Objectives: Invasive pulmonary aspergillosis (IPA) is an opportunistic fungal infection that often affects severely immunocompromised hosts. It has been recently documented as a co-infection in critically ill patients with severe viral influenza infection, although the exact risk rate is less well determined. To study the prevalence of IPA in critically ill patients with severe influenza in Evangelismos General Hospital, Greece.
Methods: We retrospectively reviewed all the ICU records for the 2018-2019 influenza season. Influenza was diagnosed using the polymerase chain reaction. Co-infection had to be confirmed using standard bacteriological tests. 28-day ICU and hospital mortality was calculated.
Results: Of the 69 patients diagnosed with influenza (34 H1NH, 31 Influenza A, 1 H1N2, 1 H1N3, 1 H1N4) in our 1000-bed tertiary hospital, 9 patients where admitted to the ICU (5 H1N1, 1 Influenza A, 1 H1N3, 1H1N4). Two patients had a co-infection (2,9% of the hospitalized patients with influenza and 22% of influenza patients admitted to the ICU). 3 ICU patients suffering influenza were severely immunocompromised but none of them developed IPA. Underlying medical conditions included hematology malignancy (3), diabetes mellitus (2), chronic renal failure (2). IPA was confirmed by histopathological findings in one patient and in combination of clinical, microbiological and radiological criteria in both. The galactomannan test in BAL was positive only in the patient with endobronchial bulky disease. Microbiology BAL cultures were Aspergillus spp positive both (A. Fumigatusand A. Nigerrespectively). Both patients were treated with isavuconazole (6 and 12 weeks respectively) and were completely cured. The 28-days ICU mortality was 22,2% in influenza ICU patients group. 90-day hospital mortality was 44,4%. None of the 2 patients with IPA co-infection has died.
Conclusion: IPA co-infection in critically ill patients with severe influenza has been increasingly reported worldwide in recent years. Infection with influenza may increase the risk of invasive aspergillosis by breaking down the bronchial mucosa facilitating Aspergillus invasion, inducing immunomodulatory effects. Aspergillus infection should be considered as a possible cause of persistent or progressing respiratory failure in immunocompetent critically ill patients suffering from influenza. The diagnosis of IPA requires awareness in order to conduct timely and appropriate testing. Microbiology laboratories also need to be aware of the suspicion of IPA. IPA is a rapidly progressive disease with high mortality rates up to 90%. Mortality can be reduced with prompt initiation of effective antifungal therapy. Isavuconazole has shown promising results in our clinical setting, for the primary treatment of IPA, especially in patients with endobronchial bulky disease and chronic renal failure.
Full conference title:
- TIMM (2019)