The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients
Abstract
:Highlights
- In this retrospective single-center cohort study, we characterized the incidence and outcomes of hospitalized COVID-19 patients with Aspergillus isolated from lower-respiratory-tract samples.
- We found that critically-ill patients with COVID-19 were at increased risk for co-infection with Aspergillus, and patients with isolated Aspergillus suffered a high mortality rate.
- Our study findings support testing for the presence of Aspergillus in lower-respiratory secretions and appropriate additional studies for critically ill patients with COVID-19.
- Early identification of patients with COVID-19-associated invasive pulmonary aspergillosis is critical to initiate prompt anti-fungal treatment.
Abstract
1. Background
2. Methods
2.1. Study Design
2.2. Definition of Probable Invasive Pulmonary Aspergillosis and Aspergillus Colonization
- Aspergillus-positive from lower-respiratory-tract culture sample.
- Compatible signs and symptoms—one or more of the following: fever refractory to at least three days of appropriate antibiotic therapy, recrudescent fever after a period of defervescence, pleuritic chest pain, pleuritic rub, dyspnea, hemoptysis, and worsening respiratory insufficiency despite appropriate antibiotic therapy and ventilatory support (in line with the modified AspICU criteria).
- Abnormal chest radiograph or computed tomography scan.
- The presence of either:
- One of the following host risk factors—neutropenia, underlying hematological or oncological malignancy, glucocorticoid treatment with prednisone equivalent > 20 mg/day, and congenital or acquired immunodeficiency.
- A positive cytological smear showing branching hyphae. Galactomannan (GM) detection values in BAL or tracheal aspirate, or positive serum sample (>0.5) were added to this algorithm as a microbiological criterion (modified AspICU).
2.3. COVID Dataset
2.4. Data Acquisition
2.5. Statistical Analysis
3. Results
4. Discussion
4.1. Mortality in Different Diagnostic Categories
4.2. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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Characteristics | Colonization (9) | Probable (21) | p-Value | |
---|---|---|---|---|
Age group (n, %) | 0.1302 | |||
<40 years | 2 (22%) | 0 | ||
40–64 years | 1 (11%) | 5 (24%) | ||
≥65 years | 6 (67%) | 16 (76%) | ||
Race | 0.8718 | |||
Black | 5 (56%) | 11 (52%) | ||
White | 2 (22%) | 3 (14%) | ||
Other | 2 (22%) | 7 (33%) | ||
Gender | 0.1682 | |||
Male | 3 (33%) | 16 (76%) | ||
Female | 6 (67%) | 5 (24%) | ||
Body mass index | 1 | |||
<18.5 | 0 | 1 (5%) | ||
18.5–24.9 | 2 (22%) | 5 (24%) | ||
25–29.9 | 3 (33%) | 7 (33%) | ||
30–39.9 | 3 (33%) | 7 (33%) | ||
>40 | 1 (11%) | 1 (5%) | ||
Medical history | ||||
