Risk factors and clinical impact of COVID-19-associated pulmonary aspergillosis: Multicenter retrospective cohort study

The clinical impact of prolonged steroid therapy in severe COVID-19 patients: a retrospective cohort study with propensity score matching

BACKGROUND

The optimal duration of steroid therapy for patients with COVID-19 remains unclear. This study compared clinical outcomes between early steroid withdrawal (EW; ≤10 days) and prolonged steroid tapering (PT; >10 days) in patients with severe COVID-19 requiring oxygen support.

METHODS

This retrospective, single-center cohort study included adult patients with COVID-19 and WHO-CPS scores of 6-9 admitted to a tertiary hospital in Seoul, Republic of Korea. After 1:1 propensity score matching, 68 patients were included in each group. Primary outcomes were 28-day and 60-day mortality. Secondary outcomes included clinical aggravation, rebound pneumonia, infectious complications, readmission or emergency department (ED) revisits, duration of oxygen support, and lengths of hospitalization and ICU stay.

RESULTS

Baseline characteristics were well balanced after matching. No significant differences were observed in 28-day mortality (5.9% vs. 10.3%, HR 0.54, 95% CI 0.16-1.84, p = 0.32) or 60-day mortality (14.7% vs. 11.8%, HR 1.22, 95% CI 0.48-3.10, p = 0.67) between PT and EW groups. Rates of clinical aggravation, rebound pneumonia, infectious complications, and readmission or ED revisit were also comparable. However, the PT group had significantly longer durations of oxygen support (17.5 vs. 13.0 days, p = 0.001), hospitalization (20.0 vs. 14.0 days, p = 0.001), and ICU stay (5.0 vs. 1.0 days, p = 0.01).

CONCLUSIONS

Prolonged steroid therapy beyond 10 days did not improve survival or other clinical outcomes in patients with severe COVID-19, suggesting that early steroid withdrawal may be appropriate for selected patients.

Impact of physician awareness and microbiological examination on incidence of COVID-19-associated pulmonary aspergillosis: a retrospective study

BACKGROUND

The reported incidence of aspergillosis among COVID-19 patients has varied significantly, which can be partly attributed to differences in diagnostic approaches and levels of physicians' proficiency in diagnosing COVID-19-associated pulmonary aspergillosis (CAPA). Consequently, we conducted a retrospective study to investigate the potential reasons for these discrepancies and analyzed the risk factors for pulmonary aspergillosis in patients with COVID-19.

METHOD

Data were retrospectively collected from December 1, 2022, to September 30, 2023, from patients who were admitted to the First Affiliated Hospital of Wenzhou Medical University. The research platform was used to screen patients with discharge diagnoses of COVID-19 pneumonia. CAPA was defined according to the 2020 ECMM/ISHAM criteria and the Chinese expert consensus. Clinical data that were collected included data about underlying diseases, laboratory examinations and microbiological detection. Analyses were conducted with R software, with continuous variables analyzed with t-tests, categorical variables analyzed with chi-square tests, and logistic regression and ROC curves used to assess risk factors for CAPA.

RESULTS

The incidence of CAPA was 13.4% in the general ward, 30.8% in the RICU, and 6.8% in other ICUs. The average time to CAPA diagnosis was 5.6 days in general wards, 3.7 days in the RICU, and 7.4 days in other ICUs. Diagnostic testing revealed the following sensitivities: 78% for BALF galactomannan (GM), 48% for serum GM, 52% for culture tests, and 71% for BALF mNGS. Risk factors for CAPA included chronic respiratory disease, chronic renal insufficiency, and diabetes. The primary Aspergillus species identified was A. fumigatus, followed by A. flavus.

CONCLUSION

Differences in incidence may arise from varying levels of physician awareness, which can influence the rate at which BALF and serum GM samples are submitted for testing. The sensitivity of BALF GM is higher than that of serum GM. Furthermore, BALF mNGS has the potential to enhance the clinical detection sensitivity of CAPA. Risk factors for CAPA include chronic respiratory disease, chronic renal insufficiency, and diabetes, which may aid in identifying at-risk patients. The primary Aspergillus species identified was A. fumigatus, followed by A. flavus, providing a reference for clinical empirical treatment.

CLINICAL TRIAL NUMBER

Not applicable.

