key: cord-0880402-r5wspwy7 authors: de Almeida, João N.; Doi, André Mario; Watanabe, Maria Julia L.; Maluf, Maira Maraghello; Calderon, Cecília Leon; Silva, Moacyr; Pasternak, Jacyr; Koga, Paula Célia M.; Santiago, Kelly Aline S.; Aranha, Luis Fernando C.; Szarf, Gilberto; da Silva Teles, Gustavo B.; Filippi, Renée Zon; Paes, Vitor Ribeiro; Baeta, Marina; Hamerschlak, Nelson; Mangueira, Cristovão Luis P.; Martino, Marines Dalla Valle title: COVID‐19‐associated aspergillosis in a Brazilian referral centre: Diagnosis, risk factors and outcomes date: 2022-02-23 journal: Mycoses DOI: 10.1111/myc.13433 sha: c96076824179e8cface961d5a31efd17fd13c03f doc_id: 880402 cord_uid: r5wspwy7 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. It is estimated that over 10%-20% of the SARS-CoV-2-infected patients require hospitalisation, 1, 2 and 3%-5% of them end up needing intensive care support. 1 Patients with severe COVID-19 requiring intensive care are at risk to develop invasive pulmonary aspergillosis (IPA). 3 With a prevalence of up to 30% in some intensive care units, 4, 5 the COVID-19associated aspergillosis (CAPA) has mortality rates over 40%. 4, 6 The diagnosis CAPA may be challenging and the radiologic findings may be unspecific and unhelpful for its diagnosis. 7 However, diagnostic criteria have been proposed and have helped researchers to better characterise and study this disease. 8 To bring additional relevant information regarding CAPA, we investigated the cases that occurred at a Brazilian referral centre between April 2020 to July 2021, including two high incidence peaks of SARS-CoV-2 infections that occurred in June 2020 and March 2021 (https://covid 19.who.int/regio n/amro/count ry/br). Moreover, we further analysed the epidemiology, laboratory and radiological findings, as well the risk factors and prognostic features of this intriguing and emergent medical entity. This retrospective study was carried out at the Albert Einstein Hospital of São Paulo, a referral Brazilian centre with 650 beds. All consecutive patients (≥18 years) with the diagnosis of COVID-19 by RT-PCR admitted to the intensive care unit (ICU) between 1 April 2020 and 31 July 2021 that had bronchoalveolar lavage (BAL) to investigate a fungal or bacterial superinfection were included. Patients with cystic fibrosis and/or lung transplant recipients with previous recurrent airways colonisation or infection by Aspergillus spp. were excluded from the study. Data were collected and held anonymously, and the study was approved by the local ethics Committee (n. 34 882 620.7.0000.0071). Other radiologic findings were described and classified as nonspecific of IPA. Variables were analysed at ICU admission and included: age, sex, body mass index (BMI), underlying conditions, haematologic or solid cancer, and sequential organ failure assessment (SOFA) score. 12 Additional variables were evaluated during ICU hospitalisation until the diagnosis of CAPA, or until hospital discharge for those without CAPA: antibacterial and/or antifungal exposure, azithromycin exposure, corticosteroid and/or tocilizumab therapy, high-level corticosteroid exposure defined as dosage higher than or equivalent to prednisone 16 mg/day ≥15 days, 13 renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO), heart failure requiring inotropic drugs, hepatic failure, previous candidaemia during hospitalisation. Prognostic factors were also analysed for the proven or probable CAPA cases at diagnosis: age, BMI, baseline diseases, galactomannan serum levels, SOFA score at CAPA diagnosis, heart failure requiring inotropic drugs, RRT, ECMO. The sensitivity, specificity, positive and negative predictive values were calculated for TA cultures for the diagnosis of proven or probable CAPA. The total and monthly incidence of CAPA were calculated per To investigate the risk factors of CAPA, proven and probable CAPA were matched to consecutive ICU-hospitalised controls that also underwent bronchoscopy to investigate a superinfection (non-CAPA patients) in a 1:3 ratio. Binomial logistic regression was used to characterise independent risk factors for the development of CAPA. Variables with p values <0.1 at the