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Despite effectiveness of broad-spectrum antifungal prophylaxis in those at highest risk,1 prevalence of invasive pulmonary aspergillosis continues to increase as it becomes increasingly recognised in non-immunosuppressed individuals, including those in the intensive care unit (ICU) with severe respiratory viral infection such as COVID-19.2–4
COVID-19-associated pulmonary aspergillosis (CAPA) has emerged as an important and deadly complication,5 6 triggered by specific immunological mechanisms including suppression of the type I interferon response,3 as well as depletion of B cells and consequently anti-Aspergillus fumigatus IgG7 predisposing to tissue invasion and invasive infection. As CAPA is difficult to diagnose, with conventional diagnostics from blood-lacking sensitivity,8 9 reported incidence rates varied widely depending strongly on how aggressive diagnostics from specimens of the respiratory tract were implemented and characteristics of the COVID-19 ICU population, including age.6 Despite significant variations of incidence rates between centres, large multicentre studies have found surprisingly consistent median incidence rates between 10% and 15% in patients with COVID-19 admitted with acute respiratory failure to the ICU.6 10 11 Here, Hurt et al report results of the first prospective multicentre study from the UK, enrolling 266 mechanically ventilated patients with COVID-19, and finding a CAPA incidence rate of 10.9%,12 which is well within those previously reported rates.
When it comes to risk factors for CAPA, this study did not only find that steroid dosing and receipt of an interleukin 6 inhibitor may be a strong risk factor for CAPA (both COVID-19 treatments, and particularly their combination, have been identified as independent major risk factors in earlier studies2 6 10), but also identified pre-existing chronic obstructive pulmonary disease …
Contributors Both authors contributed equally to all aspects of this editorial.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests CK has received speaker’s fees from Pfizer. MH received research funding from Gilead, Astellas, MSD, IMMY, Mundipharma, Scynexis, F2G and Pfizer, outside of the submitted work.
Provenance and peer review Commissioned; internally peer reviewed.