Genetic relationships of Aspergillus fumigatus in hospital settings during COVID-19

The transmission pathways and risks of COVID-19-associated pulmonary aspergillosis (CAPA) remain unclear. This study investigated the genetic relationships of Aspergillus fumigatus isolates from patients with and without COVID-19 and environmental air samples to suggest possible transmission patterns. We conducted a prospective study from March 2020 to December 2022, collecting clinical and environmental isolates from a tertiary hospital. Isolates from patients with and without COVID-19 were compared with those from air samples at four hospital locations. The genetic analysis included internal transcribed spacer and β-tubulin A sequencing, with azole resistance assessed via cyp51A gene analysis. Multiple locus variable-number tandem repeat analysis was performed to elucidate genetic relationships. A total of 155 isolates (19 from COVID-19 patients, 104 from non-COVID-19 patients, and 32 from environmental samples) were identified and genotyped, revealing 131 sequence types (Simpson Diversity Index 0.9972). Four CAPA clinical strains genetically related to environmental strains were isolated from the COVID-19 intensive care unit (ICU), while two CAPA clinical strains sharing multiple locus variable-number tandem repeat sequence types and azole-resistant mutations were isolated in the same COVID-19 ICU 4 months apart. All but one of these strains were isolated from patients requiring mechanical ventilation. The observed genetic similarities between strains from critically ill patients with COVID-19 and those from the environment, as well as within the same ICU, raise the possibility of nosocomial acquisition via contaminated air or environmental sources. These findings highlight the risks of CAPA associated with negative pressure rooms and the need for enhanced environmental infection control measures.IMPORTANCEThis study reveals genetic links between Aspergillus fumigatus in patients with COVID-19 and environmental sources, suggesting nosocomial transmission and urging a reevaluation of universal negative pressure isolation practices in hospitals, especially for critically ill patients.

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.

High-Dose Corticosteroid Use in Severe to Critically Ill Patients With COVID-19: A Nationwide Population-Based Matched Cohort Study

BACKGROUND

Systemic corticosteroids have become the standard of care for severe to critically ill patients with coronavirus disease 2019 (COVID-19). However, the real-world efficacy and safety outcomes associated with a higher dose of corticosteroids remain uncertain.

METHODS

We conducted a nationwide, population-based, matched cohort study of severe to critically ill adult patients with COVID-19 between January 2020 and June 2021 in Korea using the National Health Information Database. Patients using systemic corticosteroids were included and high-dose corticosteroid use was defined as a daily mean prescribed dose of more than 6 mg of dexamethasone. We then employed a proportional hazard regression model to identify prognostic factors for 28-day all-cause mortality and conducted a Fine and Gray regression model to assess risk factors for developing COVID-19-associated pulmonary aspergillosis (CAPA).

RESULTS

During the study period, 102,304 patients with COVID-19 were screened, 5,754 met the eligibility criteria, and 2,138 were successfully matched. The mean prescribed daily dose was 4.2 mg and 13.4 mg in the standard- and high-dose groups, respectively, and the mean duration of use was not different between the groups. High-dose corticosteroid use independently increased all-cause mortality at 28 days (adjusted hazard ratio [aHR], 1.48; 95% confidence interval [CI], 1.25-1.76) and 90 days (aHR, 1.63; CI, 1.44-1.85) after admission. Subgroup analysis revealed a statistically significant elevation in the risk of mortality among patients using low-flow or high-flow nasal cannulas, with aHRs of 1.41 and 1.46, respectively. No significant impact of high-dose steroids was observed, even in patients who underwent mechanical ventilation at 28 days (aHR, 1.17; CI, 0.79-1.72). As a safety outcome, high-dose corticosteroid use showed an association with the development of CAPA (aHR, 2.97; 95% CI, 0.94-9.43).

CONCLUSION

Among severe to critically ill patients with COVID-19, high-dose corticosteroid use was associated with increased 28-day all-cause mortality and showed a trend toward the development of CAPA.

ISCCM Position Statement on the Management of Invasive Fungal Infections in the Intensive Care Unit

Rationale

Invasive fungal infections (IFI) in the intensive care unit (ICU) are an emerging problem owing to the use of broad-spectrum antibiotics, immunosuppressive agents, and frequency of indwelling catheters. Timely diagnosis which is imperative to improve outcomes can be challenging. This position statement is aimed at understanding risk factors, providing a rational diagnostic approach, and guiding clinicians to optimize antifungal therapy.

