Risk factors for COVID-19-associated pulmonary aspergillosis: a systematic review and meta-analysis

Incidence of Coronavirus Disease 2019-Associated Pulmonary Aspergillosis and Specialist Involvement in Its Diagnosis in Japan: A Nationwide Survey and Literature Review

BACKGROUND

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has been reported worldwide. However, studies in Japan are limited, and no study has evaluated the relationship between the incidence of CAPA and specialist involvement in its diagnosis.

OBJECTIVES

We aimed to obtain new epidemiological data on CAPA in Japan and evaluate the relationship between the incidence of CAPA and specialist involvement in its diagnosis.

METHODS

A survey was conducted among chief physicians at 760 training hospitals with at least 100 beds and accredited by the Japanese Respiratory Society or the Japanese Association for Infectious Diseases. Critical patients with COVID-19 diagnosed with CAPA between 1 January 2020 and 31 August 2023 were analysed. A literature review was conducted to evaluate the correlations between the incidence of CAPA and galactomannan (GM) testing and positivity rates.

RESULTS

Responses were obtained from 221 of the 760 hospitals (29.1%). The incidence of CAPA was 0.67% (69/10,276). Hospitals with patients with CAPA had significantly more pulmonologists and infectious disease specialists than those without patients with CAPA. A strong positive correlation was observed between the incidence of CAPA and the number of pulmonologists per critical patient with COVID-19 (r = 0.824, p < 0.001). The literature review showed that bronchoalveolar lavage fluid GM testing rate was a strong positive correlation with the incidence of CAPA (r = 0.527, p = 0.014).

CONCLUSIONS

For the diagnosis of CAPA, its recognition by specialists primarily involved in managing critical patients with COVID-19 seems essential.

A nationwide epidemiological survey of coronavirus disease 2019-associated pulmonary aspergillosis in Japan

BACKGROUND

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a severe complication of COVID-19 with a poor prognosis. In this study, we aimed to analyze the nationwide epidemiology of CAPA in Japan.

METHODS

This nationwide retrospective study involved data of 98 patients with CAPA reported in 221 hospitals in Japan between January 2020 and August 2023, using both online and paper-based questionnaires. We investigated the clinical characteristics of CAPA, assessed outcomes using Kaplan-Meier curves, and identified independent predictors of 90-day mortality using Cox proportional hazards analysis.

RESULTS

The median age of the patients with CAPA was 71 years, and 71.4 % were men. The positivity rates for β-D-glucan and serum galactomannan antigen were 59.1 % and 68.4 %, respectively, while chest computed tomography revealed cavities in 25.5 % of patients. The 30-day and 90-day mortality rates were 50.0 % and 55.1 %, respectively. Kaplan-Meier analysis showed that the mortality rate of patients treated with echinocandin monotherapy was significantly higher than that of patients treated with other antifungals (log-rank test, p = 0.04). Multivariate analysis identified a neutrophil count of ≥10,000/μL (hazard ratio [HR]: 2.67, 95 % confidence interval [CI]: 1.49-4.89) and echinocandin monotherapy (HR: 2.06, 95 % CI: 1.01-3.93) as independent predictors of 90-day mortality. Patients treated with echinocandin monotherapy were older, and Aspergillus spp. was not isolated in half of these patients.

CONCLUSION

This study provides a comprehensive overview of CAPA in Japan. Appropriate antifungal therapy is essential to improve the prognosis of patients with CAPA.

Key fungal coinfections: epidemiology, mechanisms of pathogenesis, and beyond

Coinfection is defined as the occurrence of at least two genetically distinct infectious agents within the same host. Historically, fungal infections have been neglected, leading to an underestimation of their impact on public health systems. However, fungal coinfections have become increasingly prevalent, emerging as a significant global health concern. This review explores fungal coinfections commonly associated with HIV, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza, Mycobacterium tuberculosis, and Pseudomonas species. These include candidiasis, aspergillosis, paracoccidioidomycosis, cryptococcosis, histoplasmosis, pneumocystosis, sporotrichosis, and mucormycosis. We discuss the key local and systemic mechanisms that contribute to the occurrence of these coinfections. HIV infects CD4+ cells, causing systemic immunosuppression, particularly impairing the adaptive immune response. The inflammatory response to SARS-CoV-2 infection disrupts both pulmonary and systemic homeostasis, rendering individuals more vulnerable to local and disseminated fungal coinfections. Severe influenza promotes fungal coinfections by triggering the production of pro-inflammatory cytokines, which damage the epithelial-endothelial barrier and impair the recognition and phagocytosis of fungal cells. Tuberculosis can replace normal lung parenchyma with collagen tissue, leading to alterations in lung architecture, compromising its function. Interaction between Pseudomonas and Aspergillus during coinfection involves the competition for iron availability and an adaptive response to its deprivation. Therefore, the specific interactions between each underlying disease and fungal coinfections are detailed in this review. In addition, we highlight the risk factors associated with coinfections, pathophysiology, epidemiology, and the challenges of early diagnosis. Recognizing the substantial worldwide public health burden posed by fungal coinfections is crucial to improve survival rates.

