillosis (CAPA) is a serious complication affecting patients with severe SARS-CoV-2 infection, and is associated with increased mortality. OBJECTIVE The objective of this study was to investigate potential risk factors, and to estimate the incidence and mortality in patients diagnosed with CAPA. METHODS A single-center retrospective observational study was conducted on patients admitted to the intensive care unit (ICU) with severe COVID-19 from October 2020 to May 2022. Patients with deterioration of their clinical status were evaluated with serum galactomannan (GM) for probable CAPA. Baseline demographic patient characteristics, vaccination status, and time period during which each patient was infected with SARS-CoV-2 were obtained, and risk stratification according to underlying comorbidities was performed in an effort to assess various risk factors for CAPA. The incidence of CAPA in the entire cohort was measured, and mortality rates in the CAPA and non-CAPA groups were calculated and compared. RESULTS Of 488 patients admitted to the ICU, 95 (19.4%) had deterioration of their clinical status, which prompted testing with serum GM. Positive serum testing was observed in 39/95 patients, with an overall CAPA incidence in the entire study cohort reaching 7.9% (39/488). The mortality rate was 75% (42/56) in the non-CAPA group that was tested for serum GM, and 87.2% (34/39) in the CAPA group (P = 0.041). Multivariable Cox regression hazard models were tested for 28- and 90-day survival from ICU admission. An invasive pulmonary aspergillosis (IPA) risk-stratified cox regression model corrected for the SARS-CoV-2 variant of the patient identified the diagnosis of probable CAPA and elevated procalcitonin (PCT) levels measured at least 10 days after ICU admission, as significantly associated with death in the IPA-risk subgroup only, with hazard ratio (HR): 3.687 (95% confidence interval [CI], 1.030-13.199, P = 0.045) for the diagnosis of probable CAPA, and HR: 1.022 (95% CI, 1.003-1.042, P = 0.026) for every 1 ng/mL rise in PCT. CONCLUSIONS Patients in the IPA-risk subgroup that were diagnosed with CAPA had a lower 90-day survival when compared to patients in the same group without a CAPA diagnosis.
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Affiliation(s)
- Konstantinos Ouranos
- Department of Medicine, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kalliopi Tsakiri
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
| | - Eleni Massa
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
| | - Vassiliki Dourliou
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
| | - Christina Mouratidou
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
| | - Stella Soundoulounaki
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
| | - Eleni Mouloudi
- Department of Adult Intensive Care Unit, Hippokratio General Hospital, Thessaloniki, Greece
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23
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Beltrame A, Stevens DA, Haiduven D. Mortality in ICU Patients with COVID-19-Associated Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:689. [PMID: 37367625 DOI: 10.3390/jof9060689] [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: 04/26/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023] Open
Abstract
A review of 38 studies involving 1437 COVID-19 patients admitted to intensive care units (ICUs) with pulmonary aspergillosis (CAPA) was conducted to investigate whether mortality has improved since the pandemic's onset. The study found that the median ICU mortality was 56.8%, ranging from 30% to 91.8%. These rates were higher for patients admitted during 2020-2021 (61.4%) compared to 2020 (52.3%), and prospective studies found higher ICU mortality (64.7%) than retrospective ones (56.4%). The studies were conducted in various countries and used different criteria to define CAPA. The percentage of patients who received antifungal therapy varied across studies. These results indicate that the mortality rate among CAPA patients is a growing concern, mainly since there has been an overall reduction in mortality among COVID-19 patients. Urgent action is needed to improve prevention and management strategies for CAPA, and additional research is needed to identify optimal treatment strategies to reduce mortality rates among these patients. This study serves as a call to action for healthcare professionals and policymakers to prioritize CAPA, a serious and potentially life-threatening complication of COVID-19.
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Affiliation(s)
- Anna Beltrame
- College of Public Health, University of South Florida, Tampa, FL 33622, USA
| | - David A Stevens
- California Institute for Medical Research, San Jose, CA 95128, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University Medical School, Stanford, CA 94305, USA
| | - Donna Haiduven
- College of Public Health, University of South Florida, Tampa, FL 33622, USA
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24
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Mead ME, de Castro PA, Steenwyk JL, Gangneux JP, Hoenigl M, Prattes J, Rautemaa-Richardson R, Guegan H, Moore CB, Lass-Flörl C, Reizine F, Valero C, Van Rhijn N, Bromley MJ, Rokas A, Goldman GH, Gago S. COVID-19-Associated Pulmonary Aspergillosis Isolates Are Genomically Diverse but Similar to Each Other in Their Responses to Infection-Relevant Stresses. Microbiol Spectr 2023; 11:e0512822. [PMID: 36946762 PMCID: PMC10100753 DOI: 10.1128/spectrum.05128-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
Secondary infections caused by the pulmonary fungal pathogen Aspergillus fumigatus are a significant cause of mortality in patients with severe coronavirus disease 19 (COVID-19). Even though epithelial cell damage and aberrant cytokine responses have been linked to susceptibility to COVID-19-associated pulmonary aspergillosis (CAPA), little is known about the mechanisms underpinning copathogenicity. Here, we analyzed the genomes of 11 A. fumigatus isolates from patients with CAPA in three centers from different European countries. CAPA isolates did not cluster based on geographic origin in a genome-scale phylogeny of representative A. fumigatus isolates. Phenotypically, CAPA isolates were more similar to the A. fumigatus A1160 reference strain than to the Af293 strain when grown in infection-relevant stresses, except for interactions with human immune cells wherein macrophage responses were similar to those induced by the Af293 reference strain. Collectively, our data indicate that CAPA isolates are genomically diverse but are more similar to each other in their responses to infection-relevant stresses. A larger number of isolates from CAPA patients should be studied to better understand the molecular epidemiology of CAPA and to identify genetic drivers of copathogenicity and antifungal resistance in patients with COVID-19. IMPORTANCE Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has been globally reported as a life-threatening complication in some patients with severe COVID-19. Most of these infections are caused by the environmental mold Aspergillus fumigatus, which ranks third in the fungal pathogen priority list of the WHO. However, little is known about the molecular epidemiology of Aspergillus fumigatus CAPA strains. Here, we analyzed the genomes of 11 A. fumigatus isolates from patients with CAPA in three centers from different European countries, and carried out phenotypic analyses with a view to understanding the pathophysiology of the disease. Our data indicate that A. fumigatus CAPA isolates are genomically diverse but are more similar to each other in their responses to infection-relevant stresses.
