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Iacovelli A, Oliva A, Mirabelli FM, Giannone S, Laguardia M, Morviducci M, Nicolardi ML, Repaci E, Sanzari MT, Leanza C, Raponi G, Mastroianni C, Palange P. Risk factors for COVID-19 associated pulmonary aspergillosis and outcomes in patients with acute respiratory failure in a respiratory sub-intensive care unit. BMC Infect Dis 2024; 24:392. [PMID: 38605300 PMCID: PMC11007928 DOI: 10.1186/s12879-024-09283-3] [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: 01/14/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND COVID-19-associated pulmonary aspergillosis (CAPA) is burdened by high mortality. Data are lacking about non-ICU patients. Aims of this study were to: (i) assess the incidence and prevalence of CAPA in a respiratory sub-intensive care unit, (ii) evaluate its risk factors and (iii) impact on in-hospital mortality. Secondary aims were to: (i) assess factors associated to mortality, and (ii) evaluate significant features in hematological patients. MATERIALS AND METHODS This was a single-center, retrospective study of COVID-19 patients with acute respiratory failure. A cohort of CAPA patients was compared to a non-CAPA cohort. Among patients with CAPA, a cohort of hematological patients was further compared to another of non-hematological patients. RESULTS Three hundred fifty patients were included in the study. Median P/F ratio at the admission to sub-intensive unit was 225 mmHg (IQR 155-314). 55 (15.7%) developed CAPA (incidence of 5.5%). Eighteen had probable CAPA (37.3%), 37 (67.3%) possible CAPA and none proven CAPA. Diagnosis of CAPA occurred at a median of 17 days (IQR 12-31) from SARS-CoV-2 infection. Independent risk factors for CAPA were hematological malignancy [OR 1.74 (95%CI 0.75-4.37), p = 0.0003], lymphocytopenia [OR 2.29 (95%CI 1.12-4.86), p = 0.02], and COPD [OR 2.74 (95%CI 1.19-5.08), p = 0.014]. Mortality rate was higher in CAPA cohort (61.8% vs 22.7%, p < 0.0001). CAPA resulted an independent risk factor for in-hospital mortality [OR 2.92 (95%CI 1.47-5.89), p = 0.0024]. Among CAPA patients, age > 65 years resulted a predictor of mortality [OR 5.09 (95% CI 1.20-26.92), p = 0.035]. No differences were observed in hematological cohort. CONCLUSION CAPA is a life-threatening condition with high mortality rates. It should be promptly suspected, especially in case of hematological malignancy, COPD and lymphocytopenia.
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Affiliation(s)
- Alessandra Iacovelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy.
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Flavio Marco Mirabelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Silvia Giannone
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Marianna Laguardia
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Matteo Morviducci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Maria Luisa Nicolardi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Emma Repaci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Maria Teresa Sanzari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
| | - Cristiana Leanza
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giammarco Raponi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Italy Pulmonology Respiratory and Critical Care Unit, Policlinico Umberto I Hospital Rome, Rome, Italy
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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: 17] [Impact Index Per Article: 17.0] [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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Khodavaisy S, Sarrafnia H, Abdollahi A. Outcomes of Patients with COVID-19 and Fungal Coinfections: A Systematic Review and Meta-Analysis Study. IRANIAN JOURNAL OF PATHOLOGY 2024; 19:136-147. [PMID: 39118795 PMCID: PMC11304463 DOI: 10.30699/ijp.2024.2010087.3160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/16/2023] [Indexed: 08/10/2024]
Abstract
Background & Objective Fungal co-infections increase the incidence and mortality of viral respiratory tract infections. This study systematically reviews and conducts a meta-analysis to evaluate the prevalence of COVID-19 patients with fungal coinfections. The aim is to provide a concise overview of the impact of these infections on patient outcomes especially association with risk of mortality, informing future research and optimizing patient management strategies. Methods To identify relevant studies on COVID-19 patients, we conducted a systematic search of databases from the beginning of the year until July 2023, including fungal co-infections, mortality, and sequelae. Eligibility criteria were developed using the PICO framework, and data extraction was carried out separately by two authors using standard techniques. Statistical analysis was performed using the correlation model and differences between studies were evaluated using the I2 test. R and RStudio were used for statistical analysis and visualization. Results We initially identified 6,764 studies, and after checking for equivalence and consistency, 41 studies were included in the final analysis. The overall COVID-19 odds ratio for people who died from fungal infections was 2.65, indicating that patients infected with both COVID-19 and fungal infections had a higher risk of death compared to patients with COVID-19 alone. Specifically, COVID-19-associated pulmonary aspergillosis (CAPA) has a higher odds ratio of 3.36, while COVID-19-associated candidiasis (CAC) has an odds ratio of 1.84, and both are much more associated with death. However, coinfection of the fungus with other fungal species did not show a significant difference in the risk of mortality. Conclusion This study identified CAPA and CAC as the most common infections acquired in healthcare settings. Fungal coinfections may be associated with an increased risk of death in COVID-19 patients.
