Invasive Pulmonary Aspergillosis – A Common Accompanying Infection in Patients with Severe or Critical Course of COVID-19
Findings based on a literature review conducted and published in September 2020 show the occurrence of invasive pulmonary aspergillosis (IPA) in 19.6–33.3% of patients with a severe or critical course of COVID-19. The authors provide several important insights for clinical practice, including recommended management of therapy for these patients.
Complications Increasing Mortality
Invasive pulmonary aspergillosis, as an accompanying disease of COVID-19, occurs even in patients without known risk factors for this fungal infection. The most common complication in patients with this co-infection is respiratory distress syndrome requiring mechanical ventilation. An aggregate analysis of 34 reported cases of IPA in patients with COVID-19 showed a mortality of 64.7%. A comparison can be made here with influenza, where the occurrence of IPA was described in 17–29% of patients with severe courses, contributing to high mortality rates of up to 67%.
Most Common Pathogens and Treatment Management
The most common pathogen of IPA in patients with COVID-19 was Aspergillus fumigatus, followed by Aspergillus flavus. Early diagnosis can utilize culture of respiratory tract samples and the determination of galactomannan antigen.
The recommended and most commonly administered antifungal medication for aspergillosis is voriconazole. When administering it to patients with COVID-19, attention must be paid to drug interactions, especially the increased cardiotoxicity when combined with medications given in COVID-19 treatment. It should also be noted that there are cases of aspergillosis caused by strains resistant to azoles. Other administered antifungal medications included isavuconazole, caspofungin, and liposomal amphotericin B.
According to the latest recommended guidelines published in December 2020 as a consensus of several international medical mycology societies, the drug of choice besides voriconazole is also isavuconazole, which exhibits fewer interactions, shortens the QT interval, and offers other benefits considered in the cited guidelines.
Conclusion
The authors recommend that doctors caring for COVID-19 patients be vigilant for possible accompanying aspergillosis, especially in patients with severe or critical courses. The drugs of choice in the event of this co-infection are voriconazole and isavuconazole.
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Sources:
1. Lai C. C., Yu W. L. COVID-19 associated with pulmonary aspergillosis: a literature review. J Microbiol Immunol Infect 2020 Sep 24: S1684-1182(20)30238-3, doi: 10.1016/j.jmii.2020.09.004 [Epub ahead of print].
2. Koehler P., Bassetti M., Chakrabarti A et al.; European Confederation of Medical Mycology; International Society for Human Animal Mycology; Asia Fungal Working Group; INFOCUS LATAM/ISHAM Working Group; ISHAM Pan Africa Mycology Working Group; European Society for Clinical Microbiology; Infectious Diseases Fungal Infection Study Group; ESCMID Study Group for Infections in Critically Ill Patients; Interregional Association of Clinical Microbiology and Antimicrobial Chemotherapy; Medical Mycology Society of Nigeria; Medical Mycology Society of China Medicine Education Association; Infectious Diseases Working Party of the German Society for Haematology and Medical Oncology; Association of Medical Microbiology; Infectious Disease Canada. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2020 Dec 14: S1473-3099(20)30847-1, doi: 10.1016/S1473-3099(20)30847-1 [Epub ahead of print].
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