COVID-19 Associated Pulmonary Aspergillosis in Mechanically Ventilated Patients

Permpalung, Nitipong; Chiang, Teresa Po-Yu; Massie, Allan B; Zhang, Sean X; Avery, Robin K; Nematollahi, Saman; Ostrander, Darin; Segev, Dorry L; Marr, Kieren A

BACKGROUND: COVID-19 associated pulmonary aspergillosis (CAPA) occurs in critically ill COVID-19 patients. Risks and outcomes remain poorly understood. METHODS: A retrospective cohort study of adult mechanically ventilated COVID-19 patients admitted to five Johns Hopkins hospitals was conducted between March and August 2020. CAPA was defined using composite clinical criteria. Fine and Gray competing risks regression was used to analyze clinical outcomes and multilevel mixed-effects ordinal logistic regression was used to compare longitudinal disease severity scores. RESULTS: Amongst the cohort of 396 people, 39 met criteria for CAPA. Compared to those without, patients with CAPA were more likely to have underlying pulmonary vascular disease (41% vs 21.6%, p=0.01), liver disease (35.9% vs 18.2%, p=0.02), coagulopathy (51.3% vs 33.1%, p=0.03), solid tumors (25.6% vs 10.9%, p=0.017), multiple myeloma (5.1% vs 0.3%, p=0.027), corticosteroid exposure during index admission (66.7% vs 42.6%, p=0.005), and had a lower BMI (median 26.6 vs 29.9, p=0.04). People with CAPA had worse outcomes as measured by ordinal severity of disease scores, requiring longer time to improvement (adjusted odds ratio (1.08)1.09(1.1), p<0.001), and advancing in severity almost twice as fast (subhazard ratio, sHR (1.3)1.8(2.5), p<0.001). People with CAPA were intubated twice as long as those without (sHR) (0.4)0.5(0.6), p<0.001) and had a longer hospital length of stay [median (IQR) 41.1 (20.5, 72.4) vs 18.5 (10.7, 31.8), p<0.001]. CONCLUSION: CAPA is associated with poor outcomes. Attention towards preventative measures (screening and/or prophylaxis) is warranted in people with high risk of developing CAPA.