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Affiliation(s)
- Sadegh Khodavaisy
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Research center for antibiotic stewardship and antimicrobial resistance, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Haleh Sarrafnia
- Faculty of Biological Sciences, Islamic Azad University, Tehran-North Branch, Tehran, Iran
| | - Alireza Abdollahi
- Department of Pathology, School of Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Cazzaniga J, Koutras N, Patel P. Mortality and Clinical Outcomes of Aspergillus and COVID-19 Co-infection: A Retrospective Analysis. Cureus 2023; 15:e50321. [PMID: 38205484 PMCID: PMC10776451 DOI: 10.7759/cureus.50321] [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: 10/31/2023] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Patients with coronavirus disease (COVID-19) are more susceptible to secondary infections. Aspergillus co-infection has emerged as one of the most alarming complications in critically ill COVID-19 patients due to the disease itself or the use of immunomodulators and immunosuppressants for treatment. This study aimed to examine the mortality rates and clinical outcomes associated with Aspergillus and COVID-19 co-infection using data obtained from the largest nationwide inpatient sample database in the United States. METHODS The National (Nationwide) Inpatient Sample (NIS) database is a vast and openly accessible collection of data that records millions of hospital admissions in the United States. For our research, we utilized the NIS 2020 database to identify adult patients diagnosed with COVID-19 and categorized them based on co-infection with Aspergillus. To examine the NIS database, we utilized various statistical methods such as univariate and multivariate analyses, descriptive statistics, and regression analysis. RESULTS Of the 16.7 million patients hospitalized due to COVID-19 infection, 1485 developed Aspergillus co-infection. The demographics showed a predominance of males with 920 males and 565 women. A total of 46% were Caucasians, 17.2% were African-Americans, and 29.5% were Hispanics. The most common comorbidities were chronic pulmonary disease (40.7%), hypertension (41.4%), diabetes with chronic complications (37.7%), leukemia (4.0%), lymphoma (3.7%), and solid tumors (3.7%). Hospital mortality with co-infection was 53.2%, length of stay (LOS) 26.9 days, and economic utilization $138,093 in comparison to patients without co-infection with in-hospital mortality of 13.2%, LOS of 7.9 days, and cost of 21,490. Age-adjusted mortality was 6.6 (confidence interval: 5.9-7.3). CONCLUSION Our study indicated that the mortality rate in COVID-19 patients with Aspergillus infection was four-fold higher. Furthermore, comorbidities, such as diabetes mellitus, chronic pulmonary disease, and obesity, have been associated with worse outcomes. Further research is necessary to understand the etiological relationship between Aspergillus infection and COVID-19 in order to develop effective treatment strategies that mitigate the impact of this lethal combination on patient health outcomes.