univariable level were included in the multivariable models in a forward stepwise method. Results were given as odds ratios (ORs) with 95% confidence intervals (CIs). Survival curves for CAPA and non-CAPA patients were calculated by Kaplan-Meier curves, and univariable analysis was assessed by the log-rank test. Multivariable analyses of factors associated with death among CAPA patients were performed using stepwise multiple logistic regression analysis. Variables with p values <.1 at the univariable level were included in the multivariable model in a forward stepwise method. Results were given as ORs with 95% CIs. A multivariable time-to-death analysis was also performed using stepwise Cox regression analysis. Variables with p values <.1 at the univariable level were included in the multivariable model in a forward stepwise method. Results were given as hazard ratios (HRs) with 95% CIs. All tests were two-tailed, and p values <.5 were considered statistically significant. Statistical analysis was performed with SPSS version 22.0 (IBM Corp., Armonk, NY, USA). A total of 1604 COVID-19 patients were admitted to the ICUs during the study period. Among them, 87 (5.4%) had at least one bronchoscopy and BAL sampling during hospitalisation to investigate the aetiology of new pulmonary infiltrates. According to the CAPA proposed criteria, a total of 14 probable (Table 1 ) and 8 possible cases were diagnosed. Therefore, the incidence of probable CAPA in the study period was 0.9 cases per 100 ICU admissions. The higher incidence of probable CAPA occurred during August 2020 and April 2021, Aspergillus fumigatus and Aspergillus niger were found in five (5.7%) and three (3.5%) of the BAL samples respectively. A total of twelve BAL samples from 10 patients had GM ODI values above 1, and four samples from three patients had values above 10. Of note, six (50%) of these samples were culture negative. BAL direct microscopy was requested in 6 probable CAPA cases, and one sample was positive (16.6% Among the fourteen patients with probable CAPA, 9 (64.3%) had one or more typical radiologic criteria of invasive pulmonary aspergillosis: pulmonary cavity (n = 7), dense well-circumscribed lung lesions with or without halo sign (n = 5), air crescent sign (n = 4) or wedged-shape segmental consolidation (n = 1). The other 5 patients had nonspecific radiological signs of invasive pulmonary aspergillosis, including ground glass opacities, reticular pattern and consolidations, or bronchopneumonic opacities ( Figure 1 ). By analysing the data retrieved by the patients that had probable CAPA, most of the patients were males (85.7%), with a median age of 72 years (interquartile range 62 to 77 years Kaplan-Meier survival curves derived from CAPA and non-CAPA patients ( Figure 2 ) showed no statistically difference between the two groups (p =.439). The prognostic factors among the 14 patients with probable CAPA were analysed and are summarised in Table 3 The rates of reported CAPA are highly variable, ranging from 0% to 30%, 6, 14, 15 and separating colonised from infected patients is difficult in some cases. 3, 16 Moreover, autopsy studies have also shown conflicting results that mirror the reported incidences. 15, 17 Local factors such as the prevalence of comorbidities (e.g., COPD), the environment (e.g., use or lack of high-efficiency particulate air filters) and level of immunosuppression (e.g., tocilizumab exposure), among others, may influence the incidence of CAPA of each centre. 4, 8, 14 The description and validation of CAPA risk factors will be help- 19 Our results showed a trend towards COPD as a risk factor for CAPA. Indeed, a recent meta-analysis has pointed out that COPD may be also a relevant risk factor for developing CAPA. 20 These findings suggest that in the context of COVID-19 and mechanical ventilation, older and/or COPD patients with new pulmonary infiltrates that appeared despite broad-spectrum antibiotics should be investigated for IA. The diagnosis of CAPA is challenging, and the combination of different diagnostic tools may be necessary for its diagnosis. 