Effectiveness and safety of teclistamab for relapsed or refractory multiple myeloma: a systematic review and meta-analysis

Background

Multiple myeloma (MM) is a hematological malignancy with limited treatment options for patients with relapsed/refractory MM (RRMM). Teclistamab, a B-cell maturation antigen (BCMA) × CD3 bispecific antibody, has shown promising results in clinical trials and real-world studies.

Methods

PubMed/MEDLINE, Web of Science, EMBASE, Cochrane Library, ClinicalTrials.gov, and meeting libraries were searched from inception to 14 November 2024. The assessed outcomes included overall survival (OS), progression-free survival, time to next treatment, duration of response, overall response rate (ORR), ≥complete response (≥CR), ≥very good partial response (≥VGPR), VGPR, partial response, and adverse events.

Results

In total, 34 studies involving 4,064 patients were included. In pairwise meta-analysis, teclistamab demonstrated superior OS [hazard ratio (HR) = 0.69, 95% confidence interval (CI): 0.54-0.89; p = 0.037] compared to existing RRMM treatments. Real-world studies showed comparable ORR (62%, 95% CI: 58%-66%) but slightly lower survival outcomes, possibly because of shorter follow-up times and higher-risk populations. Subgroup analyses revealed enhanced efficacy with combination therapies (ORR: 85% vs 62%, p < 0.0001) and notable clinical benefits in the China cohort (≥VGPR: 77%, ≥CR: 58%). Safety profiles indicated manageable cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, though infection risks required vigilant management.

Conclusions

Teclistamab continues to be a promising and effective treatment option for RRMM patients, including those previously exposed to BCMA-targeted therapies, and offers new hope for overcoming resistance and achieving better early disease control. Further research is needed to optimize its application in diverse populations, particularly in Asian cohorts.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier CRD42025633838.

Population pharmacokinetics and dose optimization of voriconazole in patients with COVID-19-associated pulmonary aspergillosis

Objectives

The study aimed to investigate the pharmacokinetic profile of voriconazole in patients with COVID-19-associated pulmonary aspergillosis (CAPA) to optimize dosing strategies.

Methods

Population pharmacokinetic modeling was conducted using clinical data from CAPA patients to analyze voriconazole's pharmacokinetic behavior. A one-compartment model with first-order elimination was employed to characterize voriconazole disposition. Covariate analysis was further utilized to evaluate the impact of continuous renal replacement therapy (CRRT) and select biochemical markers on voriconazole clearance.

Results

The model estimated voriconazole's apparent clearance (CL/F) at 3.17 L/h and apparent volume of distribution (V/F) at 135 L for a standard patient with CAPA. Covariates such as CRRT, C-reactive protein, gamma-glutamyl transpeptidase, aspartate aminotransferase, and platelet count were found to significantly influence voriconazole clearance. Monte Carlo simulations indicated that patients on CRRT required both a higher loading dose and an increased maintenance dose compared to those not on CRRT.

Conclusion

This study provides an evidence-based guide for voriconazole dosing adjustments in CAPA patients, particularly for those undergoing CRRT. The findings emphasize the importance of individualized dosing to improve therapeutic outcomes in this high-risk population.

