Diagnosis and Antifungal Prophylaxis for COVID-19 Associated Pulmonary Aspergillosis

Abstract

The COVID-19 pandemic has redemonstrated the importance of the fungal-after-viral phenomenon, and the question of whether prophylaxis should be used to prevent COVID-19-associated pulmonary aspergillosis (CAPA). A distinct pathophysiology from invasive pulmonary aspergillosis (IPA), CAPA has an incidence that ranges from 5% to 30%, with significant mortality. The aim of this work was to describe the current diagnostic landscape of CAPA and review the existing literature on antifungal prophylaxis. A variety of definitions for CAPA have been described in the literature and the performance of the diagnostic tests for CAPA is limited, making diagnosis a challenge. There are only six studies that have investigated antifungal prophylaxis for CAPA. The two studied drugs have been posaconazole, either a liquid formulation via an oral gastric tube or an intravenous formulation, and inhaled amphotericin. While some studies have revealed promising results, they are limited by small sample sizes and bias inherent to retrospective studies. Additionally, as the COVID-19 pandemic changes and we see fewer intubated and critically ill patients, it will be more important to recognize these fungal-after-viral complications among non-critically ill, immunocompromised patients. Randomized controlled trials are needed to better understand the role of antifungal prophylaxis.

Keywords: CAPA; COVID-19; aspergillosis; fungal prophylaxis.

Figure 1

Case definitions of proven and probable CAPA and IAPA (1A: host factors; 1B: clinical factors; 1C mycological factors). CAPA: COVID-19-associated pulmonary aspergillosis; IAPA: influenza-associated pulmonary aspergillosis; EORTC/MSGERC: European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group; ECMM/ISHAM: European Confederation for Medical Mycology and the International Society for Human and Animal Mycology; BAL: bronchoalveolar lavage; GM: galactomannan; PCR: polymerase chain reaction.