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Affiliation(s)
- Matthew E. Mead
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Patrícia Alves de Castro
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jacob L. Steenwyk
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Jean-Pierre Gangneux
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
- Biotech Med, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Hélène Guegan
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
| | - Caroline B. Moore
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Cornelia Lass-Flörl
- European Excellence Center for Medical Mycology (ECMM), Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Florian Reizine
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
| | - Clara Valero
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Norman Van Rhijn
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Michael J. Bromley
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Antonis Rokas
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sara Gago
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - on behalf of the ECMM CAPA Study Group
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
- Biotech Med, Graz, Austria
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- European Excellence Center for Medical Mycology (ECMM), Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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Pulmonary Aspergillosis in Critically Ill COVID-19 Patients Admitted to the Intensive Care Unit: A Retrospective Cohort Study. J Fungi (Basel) 2023; 9:jof9030315. [PMID: 36983483 PMCID: PMC10054145 DOI: 10.3390/jof9030315] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
COVID-19-associated pulmonary aspergillosis (CAPA) is a life-threatening fungal infection that mainly affects critically ill patients. The aim of this study was to assess the incidence and clinical outcomes of putative CAPA in critically ill COVID-19 patients. This retrospective observational cohort study included 181 cases from 5 ICUs at Vienna General Hospital between January 2020 and April 2022. Patients were diagnosed with putative CAPA according to the AspICU classification, which included a positive Aspergillus culture in a bronchoalveolar lavage sample, compatible signs and symptoms, and abnormal medical imaging. The primary outcome was adjusted 60-day all-cause mortality from ICU admission in patients with vs. without putative CAPA. Secondary outcomes included time from ICU admission to CAPA diagnosis and pathogen prevalence and distribution. Putative CAPA was identified in 35 (19.3%) of 181 COVID-19 patients. The mean time to diagnosis was 9 days. Death at 60 days occurred in 18 of 35 (51.4%) patients with CAPA and in 43 of 146 (29.5%) patients without CAPA (adjusted HR (95%CI) = 2.15 (1.20–3.86, p = 0.002). The most frequently isolated Aspergillus species was Aspergillus fumigatus. The prevalence of putative pulmonary aspergillosis in critically ill COVID-19 patients was high and was associated with significantly higher mortality.
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26
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Managing the Next Wave of Influenza and/or SARS-CoV-2 in the ICU—Practical Recommendations from an Expert Group for CAPA/IAPA Patients. J Fungi (Basel) 2023; 9:jof9030312. [PMID: 36983480 PMCID: PMC10058160 DOI: 10.3390/jof9030312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
The aim of this study was to establish practical recommendations for the diagnosis and treatment of influenza-associated invasive aspergillosis (IAPA) based on the available evidence and experience acquired in the management of patients with COVID-19-associated pulmonary aspergillosis (CAPA). The CAPA/IAPA expert group defined 14 areas in which recommendations would be made. To search for evidence, the PICO strategy was used for both CAPA and IAPA in PubMed, using MeSH terms in combination with free text. Based on the results, each expert developed recommendations for two to three areas that they presented to the rest of the group in various meetings in order to reach consensus. As results, the practical recommendations for the management of CAPA/IAPA patients have been grouped into 12 sections. These recommendations are presented for both entities in the following situations: when to suspect fungal infection; what diagnostic methods are useful to diagnose these two entities; what treatment is recommended; what to do in case of resistance; drug interactions or determination of antifungal levels; how to monitor treatment effectiveness; what action to take in the event of treatment failure; the implications of concomitant corticosteroid administration; indications for the combined use of antifungals; when to withdraw treatment; what to do in case of positive cultures for Aspergillus spp. in a patient with severe viral pneumonia or Aspergillus colonization; and how to position antifungal prophylaxis in these patients. Available evidence to support the practical management of CAPA/IAPA patients is very scarce. Accumulated experience acquired in the management of CAPA patients can be very useful for the management of IAPA patients. The expert group presents eminently practical recommendations for the management of CAPA/IAPA patients.
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Shah M, Reveles K, Moote R, Hand E, Kellogg Iii D, Attridge RL, Maselli DJ, Gutierrez GC. Risk of Coronavirus Disease 2019-Associated Pulmonary Aspergillosis Based on Corticosteroid Duration in Intensive Care Patients. Open Forum Infect Dis 2023; 10:ofad062. [PMID: 36879627 PMCID: PMC9984984 DOI: 10.1093/ofid/ofad062] [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: 10/20/2022] [Indexed: 03/07/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a potential complication in critically ill COVID-19 patients. Corticosteroids are standard of care for hospitalized COVID-19 patients but carry an increased risk of secondary infections including CAPA. The objective of this study was to evaluate if duration of corticosteroid therapy ≤10 days versus >10 days affects the risk of developing CAPA. Methods This was a retrospective cohort study of adult patients with severe COVID-19 pneumonia requiring mechanical ventilation who received at least 3 days of corticosteroid treatment. Incidence of CAPA and secondary outcomes were compared using appropriate bivariable analyses. Steroid duration was evaluated as an independent predictor in a logistic regression model. Results A total of 278 patients were included (n = 169 for ≤10 days' steroid duration; n = 109 for >10 days). CAPA developed in 20 of 278 (7.2%) patients. Patients treated with >10 days of corticosteroid therapy had significantly higher incidence of CAPA (11.9% vs 4.1%; P = .0156), and steroid duration >10 days was independently associated with CAPA (odds ratio, 3.17 [95% confidence interval, 1.02-9.83]). Secondary outcomes including inpatient mortality (77.1% vs 43.2%; P < .0001), mechanical ventilation-free days at 28 days (0 vs 1.5; P < .0001), and secondary infections (44.9% vs 28.4% P = .0220) were worse in the >10 days cohort. Conclusions Corticosteroid treatment >10 days in critically ill COVID-19 patients is associated with an increased risk of CAPA. Patients may require corticosteroids for reasons beyond COVID-19 and clinicians should be cognizant of risk of CAPA with prolonged courses.
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Affiliation(s)
- Meera Shah
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, Texas, USA.,Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas, USA
| | - Kelly Reveles
- Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas, USA
| | - Rebecca Moote
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, Texas, USA.,Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas, USA
| | - Elizabeth Hand
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, Texas, USA.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas, USA
| | - Dean Kellogg Iii
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, Joe R. and Terry Lozano Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Rebecca L Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, Texas, USA.,The Craneware Group, Deerfield Beach, Florida, USA
| | - Diego J Maselli
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, Joe R. and Terry Lozano Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - G Christina Gutierrez
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, Texas, USA.,Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas, USA
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Statement des Netzwerkes Schimmelpilzberatung Deutschland zu
gesundheitlichen Risiken durch Schimmel im Innenraum in Zusammenhang mit
Armutsgefährdung. DAS GESUNDHEITSWESEN 2023. [DOI: 10.1055/a-1980-1749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Das Netzwerk Schimmelpilzberatung Deutschland kam bei seinem Treffen am 20. Juni
2022 zu dem Schluss, dass armutsgefährdete Menschen einem
erhöhten gesundheitlichen Risiko durch
Feuchte-/Schimmelschäden im Innenraum ausgesetzt sind, und hat
hierzu eine ausführliche Stellungnahme verfasst, die in der Zeitschrift
Umweltmedizin – Hygiene – Arbeitsmedizin 2022; 27(5):
249–252 veröffentlicht wurde. Im Folgenden sind die Kernaussagen
des Statements dargestellt.