KL-6 as a predictor of coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) and mortality in critically ill COVID-19 patients: A single-center retrospective cohort study

This study evaluated the predictive value of Krebs von den Lungen-6 (KL-6) for the development of coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) and its association with mortality in critically ill COVID-19 patients. A retrospective single-center cohort study was conducted on critically ill COVID-19 patients who required high-flow oxygen or mechanical ventilation between January 2021 and June 2023. Serial serum KL-6 levels were measured at admission and weekly thereafter. The predictive performance of initial KL-6 was assessed using ROC curve analysis, and risk factors for CAPA and 30-day mortality were analyzed using multivariable models. Among 238 patients, 25 (10.5%) developed CAPA. Initial KL-6 demonstrated good discriminative ability for CAPA prediction (AUC 0.745; 95% CI: 0.685-0.799), with an optimal cutoff of 270.9 U/ml (sensitivity: 88.0%, specificity: 55.4%). KL-6 ≥ 270.9 U/ml remained independently associated with CAPA (aHR: 9.66; 95% CI: 2.28-40.89) after multivariable analysis. Serial measurements showed a trend toward a greater increase in KL-6 levels among CAPA patients than non-CAPA patients (median difference: 259.9 vs. 73.0 U/ml, P = .053). Additional independent predictors of CAPA included inotropic/vasopressor support, diabetes mellitus, and tocilizumab use. CAPA patients had higher all-cause 30-day mortality (60.8% vs. 45.2%; P = .020), which remained significant after adjustment (aHR: 2.19; 95% CI: 1.08-4.15). Furthermore, KL-6 was independently associated with 30-day mortality (aHR: 1.03 per 100 U/ml; 95% CI: 1.00-1.07). These findings suggest that KL-6 is a promising biomarker for predicting CAPA and mortality in critically ill COVID-19 patients.

Incidence and risk factors of COVID-19-associated pulmonary aspergillosis in severe cases: A single-center study from Japan

OBJECTIVE

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a serious complication in patients with severe COVID-19. This study investigated the incidence and risk factors for CAPA in patients with severe COVID-19 at Osaka Public University Hospital from April 2020 to November 2021.

METHODS

This retrospective study involved patients with CAPA patients requiring invasive ventilation who were diagnosed according to the European Confederation of Medical Mycology and the International Society of Human and Animal Mycology criteria. Patients were classified into the CAPA and non-CAPA groups. Data collected included age, sex, body mass index, smoking history, underlying disease, length of hospital stay, steroid and other drug use, extracorporeal membrane oxygenation use, and outcome. Univariate analysis was used to identify risk factors associated with CAPA.

RESULTS

Of the 256 COVID-19 patients, 187 required invasive ventilation, and eight were diagnosed with CAPA. The incidence of CAPA among COVID-19 patients requiring ventilator management was 4.28 %. Tracheostomy was performed in seven patients, and Aspergillus spp. was detected in six, of whom four were confirmed to have A. fumigatus. CAPA mortality was high, with six of eight patients dying. Univariate analysis showed COPD (P = 0.04) and chronic liver disease (P = 0.04) as common comorbidities. β-D-glucan positivity, tracheostomy, prolonged hospitalization, prolonged steroid use, and death (P < 0.01) were more prevalent in the CAPA group.

CONCLUSIONS

When bronchoscopy is unfeasible, early diagnosis using serum Aspergillus antigen measurement and imaging is essential, particularly for patients with COPD, liver disease, or risk factors like prolonged hospitalization or steroid use post-COVID-19 treatment.

An Observational Cohort Study of Bronchoalveolar Lavage Fluid Galactomannan and Aspergillus Culture Positivity in Patients Requiring Mechanical Ventilation

Background

Critically ill patients who develop invasive pulmonary aspergillosis (IPA) have high mortality rates despite antifungal therapy. Diagnosis is difficult in these patients and incidences vary in the literature. Bronchoalveolar lavage (BAL) fluid galactomannan (GM) is a helpful marker, although the optimal cutoff is unclear.

Methods

This was a single-center cohort study of patients requiring mechanical ventilation in the medical intensive care unit (ICU) from June 2018 to March 2023. Demographics, BAL, and outcome data were extracted from the electronic health record and compared between groups of patients who grew Aspergillus from BAL, those who had elevated BAL GM levels (>0.5, >0.8, or >1.0) but did not grow Aspergillus, and those with neither.

Results

Of >1700 BALs from 688 patients, only 18 BALs from 15 patients grew Aspergillus. Patients who grew Aspergillus had more intubated days (29 vs 11, P = .002) and more ICU days (34 vs 15, P = .002). BAL GM level was higher from samples that grew Aspergillus than those that did not (median optical density index: 7.08 vs 0.11, P < .001).