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Affiliation(s)
- Juliana Cazzaniga
- Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Nicole Koutras
- Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
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Tehrani S, Fekri S, Demirci H, Nourizadeh AM, Kashefizadeh A, Shahrbaf MA, Keyvanfar A, Maghsoudi Nejad F. Coincidence of Candida Endophthalmitis, and Aspergillus and Pneumocystis jirovecii Pneumonia in a COVID-19 Patient: Case Report. Ocul Immunol Inflamm 2023:1-4. [PMID: 36952481 DOI: 10.1080/09273948.2023.2188224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) is associated with immune system dysfunction and makes patients vulnerable to opportunistic infections. This report presents a patient with a history of COVID-19, suffering from opportunistic infections. CASE DESCRIPTION We reported a 64-year-old man complaining of progressive visual loss in his left eye, who had previously been hospitalized for three weeks due to COVID-19. In the ophthalmologic assessment, large foci of dense subretinal and intraretinal infiltrations involving the macula were observed (compatible with endogenous fungal endophthalmitis). Real-time PCR result of intraocular fluid was positive for Candida spp. During subsequent hospitalization, the patient also suffered from fever and productive coughs (manifestations of pneumonia caused by Aspergillus fumigatus and Pneumocystis jirovecii). In response to antibiotic therapy, the fever and coughs subsided, and the ocular examination revealed a dramatic decrease in the size of retinal infiltrations. CONCLUSIONS In patients with severe COVID-19, long-term ICU admission and immunosuppressive drugs lead to immune system dysfunction and make the patient more susceptible to opportunistic infections. Consequently, fungal pathogens such as Aspergillus, Pneumocystis jirovecii, and Candida spp. may cause infection in different body organs. Thus, clinicians should be alert and have clinical suspicion to diagnose accurately and manage patients accordingly.
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Affiliation(s)
- Shabnam Tehrani
- Department of Infectious Disease, Labbafinejad Clinical Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahba Fekri
- Department of Ophthalmology, Labbafinejad Clinical Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hakan Demirci
- Department of Ophthalmology and Visual Science, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Alireza Kashefizadeh
- Department of Internal Medicine, Labbafinejad Clinical Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Amirreza Keyvanfar
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Maghsoudi Nejad
- Department of Infectious Disease, Labbafinejad Clinical Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Calderón-Parra J, Mills-Sanchez P, Moreno-Torres V, Tejado-Bravo S, Romero-Sánchez I, Balandin-Moreno B, Calvo-Salvador M, Portero-Azorín F, García-Masedo S, Muñez-Rubio E, Ramos-Martinez A, Fernández-Cruz A. COVID-19-associated pulmonary aspergillosis (CAPA): Risk factors and development of a predictive score for critically ill COVID-19 patients. Mycoses 2022; 65:541-550. [PMID: 35212030 PMCID: PMC9115267 DOI: 10.1111/myc.13434] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND COVID-19-associated pulmonary aspergillosis (CAPA) is a major complication of critically ill COVID-19 patients, with a high mortality rate and potentially preventable. Thus, identifying patients at high risk of CAPA would be of great interest. We intended to develop a clinical prediction score capable of stratifying patients according to the risk for CAPA at ICU admission. METHODS Single center retrospective case-control study. A case was defined as a patient diagnosed with CAPA according to 2020 ECMM/ISHAM consensus criteria. 2 controls were selected for each case among critically ill COVID-19 patients. RESULTS 28 CAPA patients and 56 matched controls were included. Factors associated with CAPA included old age (68 years vs 62, p=0.033), active smoking (17.9% vs 1.8%, p=0.014), chronic respiratory diseases (48.1% vs 26.3%, p=0.043), chronic renal failure (25.0% vs 3.6%, p=0.005), chronic corticosteroid treatment (28.6% vs 1.8%, p<0.001), tocilizumab therapy (92.9% vs 66.1%, p=0.008) and high APACHE II at ICU admission (median 13 vs 10 points, p=0.026). A score was created including these variables, which showed an area under the receiver operator curve of 0.854 (95% CI 0.77-0.92). A punctuation below 6 had a negative predictive value of 99.6%. A punctuation of 10 or higher had a positive predictive value of 27.9%. CONCLUSION We present a clinical prediction score that allowed to stratify critically ill COVID-19 patients according to the risk for developing CAPA. This CAPA-score would allow to target preventive measures. Further evaluation of the score, as well as the utility of these targeted preventive measures, is needed.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain.,Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA)
