A National Strategy to Diagnose COVID-19 Associated Invasive Fungal Disease in the ICU

Abstract

Rationale: Fungal co-infection is a recognised complication of respiratory virus infections, increasing morbidity and mortality, but can be readily treated if diagnosed early. An increasing number of small studies describing aspergillosis in COVID-19 patients with severe respiratory distress are being reported, but comprehensive data is lacking.

Objectives: To determine the incidence, risk factors and impact of invasive fungal disease in adult COVID-19 patients with severe respiratory distress.

Methods: An evaluation of a national, multi-centre, prospective cohort evaluation of an enhanced testing strategy to diagnose invasive fungal disease in COVID-19 intensive care patients. Results were used to generate a mechanism to define aspergillosis in future COVID-19 patients.

Measurements and Main Results: One-hundred and thirty-five adults (median age: 57, M/F: 2·2/1) were screened. The incidence was 25·9% (13·3% aspergillosis, 12·6% yeast infections). The overall mortality rate was 38%; 51% and 31% in patients with and without fungal disease, respectively (P: 0·0398). The mortality rate was reduced by the use of antifungal therapy (Mortality: 38·5% in patients receiving therapy versus 89% in patients not receiving therapy (P: 0·0178). The use of corticosteroids (P: 0·002) and history of chronic respiratory disease (P: 0·043) increased the likelihood of aspergillosis.

Conclusions: Fungal disease occurs frequently in critically ill, mechanically ventilated COVID-19 patients. The survival benefit observed in patients receiving antifungal therapy implies that the proposed diagnostic and defining criteria are appropriate. Screening using a strategic diagnostic approach and antifungal prophylaxis of patients with risk factors will likely enhance the management of COVID-19 patients.

Note: Funding: None.

Ethical Approval: All data generated and interpreted was part of routine patient management, 109 forming a prospective, consecutive cohort study covering the first seven weeks of service, with one 110 month follow-up, not requiring ethical approval.

Declaration of Interest: P Lewis White: Performed diagnostic evaluations and received meeting sponsorship from Bruker, Dynamiker, and Launch Diagnostics; Speakers fees, expert advice fees and meeting sponsorship from Gilead; and speaker and expert advice fees from F2G and speaker fees MSD and Pfizer. Is a founding member of the European _Aspergillus_ PCR Initiative. Matthijs Backx: Speakers fees, expert advice fees and meeting sponsorship from Gilead. Meeting sponsorship form Abbvie. Rishi Dhillon: Educational grants from Gilead, Eumedica, Astellas Pharma, TEVA Pharmaceutical Industries, MSD and Chiesi. All other authors (AC, HH, FF SS, MP, HW AM, MM, MPW, BH, IB, JSP, LV, RP, JK, AB, HR, AMo, AT, SG and TH): Disclose no COI