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Objectives Coronavirus disease 2019 (COVID-19) associated pulmonary aspergillosis (CAPA) has emerged as a complication in critically ill COVID-19 patients. The objectives of this multinational study were to determine the prevalence of CAPA in patients with COVID-19 in intensive care units (ICU) and to investigate risk factors for CAPA as well as outcome. Methods The European Confederation of Medical Mycology (ECMM) conducted a multinational study including 20 centers from nine different countries to assess epidemiology, risk factors, and outcome of CAPA. CAPA was defined according to the 2020 ECMM/ISHAM consensus definitions. Results A total of 592 patients were included in this study, including 11 (1.9%) patients with histologically proven CAPA, 80 (13.5%) patients with probable CAPA, 18 (3%) with possible CAPA and 483 (81.6%) without CAPA. CAPA was diagnosed a median of 8 days (range 0-31) after ICU admission predominantly in older patients [adjusted hazard ratio (aHR) 1.04 per year; 95%CI 1.02-1.06] with any form of invasive respiratory support (HR 3.4; 95%CI 1.84-6.25) and receiving tocilizumab (HR 2.45; 95%CI 1.41-4.25). Median prevalence of CAPA per center was 10.7% (range 1.7%-26.8%). CAPA was associated with significantly lower 90-day ICU survival rate (29% in patients with CAPA versus 57% in patients without CAPA; Mantel-Byar p<0.001 ) and remained an independent negative prognostic variable after adjusting for other predictors of survival (HR=2.14; 95%CI: 1.59-2.87, p<=0.001 ). Conclusion Prevalence of CAPA varied between centers. CAPA was significantly more prevalent among older patients, patients receiving invasive ventilation and patients receiving tocilizumab, and was an independent strong predictor of ICU mortality.

I ncidence of coronavirus disease (COVID-19)associated pulmonary aspergillosis (CAPA) in hospital intensive care units (ICUs) is 3.8%-33.3% (1-9). Variations might be explained by differences in patient populations and CAPA defi nitions used, complicating direct comparisons between studies.Diagnosing CAPA is complex because cases frequently lack typical radiologic features and European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) host factors ( 10) and because mycologic evidence is diffi cult to obtain. Serum galactomannan (GM) detection has low sensitivity in CAPA (7,10).The European Confederation of Medical Mycology and International Society for Human and Animal Mycology (ECMM/ISHAM) published consensus criteria for a CAPA defi nition (11). We used these criteria to perform an observational cohort study to assess CAPA incidence in patients with COVID-19 admitted to ICUs during the fi rst wave of the COVID-19 pandemic. The StudyWe collected partially prospective and partially retrospective data for 823 patients in 2 cohorts. The discovery cohort comprised patients with PCR-confi rmed or clinically presumed COVID-19 admitted to 4 ICUs in the Netherlands and 4 ICUs in Belgium during February 28-May 27, 2020. The validation cohort comprised patients with PCR-confi rmed COVID-19 admitted because of respiratory insuffi ciency to 3 participating ICUs in France during April 7-May 31, 2020 (Appendix Methods, Table 1, https://wwwnc.cdc.gov/EID/ article/27/11/21-1174-App1.pdf).

Dear Editor,Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has emerged as an important complication among patients with acute respiratory failure caused by SARS-CoV-2 [1-3]. A cornerstone in CAPA diagnosis is microbiology, including culture from lower respiratory tract samples, and bronchoalveolar lavage fluid (BALF) galactomannan (GM) [4,5].We performed a multinational cohort study including 20 centers in 9 countries with the aim to evaluate diagnostic approaches and treatment of CAPA as well as CAPA prevalence. All participating centers were invited to provide data on diagnostic work-up, treatment and outcome on prospective cohorts of consecutive COVID-19 ICU patients (inclusion criteria: SARS-CoV-2-positive polymerase chain reaction, admission to intensive care unit (ICU) due to respiratory failure) with and without CAPA via an online case report form between 03/2020 and 05/2021. Cases were then classified according to the 2020 ECMM/ISHAM consensus criteria [4]. The study protocol was approved by the Medical University of

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