COVID‐19‐associated aspergillosis in a Brazilian referral centre: Diagnosis, risk factors and outcomes

Abstract

Background COVID‐19 patients on mechanical ventilation are at risk to develop invasive aspergillosis. To provide additional data regarding this intriguing entity, we conducted a retrospective study describing risk factors, radiology and prognosis of this emerging entity in a Brazilian referral centre. Methods This retrospective study included intubated (≥18 years) patients with COVID‐19 admitted from April 2020 until July 2021 that had bronchoscopy to investigate pulmonary co‐infections. COVID‐19‐associated aspergillosis (CAPA) was defined according to the 2020 European Confederation of Medical Mycology/International Society of Human and Animal Mycosis consensus criteria. The performance of tracheal aspirate (TA) cultures to diagnose CAPA were described, as well as the radiological findings, risk factors and outcomes. Results Fourteen patients (14/87, 16%) had probable CAPA (0.9 cases per 100 ICU admissions). The sensitivity, specificity, positive predictive value and negative predictive value of TA for the diagnosis of CAPA were 85.7%, 73.1%, 46.2% and 95% respectively. Most of the radiological findings of CAPA were classified as typical of invasive pulmonary aspergillosis (64.3%). The overall mortality rate of probable CAPA was 71.4%. Age was the only independent risk factor for CAPA [p = .03; odds ratio (OR) 1.072]. CAPA patients under renal replacement therapy (RRT) may have a higher risk for a fatal outcome (p = .053, hazard ratio 8.047). Conclusions CAPA was a prevalent co‐infection in our cohort of patients under mechanical ventilation. Older patients had a higher risk to develop CAPA, and a poor prognosis may be associated with RRT.

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

“…17,20,24,25 However, despite higher mortality with CAPA in COVID-19 patients in Brazil, no significant difference was observed in comparison with non-CAPA patients. 19 To the best of our knowledge, our study is the one of the few and the largest from LMICs, from an area with a high fungal disease burden with limited resources for diagnosis. 26 Moreover, our study evaluated the impact of CAPA on patient outcomes.…”

“… 17 Most studies exploring CAPA risk factors have either included all intubated patients or critically ill patients, hence excluding possibility of analysing this as a risk factor for CAPA. 18 , 19 …”

“… 17 , 20 , 24 , 25 However, despite higher mortality with CAPA in COVID‐19 patients in Brazil, no significant difference was observed in comparison with non‐CAPA patients. 19 …”

Isavuconazole for COVID-19-Associated Invasive Mold Infections

“…We identified 14 studies reporting the use of isavuconazole for CAPA, as shown in Table 2 [ 3 , 5 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. In these 14 studies, 235 of 275 CAPA patients (85%) received antifungal treatment, whereas 40 patients did not receive any type of antifungal treatment.…”

“…In a report from Brazil, 12 of 14 ICU CAPA cases received antifungal treatment, mainly voriconazole monotherapy (67%), while in 1 case L-AmB was changed to isavuconazole due to chronic renal failure [ 55 ]. On the contrary, in two small studies from Greece and Spain, isavuconazole monotherapy was the most frequently used (approximately 80% of patients) [ 50 , 51 ].…”