21 If only tracheal aspirate cultures were considered for CAPA diagnosis, several cases would have been treated unnecessarily in our centre. Serum galactomannan was requested for 43 patients in our cohort. Although serum GM for CAPA diagnosis may produce false-positive results, occasionally related to the prescription of nutritional supplements containing Bifidobacterium, 22 positive results may be related to angioinvasion that has been reported in some CAPA cases. 23, 24 Therefore, serum GM may be useful for the diagnosis of CAPA if requested in scenarios of high pre-test probability in patients without ongoing known risk factors for false-positive results. We provided additional data that illustrate the radiologic findings of CAPA. Our findings are different from some other cohorts where most of the patients lacked typical radiological findings of IPA. 3, 25, 26 Typical lesions such as nodules with halo sign were seen in our cohort, corroborating that CAPA may evolve to angioinvasion. Indeed, CAPA is a complex disease presenting a continuum that progresses from respiratory colonisation, to tissue damage and ultimately, to angioinvasion. 27 Voriconazole has been widely used in some centres for the treatment of CAPA, 4, 5, 18 and serum levels have been reported to be very erratic among critically ill COVID-19 patients. 28 In our cohort, a high proportion of the patients receiving voriconazole showed low serum levels. Isavuconazole is another therapeutic option for the F I G U R E 1 Examples of typical radiologic criteria of invasive pulmonary aspergillosis according to the EORTC/MSG criteria (arrows). (A) Pulmonary cavity (Case 2, see Table 1 ); (B) air crescent sign (Case 1, see Table 1 ); (C) wedged-shape segmental consolidation with reversed halo sign(Case 3, see Table 1 ); (D) dense well-circumscribed lesion without halo sign (Case 10, see Table 1 ) treatment of invasive aspergillosis, and some centres have reported successful treatment of CAPA with this drug. 18 However, low isavuconazole serum levels have been reported in patients under RRT. 29 In our cohort, 10 CAPA patients were under RRT during the azole treatment. Therefore, critically ill COVID-19 patients receiving either voriconazole or isavuconazole may need TDM for the optimal management of CAPA. Regarding the outcomes, CAPA has shown high mortality rates in different centres, usually above 40%. 18, 20 We compared the mortality rates of CAPA and non-CAPA patients, and, differently from other studies, we found no statistical difference in the outcome. Our study included only COVID-19 patients that underwent bronchoscopy for the investigation of a superinfection. Most of the non-CAPA patients had a bacterial infection diagnosed (data not shown), which may explain the poor outcomes of both groups. A high mortality rate has also been reported for ventilator-associated pneumonia by multidrug-resistant bacteria in COVID-19 patients. 30 A high proportion of critically ill COVID-19 patients develops acute kidney injury. 31 In this context, renal failure has been associated with poor prognosis in COVID- 19, 31 and consequently, it may also negatively impact the outcomes of CAPA. In our cohort, 90% of the patients with probable CAPA that deceased had severe renal failure requiring RRT. Continuous research to investigate strategies to mitigate the acute kidney injury in COVID-19 is necessary to achieve a better global prognosis for these patients. 32 Our study has limitations that need to be pointed out. (7) 10 (24) 0.17 Abbreviations: BMI, body mass index; ECMO, extracorporeal membrane oxygenation; SOFA, sequential organ failure assessment. Statistically significant p values were highlighted in bold. Investigation (equal) Paula Célia Koga: Data curation (equal) Investigation (equal) Kelly Aline Santiago: Data curation (equal) Investigation (equal) Luis Fernando Aranha: Formal analysis (equal) Investigation (equal) Gilberto Szarf: Data curation (equal) Writing -review & editing (equal) Gustavo Teles: Data curation (equal); Formal analysis (equal) Investigation (equal) Renée Filippi: Data curation (equal) Investigation (equal) Writing -review & editing (equal) Investigation (equal) Writing -review & editing (equal). 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