Incidence and risk factors for coronavirus disease 2019-associated pulmonary aspergillosis using administrative claims data

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.

Epidemiology, antifungal susceptibility and biological characteristics of clinical Aspergillus fumigatus in a tertiary hospital

Azole resistance in Aspergillus fumigatus poses a significant clinical challenge globally. In this study, we analyzed 307 clinical A. fumigatus isolates from General Hospital of Ningxia Medical University in China, collected between July 2023 and July 2024, to explore their susceptibility profiles, genotypic characteristics and biological traits. The overall frequency of azole resistance among clinical isolates in Ningxia province was found to be 1.20% (7 azole-resistant A. fumigatus, designated AF1-AF7), each exhibiting distinct phenotypes in terms of azole resistance, spore viability, and resilience to environmental stress. Among these strains, the cyp51A mutations predominantly included TR43/L98H, while the hmg1 mutations were primarily S212P/Y564H. Additionally, novel mutations were discovered in cyp51B, specifically the t-215c point mutation and a base deletion (gatgccta) in the - 213 to - 206 region. The AF3 strain demonstrated the highest spore activity and anti-SDS efficacy. In contrast, the AF1 and AF2 strains were resistant to three azoles and also exhibited resistance to Menadione, similar to AF7. Notably, six out of the seven strains displayed resistance to NaCl and KCl, indicating a strong tolerance to saline conditions. These findings suggest that azole-resistant strains possess varying degrees of resistance to environmental stressors, implying that they may adapt to their surroundings through different evolutionary pathways, which could complicate clinical treatment strategies. Effective surveillance and control strategies are essential to control the widespread prevalence of azole-resistant A. fumigatus and to reduce the risk of infection in patients.

Assessment of incidence and risk factors of COVID-19-associated candidemia using diagnosis procedure combination data

BACKGROUND

Candidemia is an important coronavirus disease 2019 (COVID-19)-associated invasive fungal infection. Patients with COVID-19 may be susceptible to candidemia; however, evidence regarding its incidence, risk factors, and involvement in mortality is insufficient.

OBJECTIVES

To explore the incidence of and potential risk factors for candidemia in patients with severe or critical COVID-19 and evaluate the relationship between candidemia and mortality in patients with severe or critical COVID-19.

METHODS

The incidence of candidemia in patients with severe and critical COVID-19 was evaluated using administrative claims data from acute care hospitals in Japan. Multivariable regression models were used to explore potential risk factors for candidemia and their contribution to mortality in patients with severe and critical COVID-19.

RESULTS

Candidemia occurred in 0.3-1.1 % of patients with severe or critical COVID-19. Renal impairment, use of steroid, blood transfusion, and use of central venous catheter were potential risk factors for candidemia in patients with severe to critical COVID-19.

CONCLUSIONS

Candidemia in patients with COVID-19 was an independent risk factor for mortality. Candidemia in patients with severe to critical COVID-19 is a grave complication and may increase mortality.

Changes in Candidemia during the COVID-19 Pandemic: Species Distribution, Antifungal Susceptibility, Initial Antifungal Usage, and Mortality Trends in Two Korean Tertiary Care Hospitals

This study aimed to investigate changes in candidemia incidence, species distribution, antifungal susceptibility, initial antifungal use, and mortality trends in Korea before and during the COVID-19 pandemic. A retrospective analysis was conducted on candidemia cases from two tertiary care hospitals in Korea between 2017 and 2022. Data were compared between the pre-pandemic (2017-2019) and pandemic (2020-2022) periods. Statistical methods included incidence rate ratios (IRRs) and multivariate Cox regression to assess 30-day mortality risk factors. A total of 470 candidemia cases were identified, with 48.7% occurring pre-pandemic and 51.3% during the pandemic. While the overall incidence of candidemia remained similar across the two periods (IRR 1.15; p=0.13), the incidence in intensive care units (ICUs) significantly increased during the pandemic (IRR 1.50; p<0.01). The distribution of Candida species did not differ significantly between the two periods. Fluconazole non-susceptibility in C. albicans markedly decreased (10.0% vs. 0.9%, p<0.01), whereas C. glabrata exhibited a significant rise in caspofungin non-susceptibility during the pandemic (0% vs. 22.4%, p<0.01). Echinocandin use increased (21.8% vs. 34.4%; p<0.01), while fluconazole use declined (48.0% vs. 32.8%; p<0.01). Although the 30-day mortality rate was higher during the pandemic (60.2% vs. 57.2%), the difference was not statistically significant (p=0.57). The findings highlight the need for region-specific surveillance and tailored management strategies to improve candidemia outcomes, especially during healthcare disruptions like the COVID-19 pandemic.