Taskforce report on the diagnosis and clinical management of COVID-19 associated pulmonary aspergillosis

• Published in: Intensive care medicine 2021-08, Vol.47 (8), p.819-834
• Main Authors: Verweij, Paul E., Brüggemann, Roger J. M., Azoulay, Elie, Bassetti, Matteo, Blot, Stijn, Buil, Jochem B., Calandra, Thierry, Chiller, Tom, Clancy, Cornelius J., Cornely, Oliver A., Depuydt, Pieter, Koehler, Philipp, Lagrou, Katrien, de Lange, Dylan, Lass-Flörl, Cornelia, Lewis, Russell E., Lortholary, Olivier, Liu, Peter-Wei Lun, Maertens, Johan, Nguyen, M. Hong, Patterson, Thomas F., Rijnders, Bart J. A., Rodriguez, Alejandro, Rogers, Thomas R., Schouten, Jeroen A., Wauters, Joost, van de Veerdonk, Frank L., Martin-Loeches, Ignacio
• Format: Article
• Language: English
• Subjects: Anesthesiology; Antifungal agents; Aspergillosis; Aspergillus; Biological products industry; Biomarkers; Bronchoscopy; Bronchus; Care and treatment; Colonization; Computed tomography; Conference Reports and Expert Panel; Coronavirus; Coronaviruses; Corticosteroids; COVID-19; Critical Care Medicine; Diagnosis; Emergency Medicine; Epidemiology; Fungal infections; Fungicides; Health aspects; Humans; Intensive; Intensive care; Intensive Care Units; Interleukin 6; Invasive Pulmonary Aspergillosis - diagnosis; Lung diseases; Medical colleges; Medical diagnosis; Medicine; Medicine & Public Health; Pain Medicine; Patients; Pediatrics; Pharmaceutical industry; Pneumology/Respiratory System; Pulmonary aspergillosis; Pulmonary Aspergillosis - diagnosis; Pulmonary Aspergillosis - drug therapy; Pulmonary Aspergillosis - epidemiology; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2; Strategic planning (Business); Task forces; Therapy; Tracheobronchitis; Viral diseases
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-021-06449-4

Purpose Invasive pulmonary aspergillosis (IPA) is increasingly reported in patients with severe coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). Diagnosis and management of COVID-19 associated pulmonary aspergillosis (CAPA) are challenging and our aim was to develop practical guidance. Methods A group of 28 international experts reviewed current insights in the epidemiology, diagnosis and management of CAPA and developed recommendations using GRADE methodology. Results The prevalence of CAPA varied between 0 and 33%, which may be partly due to variable case definitions, but likely represents true variation. Bronchoscopy and bronchoalveolar lavage (BAL) remain the cornerstone of CAPA diagnosis, allowing for diagnosis of invasive Aspergillus tracheobronchitis and collection of the best validated specimen for Aspergillus diagnostics. Most patients diagnosed with CAPA lack traditional host factors, but pre-existing structural lung disease and immunomodulating therapy may predispose to CAPA risk. Computed tomography seems to be of limited value to rule CAPA in or out, and serum biomarkers are negative in 85% of patients. As the mortality of CAPA is around 50%, antifungal therapy is recommended for BAL positive patients, but the decision to treat depends on the patients’ clinical condition and the institutional incidence of CAPA. We recommend against routinely stopping concomitant corticosteroid or IL-6 blocking therapy in CAPA patients. Conclusion CAPA is a complex disease involving a continuum of respiratory colonization, tissue invasion and angioinvasive disease. Knowledge gaps including true epidemiology, optimal diagnostic work-up, management strategies and role of host-directed therapy require further study.