key: cord-0823350-ehrelo3y authors: van Grootveld, Rebecca; van Paassen, Judith; de Boer, Mark G.J.; Claas, Eric C.J.; Kuijper, Ed J.; van der Beek, Martha T. title: Systematic screening for COVID‐19 associated invasive aspergillosis in ICU patients by culture and PCR on tracheal aspirate date: 2021-03-05 journal: Mycoses DOI: 10.1111/myc.13259 sha: 22aa48c6c7210e49d236c28961f8df200c68dc63 doc_id: 823350 cord_uid: ehrelo3y BACKGROUND: A high prevalence of COVID‐19 associated pulmonary aspergillosis (CAPA) has been reported, though histopathological evidence is frequently lacking. To assess the clinical significance of Aspergillus species in respiratory samples of mechanically ventilated COVID‐19 patients, we implemented routine screening for Aspergillus in tracheal aspirate (TA). PATIENTS/METHODS: From all adult COVID‐19 patients admitted to the intensive care unit (ICU), TA samples were collected twice a week for Aspergillus screening by PCR and or culture. Bronchoalveolar lavage (BAL) sampling was performed in patients with a positive screening result if possible. Clinical information was obtained from the electronic patient record and patients were categorised according to the recently published consensus case definition for CAPA. RESULTS: Our study population consisted of 63 predominantly (73%) male patients, with a median age of 62 years and total median ICU stay of 18 days. Aspergillus species were present in TA screening samples from 15 patients (24%), and probable CAPA was diagnosed in 11 (17%) patients. Triazole resistance was detected in one patient (14%). Concordance between TA and BAL was 86%, and all TA culture positives were confirmed in BAL. We were able to withhold treatment in three of fifteen patients with positive screening (20%) but negative BAL results. CONCLUSIONS: Positive culture, molecular detection and or antigen detection of Aspergillus species do not equal infection. Until we understand the clinical relevance of Aspergillus species detected in respiratory samples of COVID‐19 patients, minimal‐invasive screening by TA is a feasible method to monitor patients. Positive screening results should be an indication to perform a BAL to rule out upper airway colonisation. Soon after the COVID-19 pandemic emerged worldwide a high prevalence of COVID-19 associated pulmonary aspergillosis (CAPA) was reported in patients admitted to the intensive care unit (ICU). [1] [2] [3] [4] Histopathological evidence for CAPA has been described in a number of cases. [5] [6] [7] Furthermore, in recent years, severe influenza requiring mechanical ventilation has been recognised as an independent risk factor for invasive pulmonary aspergillosis (IPA) in immunocompetent patients. 8 However, histopathological evidence for CAPA is missing in most reports. 9 Furthermore, a recent summary of available autopsy findings in a series of seven cases did not show signs of invasive aspergillosis (IA) in patients with positive Aspergillus cultures and or positive bronchoalveolar lavage (BAL) galactomannan (GM). 10 Neither was IA reported in a meta-analysis of pulmonary histopathology reports of 129 COVID-19 patients, 11 but standard histological stains for fungi were not always performed. Hence, the true prevalence of invasive infection in COVID-19 patients remains to be elucidated. Also, neither the benefit of (pre-emptive) antifungal treatment nor the consequences of withholding treatment with antifungals are known yet. 4, 12 Given that at the moment dexamethasone is the cornerstone of treatment for patients with COVID-19 admitted to hospital requiring oxygen, 13, 14 more COVID-19 patients may be put at risk for IA. Diagnosing CAPA is difficult, because most patients do not fulfil EORTC/MSGERC or AspICU criteria [1] [2] [3] [4] 15, 16 and CT-scans usually reveal severely damaged lungs because of COVID-19. 2, 4 Hence, in clinical practice, Aspergillus positive respiratory cultures from COVID-19 patients cause the following clinical dilemma: are we dealing with colonisation or infection? Although, excess mortality has been observed in patients with COVID-19 with suspicion of Aspergillus in the lower respiratory tract. 7, 17, 18 During the COVID-19 pandemic diagnosing CAPA was further complicated by concerns about the risk of SARS-CoV-2 infection in healthcare workers by aerosol forming diagnostic procedures such as BAL sampling. 