The Incidence, Diagnosis, and Outcomes of COVID-19-associated Pulmonary Aspergillosis (CAPA): A Systematic Review

Chong, Woon H.; Neu, Kristoffer P.

BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) is defined as invasive pulmonary aspergillosis occurring in COVID-19 patients. OBJECTIVE: The purpose of this review is to discuss the incidence, characteristics, diagnostic criteria, biomarkers, and outcomes of hospitalized patients diagnosed with CAPA. METHODS: A literature search was performed through Pubmed and Web of Science databases for articles published up to March 20th, 2021. RESULTS: In 1,421 COVID-19 patients, the overall CAPA incidence was 13.5% (ranging 2.5-35.0%). The majority required invasive mechanical ventilation (IMV). The time to CAPA diagnosis from illness onset varied between 8.0-16.0 days. However, the time to CAPA diagnosis from ICU admission and IMV initiation ranged between 4.0-15.0 days and 3.0-8.0 days. The most common diagnostic criteria were the modified AspICU-Dutch/Belgian Mycosis Study Group and IAPA-Verweij et al. 77.6% of patients had positive lower respiratory tract cultures, other fungal biomarkers of BAL and serum galactomannan were positive in 45.3% and 18.2% of patients. The CAPA mortality rate was high at 48.4%, despite the widespread use of antifungals. Lengthy hospital and ICU LOS ranging between 16.0-37.5 days and 10.5-37.0 days were observed. CAPA patients had prolonged IMV duration of 13.0-20.0 days. CONCLUSION: The true incidence of CAPA likely remains unknown as the diagnosis is limited by the lack of standardized diagnostic criteria that rely solely on microbiological data with direct or indirect detection of Aspergillus in respiratory specimens, particularly in clinical conditions with a low pretest probability. A well-designed, multi-center study to determine the optimal diagnostic approach for CAPA is required.