Objectives

To update evidence on epidemiology, risk factors, diagnostic approach, antifungal initiation strategy, therapeutic interventions including site-specific infections and role of therapeutic drug monitoring in IFI in ICU and focus on some practice points relevant to these domains.

Methodology

A committee comprising critical care specialists across the country was formed and specific aspects of fungal infections and antifungal treatment were assigned to each member. They extensively reviewed the literature including the electronic databases and the international guidelines and cross-references. The information was shared and discussed over several meetings and position statements were framed to ensure their reliability and relevance in critical practice. The draft document was prepared after obtaining inputs and consensus from all the members and was reviewed by an expert in this field.

Results

The existing evidence on the management of IFI was updated and practice points were prepared under each subheading to enable critical care practitioners to streamline diagnosis and treatment strategies for patients in the ICU with additional detail on site-specific infections therapeutic drug monitoring.

Conclusion

This position statement attempts to address the management of IFI in immunocompetent and non-neutropenic ICU patients. The practice points should guide in optimization of the management of critically ill patients with suspected or proven fungal infections.

How to cite this article

Bhattacharya PK, Chakrabarti A, Sinha S, Pande R, Gupta S, Kumar AAK, et al. ISCCM Position Statement on the Management of Invasive Fungal Infections in the Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S20-S41.

Real-world study of lazertinib as second-line or greater treatment in advanced non-small cell lung cancer

BACKGROUND

Lazertinib is an oral, third-generation EGFR-TKI, which specifically targets the EGFR T790M mutation along with activating mutations Ex19del and L858R. More real-world data are needed to evaluate its efficacy and safety in treating locally advanced and metastatic non-small cell lung cancer (NSCLC) following prior EGFR TKI treatment.

METHODS

This multicenter retrospective study was conducted at seven university hospitals affiliated to the Catholic Medical Center (CMC) in Korea. A clinical data warehouse (CDW) platform was used to access and extract information.

RESULTS

A total of 48 patients were assessed. The majority were female (75%) and diagnosed with adenocarcinoma (95.8%). All patients had the EGFR mutation at diagnosis, 27 (56.3%) had the exon 19 deletion, 20 (41.7%) had the L858R mutation, and one (2.0%) had the exon 18 mutation. The median progression-free survival (PFS) was 15.4 months. At 6, 12, and 18 months, PFS rates were 79.1%, 53.6%, and 27.3%, respectively. When PFS was analyzed by prior TKI duration (<18 months vs. >18 months), significant differences were noted at the 6 and 9-month mark (p = 0.013 and p = 0.010, respectively). In multivariate analysis for PFS, only prior TKI duration and ECOG score showed statistical significance (p = 0.026 and p = 0.049, respectively). In the multivariate analysis for OS, ECOG score showed statistical significance (p = 0.006). Among 48 patients, 34 (70.8%) experienced adverse events (AEs) related to lazertinib. The most frequent AEs were skin reaction (29.8%), diarrhea (21.3%), and peripheral neuropathy (20.8%).

CONCLUSIONS

The results suggest that lazertinib is effective in second or more line settings, with tolerable safety profile. More patient data are necessary to find possible prognostic markers associated with patient outcome.

Age difference of patients with and without invasive aspergillosis: a systematic review and meta-analysis

BACKGROUND

Invasive Aspergillosis (IA) is a life-threatening fungal disease with significant mortality rates. Timely diagnosis and treatment greatly enhance patient outcomes. This study aimed to explore the association between patient age and the development of IA, as well as the potential implications for risk stratification strategies.

METHODS

We searched National Center for Biotechnology Information (NCBI) databases for publications until October 2023 containing age characteristics of patients with and without IA. A random-effects model with the application of inverse-variance weighting was used to pool reported estimates from each study, and meta-regression and subgroup analyses were utilized to assess sources of heterogeneity.

RESULTS

A systematic review was conducted, resulting in the inclusion of 55 retrospective observational studies with a total of 13,983 patients. Meta-analysis revealed that, on average, patients with IA were approximately two and a half years older (95% Confidence Interval [CI] 1.84-3.31 years; I2 = 26.1%) than those without the disease (p < 0.0001). No significant moderators could explain the observed heterogeneity in age difference. However, subgroup analysis revealed that age differences were more pronounced within particular patient groups compared to others. For example, patients with and without IA who had primary severe lung infections exhibited a greater difference in mean age than other patient cohorts.

