Coronavirus Disease 2019-Associated Pulmonary Aspergillosis in Mechanically Ventilated Patients

Background Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) occurs in critically ill patients with COVID-19. Risks and outcomes remain poorly understood. Methods A retrospective cohort study of mechanically ventilated adult patients with COVID-19 admitted to 5 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 In the cohort of 396 people, 39 met criteria for CAPA. Patients with CAPA were more likely than those without CAPA to have underlying pulmonary vascular disease (41% vs 21.6%, respectively; P=.01), liver disease (35.9% vs 18.2%; P=.02), coagulopathy (51.3% vs 33.1%; P=.03), solid tumors (25.6% vs 10.9%; P=.02), multiple myeloma (5.1% vs 0.3%; P=.03), and corticosteroid exposure during the index admission (66.7% vs 42.6%; P=.005), and had lower body mass indexes (median, 26.6 vs 29.9 [calculated as weight in kilograms divided by height in meters squared]; P=.04). Patients 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<.001), and advancing in severity almost twice as quickly (subhazard ratio, (1.3)1.8(2.5); P<.001). They were intubated twice as long as those without CAPA (subhazard ratio, (0.4)0.5(0.6); P<.001) and had longer hospital stays (median [interquartile range], 41.1 [20.5-72.4) vs 18.5 [10.7-31.8] days; P<.001). Conclusion CAPA is associated with poor outcomes. Attention to preventive measures (screening and/or prophylaxis) is warranted in people with high risk of CAPA. Aspergillosis occurs at a variable incidence in people with severe coronavirus disease 2019, depending on diagnostic approach and definitions. Associated poor outcomes may be improved with early detection and antifungal therapy, warranting development of better noninvasive diagnostic and prevention strategies.