Is the COVID-19 Pandemic a Good Time to Include Aspergillus Molecular Detection to Categorize Aspergillosis in ICU Patients? A Monocentric Experience

Abstract

(1) Background: The diagnosis of invasive aspergillosis (IA) in an intensive care unit (ICU)remains a challenge and the COVID-19 epidemic makes it even harder. Here, we evaluatedAspergillus PCR input to help classifying IA in SARS-CoV-2-infected patients. (2) Methods: 45COVID-19 patients were prospectively monitored twice weekly for Aspergillus markers and anti-Aspergillus serology. We evaluated the concordance between (Ι) Aspergillus PCR and culture inrespiratory samples, and (ΙΙ) blood PCR and serum galactomannan. Patients were classified asputative/proven/colonized using AspICU algorithm and two other methods. (3) Results: Theconcordance of techniques applied on respiratory and blood samples was moderate (kappa = 0.58and kappa = 0.63, respectively), with a higher sensitivity of PCR. According to AspICU, 9/45 patientswere classified as putative IA. When incorporating PCR results, 15 were putative IA because theymet all criteria, probably with a lack of specificity in the context of COVID-19. Using a modifiedAspICU algorithm, eight patients were classified as colonized and seven as putative IA. (4)Conclusion: An appreciation of the fungal burden using PCR and Aspergillus serology was addedto propose a modified AspICU algorithm. This proof of concept seemed relevant, as it was inagreement with the outcome of patients, but will need validation in larger cohorts.

Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance

“…4 There have been several reports of COVID-19-associated pulmo nary aspergillosis (CAPA), raising concerns about this superinfection as an addi tional contributing factor to mortality. [5][6][7][8][9][10] Indeed, in a prospective cohort of 108 criti cally ill patients with ARDS, a higher 30-day mortality was observed in patients with CAPA than in patients without aspergillosis (44% vs 19%), and the association of COVID-19-associated fungal disease with mortality was also supported by another study. 11,12 The population of patients with CAPA harbours many baseline prognostic factors with negative effects on survival, 13 which might be further compromised by azole-resistant CAPA, with an increasing number of patients reported in the literature.…”

“…Although host factors, clinical factors (including radiology), and mycological evidence are often used to diagnose and classify patients with IFD, patients with CAPA might not have host factors and typical radiological features. 5 , 6 , 7 , 8 , 9 , 10 , 11 Obtaining mycological evidence of airway-invasive aspergillosis in patients with COVID-19 is complicated by decreased use of diagnostic bronchoscopy, which is necessary to protect health-care workers from aerosol exposure, 21 , 22 and the low sensitivity of detection of circulating galactomannan in serum. 11 Further, detection of aspergillus in specimens of the upper respiratory tract, such as sputum or tracheal aspirate, often does not distinguish between aspergillus colonisation and invasive disease.…”

Invasive pulmonary aspergillosis in the COVID‐19 era: An expected new entity

“…However, the incidence rate in ICU patients with COVID‐19 (3.3%) is lower than the reported in other series from Western countries (3.8%–33.3%) (Table 3). 1–8 In a case series from China, the rate of CAPA was 7.7% among 104 COVID‐19 patients and 30.7% among 26 ICU patients 29 . The main difference may rely on the fact that there was no patient selection in our study and we used as the denominator all patients admitted to an ICU during the pandemic months.…”

“…COVID‐19‐associated pulmonary aspergillosis has been described to occur in patients that do not fulfil typical risk factors for IPA (such as underlying haematological malignancy or neutropenia) 1–18 . The criteria described by Blot et al and Schauwvlieghe et al may help differentiate between patients who are just colonised with Aspergillus spp.…”

COVID-19-Associated Invasive Aspergillosis: Data from the UK National Mycology Reference Laboratory

“…As discussed above, several modified diagnostic algorithms have been proposed for IA in nonimmunocompromised ICU patients ( 2 , 5 , 6 , 8 , 9 ), as the EORTC/MSG criteria for the diagnosis of IA in immunocompromised patients cannot be applied to nonneutropenic patients in ICU. Essentially, here, we have employed the modified AspICU algorithm incorporating PCR, serology, and angioinvasion biomarkers as proposed by Gangneux and colleagues ( 31 ), with some additional subtleties as described below. Due to the nonspecific and overlapping radiological appearances of patients with COVID and CAPA, the clinical criterion of abnormal thoracic medical imaging was extended to include worsening clinical symptoms despite optimal management (increasing inflammatory markers, new chest changes, persistent fever, deteriorating pulmonary function, new episodes of unexplained sepsis, etc.).…”