CONCLUSIONS

Further research, such as individual patient data meta-analysis, is necessary to better understand the potential relationship between increasing age and the likelihood of IA. Improved risk stratification strategies based on patient age could potentially enhance the early detection and treatment of IA, ultimately improving patient outcomes.

Clinical Implementation of β-Tubulin Gene-Based Aspergillus Polymerase Chain Reaction for Enhanced Aspergillus Diagnosis in Patients with Hematologic Diseases: A Prospective Observational Study

The β-tubulin (benA) gene is a promising target for the identification of Aspergillus species. Assessment of the clinical implementation and performance of benA gene-based Aspergillus polymerase chain reaction (PCR) remains warranted. In this study, we assessed the analytical performance of the BenA probe PCR in comparison with the Aspergenius kit. We prospectively collected bronchoalveolar lavage (BAL) fluid via diagnostic bronchoscopy from adult patients with hematologic diseases. BenA gene-based multiplex real-time PCR and sequential melting temperature analysis were performed to detect the azole resistance of Aspergillus fumigatus. In total, 76 BAL fluids in 75 patients suspicious of invasive pulmonary aspergillosis (IPA) were collected. Before the application of PCR, the prevalence of proven and probable IPA was 32.9%. However, after implementing the benA gene-based PCR, 15.8% (12 out of 76) of potential IPA cases were reclassified as probable IPA. The analytical performance of the BenA probe PCR in BAL samples was comparable to that of the Aspergenius kit. The diagnostic performance was as follows: sensitivity, 52.0%; specificity, 64.7%; positive predictive value, 41.9%; negative predictive value, 73.3%; positive likelihood ratio, 1.473; and negative likelihood ratio, 0.741. Moreover, benA gene-based Aspergillus PCR discriminated all major sections of Aspergillus, including cryptic species such as Aspergillus tubingensis. Sequential melting temperature analysis successfully detected 2 isolates (15.4%) of A. fumigatus carrying resistant mutations. BenA gene-based Aspergillus PCR with melting temperature analysis enhances diagnostic accuracy and detects not only cryptic species but also resistant mutations of A. fumigatus. It shows promise for clinical applications in the diagnosis of IPA.

Prediction of intradialytic hypotension using pre-dialysis features-a deep learning-based artificial intelligence model

BACKGROUND

Intradialytic hypotension (IDH) is a serious complication of hemodialysis (HD) that is associated with increased risks of cardiovascular morbidity and mortality. However, its accurate prediction remains a clinical challenge. The aim of this study was to develop a deep learning-based artificial intelligence (AI) model to predict IDH using pre-dialysis features.

METHODS

Data from 2007 patients with 943 220 HD sessions at seven university hospitals were used. The performance of the deep learning model was compared with three machine learning models (logistic regression, random forest and XGBoost).

RESULTS

IDH occurred in 5.39% of all studied HD sessions. A lower pre-dialysis blood pressure (BP), and a higher ultrafiltration (UF) target rate and interdialytic weight gain in IDH sessions compared with non-IDH sessions, and the occurrence of IDH in previous sessions was more frequent among IDH sessions compared with non-IDH sessions. Matthews correlation coefficient and macro-averaged F1 score were used to evaluate both positive and negative prediction performances. Both values were similar in logistic regression, random forest, XGBoost and deep learning models, developed with data from a single session. When combining data from the previous three sessions, the prediction performance of the deep learning model improved and became superior to that of other models. The common top-ranked features for IDH prediction were mean systolic BP (SBP) during the previous session, UF target rate, pre-dialysis SBP, and IDH experience during the previous session.

CONCLUSIONS

Our AI model predicts IDH accurately, suggesting it as a reliable tool for HD treatment.