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Muacevic A, Adler JR. A Case Series Demonstrating the Difficulties in Diagnosing COVID-19 Associated Pulmonary Aspergillus. Cureus 2023; 15:e33802. [PMID: 36819356 PMCID: PMC9928575 DOI: 10.7759/cureus.33802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/24/2023] Open
Abstract
Many bacterial, viral, and fungal co-infections have been reported with COVID-19-associated acute respiratory distress syndrome (ARDS). Invasive Aspergillosis has been described with COVID-19 ARDS. However, it continues to evade diagnosis in critically ill patients admitted to the intensive care unit (ICU). The difficulty is discerning an actual infection from colonization. Unfortunately, a timely diagnosis is crucial since COVID-19-associated pulmonary Aspergillus (CAPA) has high morbidity and mortality. We present three ICU cases of CAPA to illustrate the difficulty in diagnosing and treating the disease. We hope to bring awareness and improve patient outcomes of CAPA.
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Siopi M, Antonopoulou S, Mantzana P, Georgiou PC, Vourli S, Protonotariou E, Vagiakou E, Skoura L, Pournaras S, Meletiadis J. Can bronchial secretion cultures identify the etiologic agent of COVID-19-associated pulmonary aspergillosis in ICU patients? Comparison with a species-specific Aspergillus PCR in serum. Med Mycol 2022; 61:6881722. [PMID: 36477291 DOI: 10.1093/mmy/myac094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/23/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
Aspergillus spp. isolated from non-BAL cultures of coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) patients may reflect colonization rather than infection. Sera (n = 181) from 49 adult ICU CAPA patients (24 probable and 25 possible CAPA) with bronchial secretions (BS) culture positive for Aspergillus spp. were collected and tested for Aspergillus DNA detection by species-specific real-time PCR. Overall, 30/49 (61%) patients were PCR positive. BS culture/serum PCR agreement was moderate (21/30; 70%). Based on serum PCR positive patients, all CAPAs were due to A. fumigatus (80%), A. flavus (10%), and A. terreus (10%). No A. niger/A. nidulans or mixed infections were found despite positive BS cultures.
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Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Paraskevi Mantzana
- Department of Microbiology, "AHEPA" University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota-Christina Georgiou
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Vourli
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthymia Protonotariou
- Department of Microbiology, "AHEPA" University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Vagiakou
- Department of Microbiology, "G. Gennimatas" General Hospital, Athens, Greece
| | - Lemonia Skoura
- Department of Microbiology, "AHEPA" University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Severe Recurrent COVID-Associated Pulmonary Aspergillosis: A Challenging Case. Healthcare (Basel) 2022; 10:healthcare10122483. [PMID: 36554008 PMCID: PMC9778552 DOI: 10.3390/healthcare10122483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022] Open
Abstract
We report a rare case of severe COVID-19-associated pulmonary aspergillosis presenting as invasive pulmonary aspergillosis and subsequently invasive tracheobronchial aspergillosis during hospitalization in a critically ill patient who developed a further Aspergillus infection after home discharge. He needed readmission to the ICU and mechanical ventilation. We therefore strongly encourage a high degree of attention to fungal complications, even after viral recovery and ICU discharge.
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Ketai L, Febbo J, Busby HK, Sheehan EB. Community-Acquired Pneumonia: Postpandemic, Not Post-COVID-19. Semin Respir Crit Care Med 2022; 43:924-935. [PMID: 36442476 DOI: 10.1055/s-0042-1755186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic upended our approach to imaging community-acquired pneumonia, and this will alter our diagnostic algorithms for years to come. In light of these changes, it is worthwhile to consider several postpandemic scenarios of community-acquired pneumonia: (1) patient with pneumonia and recent positive COVID-19 testing; (2) patient with air space opacities and history of prior COVID-19 pneumonia (weeks earlier); (3) multifocal pneumonia with negative or unknown COVID-19 status; and (4) lobar or sublobar pneumonia with negative or unknown COVID-19 status. In the setting of positive COVID-19 testing and typical radiologic findings, the diagnosis of COVID-19 pneumonia is generally secure. The diagnosis prompts vigilance for thromboembolic disease acutely and, in severely ill patients, for invasive fungal disease. Persistent or recurrent air space opacities following COVID-19 infection may more often represent organizing pneumonia than secondary infection. When COVID-19 status is unknown or negative, widespread airway-centric disease suggests infection with mycoplasma, Haemophilus influenzae, or several respiratory viruses. Necrotizing pneumonia favors infection with pneumococcus, Staphylococcus, Klebsiella, and anaerobes. Lobar or sublobar pneumonia will continue to suggest the diagnosis of pneumococcus or consideration of other pathogens in the setting of local outbreaks. A positive COVID-19 test accompanied by these imaging patterns may suggest coinfection with one of the above pathogens, or when the prevalence of COVID-19 is very low, a false positive COVID-19 test. Clinicians may still proceed with testing for COVID-19 when radiologic patterns are atypical for COVID-19, dependent on the patient's exposure history and the local epidemiology of the virus.
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Affiliation(s)
- Loren Ketai
- Department of Radiology, University of New Mexico HSC, Albuquerque, New Mexico
| | - Jennifer Febbo
- Department of Radiology, University of New Mexico HSC, Albuquerque, New Mexico
| | - Hellen K Busby
- Department of Internal Medicine, Pulmonary Division, University of New Mexico HSC, Albuquerque, New Mexico
| | - Elyce B Sheehan
- Department of Internal Medicine, Pulmonary Division, University of New Mexico HSC, Albuquerque, New Mexico
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Gut Microbial Disruption in Critically Ill Patients with COVID-19-Associated Pulmonary Aspergillosis. J Fungi (Basel) 2022; 8:jof8121265. [PMID: 36547598 PMCID: PMC9787122 DOI: 10.3390/jof8121265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES COVID-19 disease can be exacerbated by Aspergillus superinfection (CAPA). However, the causes of CAPA are not yet fully understood. Recently, alterations in the gut microbiome have been associated with a more complicated and severe disease course in COVID-19 patients, most likely due to immunological mechanisms. The aim of this study was to investigate a potential association between severe CAPA and alterations in the gut and bronchial microbial composition. METHODS We performed 16S rRNA gene amplicon sequencing of stool and bronchial samples from a total of 16 COVID-19 patients with CAPA and 26 patients without CAPA. All patients were admitted to the intensive care unit. Results were carefully tested for potentially confounding influences on the microbiome during hospitalization. RESULTS We found that late in COVID-19 disease, CAPA patients exhibited a trend towards reduced gut microbial diversity. Furthermore, late-stage patients with CAPA superinfection exhibited an increased abundance of Staphylococcus epidermidis in the gut which was not found in late non-CAPA cases or early in the disease. The analysis of bronchial samples did not yield significant results. CONCLUSIONS This is the first study showing that alterations in the gut microbiome accompany severe CAPA and possibly influence the host's immunological response. In particular, an increase in Staphylococcus epidermidis in the intestine could be of importance.
