Invasive aspergillosis in Iran: a systematic review and meta-analysis

MT Hedayati1, M Tavakoli1, M Mosazadeh2, J Yazdani Charati3, SM Seyedmousavi 4, DW Denning5

Author address: 

1Invasive Fungi Research Center, Mazandaran University of Medical Sciences, Sari, Iran 2Health Sciences Research center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran 3Department of statistic, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran 4Molecular Microbiology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryla 5The University of Manchester and the LIFE program at


Purpose: Invasive aspergillosis (IA) is a potentially lethal infection, caused by Aspergillus species. Currently, among four main clinical manifestations of aspergillosis, the rates of morbidity and mortality related to IA are increasing, especially in those at high risk such as patients with neutropenia, hematological malignancies, and transplant recipients. In this review, according to published data in Iran, we aimed to provide an overview of IA in aspects of etiologic agent, the epidemiology and geographic distribution, the effect of demographic variables, clinical manifestations, the presence or absence of underlying diseases, the survival rates of patients, outcomes, treatment regimen and type of treatment (empirical, definitive).

Methods: This systematic review provides an update on the epidemiology or geographic distribution of IA, disability-adjusted life years (DALYs), the sum of years of life lost (YLLs), years lost to disability (YLDs), the most common cause of IA, site of infection, risk factors, and comorbidity from Iran. A cross-sectional population-based study was used to estimate the average prevalence of aspergillosis in hospital-based samples obtained from suspected patients of IA. To identify all published papers reporting IA from Iran, we searched national and international databases. The data analysis was performed using the Stata version 13. Under random effect model (Q = Heterogeneity chi-squared = 26.3, I-squared = 96.85%, P<0.001). 

Results: Out of 91 published studies during the past 25 years from Iran, 23 met the inclusion criteria. A total of 2947 patients were included, of whom 387 (13.1%) patients were diagnosed with IA including as proven IA (11.7%), probable IA (39.5 %) and possible IA (48.8%), according to EORTC/MSG criteria. The most common clinical manifestation of IA was invasive pulmonary aspergillosis. The main underlying diseases in patients with proven, probable and possible IA were hematologic disorders (38%) and solid organ transplantation (SOT) (32.8%). Our findings showed that the site of infection in patients with IA was mainly confined to the lung (76.8%). The total rate of DALYs was estimated as 469.66 year per 1000 IA patients. The highest rate of YLLs resulted from IA was observed among subjects aged 25-29 years (Fig. 1). The average prevalence of IA was estimated as 20.48 (95% confidence interval: 12.461–29.894) in patients who were suspected to IA. A total of 200 reported isolates of Aspergillus species in the included studies, A. flavus 86 (43%) was the most common isolate, followed by A. fumigatus 57 (28.5%), Aspergillus spp. 29 (14.5%), A. niger 17 (8.5%), A. terreus 2 (1%), and flavus/niger complex 7 (3.5%), A. fumigatus/C. albicans complex 1 (0.5%), A. niger/C. albicans complex 1 (0.5%). 

Conclusion: According to this review, the frequency of IA increased from 1990 to 2016 in Iran. In contrast to different studies from different countries, A. flavus was introduced as the most common etiologic agent of IA in Iran. On the other hand, A. flavus was reported as the most prevalent pathogen responsible for mortality. Because of early death due to IA the most years of life lost was observed during third decade of life.



Full conference title: 

The 8th Advances Against Aspergillus, Lisbon Conference Center, Lisbon, Portugal
    • AAA 8th (2018)