Significance of Aspergillus spp. isolation in defining cases of COVID-19 Associated Pulmonary Aspergillosis - CAPA

COVID-19-Associated Pulmonary Aspergillosis (CAPA) is a relatively common complication in patients with severe forms of the disease caused by the SARS-CoV-2 virus. Diagnosing and confirming CAPA is challenging. In this study, Aspergillus spp. isolation in respiratory specimens from patients with COVID-19 was evaluated for identifying cases of CAPA. In 2020‒2021, 17 Aspergillus spp. were isolated from 15 COVID-19 patients admitted to a university hospital in Brazil. Patient records were retrospectively reviewed to obtain clinical-epidemiological data and other markers of Aspergillus spp. infection and then compared with the ECMM/ISHAM criteria for defining CAPA. Probable CAPA was defined in 5/10 patients, who had Aspergillus spp. isolated from Bronchoalveolar Lavage (BAL) or a positive galactomannan blood test. Additionally, anti-Aspergillus antibodies were detected in two of these patients, during active or follow-up phases of CAPA. In another seven patients with Aspergillus spp. isolated from tracheobronchial aspirate or sputum, CAPA was presumed, mainly due to deterioration of clinical conditions and new lung imaging suggestive of fungal infection. Antifungal agents to control CAPA, particularly voriconazole, were used in 9/15 cases. In cases of probable CAPA and remaining patients, clinical conditions and comorbidities were similar, with lethality being high, at 60% and 71%, respectively. The number of CAPA cases defined by scientific criteria was lower than that assumed in the clinical context. This was largely due to the lack of BAL collection for fungal culture and the non-intensive use of other markers of invasive aspergillosis. The isolation of Aspergillus spp. in different respiratory specimens should alert clinicians to the diagnosis of CAPA.

Mortality in ICU Patients with COVID-19-Associated Pulmonary Aspergillosis

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.

The Impact of Corticosteroids on the Outcome of Fungal Disease: a Systematic Review and Meta-analysis

Purpose of Review

Corticosteroids have a complex relationship with fungal disease - risk for many, benefit for others. This systematic review aims to address the effect of corticosteroids on mortality and visual outcome in different fungal diseases.

Recent Findings

Corticosteroids are a risk factor of aspergillosis for patients who have COVID-19, and they also led to a worse outcome. Similarity, corticosteroids are a risk factor for candidemia and mucormycosis. Some researchers reported that using topical corticosteroid in keratitis was associated with worse visual outcome if fungal keratitis. Some studies showed that corticosteroids are linked to a negative outcome for non-HIV patients with Pneumocystis jirovecii pneumonia (PCP), in contrast to those with HIV and PCP.

Summary

In 59 references, we found that corticosteroid therapy showed a worse clinical outcome in invasive aspergillosis (IA) (HR: 2.50, 95%CI: 1.89-3.31, p < 0.001) and chronic pulmonary aspergillosis (CPA) (HR: 2.74, 95%CI: 1.48-5.06, p = 0.001), PCP without HIV infection (OR: 1.29, 95%CI: 1.09-1.53, p = 0.003), invasive candidiasis and candidaemia (OR: 2.13, 95%CI: 1.85-2.46, p < 0.001), mucormycosis (OR: 4.19, 95%CI: 1.74-10.05, p = 0.001) and early in the course of fungal keratitis (OR: 2.99, 95%CI: 1.14-7.84, p = 0.026). There was equivocal outcome in cryptococcal meningoencephalitis in AIDS and primary coccidioidomycosis, while corticosteroid therapy showed a better outcome in PCP in HIV-infected patients (RR: 0.62, 95%CI: 0.46-0.83, p=0.001) and fungal keratitis patients after keratoplasty surgery (OR: 0.01, 95%CI: 0.00-0.41, p = 0.041) and probably in cryptococcal meningoencephalitis in non-immunocompromised patients. A sub-analysis in invasive aspergillosis and CPA showed that use of more than 2 mg/kg/day of prednisolone equivalents per day is a significant factor in increasing mortality (HR: 2.94, 95%CI: 2.13-4.05, p < 0.001). Corticosteroid therapy during invasive fungal disease was usually associated with a slightly or greatly increased mortality or worse visual outcome (in fungal keratitis), with two disease exceptions. Avoiding the addition of corticosteroids, or minimising dose and duration in those who require them, is likely to improve the outcome of most life- and vision-threatening fungal diseases. This review provides a cornerstone for further research in exploring the accuracy of suitable dose and duration of corticosteroids treatment in fungal diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-023-00456-2.