Conclusions

In this large cohort of critically ill patients, we found a low rate of Aspergillus growth and variable BAL GM elevation. These data suggest that the pretest probability of IPA should be considered low in a general ICU population undergoing BAL evaluation to define the etiology of pneumonia. Elevated BAL GM may not reliably indicate invasive disease, but lack of culture positivity may also miss true infection. Improved scoring systems are needed to enhance pretest probability for diagnostic test stewardship purposes, and tests must be interpreted in their own clinical contexts.

Machine Learning Methods Based on Chest CT for Predicting the Risk of COVID-19-Associated Pulmonary Aspergillosis

RATIONALE AND OBJECTIVES

To develop and validate a machine learning model based on chest CT and clinical risk factors to predict secondary aspergillus infection in hospitalized COVID-19 patients.

MATERIALS AND METHODS

This retrospective study included 291 COVID-19 patients with complete clinical data between December 2022 and March 2024, and some (n=82) of them developed secondary aspergillus infection after admission. Patients were divided into training (n=162), internal validation (n=69) and external validation (n=60) cohorts. The least absolute shrinkage and selection operator regression was applied to select the most significant image features extracted from chest CT. Univariate and multivariate logistic regression analyses were performed to develop a multifactorial model, which integrated chest CT with clinical risk factors, to predict secondary aspergillus infection in hospitalized COVID-19 patients. The performance of the constructed models was assessed with the receiver operating characteristic curve and the area under the curve (AUC). The clinical application value of the models was comprehensively evaluated using decision curve analysis (DCA).

RESULTS

Eleven radiomics features and seven clinical risk factors were selected to develop prediction models. The multifactorial model demonstrated a favorable predictive performance with the highest AUC values of 0.98 (95% CI, 0.96-1.00) in the training cohort, 0.98 (95% CI, 0.96-1.00) in the internal validation cohort, and 0.87 (95% CI, 0.75-0.99) in the external validation cohort, which was significantly superior to the models relied solely on chest CT or clinical risk factors. The calibration curves from Hosmer-Lemeshow tests showed that there were no significant differences in the training cohort (p=0.359) and internal validation cohort (p=0.941), suggesting the good performance of the multifactorial model. DCA indicated that the multifactorial model exhibited better performance than others.

CONCLUSION

The multifactorial model can serve as a reliable tool for predicting the risk of COVID-19-associated pulmonary aspergillosis.

Pulmonary aspergillosis in US Veterans with COVID-19: a nationwide, retrospective cohort study

Background

COVID-associated pulmonary aspergillosis (CAPA) was described early in the pandemic as a complication of SARS-CoV-2. Data about incidence of aspergillosis and characteristics of affected patients after mid-2021 are limited.

Methods

A retrospective, nationwide cohort of US Veterans with SARS-CoV-2 from 1/1/2020 to 2/7/2024 was created. Potential cases of aspergillosis ≤12 weeks of a SARS-CoV-2 test were flagged electronically (based on testing results indicative of invasive fungal infection, antifungal therapy, and/or ICD-10 codes), followed by manual review to establish the clinical diagnosis of pulmonary aspergillosis. Incidence rates were calculated per 10,000 SARS-CoV-2 cases. Selected clinical characteristics included age >70, receipt of immune-compromising drugs, hematologic malignancy, chronic respiratory disease, vaccination status, and vaccine era. Multivariate logistic regression was used to estimate the independent effects of these variables via adjusted odds ratios (aOR).

Results

Among 674,343 Veterans with SARS-CoV-2, 165 were electronically flagged for review. Of these, 66 were judged to be cases of aspergillosis. Incidence proportions ranged from 0.30/10,000 among patients with zero risk factors to 34/10,000 among those with ≥3 risk factors; rates were similar in the pre- and post-vaccination eras. The 90-day mortality among aspergillosis cases was 50%. In the multivariate analysis, immune suppression (aOR 6.47, CI 3.84-10.92), chronic respiratory disease (aOR 3.57, CI 2.10-6.14), and age >70 (aOR 2.78, CI 1.64-4.80) were associated with aspergillosis.

Conclusions

Patients with underlying risk factors for invasive aspergillosis continue to be at some risk despite SARS-CoV-2 immunization. Risk in patients without immune suppression or preexisting lung disease is very low.