| | - Patricia Mills-Sanchez
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain
| | - Victor Moreno-Torres
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain.,Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA)
| | - Sandra Tejado-Bravo
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Isabel Romero-Sánchez
- Microbiology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain
| | | | | | | | - Sarela García-Masedo
- Microbiology Service, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain
| | - Elena Muñez-Rubio
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain
| | - Antonio Ramos-Martinez
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain
| | - Ana Fernández-Cruz
- Infectious Diseases Unit, Service of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Majadahonda, Spain.,Research Institute Puerta de Hierro-Segovia de Aranda (IDIPHSA)
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Defining COVID-19 associated pulmonary aspergillosis: systematic review and meta-analysis. Clin Microbiol Infect 2022; 28:920-927. [PMID: 35150878 PMCID: PMC8828380 DOI: 10.1016/j.cmi.2022.01.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 01/06/2023]
Abstract
Background Pulmonary aspergillosis may complicate coronavirus disease 2019 (COVID-19) and contribute to excess mortality in intensive care unit (ICU) patients. The disease is poorly understood, in part due to discordant definitions across studies. Objectives We sought to review the prevalence, diagnosis, treatment, and outcomes of COVID-19–associated pulmonary aspergillosis (CAPA) and compare research definitions. Data sources PubMed, Embase, Web of Science, and MedRxiv were searched from inception to October 12, 2021. Study eligibility criteria ICU cohort studies and CAPA case series including ≥3 patients were included. Participants Adult patients in ICUs with COVID-19. Interventions Patients were reclassified according to four research definitions. We assessed risk of bias with an adaptation of the Joanna Briggs Institute cohort checklist tool for systematic reviews. Methods We calculated CAPA prevalence using the Freeman-Tukey random effects method. Correlations between definitions were assessed with Spearman's rank test. Associations between antifungals and outcome were assessed with random effects meta-analysis. Results Fifty-one studies were included. Among 3297 COVID-19 patients in ICU cohort studies, 313 were diagnosed with CAPA (prevalence 10%; 95% CI 8%–13%). Two hundred seventy-seven patients had patient-level data allowing reclassification. Definitions had limited correlation with one another (ρ = 0.268–0.447; p < 0.001), with the exception of Koehler and Verweij (ρ = 0.893; p < 0.001); 33.9% of patients reported to have CAPA did not fulfill any research definitions. Patients were diagnosed after a median of 8 days (interquartile range 5–14) in ICUs. Tracheobronchitis occurred in 3% of patients examined with bronchoscopy. The mortality rate was high (59.2%). Applying CAPA research definitions did not strengthen the association between mould-active antifungals and survival. Conclusions The reported prevalence of CAPA is significant but may be exaggerated by nonstandard definitions.
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Feys S, Almyroudi MP, Braspenning R, Lagrou K, Spriet I, Dimopoulos G, Wauters J. A Visual and Comprehensive Review on COVID-19-Associated Pulmonary Aspergillosis (CAPA). J Fungi (Basel) 2021; 7:1067. [PMID: 34947049 PMCID: PMC8708864 DOI: 10.3390/jof7121067] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 19 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a severe fungal infection complicating critically ill COVID-19 patients. Numerous retrospective and prospective studies have been performed to get a better grasp on this lethal co-infection. We performed a qualitative review and summarized data from 48 studies in which 7047 patients had been included, of whom 820 had CAPA. The pooled incidence of proven, probable or putative CAPA was 15.1% among 2953 ICU-admitted COVID-19 patients included in 18 prospective studies. Incidences showed great variability due to multiple factors such as discrepancies in the rate and depth of the fungal work-up. The pathophysiology and risk factors for CAPA are ill-defined, but therapy with corticosteroids and anti-interleukin-6 therapy potentially confer the biggest risk. Sampling for mycological work-up using bronchoscopy is the cornerstone for diagnosis, as imaging is often aspecific. CAPA is associated with an increased mortality, but we do not have conclusive data whether therapy contributes to an increased survival in these patients. We conclude our review with a comparison between influenza-associated pulmonary aspergillosis (IAPA) and CAPA.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Reinout Braspenning
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - George Dimopoulos
- ICU of 1st Department of Critical Care, Sotiria Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
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