Accuracy of galactomannan testing on tracheal aspirates in COVID‐19‐associated pulmonary aspergillosis

Abstract

Objective Our aim was to evaluate the performance of two galactomannan assays (Platelia Aspergillus EIA, BioRadⓇ, and Aspergillus Galactomannan LFA, IMMYⓇ, Norman, OK, USA) in tracheal aspirate (TA) samples of consecutive critically ill patients with COVID‐19. Methods We included critically ill patients, performed GM‐EIA and GM‐LFA in TA and followed them until development of CAPA or alternate diagnosis. CAPA was defined according to the modified AspICU criteria in patients with SARS‐CoV‐2 infection. We estimated sensitivity, specificity, positive and negative predictive values for GM‐EIA, GM‐LFA, the combination of both or either positive results for GM‐EIA and GM‐LFA. We explored accuracy using different breakpoints, through ROC analysis and Youden index to identify the optimal cutoffs. We described antifungal treatment and 30‐day mortality. Results We identified 14/144 (9.7%) patients with CAPA, mean age was 50.35 (SD 11.9), the median time from admission to CAPA was eight days; 28.5% received tocilizumab and 30‐day mortality was 57%. ROC analysis and Youden index identified 2.0 OD as the best cut‐off, resulting in sensitivity and specificity of 57.1% and 81.5% for GM‐EIA and 60% and 72.6% for GM‐LFA, respectively. Conclusions The diagnostic performance of galactomannan in tracheal aspirates improved after using a cutoff of 2 OD. Although BAL testing is the ideal test, centers with limited access to bronchoscopy may consider this approach to identify or rule out CAPA.

Incidence, diagnosis and outcomes of COVID-19-associated pulmonary aspergillosis (CAPA): a systematic review

“…A single-center, retrospective study by Roman-Montes et al revealed the incidence of putative CAPA at 9.7% in 144 patients using the modified AspICU-Dutch/Belgian Mycosis Study Group criteria. [ 27 ] Respiratory tract cultures were obtained if clinical status worsens during ICU admission. Finally, the largest study was a prospective single-center cohort by Machado et al with an incidence of putative CAPA at 2.5% in 239 patients using the modified AspICU-Dutch/Belgian Mycosis Study Group criteria.…”

“…[ 15 ] It is important to note that Roman-Montes et al used GM obtained from ETA as an equivalent for BAL GM, whereas studies by Dupont et al and Lamoth et al used bronchial aspirates (BAS) as an equivalent for BAL in assisting with diagnosis of putative CAPA due to concerns of exposure and transmission associated with bronchoscopy. [ 27 , 42 , 43 ]…”

“…This can very well explain the low incidence of CAPA (10% and less) observed in developing countries (e.g., Mexico and Pakistan), although mortality rates observed were similar. [ 19 , 27 ] Better studies are required to confirm this hypothesis.…”

“… A. fumigatus (100) Probable (61.5), Possible (38.5) CAPA [CAPA-ECMM] NR NR 15.4 7.7 Voriconazole (100); amphotericin B (38.5); caspofungin (38.5). Nasir et al[ 19 ] 100 Sputum/ ETA/BAL (100) NR A. flavus (60), A. fumigatus (20), A. terreus (20) Putative CAPA (Modified AspICU-DB) NR NR NR 20.0 Voriconazole (33.3), amphotericin B (22.2) Roman-Montes et al[ 27 ] 78.6 ETA (100) NR A. fumigatus (54.5), A. spp. (27.3), A. flavus (9.1), A. niger (9.1) Putative CAPA (Modified AspICU-DB) NR 42.9 85.7 (ETA) NR Voriconazole (83.3), echinocandin (15.3) Rutsaert et al[ 20 ] 85.7 BAL (83.3), ETA (16.7) NR A. fumigatus (83.3), A. flavus (16.7) Putative CAPA (AspICU) 42.9 14.3 57.1 NR Voriconazole (85.7), isavuconazole (28.6) Van Arkel et al[ 62 ] 83.3 BAL (40), ETA (40), Sputum (20) NR A. fumigatus (100) Probable CAPA (IAPA) NR NR 50.0 NR Voriconazole/ anidulafungin (83.3), amphotericin B (16.7) Van Biesen et al[ 23 ] 77.7 BAL (100) NR A. fumigatus (71.4), A. flavus (14.3), A. terreus (14.3) Probable CAPA (IAPA) 11.1 NR 100 NR Voriconazole/ amphotericin B (100) Velez Pintado et al[ 63 ] 12.5 BAL (100) NR A. spp.…”

COVID‐19–associated pulmonary aspergillosis: a prospective single‐center dual case series

“…In Denmark, 10 a 25% ( n = 2/8) incidence of invasive aspergillosis in COVID‐19 patients undergoing extracorporeal membrane oxygenation (ECMO) was described, totalling 7.4% when adding the non‐ECMO ICU population ( n = 19). China, 11 Mexico 12 and Switzerland 13 report incidences of 8%, 9.7% and 3.8% in mechanically ventilated patients, respectively. In addition, Spain 14 and Pakistan 15 reported CAPA incidences of 3.3% and 21.7% in single studies, respectively, although patient data describing the use of mechanical ventilation were incomplete.…”