Invasive Aspergillosis in the Intensive Care Unit

Invasive aspergillosis (IA) is a fungal infection, which has traditionally been associated with neutropenia and immunosuppressive therapies. Our understanding of invasive aspergillosis has been evolving and, in the past few decades, IA among ICU patients has been recognized as a common infection and has become more widely recognized. The diagnosis and management of invasive aspergillosis in the ICU is particularly challenging, due to the unstable clinical condition of the patients, lack of diagnostic markers, increased risk of further clinical deterioration, multiple comorbidities, and a need for early assessment and treatment. In this article, we will discuss the challenges and pitfalls of the diagnosis and management of invasive aspergillosis in an ICU setting, along with a review of the current literature that is pertinent and specific to this population.

Implications for the diagnosis of aspiration and aspergillosis in critically ill patients with detection of galactomannan in broncho-alveolar lavage fluids

Invasive infections with Aspergillus fumigatus in ICU patients are linked to high morbidity and mortality. Diagnosing invasive pulmonary aspergillosis (IPA) in non-immunosuppressed patients is difficult, as Aspergillus antigen (galactomannan [GM]) may have other causes. This retrospective study analyzed 160 ICU surgical patients with positive GM in broncho-alveolar lavage fluid (BALF), classifying them based on AspICU criteria for suspected IPA (pIPA) or aspiration. Patients with pIPA had higher disease severity than those with aspiration, including higher dialysis rates, organ transplantation, corticosteroid use, and Sequential Organ Failure Assessment (SOFA) score. Aspergillus culture was positive in 47.0% of pIPA cases but only 2.6% of aspiration cases (p < 0.001). SOFA score at first positive GM in BALF independently predicted 28-day mortality. In surgical patients with a positive GM in BALF, aspiration is more likely if there's no corticosteroid therapy, negative Aspergillus culture, and a history of aspiration events. Diagnosis of pIPA requires Aspergillus culture or prior corticosteroid therapy in this cohort of critically ill patients.

Viral reactivations and fungal infections in nonresolving acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a condition affecting 10% of patients requiring admission to the intensive care unit and results from endothelial dysfunction, alveolar epithelial injury and unbalanced inflammation, leading to exudative pulmonary oedema. A significant portion of these patients experience a lung injury that fails to resolve. Persistent or worsening respiratory failure beyond 5 days after the initiation of mechanical ventilation is referred to as nonresolving ARDS. Viral and fungal pathogens can exploit the hyperinflammatory environment and altered immune landscape in ARDS, perpetuating a cycle of ongoing inflammation and lung injury, thereby contributing to the progression towards and persistence of nonresolving ARDS, even in previously immunocompetent patients. This review discusses the significance, pathophysiology, diagnostic challenges and key knowledge gaps concerning various viral and fungal pathogens in nonresolving ARDS, with a particular focus on influenza-associated and COVID-19-associated pulmonary aspergillosis and pulmonary reactivation of Herpesviridae, such as cytomegalovirus and herpes simplex virus. Diagnosing these infections is challenging due to their nonspecific clinical presentation and the inability of current tests to distinguish between fungal colonisation or asymptomatic viral shedding and clinically significant infections or reactivations. A deeper understanding of the complex interplay between these pathogens and the host immune system in the context of ARDS, combined with advances in diagnostic and therapeutic strategies, has the potential to enhance the management and prognosis of patients with nonresolving ARDS.

A global perspective of the changing epidemiology of invasive fungal disease and real-world experience with the use of isavuconazole

Global epidemiological data show that the incidence of invasive fungal disease (IFD) has increased in recent decades, with the rising frequency of infections caused by Aspergillus and Mucorales order species. The number and variety of patients at risk of IFD has also expanded, owing in part to advances in the treatment of hematologic malignancies and other serious diseases, including hematopoietic stem cell transplantation (HCT) and other therapies causing immune suppression. Isavuconazonium sulfate (active moiety: isavuconazole) is an advanced-generation triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis that has demonstrated activity against a variety of yeasts, moulds, and dimorphic fungi. While real-world clinical experience with isavuconazole is sparse in some geographic regions, it has been shown to be effective and well tolerated in diverse patient populations, including those with multiple comorbidities who may have failed to respond to prior triazole antifungal therapy. Isavuconazole may be suitable for patients with IFD receiving concurrent QTc-prolonging therapy, as well as those on venetoclax or ruxolitinib. Data from clinical trials are not available to support the use of isavuconazole prophylactically for the prevention of IFD or for the treatment of endemic IFD, such as those caused by Histoplasma spp., but real-world evidence from case studies suggests that it has clinical utility in these settings. Isavuconazole is an option for patients at risk of IFD, particularly when the use of alternative antifungal therapies is not possible because of toxicities, pharmacokinetics, or drug interactions.

