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Intensive Care Med
. 2021 Jun 23.
doi: 10.1007/s00134-021-06449-4. Online ahead of print.
Taskforce report on the diagnosis and clinical management of COVID-19 associated pulmonary aspergillosis
Paul E Verweij 1 2 3 , Roger J M Brüggemann 4 5 , Elie Azoulay 6 , Matteo Bassetti 7 8 , Stijn Blot 9 10 , Jochem B Buil 11 4 , Thierry Calandra 12 , Tom Chiller 13 , Cornelius J Clancy 14 , Oliver A Cornely 15 16 17 , Pieter Depuydt 18 , Philipp Koehler 15 16 , Katrien Lagrou 19 20 , Dylan de Lange 21 , Cornelia Lass-Flörl 22 , Russell E Lewis 23 , Olivier Lortholary 24 25 , Peter-Wei Lun Liu 26 27 , Johan Maertens 28 , M Hong Nguyen 14 , Thomas F Patterson 29 30 , Bart J A Rijnders 31 , Alejandro Rodriguez 32 , Thomas R Rogers 33 , Jeroen A Schouten 34 35 , Joost Wauters 36 , Frank L van de Veerdonk 37 , Ignacio Martin-Loeches 38 39 40
Affiliations
- PMID: 34160631
- DOI: 10.1007/s00134-021-06449-4
Abstract
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.
Keywords: COVID-19; ICU; Invasive aspergillosis; SARS-CoV-2; Viral pneumonia.