19 Currently the optimal diagnostic workflow for CAPA is unknown, but recently a CAPA consensus definition has been proposed. 20 To fully comprehend the diagnostic value and dilemmas of Aspergillus screening we initiated systematic screening for Aspergillus in COVID-19 patients admitted to the ICU of our academic medical centre. In this study, we evaluated our CAPA screening programme after one month of screening for Aspergillus species by tracheal aspirate (TA). Our goals were to assess the value of TA as a screening sample, to compare different diagnostic tests and to characterise patients with CAPA. By doing so, we wanted to optimise the diagnostic workflow. From all adult patients with PCR confirmed COVID-19, admitted to the ICU of the Leiden University Medical Center (LUMC), TA samples were routinely collected twice a week for bacterial culture, SARS-CoV2 PCR and Aspergillus screening (culture and Aspergillus PCR). Few BAL procedures were performed at first, but BAL samples were obtained more frequently from mid-April. In comparison to BAL sampling, TA sampling is a minimal-invasive method to collect a specimen from the lower respiratory tract. Because TA samples can be contaminated with micro-organisms from the upper respira- Categorisation according to CAPA consensus definition We obtained data from the laboratory information system about bacterial culture, SARS-CoV-2 PCR, Aspergillus culture and resistance, Aspergillus PCR and GM results between April 1st 2020 and May 11th 2020 (first COVID-19 peak). These data included TA sam- an approved opt-out procedure active in our institution. If patients weren't able to consent because they were intubated, the opt-out procedure for clinical data for the National Intensive Care Evaluation (NICE) was applied. The screening programme was implemented as temporary routine care. Both TA and BAL samples were inoculated on sheep blood agar, chocolate agar, sheep blood agar with colistin and nalidixic acid and cystine-lactose-electrolyte-deficient (CLED) agar and incubated in an atmosphere enriched with 5% CO 2 at 37°C for two days according to standard protocol. In addition, BAL samples were inoculated on Sabouraud dextrose agar with gentamicin (0.04 g/L) and chloramphenicol (0.5 g/L) and incubated at 28°C and 35°C for 10 days. Tracheal aspirate samples were inoculated on Sabouraud agar and were incubated at 35°C for 10 days if they were part of the A GM optical density (OD) cut-off of ≥ 0.5 was deemed positive. Categorial variables were described as numbers and percentages. Probable CAPA was diagnosed in 11 of 63 (17%) patients and included four patients who were only BAL GM positive and negative in screening. Patient categorisation is depicted in Figure 1 . The clinical characteristics of the patients with positive Aspergillus diagnostics are described in more detail in Table S1 . At the time of diagnosis of CAPA CT-scanning revealed COVID-19 associated radiographic abnormalities in nine of these patients and cavitation in one patient, who was also diagnosed with a bacterial lung Table S1 . Serum was not routinely col- Table 2 and in Table S2 . Whether CAPA is a clinical entity that requires routine screening, invasive diagnostics and treatment is yet unknown. 7 They concluded that the use of the newly proposed CAPA criteria may allow earlier diagnosis than AspICU, 7 but it may also lead to overtreatment. One of the difficulties is that most COVID-19 ICU patients have extensive pulmonary infiltrates. Also, Aspergillus is considered a core component of the basal oral microbiome, 9 and false-positive BAL GM results occur in patients without pulmonary aspergillosis due to various causes. 25 By applying a GM cut-off value of one, still 32% false-positive results were seen even in a population including patients with classical host risk factors for IA. 26 PCR is included in the revised EORTC/MSGERC, 15 but not in the AspICU criteria. 16 an approved opt-out procedure active in our institution. If patients weren't able to consent because they were intubated, the opt-out procedure for clinical data for the National Intensive Care Evaluation (NICE) was applied. The screening programme was implemented as temporary routine care. 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