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A Regional Observational Study on COVID-19-Associated Pulmonary Aspergillosis (CAPA) within Intensive Care Unit: Trying to Break the Mold. J Fungi (Basel) 2022; 8:jof8121264. [PMID: 36547597 PMCID: PMC9785727 DOI: 10.3390/jof8121264] [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: 11/03/2022] [Revised: 11/24/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022] Open
Abstract
The reported incidence of COVID-19-associated pulmonary aspergillosis (CAPA) ranges between 2.4% and 35% in intensive care unit (ICU) patients, and awareness in the medical community is rising. We performed a regional retrospective observational study including patients diagnosed with CAPA defined according to the Modified AspICU Dutch/Belgian Mycosis Study Group and CAPA-EECMM, from five different ICUs, admitted between March, 2020 and September, 2021. Forty-five patients were included. The median age was 64 (IQR 60-72), mostly (73%) males. At ICU admission, the median Charlson comorbidity index was 3 (2-5), and the simplified acute physiology score (SAPS)-II score was 42 (31-56). The main underlying diseases were hypertension (46%), diabetes (36%) and pulmonary diseases (15%). CAPA was diagnosed within a median of 17 days (IQR 10-21.75) after symptoms onset and 9 days (IQR 3-11) after ICU admission. The overall 28-day mortality rate was 58%, and at univariate analysis, it was significantly associated with older age (p = 0.009) and SAPS-II score at admission (p = 0.032). The use of immunomodulatory agents, p = 0.061; broad-spectrum antibiotics, p = 0.091; positive culture for Aspergillus on BAL, p = 0.065; and hypertension, p = 0.083, were near reaching statistical significance. None of them were confirmed in multivariate analysis. In critically ill COVID-19 patients, CAPA acquired clinical relevance in terms of incidence and reported mortality. However, the risk between underdiagnosis-in the absence of specific invasive investigations, and with a consequent possible increase in mortality-and over-diagnosis (case identification with galactomannan on broncho-alveolar fluid alone) might be considered. Realistic incidence rates, based on local, real-life epidemiological data, might be helpful in guiding clinicians.
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Castro-Fuentes CA, Reyes-Montes MDR, Frías-De-León MG, Valencia-Ledezma OE, Acosta-Altamirano G, Duarte-Escalante E. Aspergillus-SARS-CoV-2 Coinfection: What Is Known? Pathogens 2022; 11:1227. [PMID: 36364979 PMCID: PMC9694759 DOI: 10.3390/pathogens11111227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 07/30/2023] Open
Abstract
COVID-19-associated pulmonary aspergillosis (CAPA) has had a high incidence. In addition, it has been associated with prolonged hospital stays, as well as several predisposing risk factors, such as fungal factors (nosocomial organism, the size of the conidia, and the ability of the Aspergillus spp. of colonizing the respiratory tract), environmental factors (remodeling in hospitals, use of air conditioning and negative pressure in intensive care units), comorbidities, and immunosuppressive therapies. In addition to these factors, SARS-CoV-2 per se is associated with significant dysfunction of the patient's immune system, involving both innate and acquired immunity, with reduced CD4+ and CD8+ T cell counts and cytokine storm. Therefore, this review aims to identify the factors influencing the fungus so that coinfection with SARS-CoV-2 can occur. In addition, we analyze the predisposing factors in the fungus, host, and the immune response alteration due to the pathogenicity of SARS-CoV-2 that causes the development of CAPA.
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Affiliation(s)
- Carlos Alberto Castro-Fuentes
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico
| | - María del Rocío Reyes-Montes
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico
| | - María Guadalupe Frías-De-León
- Hospital Regional de Alta Especialidad de Ixtapaluca, Carretera Federal México-Puebla Km. 34.5, Pueblo de Zoquiapan, Ixtapaluca 56530, Mexico
| | - Omar E. Valencia-Ledezma
- Hospital Regional de Alta Especialidad de Ixtapaluca, Carretera Federal México-Puebla Km. 34.5, Pueblo de Zoquiapan, Ixtapaluca 56530, Mexico
| | - Gustavo Acosta-Altamirano
- Hospital Regional de Alta Especialidad de Ixtapaluca, Carretera Federal México-Puebla Km. 34.5, Pueblo de Zoquiapan, Ixtapaluca 56530, Mexico
| | - Esperanza Duarte-Escalante
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico
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Ding L, Chen Y, Su N, Xu X, Yin J, Qiu J, Wang J, Zheng D. Comparison of acute respiratory distress syndrome in patients with COVID-19 and influenza A (H7N9) virus infection. Int J Infect Dis 2022; 122:593-598. [PMID: 35793755 PMCID: PMC9250702 DOI: 10.1016/j.ijid.2022.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES We aimed to compared the clinical features of acute respiratory distress syndrome (ARDS) induced by COVID-19 and H7N9 virus infections. METHODS Clinical data of 100 patients with COVID-19 and 46 patients with H7N9 were retrospectively analyzed. RESULTS Elevated inflammatory indices and coagulation disorders were more common in COVID-19-ARDS group than in the H7N9-ARDS group. The median interval from illness onset to ARDS development was shorter in H7N9-ARDS. The PaO2/FiO2 level was lower in H7N9-ARDS, whereas the Sepsis-related Organ Failure Assessment score was higher in COVID-19-ARDS. The proportion of patients with disseminated intravascular coagulation and liver injury in COVID-19-ARDS and H7N9-ARDS was 45.5% versus 3.1% and 28.8% versus 50%, respectively (P <0.05). The mean interval from illness onset to death was shorter in H7N9-ARDS. A total of 59.1% patients with H7N9-ARDS died of refractory hypoxemia compared with 28.9% with COVID-19-ARDS (P = 0.014). Patients with COVID-19-ARDS were more likely to die of septic shock and multiple organ dysfunction compared with H7N9-ARDS (71.2% vs 36.4%, P = 0.005). CONCLUSION Patients with H7N9 were more susceptible to develop severe ARDS and showed a more acute disease course. COVID-19-ARDS was associated with severe inflammatory response and coagulation dysfunction, whereas liver injury was more common in H7N9-ARDS. The main causes of death between patients with the two diseases were different.