Investigation of risk factors for invasive pulmonary aspergillosis among patients with COVID-19

COVID-19 associated pulmonary aspergillosis (CAPA) had been reported, and raised concern about this secondary infection due to the high mortality. This study aimed to investigate the risk factors for CAPA. The enrolled 114 COVID-19 patients were further divided into CAPA group and non-CAPA group. Demographic characteristics, underlying diseases, laboratory parameters and therapeutic schedule between the two groups were compared to identify the independent risk factors for CAPA by univariate analysis and multivariable logistic regression analysis. Sensitivity and specificity of independent risk factors were confirmed by receiver operating characteristic (ROC) curve analysis. Univariate analysis showed that renal transplant, IL-6 and CRP levels, decreased CD4 + T cell and CD8 + T cell, duration of antibiotics therapy, and prolonged mechanical ventilation were risk factors for development of CAPA. These factors were further analyzed by multivariable logistic regression analysis and the results indicated that elevated IL-6 level, decreased CD4 + T cell and prolonged mechanical ventilation could be recognized as independent risk factors for CAPA in COVID-19 patients. Identification of these risk factors is essential to initiate antifungal therapy as soon as possible to improve outcome of patients with CAPA.

Influenza-associated and COVID-19-associated pulmonary aspergillosis in critically ill patients

Influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) are increasingly recognised as important complications in patients requiring intensive care for severe viral pneumonia. The diagnosis can typically be made in 10-20% of patients with severe influenza or COVID-19, but only when appropriate diagnostic tools are used. Bronchoalveolar lavage sampling for culture, galactomannan testing, and PCR forms the cornerstone of diagnosis, whereas visual examination of the tracheobronchial tract during bronchoscopy is required to detect invasive Aspergillus tracheobronchitis. Azoles are the first-choice antifungal drugs, with liposomal amphotericin B as an alternative in settings where azole resistance is prevalent. Despite antifungal therapy, IAPA and CAPA are associated with poor outcomes, with fatality rates often exceeding 50%. In this Review, we discuss the mechanistic and clinical aspects of IAPA and CAPA. Moreover, we identify crucial knowledge gaps and formulate directions for future research.

Low-Dose Corticosteroids for Critically Ill Adults With Severe Pulmonary Infections: A Review

Importance

Severe pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%.

Observations

Corticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections.

Conclusions and Relevance

Treatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.

COVID-19 associated pulmonary aspergillosis in critically-ill patients: a prospective multicenter study in the era of Delta and Omicron variants

BACKGROUND

During the first COVID-19 pandemic wave, COVID-19-associated pulmonary aspergillosis (CAPA) has been reported in up to 11-28% of critically ill COVID-19 patients and associated with increased mortality. As new SARS-CoV-2 variants emerged, the characteristics of critically ill COVID-19 patients have evolved, particularly in the era of Omicron. The purpose of this study is to investigate the characteristics of CAPA in the era of new variants.

METHODS

This is a prospective multicenter observational cohort study conducted in France in 36 participating intensive care units (ICU), between December 7th, 2021 and April 26th 2023. Diagnosis criteria of CAPA relied on European Confederation of Medical Mycology (ECMM)/International Society for Human & Animal Mycology (ISHAM) consensus criteria.

RESULTS

566 patients were included over the study period. The prevalence of CAPA was 5.1% [95% CI 3.4-7.3], and rose to 9.1% among patients who required invasive mechanical ventilation (IMV). Univariable analysis showed that CAPA patients were more frequently immunosuppressed and required more frequently IMV support, vasopressors and renal replacement therapy during ICU stay than non-CAPA patients. SAPS II score at ICU admission, immunosuppression, and a SARS-CoV-2 Delta variant were independently associated with CAPA in multivariable logistic regression analysis. Although CAPA was not significantly associated with day-28 mortality, patients with CAPA experienced a longer duration of mechanical ventilation and ICU stay.

CONCLUSION

This study contributes valuable insights into the prevalence, characteristics, and outcomes of CAPA in the era of Delta and Omicron variants. We report a lower prevalence of CAPA (5.1%) among critically-ill COVID-19 patients than previously reported, mainly affecting intubated-patients. Duration of mechanical ventilation and ICU stay were significantly longer in CAPA patients.