Diabetes | 5 (56%) | 7 (33%) | 0.4181 | |
Chronic kidney disease | 2 (22%) | 4 (19%) | 1 | |
Chronic lung disease | 4 (44%) | 7 (33%) | 0.6871 | |
On home oxygen | 1 (11%) | 1 (5%) | 0.5172 | |
Heart disease | 2 (22%) | 8 (38%) | 0.6749 | |
Liver disease | 1 (11%) | 1 (5%) | 0.5172 | |
Immunocompromised | 0 | 2 (10%) | 1 | |
Neurologic disorders | 1 (11%) | 3 (14%) | 1 | |
Hypertension | 7 (78%) | 13 (62%) | 0.6749 | |
Hematologic malignancy with HSCT | 0 | 1 (5%) | 1 | |
Solid tumor w/o chemo | 0 | 1 (5%) | 1 | |
Long-term steroid use | 1 (11%) | 0 | 0.267 | |
Admission characteristics | ||||
Oxygen therapy (median ± SD) | ||||
SpO2 | 89 ± 5.61 | 92 ± 5.92 | 0.671 | |
FiO2 | 0.32 ± 0.240 | 0.5 ± 0.351 | 0.06498 | |
Labs | ||||
CRP | 81.8 ± 96.5 | 142 ± 77.9 | 0.2425 | |
CPK | 598 ± 1041 | 146 ± 252 | 0.0795 | |
LDH | 514 ± 608 | 482 ± 284 | 0.7725 | |
Ferritin | 481 ± 1169 | 1186 ± 1301 | 0.3042 | |
Troponin | 36 ± 94.5 | 42.5 ± 79.0 | 0.8469 | |
WBC | 10.2 ± 4.60 | 6 ± 5.12 | 0.2305 | |
ALC | 0.9 ± 1.27 | 0.85 ± 0.608 | 0.4987 | |
D-dimer | 2.22 ± 12.8 | 1.80 ± 9.49 | 0.6716 | |
PTT | 27.7 ± 3.56 | 30.5 ± 3.41 | 0.2061 | |
PT | 12 ± 0.844 | 11.2 ± 2.33 | 0.8181 | |
INR | 1.13 ± 0.0754 | 1.06 ± 0.234 | 0.8094 | |
Hospital course | ||||
Organ dysfunction | ||||
Renal injury | 5 (56%) | 13 (62%) | 1 | |
Hepatic injury | 4 (44%) | 9 (43%) | 1 | |
Cardiac injury | 2 (22%) | 2 (10%) | 1 | |
Coagulation dysfunction | 1 (11%) | 2 (10%) | 1 | |
mSOFA | 0.06276 | |||
<8 | 1 (11%) | 11 (52%) | ||
8–11 | 2 (22%) | 4 (19%) | ||
>11 | 6 (67%) | 6 (29%) | ||
Treatment | ||||
Antifungal | 2 (22%) | 13 (62%) | 0.1086 | |
Azithromycin | 0 | 4 (19%) | 0.2874 | |
Hydroxychloroquine | 2 (22%) | 5 (24%) | 1 | |
Other antibiotics | 8 (89%) | 20 (95%) | 0.5172 | |
Remdesivir | 3 (33%) | 7 (33%) | 1 | |
IL-6 inhibitor | 0 | 4 (19%) | 0.2874 | |
Anticoagulation | 3 (33%) | 11 (52%) | 0.4397 | |
Vasopressors | 8 (89%) | 14 (67%) | 0.3742 | |
Renal replacement therapy | 6 (67%) | 9 (43%) | 0.427 | |
Alive/dead | 0.6662 | |||
Alive | 3 (33%) | 5 (24%) | ||
Dead | 6 (67%) | 16 (76%) |
Characteristics | Alive (8) | Deceased (22) | p-Value | |
---|---|---|---|---|
Age group (n, %) | 0.256 | |||
<40 | 1 (12.5%) | 1 (4.5%) | ||
40–64 | 0 | 6 (27.3%) | ||
≥65 | 7 (87.5%) | 15 (68.2%) | ||
Race | 1 | |||
Black | 5 (62.5%) | 11 (50%) | ||
White | 1 (12.5%) | 4 (18.2%) | ||
Other | 2 (25%) | 7 (31.8%) | ||
Gender | 0.479 | |||
Male | 4 (50%) | 15 (68.2%) | ||
Female | 4 (50%) | 7 (31.8%) | ||
Body mass index | 0.518 | |||
<18.5 | 0 | 1 (4.5%) | ||
18.5–24.9 | 2 (25%) | 5 (22.7%) | ||
25–29.9 | 1 (12.5%) | 9 (40.9%) | ||
30–39.9 | 4 (50%) | 6 (27.3%) | ||
>40 | 1 (12.5%) | 1 (4.5%) | ||
Medical history | ||||
Diabetes | 5 (62.5%) | 7 (31.8%) | 0.210 | |
Chronic kidney disease | 2 (25%) | 4 (18.2%) | 0.645 | |