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Affiliation(s)
- Ling Ding
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China
| | - Yikun Chen
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jiangsu University, Zhenjiang, 212001, China
| | - Nan Su
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China
| | - Xizhen Xu
- Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jingping Yin
- Center of Clinical Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China
| | - Jun Qiu
- Center of Clinical Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China
| | - Jiajia Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China,Corresponding author: Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Address: Pinghai Road No. 899, Suzhou 215000, China, Phone: +86-51267972108; fax: +86-51267972108
| | - Dong Zheng
- Center of Clinical Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, 215000, China,Corresponding author: Center of Clinical Laboratory, The First Affiliated Hospital of Soochow University, Address: Pinghai Road No. 899, Suzhou 215000, China, Phone: +86-51267973327; fax: +86-51267973327
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37
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Casalini G, Giacomelli A, Galimberti L, Colombo R, Ballone E, Pozza G, Zacheo M, Galimberti M, Oreni L, Carsana L, Longo M, Gismondo MR, Tonello C, Nebuloni M, Antinori S. Challenges in Diagnosing COVID-19-Associated Pulmonary Aspergillosis in Critically Ill Patients: The Relationship between Case Definitions and Autoptic Data. J Fungi (Basel) 2022; 8:jof8090894. [PMID: 36135619 PMCID: PMC9504285 DOI: 10.3390/jof8090894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Critically ill COVID-19 patients can develop invasive pulmonary aspergillosis (CAPA). Considering the weaknesses of diagnostic tests/case definitions, as well as the results from autoptic studies, there is a debate on the real burden of aspergillosis in COVID-19 patients. We performed a retrospective observational study on mechanically ventilated critically ill COVID-19 patients in an intensive care unit (ICU). The primary objective was to determine the burden of CAPA by comparing clinical diagnosis (through case definitions/diagnostic algorithms) with autopsy results. Twenty patients out of 168 (11.9%) developed probable CAPA. Seven (35%) were females, and the median age was 66 [IQR 59–72] years. Thirteen CAPA patients (65%) died and, for six, an autopsy was performed providing a proven diagnosis in four cases. Histopathology findings suggest a focal pattern, rather than invasive and diffuse fungal disease, in the context of prominent viral pneumonia. In a cohort of mechanically ventilated patients with probable CAPA, by performing a high rate of complete autopsies, invasive aspergillosis was not always proven. It is still not clear whether aspergillosis is the major driver of mortality in patients with CAPA.
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Affiliation(s)
- Giacomo Casalini
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Andrea Giacomelli
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Laura Galimberti
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Elisabetta Ballone
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Giacomo Pozza
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
| | - Martina Zacheo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Miriam Galimberti
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Letizia Oreni
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Luca Carsana
- Pathology Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Margherita Longo
- Clinical Microbiology, Virology and Bioemergency Diagnostics, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Maria Rita Gismondo
- Clinical Microbiology, Virology and Bioemergency Diagnostics, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Cristina Tonello
- Pathology Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Manuela Nebuloni
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
- Pathology Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
- Correspondence: ; Tel.: +39-025-031-9765; Fax: +39-025-031-9758
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38
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Tappe B, Lauruschkat CD, Strobel L, Pantaleón García J, Kurzai O, Rebhan S, Kraus S, Pfeuffer-Jovic E, Bussemer L, Possler L, Held M, Hünniger K, Kniemeyer O, Schäuble S, Brakhage AA, Panagiotou G, White PL, Einsele H, Löffler J, Wurster S. COVID-19 patients share common, corticosteroid-independent features of impaired host immunity to pathogenic molds. Front Immunol 2022; 13:954985. [PMID: 36052094 PMCID: PMC9427195 DOI: 10.3389/fimmu.2022.954985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022] Open
Abstract
Patients suffering from coronavirus disease-2019 (COVID-19) are susceptible to deadly secondary fungal infections such as COVID-19-associated pulmonary aspergillosis and COVID-19-associated mucormycosis. Despite this clinical observation, direct experimental evidence for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2)-driven alterations of antifungal immunity is scarce. Using an ex-vivo whole blood stimulation assay, we challenged blood from twelve COVID-19 patients with Aspergillus fumigatus and Rhizopus arrhizus antigens and studied the expression of activation, maturation, and exhaustion markers, as well as cytokine secretion. Compared to healthy controls, T-helper cells from COVID-19 patients displayed increased expression levels of the exhaustion marker PD-1 and weakened A. fumigatus- and R. arrhizus-induced activation. While baseline secretion of proinflammatory cytokines was massively elevated, whole blood from COVID-19 patients elicited diminished release of T-cellular (e.g., IFN-γ, IL-2) and innate immune cell-derived (e.g., CXCL9, CXCL10) cytokines in response to A. fumigatus and R. arrhizus antigens. Additionally, samples from COVID-19 patients showed deficient granulocyte activation by mold antigens and reduced fungal killing capacity of neutrophils. These features of weakened anti-mold immune responses were largely decoupled from COVID-19 severity, the time elapsed since diagnosis of COVID-19, and recent corticosteroid uptake, suggesting that impaired anti-mold defense is a common denominator of the underlying SARS-CoV-2 infection. Taken together, these results expand our understanding of the immune predisposition to post-viral mold infections and could inform future studies of immunotherapeutic strategies to prevent and treat fungal superinfections in COVID-19 patients.
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Affiliation(s)
- Beeke Tappe
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Chris D. Lauruschkat
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Lea Strobel
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Jezreel Pantaleón García
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Silke Rebhan
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Elena Pfeuffer-Jovic
- Department of Pulmonary Medicine, Missionsärztliche Klinik Würzburg, Würzburg, Germany
| | - Lydia Bussemer
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Lotte Possler
- Department of Internal Medicine, Main-Klinik Ochsenfurt, Würzburg, Germany
| | - Matthias Held
- Department of Pulmonary Medicine, Missionsärztliche Klinik Würzburg, Würzburg, Germany
| | - Kerstin Hünniger
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Olaf Kniemeyer
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Sascha Schäuble
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Axel A. Brakhage
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
- Department of Microbiology and Molecular Biology, Institute of Microbiology, Friedrich Schiller University, Jena, Germany
| | - Gianni Panagiotou
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - P. Lewis White
- Public Health Wales, Microbiology Cardiff, Wales, United Kingdom
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
- *Correspondence: Jürgen Löffler, ; Sebastian Wurster,
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
- *Correspondence: Jürgen Löffler, ; Sebastian Wurster,
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39
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Abstract
Coronavirus disease 2019 (COVID-19)-associated invasive fungal infections are an important complication in a substantial number of critically ill, hospitalized patients with COVID-19. Three groups of fungal pathogens cause co-infections in COVID-19: Aspergillus, Mucorales and Candida species, including Candida auris. Here we review the incidence of COVID-19-associated invasive fungal infections caused by these fungi in low-, middle- and high-income countries. By evaluating the epidemiology, clinical risk factors, predisposing features of the host environment and immunological mechanisms that underlie the pathogenesis of these co-infections, we set the scene for future research and development of clinical guidance. Hoenigl and colleagues review the epidemiology, immunology and clinical risk factors contributing to COVID-19-associated fungal infections.
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40
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Elbaz M, Korem M, Ayalon O, Wiener-Well Y, Shachor-Meyouhas Y, Cohen R, Bishara J, Atamna A, Brosh-Nissimov T, Maaravi N, Nesher L, Chazan B, Reisfeld S, Zimhony O, Chowers M, Maor Y, Katchman E, Ben-Ami R. Invasive Fungal Diseases in Hospitalized Patients with COVID-19 in Israel: A Multicenter Cohort Study. J Fungi (Basel) 2022; 8:jof8070721. [PMID: 35887476 PMCID: PMC9317957 DOI: 10.3390/jof8070721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
Highly variable estimates of COVID-19-associated fungal diseases (IFDs) have been reported. We aimed to determine the incidence of clinically important fungal diseases in hospitalized COVID-19 patients during the first year of the pandemic. We performed a multicenter survey of IFDs among patients hospitalized with COVID-19 in 13 hospitals in Israel between February 2020 and May 2021. COVID-19-associated pulmonary mold disease (PMD) and invasive candidiasis (IC) were defined using ECMM/ISHAM and EORTC/MSG criteria, respectively. Overall rates of IC and PMD among patients with critical COVID-19 were 10.86 and 10.20 per 1000 admissions, respectively, with significant variability among medical centers. PMD rates were significantly lower in centers where galactomannan was a send-out test versus centers with on-site testing (p = 0.035). The 30-day mortality rate was 67.5% for IC and 57.5% for PMD. Treatment with an echinocandin for IC or an extended-spectrum azole for PMD was associated with significantly lower mortality rates (adjusted hazard ratio [95% confidence interval], 0.26 [0.07–0.91] and 0.23 [0.093–0.57], respectively). In this multicenter national survey, variable rates of PMD were associated with on-site galactomannan testing, suggesting under-detection in sites lacking this capacity. COVID-19-related IFDs were associated with high mortality rates, which were reduced with appropriate antifungal therapy.
