Putative invasive pulmonary aspergillosis in critically ill patients with chronic obstructive pulmonary disease: a matched cohort study.

Claire Delsuc,Marion Le Maréchal,Thomas Rimmelé,Arnaud Friggeri,Sophie Jarraud,Anne-Lise Bienvenu,Oana Dumitrescu,Aurélie Cottereau,Laurent Argaud,Rodrigue Dessein,Florent Wallet,Florence Ader,Saad Nseir,Emilie Frealle

doi:10.1186/s13054-015-1140-1

Abstract

IntroductionPatients with advanced chronic obstructive pulmonary disease (COPD) are at risk for developing invasive pulmonary aspergillosis. A clinical algorithm has been validated to discriminate colonization from putative invasive pulmonary aspergillosis (PIPA) in Aspergillus-positive respiratory tract cultures of critically ill patients. We focused on critically ill patients with COPD who met the criteria for PIPA.MethodsThis matched cohort study included critically ill patients with COPD from two university hospital intensive care units (ICUs). We studied the risk factors for PIPA as well as the impact of PIPA on short- and long-term outcomes. Whether PIPA was associated with a pattern of bacterial colonization and/or infection 6 months before and/or during ICU stay was assessed. In addition, antifungal strategies were reviewed.ResultsFifty cases of PIPA in critically ill patients with COPD in the ICU were matched with one hundred control patients with COPD. The ICU short- and the long-term (at 1 year) mortality were significantly increased in the PIPA group (p < 0.001 for all variables). PIPA was a strong independent risk factor for mortality in the ICU (odds ratio 7.44, 95 % confidence interval 2.93–18.93, p < 0.001) before vasopressor therapy, renal replacement therapy, and duration of mechanical ventilation. Before ICU admission, the use of corticosteroids and antibiotics significantly increased the risk of PIPA (p = 0.004 and p < 0.001, respectively). No significant difference in bacterial etiologic agents responsible for colonization and/or infection was found between the groups. Antifungal treatment was started in 64 % of PIPA cases, with a poor impact on the overall outcome.ConclusionsPIPA was a strong death predictor in critically ill patients with COPD. The use of corticosteroids and antibiotics before ICU admission was a risk factor for PIPA. PIPA was not associated with a specific bacterial pattern of colonization or infection. Prompting antifungal treatment in critically ill patients with COPD who have PIPA may not be the only factor involved in prognosis reversal.

Highlights

Patients with advanced chronic obstructive pulmonary disease (COPD) are at risk for developing invasive pulmonary aspergillosis
We focused on critically ill patients with COPD who met the criteria for putative invasive pulmonary aspergillosis (PIPA) according to the clinical algorithm
In the setting of critically ill patients with COPD, using a clinical algorithm designed to discriminate Aspergillus spp. colonization from PIPA, we could determine that PIPA was a strong predictor of lethal outcome in patients with COPD

Summary

Introduction

Patients with advanced chronic obstructive pulmonary disease (COPD) are at risk for developing invasive pulmonary aspergillosis. IA is associated with immunocompromised status that occurs in patients undergoing hematopoietic stem cell or solid organ transplants, in those with solid tumors, and in patients receiving corticosteroids [1,2,3] In these settings, IA is defined by the European Organization for Research and Treatment of Cancer/ Mycosis Study Group (EORTC/MSG) as proven, probable, or possible, based on a level of proof ranging from the decisive histopathological evidence of fungal invasion (proven) to a set of host risk factors and clinical features either associated (probable) or not (possible) with the positivity of mycological criteria [4]. An alternative critically ill patient–adapted algorithm has been proposed to discriminate Aspergillus colonization from invasive pulmonary aspergillosis (IPA) [7, 8] It has been externally validated by a multicenter study designed to confront the clinical criteria included in the algorithm with histopathology-proven cases of IPA [9]. For an assumed IPA prevalence of 40 %, the positive and negative predictive values are 61 % and 92 %, respectively

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