Chronic lung disease | 5 (62.5%) | 6 (27.3%) | 0.104 | |
On home oxygen | 0 | 2 (9.1%) | 1 | |
Heart disease | 4 (50%) | 6 (27.3%) | 0.384 | |
Liver disease | 0 | 2 (9.1%) | 1 | |
Immunocompromised | 1 (12.5%) | 1 (4.5%) | 0.469 | |
Neurologic disorders | 0 | 4 (18.2%) | 0.550 | |
Hypertension | 5 (62.5%) | 15 (68.2%) | 1 | |
Hx of malignancy (hematologic or solid) | 0 | 2 (9.0%) | 1 | |
Long-term steroid use | 1 (12.5%) | 0 | 0.267 | |
Admission characteristics | ||||
Oxygen therapy (median ± SD) | ||||
SpO2 | 91.5 ± 4.36 | 90.5 ± 6.15 | 0.256 | |
FiO2 | 0.36 ± 0.094 | 0.65 ± 0.35 | <0.001 | |
Labs | ||||
CRP | 110 ± 70.2 | 124 ± 88.8 | 0.157 | |
CPK | 213 ± 585 | 323 ± 789 | 0.586 | |
LDH | 442 ± 185 | 582 ± 470 | 0.055 | |
Ferritin | 714 ± 1188 | 1077 ± 1323 | 0.706 | |
Troponin | 40 ± 27.8 | 36 ± 98.5 | 0.095 | |
WBC | 6.20 ± 3.99 | 7.15 ± 5.37 | 0.383 | |
ALC | 0.85 ± 1.26 | 0.9 ± 0.68 | 0.706 | |
D-dimer | 0.97 ± 12.2 | 3.08 ± 9.62 | 0.713 | |
PTT | 29.1 ± 2.92 | 29.5 ± 3.74 | 0.611 | |
PT | 11.3 ± 0.618 | 11.3 ± 2.25 | 0.322 | |
INR | 1.08 ± 0.066 | 1.06 ± 0.225 | 0.340 | |
Hospital course | ||||
Invasive pulmonary aspergillosis | 0.666 | |||
Probable | 5 (62.5%) | 16 (72.7%) | ||
Colonization | 3 (37.5%) | 6 (27.3%) | ||
Organ dysfunction | ||||
Renal injury | 3 (37.5%) | 15 (68.2%) | 0.198 | |
Hepatic injury | 2 (25%) | 11 (50%) | 0.238 | |
Cardiac injury | 0 | 4 (18.2%) | 0.119 | |
Coagulation dysfunction | 0 | 3 (13.6%) | 1 | |
mSOFA | 0.054 | |||
<8 | 6 (75%) | 6 (27.3%) | ||
8–11 | 0 | 6 (27.3%) | ||
>11 | 2 (25%) | 10 (45.5%) | ||
Treatment | ||||
Antifungal | 1 (12.5%) | 14 (63.6%) | 0.035 | |
Azithromycin | 2 (25%) | 2 (9.1%) | 0.284 | |
Hydroxychloroquine | 1 (12.5%) | 6 (27.3%) | 0.638 | |
Other antibiotics | 8 (100%) | 20 (90.9%) | 1 | |
Remdesivir | 2 (25%) | 8 (36.4%) | 0.682 | |
IL-6 inhibitor | 1 (12.5%) | 3 (13.6%) | 1 | |
Anticoagulation | 2 (25%) | 12 (54.5%) | 0.226 | |
Vasopressors | 3 (37.5%) | 19 (86.4%) | 0.016 | |
Renal replacement therapy | 4 (50%) | 11 (50%) | 1 |
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Osman, H.; Shaik, A.N.; Nguyen, P.L.; Cantor, Z.; Kaafarani, M.; Soubani, A.O. The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients. Adv. Respir. Med. 2023, 91, 337-349. https://doi.org/10.3390/arm91050027
Osman H, Shaik AN, Nguyen PL, Cantor Z, Kaafarani M, Soubani AO. The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients. Advances in Respiratory Medicine. 2023; 91(5):337-349. https://doi.org/10.3390/arm91050027
Chicago/Turabian StyleOsman, Heba, Asra N. Shaik, Paul L. Nguyen, Zachary Cantor, Mirna Kaafarani, and Ayman O. Soubani. 2023. "The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients" Advances in Respiratory Medicine 91, no. 5: 337-349. https://doi.org/10.3390/arm91050027