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Affiliation(s)
- Meital Elbaz
- Tel Aviv Sourasky Medical Center, Tel Aviv 6997801, Israel; (M.E.); (E.K.)
| | - Maya Korem
- Hadassah Medical Center, Jerusalem 9101002, Israel; (M.K.); (O.A.)
- Faculty of Medicine, Hebrew University, Jerusalem 9101002, Israel; (Y.W.-W.); (O.Z.)
| | - Oshrat Ayalon
- Hadassah Medical Center, Jerusalem 9101002, Israel; (M.K.); (O.A.)
- Faculty of Medicine, Hebrew University, Jerusalem 9101002, Israel; (Y.W.-W.); (O.Z.)
| | - Yonit Wiener-Well
- Faculty of Medicine, Hebrew University, Jerusalem 9101002, Israel; (Y.W.-W.); (O.Z.)
- Shaare Zedek Medical Center, Jerusalem 9101002, Israel
| | - Yael Shachor-Meyouhas
- Rambam Medical Center, Haifa 3109601, Israel;
- Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel; (R.C.); (B.C.); (S.R.)
| | - Regev Cohen
- Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel; (R.C.); (B.C.); (S.R.)
- Laniado Medical Center, Netanya 4290200, Israel
| | - Jihad Bishara
- Rabin Medical Medical Center, Petah-Tiqva 4910002, Israel; (J.B.); (A.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.C.); (Y.M.)
| | - Alaa Atamna
- Rabin Medical Medical Center, Petah-Tiqva 4910002, Israel; (J.B.); (A.A.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.C.); (Y.M.)
| | - Tal Brosh-Nissimov
- Samson Assuta Ashdod University Hospital, Ashdod 7747629, Israel; (T.B.-N.); (N.M.)
- Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba 8443944, Israel;
| | - Nir Maaravi
- Samson Assuta Ashdod University Hospital, Ashdod 7747629, Israel; (T.B.-N.); (N.M.)
| | - Lior Nesher
- Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba 8443944, Israel;
- Soroka Medical Center, Beer Sheba 8443944, Israel
| | - Bibiana Chazan
- Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel; (R.C.); (B.C.); (S.R.)
- Ha’Emek Medical Center, Afula 1834111, Israel
| | - Sharon Reisfeld
- Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel; (R.C.); (B.C.); (S.R.)
- Hillel Yaffe Medical Center, Hadera 3810101, Israel
| | - Oren Zimhony
- Faculty of Medicine, Hebrew University, Jerusalem 9101002, Israel; (Y.W.-W.); (O.Z.)
- Kaplan Medical Center, Rehovot 7610001, Israel
| | - Michal Chowers
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.C.); (Y.M.)
- Meir Medical Center, Kfar Saba 4428164, Israel
| | - Yasmin Maor
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.C.); (Y.M.)
- Wolfson Medical Center, Holon 5822012, Israel
| | - Eugene Katchman
- Tel Aviv Sourasky Medical Center, Tel Aviv 6997801, Israel; (M.E.); (E.K.)
| | - Ronen Ben-Ami
- Tel Aviv Sourasky Medical Center, Tel Aviv 6997801, Israel; (M.E.); (E.K.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.C.); (Y.M.)
- Correspondence: ; Tel.: +972-3-6974347
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41
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Domán M, Bányai K. COVID-19-Associated Fungal Infections: An Urgent Need for Alternative Therapeutic Approach? Front Microbiol 2022; 13:919501. [PMID: 35756020 PMCID: PMC9218862 DOI: 10.3389/fmicb.2022.919501] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/19/2022] [Indexed: 12/19/2022] Open
Abstract
Secondary fungal infections may complicate the clinical course of patients affected by viral respiratory diseases, especially those admitted to intensive care unit. Hospitalized COVID-19 patients are at increased risk of fungal co-infections exacerbating the prognosis of disease due to misdiagnosis that often result in treatment failure and high mortality rate. COVID-19-associated fungal infections caused by predominantly Aspergillus and Candida species, and fungi of the order Mucorales have been reported from several countries to become significant challenge for healthcare system. Early diagnosis and adequate antifungal therapy is essential to improve clinical outcomes, however, drug resistance shows a rising trend highlighting the need for alternative therapeutic agents. The purpose of this review is to summarize the current knowledge on COVID-19-associated mycoses, treatment strategies and the most recent advancements in antifungal drug development focusing on peptides with antifungal activity.
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Affiliation(s)
- Marianna Domán
- Veterinary Medical Research Institute, Budapest, Hungary
| | - Krisztián Bányai
- Veterinary Medical Research Institute, Budapest, Hungary.,Department of Pharmacology and Toxicology, University of Veterinary Medicine, Budapest, Hungary
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42
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Isavuconazole for COVID-19-Associated Invasive Mold Infections. J Fungi (Basel) 2022; 8:jof8070674. [PMID: 35887431 PMCID: PMC9323932 DOI: 10.3390/jof8070674] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Isavuconazole is a broad-spectrum antifungal drug recently approved as a first-line treatment for invasive aspergillosis and as a first or alternative treatment for mucormycosis. The purpose of this review was to report and discuss the use of isavuconazole for the treatment of COVID-19-associated aspergillosis (CAPA), and COVID-19-associated mucormycosis (CAM). Among all studies which reported treatment of CAPA, approximately 10% of patients were reportedly treated with isavuconazole. Considering 14 identified studies that reported the use of isavuconazole for CAPA, isavuconazole was used in 40% of patients (95 of 235 treated patients), being first-line monotherapy in over half of them. We identified six studies that reported isavuconazole use in CAM, either alone or in combination therapy. Overall, isavuconazole was used as therapy in 13% of treated CAM patients, frequently as combination or sequential therapy. The use of isavuconazole in CAPA and CAM is complicated by the challenge of achieving adequate exposure in COVID-19 patients who are frequently obese and hospitalized in the ICU with concomitant renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO). The presence of data on high efficacy in the treatment of aspergillosis, lower potential for drug–drug interactions (DDIs) and for subtherapeutic levels, and no risk of QT prolongation compared to other mold-active azoles, better safety profile than voriconazole, and the possibility of using an intravenous formulation in the case of renal failure are the advantages of using isavuconazole in this setting.