Diagnosis and Treatment of Invasive Mold Diseases

Although invasive fungal diseases are relatively less common than superficial diseases, there has been an overall increase in their incidence. Here, I review the epidemiology, diagnosis, and treatment of invasive mold diseases (IMDs) such as aspergillosis, mucormycosis, hyalohyphomycosis, and phaeohyphomycosis. Histopathologic demonstration of tissue invasion by hyphae or recovery of mold by the culture of a specimen obtained by a sterile procedure provides definitive evidence of IMD. If IMD cannot be confirmed through invasive procedures, IMD can be diagnosed through clinical criteria such as the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Instituteof Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions. For initial primary therapy of invasive aspergillosis, voriconazole or isavuconazole is recommended and lipid formulations of amphotericin B are useful primary alternatives. Echinocandins are representative antifungal agents for salvage therapy. Treatment of invasive mucormycosis involves a combination of urgent surgical debridement of involved tissues and antifungal therapy. Lipid formulations of amphotericin B are the drug of choice for initial therapy. Isavuconazole or posaconazole can be used as salvage or step-down therapy. IMDs other than aspergillosis and mucormycosis include hyalohyphomycosis and phaeohyphomycosis, for which there is no standard therapy and the treatment depends on the clinical disease and status of the patient.

Comparison of risk factors and outcome of patients with and without COVID ‐19 associated pulmonary aspergillosis from Pakistan: A case‐control study

Background

Early identification of COVID‐19‐associated pulmonary aspergillosis (CAPA) is particularly challenging in low‐ middle‐income countries where diagnostic capabilities are limited, and risk factors for CAPA have not been identified. It is also essential to recognise CAPA patients who are likely to have a poorer outcome to decide on aggressive management approaches. Therefore, this study aimed to identify risk factors and outcomes for CAPA among admitted moderate to critical COVID‐19 patients at our centre in Pakistan.

Methods

An unmatched case–control study with ratio of 1:2 was conducted on hospitalised adult patients with COVID‐19 from March 2020–July 2021. Cases were defined according to European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus criteria. Controls were defined as patients hospitalised with moderate, severe or critical COVID‐19 without CAPA.

Results

A total of 100 CAPA cases (27 probable CAPA; 73 possible CAPA) were compared with 237 controls. Critical disease at presentation (aOR 5.04; 95% CI 2.18–11.63), age ≥ 60 years (aOR 2.00; 95% CI 1.20–3.35) and underlying co‐morbid of chronic kidney disease (CKD) (aOR 3.78; 95% CI 1.57–9.08) were identified as risk factors for CAPA. Patients with CAPA had a significantly greater proportion of complications and longer length of hospital stay (p‐value < .001). Mortality was higher in patients with CAPA (48%) as compared to those without CAPA (13.5%) [OR = 6.36(95% CI 3.6–11)].

Conclusions

CAPA was significantly associated with advanced age, CKD and critical illness at presentation, along with a greater frequency of complications and higher mortality.

COVID-19 Syndemic: Convergence of COVID-19, Pulmonary Aspergillosis (CAPA), Pulmonary Tuberculosis, Type 2 Diabetes Mellitus, and Arterial Hypertension

Bacterial coinfections, which increase the severity of respiratory viral infections, are frequent causes of mortality in influenza pandemics but have not been well characterized in patients with Coronavirus disease 2019 (COVID-19). Moreover, the association of COVID-19 infection with pulmonary Mycobacterium tuberculosis disease (TB) and concurrent pulmonary fungal infection is not well known. The classification of patients with COVID-19-associated pulmonary aspergillosis (CAPA) using the current definitions for invasive fungal diseases has proven difficult. In this study, we aimed to provide information about three patients with underlying diseases ongoing with COVID-19 and co-infection with pulmonary TB, and with COVID-19-associated pulmonary aspergillosis (CAPA). At the time of hospital admission, each patient presented complications such as decompensated T2DM with diabetic ketoacidosis and/or hypertension. Findings of chest computed tomography and serum galactomannan by radioimmunoassay were useful for classifying them as possible CAPA. One of the three possible CAPA cases was fatal. These three cases are rare and are the first of their kind reported worldwide. The generation of reliable algorithms, early diagnosis, standardization of classification criteria, and the selection of specific and personalized treatments for COVID-19-associated opportunistic infections, including CAPA, are necessary to improve outcomes in these kinds of patients.