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43
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Hashim Z, Nath A, Khan A, Neyaz Z, Marak RSK, Areekkara P, Tiwari A, Srivastava S, Agarwal V, Saxena S, Tripathy N, Azim A, Gupta M, Mishra DP, Mishra P, Singh RK, Gupta D, Gupta A, Sanjeev OP, Ghatak T, Ghoshal U, Dhiman RK, Tripathy NK. New Insights into Development and Mortality of COVID-19-Associated Pulmonary Aspergillosis in a Homogenous Cohort of 1161 Intensive Care Patients. Mycoses 2022; 65:1010-1023. [PMID: 35716344 PMCID: PMC9349548 DOI: 10.1111/myc.13485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND COVID-19-associated pulmonary aspergillosis (CAPA) has been widely reported but homogenous large cohort studies are needed to gain real-world insights about the disease. METHODS We collected clinical and laboratory data of 1161 patients hospitalized at our Institute from March 2020 to August 2021, defined their CAPA pathology, and analyzed the data of CAPA/non-CAPA and deceased/survived CAPA patients using univariable and multivariable models. RESULTS The overall prevalence and mortality of CAPA in our homogenous cohort of 1161 patients was 6.4% and 47.3%, respectively. The mortality of CAPA was higher than that of non-CAPA patients (Hazard ratio: 1.8 [95% confidence interval: 1.1-2.8]). Diabetes (odds ratio 1.92 [1.15-3.21]); persistent fever (2.54 [1.17- 5.53]); hemoptysis (7.91[4.45-14.06]); and lung lesions of cavitation (8.78 [2.27-34.03]), consolidation (9.06 [2.03-40.39]), and nodules (8.26 [2.39-28.58]) were associated with development of CAPA by multivariable analysis. Acute respiratory distress syndrome (ARDS) (2.68 [1.09-6.55]), a high computed tomography score index (OR 1.18 [1.08-1.29]; p<0.001), and pulse glucocorticoid treatment (HR 4.0 [1.3-9.2]) were associated with mortality of the disease. Whereas neutrophilic leukocytosis (development: 1.09 [1.03-1.15]; mortality: 1.17 [1.08-1.28]) and lymphopenia (development: 0.68 [0.51-0.91]; mortality: 0.40 [0.20-0.83]) were associated with the development as well as mortality of CAPA. CONCLUSION We observed a low but likely underestimated prevalence of CAPA in our study. CAPA is a disease with highly mortality and diabetes is a significant factor for its development while ARDS and pulse glucocorticoid treatment are significant factors for its mortality. The cellular immune dysregulation may have a central role in CAPA from its development to mortality.
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Affiliation(s)
- Zia Hashim
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Ajmal Khan
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Zafar Neyaz
- Department of Radiodiagnosis, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Rungmei S K Marak
- Department of Microbiology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Prasant Areekkara
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Atul Tiwari
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Shivani Srivastava
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Swati Saxena
- Department of Molecular Medicine, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Nidhi Tripathy
- Department of Endocrinology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Afzal Azim
- Department of Critical Care Medicine, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow-226014, India
| | - Durga Prasanna Mishra
- Department of Clinical Immunology and Rheumatology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Prabhakar Mishra
- Department of Biostatistics and Health Informatics, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Ratender Kumar Singh
- Department of Emergency Medicine, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Devender Gupta
- Department of Anesthesiology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Anshul Gupta
- Department of Hematology, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Om Prakash Sanjeev
- Department of Emergency Medicine, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Tanmoy Ghatak
- Department of Emergency Medicine, SGPGIMS, Raebareli Road, Lucknow-226014, India
| | - Ujjala Ghoshal
- Department of Microbiology, SGPGIMS, Raebareli Road, Lucknow-226014, India
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Concurrent Infection with SARS-CoV-2 and Pneumocystis jirovecii in Immunocompromised and Immunocompetent Individuals. J Fungi (Basel) 2022; 8:jof8060585. [PMID: 35736068 PMCID: PMC9225243 DOI: 10.3390/jof8060585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) may occur with concurrent infections caused by bacterial and fungal microorganisms. This systematic review evaluated studies reporting concomitant COVID-19 and Pneumocystis jirovecii pneumonia (PJP). We found 39 patients (74% male, median age: 56.8 (range: 11–83) years), including 66% immunosuppressed individuals (23% HIV-infected and 41% on long-term corticosteroid therapy). Patients were characteristically severely ill (mechanical ventilation: 70%), associated with 41% mortality. The median lymphocyte count was 527 cells/mm3 (range: 110–2200), and the median CD4+ T cell count was 206 cells/mm3 (range: 8–1021). We identified three patterns of concurrent COVID-19 and P. jirovecii infection. The first pattern (airway colonization with a low burden of P. jirovecii) does not seem to modify the COVID-19 course of illness. However, P. jirovecii superinfection, typically occurring weeks after COVID-19 diagnosis as a biphasic illness, and P. jirovecii coinfection characteristically results in progressive multilobar pneumonia, which is associated with poor outcomes. To support this categorization, we reported three patients with concurrent PJP and COVID-19 identified in our institution, presenting these clinical scenarios. The diagnosis of PJP requires a high index of suspicion, since clinical and radiological characteristics overlap with COVID-19. Observational studies are necessary to determine the PJP burden in patients with COVID-19 requiring hospitalization.
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Nebulized Amphotericin B in Mechanically Ventilated COVID-19 Patients to Prevent Invasive Pulmonary Aspergillosis: A Retrospective Cohort Study. Crit Care Explor 2022; 4:e0696. [PMID: 35558738 PMCID: PMC9088229 DOI: 10.1097/cce.0000000000000696] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Despite high mortality rates of COVID-19-associated pulmonary aspergillosis (CAPA) in the ICU, antifungal prophylaxis remains a subject of debate. We initiated nebulized conventional amphotericin B (c-AmB) as antifungal prophylaxis in COVID-19 patients on invasive mechanical ventilation (IMV).
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Invasive Respiratory Fungal Infections in COVID-19 Critically Ill Patients. J Fungi (Basel) 2022; 8:jof8040415. [PMID: 35448646 PMCID: PMC9025868 DOI: 10.3390/jof8040415] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with coronavirus disease 19 (COVID-19) admitted to the intensive care unit (ICU) often develop respiratory fungal infections. The most frequent diseases are the COVID-19 associated pulmonary aspergillosis (CAPA), COVID-19 associated pulmonary mucormycosis (CAPM) and the Pneumocystis jirovecii pneumonia (PCP), the latter mostly found in patients with both COVID-19 and underlying HIV infection. Furthermore, co-infections due to less common mold pathogens have been also described. Respiratory fungal infections in critically ill patients are promoted by multiple risk factors, including epithelial damage caused by COVID-19 infection, mechanical ventilation and immunosuppression, mainly induced by corticosteroids and immunomodulators. In COVID-19 patients, a correct discrimination between fungal colonization and infection is challenging, further hampered by sampling difficulties and by the low reliability of diagnostic approaches, frequently needing an integration of clinical, radiological and microbiological features. Several antifungal drugs are currently available, but the development of new molecules with reduced toxicity, less drug-interactions and potentially active on difficult to treat strains, is highly warranted. Finally, the role of prophylaxis in certain COVID-19 populations is still controversial and must be further investigated.
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Román-Montes CM, Bojorges-Aguilar S, Díaz-Lomelí P, Cervantes-Sánchez A, Rangel-Cordero A, Martínez-Gamboa A, Sifuentes-Osornio J, Ponce-de-León A, González-Lara MF. Tracheal Aspirate Galactomannan Testing in COVID-19-Associated Pulmonary Aspergillosis. FRONTIERS IN FUNGAL BIOLOGY 2022; 3:855914. [PMID: 37746186 PMCID: PMC10512352 DOI: 10.3389/ffunb.2022.855914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/09/2022] [Indexed: 09/26/2023]
Abstract
Among critically ill patients, COVID-19-associated pulmonary aspergillosis (CAPA) is a challenging complication. The recommended diagnostic methods for this disease are bronchoalveolar lavage (BAL) culture and galactomannan (GM) testing, which were not widely available during the pandemic. There is scarce information regarding GM testing in other respiratory specimens. Our objective was to compare the agreement of GM between BAL and tracheal aspirate (TA) samples. We selected patients with COVID-19 and those with suspected CAPA who were admitted in the intensive care unit (ICU). GM was routinely done in BAL. We performed GM in TA samples and compared the results. The agreement was evaluated with Cohen's Kappa coefficient. GM was considered positive when an OD index ≥ 1 in BAL and ≥ 2 in TA were found. Probable CAPA was considered when the ECMM/ISHAM criteria were met. A descriptive analysis of clinical characteristics and mortality was made. We included 20 patients with suspected CAPA from 54 patients with critical COVID-19, of which 5 (9%) met the probable category. Aspergillus fumigatus was the most frequent isolate. We found moderate agreement between BAL and TA GM (Kappa = 0.47, p = 0.01, 95% CI.04-0.9), whereas TA GM had 75% sensitivity (95% CI 19.4-99.4%), 81.2% specificity (95% CI 54.4-95.9%), 50% positive predictive value (95% CI 23.8-76.3%),] and 92.8% negative predictive value (95% CI 70.1-98.6%), and 80% accuracy (95% CI 56.3-94.3%). Lastly, three (60%) patients with CAPA died during hospitalization compared to 40% (6/15) without CAPA (p = 0.4). In conclusion, a moderate agreement between TA GM and BAL was found. Therefore, TA testing may aid in ruling out CAPA due to high negative predictive value when bronchoscopies are unavailable.
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Affiliation(s)
- Carla M. Román-Montes
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
- Medicine Direction, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Saúl Bojorges-Aguilar
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
- Medicine Direction, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Paulette Díaz-Lomelí
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Axel Cervantes-Sánchez
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Andrea Rangel-Cordero
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Areli Martínez-Gamboa
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - José Sifuentes-Osornio
- Infectious Diseases Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Alfredo Ponce-de-León
- Medicine Direction, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
| | - Maria F. González-Lara
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
- Medicine Direction, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
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48
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SARS-CoV-2 Associated Immune Dysregulation and COVID-Associated Pulmonary Aspergilliosis (CAPA): A Cautionary Tale. Int J Mol Sci 2022; 23:ijms23063228. [PMID: 35328649 PMCID: PMC8953852 DOI: 10.3390/ijms23063228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 02/01/2023] Open
Abstract
As the global SARS-CoV-2 pandemic continues to plague healthcare systems, it has become clear that opportunistic pathogens cause a considerable proportion of SARS-CoV-2-associated mortality and morbidity cases. Of these, Covid-Associated Pulmonary Aspergilliosis (CAPA) is a major concern with evidence that it occurs in the absence of traditional risk factors such as neutropenia and is diagnostically challenging for the attending physician. In this review, we focus on the immunopathology of SARS-CoV-2 and how this potentiates CAPA through dysregulation of local and systemic immunity as well as the unintended consequences of approved COVID treatments including corticosteroids and IL-6 inhibitors. Finally, we will consider how knowledge of the above may aid in the diagnosis of CAPA using current diagnostics and what treatment should be instituted in probable and confirmed cases.
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Seldeslachts L, Jacobs C, Tielemans B, Vanhoffelen E, Van der Sloten L, Humblet-Baron S, Naesens L, Lagrou K, Verbeken E, Wauters J, Vande Velde G. Overcome Double Trouble: Baloxavir Marboxil Suppresses Influenza Thereby Mitigating Secondary Invasive Pulmonary Aspergillosis. J Fungi (Basel) 2021; 8:1. [PMID: 35049941 PMCID: PMC8777735 DOI: 10.3390/jof8010001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022] Open
Abstract
Influenza-associated pulmonary aspergillosis (IAPA) is a global recognized superinfection in critically ill influenza patients. Baloxavir marboxil, a cap-dependent endonuclease inhibitor, is a newly approved anti-influenza therapeutic. Although the benefits as a treatment for influenza are clear, its efficacy against an influenza-A. fumigatus co-infection has yet to be determined. We investigated the therapeutic effect of baloxavir marboxil in a murine model for IAPA. Immunocompetent mice received intranasal instillation of influenza A followed by orotracheal inoculation with Aspergillus fumigatus 4 days later. Administration of baloxavir marboxil or sham was started at day 0, day 2 or day 4. Mice were monitored daily for overall health status, lung pathology with micro-computed tomography (µCT) and fungal burden with bioluminescence imaging (BLI). In vivo imaging was supplemented with virological, mycological and biochemical endpoint investigations. We observed an improved body weight, survival and viral clearance in baloxavir marboxil treated mice. µCT showed less pulmonary lesions and bronchial dilation after influenza and after Aspergillus co-infection in a treatment-dependent pattern. Furthermore, baloxavir marboxil was associated with effective inhibition of fungal invasion. Hence, our results provide evidence that baloxavir marboxil mitigates severe influenza thereby decreasing the susceptibility to a lethal invasive Aspergillus superinfection.
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Affiliation(s)
- Laura Seldeslachts
- Biomedical MRI Unit/MoSAIC, Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium; (L.S.); (B.T.); (E.V.)
| | - Cato Jacobs
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (C.J.); (L.V.d.S.); (J.W.)
| | - Birger Tielemans
- Biomedical MRI Unit/MoSAIC, Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium; (L.S.); (B.T.); (E.V.)
| | - Eliane Vanhoffelen
- Biomedical MRI Unit/MoSAIC, Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium; (L.S.); (B.T.); (E.V.)
| | - Lauren Van der Sloten
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (C.J.); (L.V.d.S.); (J.W.)
| | - Stephanie Humblet-Baron
- Laboratory of Adaptive Immunity, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Lieve Naesens
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Erik Verbeken
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium;
| | - Joost Wauters
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (C.J.); (L.V.d.S.); (J.W.)
| | - Greetje Vande Velde
- Biomedical MRI Unit/MoSAIC, Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium; (L.S.); (B.T.); (E.V.)
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