Objectives: Invasive pulmonary aspergillosis (IPA) in patients with influenza is increasingly being identified in recent years. Cases of influenza-associated IPA with high mortality have been reported from several developed countries with a reported incidence between 19-28 % (1, 2). So far no significant data is available from developing countries. The aim was to determine the incidence and outcome of IPA in patients with severe influenza pneumonia admitted in an intensive care unit (ICU) of a developing country.
Methods: This was an observational study on confirmed influenza patients with respiratory failure admitted to the Aga Khan University hospital (AKUH) ICU from November 2018- March 2019. Patients older than 18 years, acute respiratory failure, pulmonary infiltrates on imaging, and a confirmed influenza infection based on a positive influenza PCR were included. The diagnostic criteria used for IPA was based on suggestive clinical signs and symptoms, radiological findings and mycological data (2). Like other studies, we have also not included the host factors as this criterion was largely created for immunosuppressed hosts, and influenza‐related aspergillosis may occur in previously normal hosts (2). The clinical characteristics, radiology, laboratory data and outcome were recorded on a predesigned performa.
Results: A total of 92 patients with confirmed influenza were admitted at AKUH during study period. Of these 16/92 (17.02%) were admitted in ICU due to respiratory failure. Among these 16 patients, IPA was diagnosed in 5 patients, giving an incidence of 31.25%. The mean age of IPA patients was 61.2 (±5.02) years (Range 53-65 years) and 60% were female. Three (60%) patients had non H1N1 Influenza A and 2 (40%) had H1N1 Influenza A infection. Three (60%) patients had underlying diseases (diabetes, hypertension and ischemic heart disease) and one patient was immunosuppressed. Systemic steroids were used after ICU admission in all patients. On admission 3 (60%) patients had acute kidney injury and 2 (40%) had deranged liver enzymes. Invasive positive pressure ventilation (IPPV) was required in 04 (80%) patients and one patient was managed on noninvasive ventilation (NIV). The average duration of IPPV use was 10.8 (range: 5‐24) days. All 5 patients had received voriconazole after diagnosis of IPA. The overall mortality rate of influenza patients admitted in ICU was 50% and in patients with IPA was 60%. The causes of death were ARDS and multisystem organ failure.
Conclusion: High incidence (31.25%) of IPA was found in influenza patients requiring ICU admission and was associated with high (60%) mortality. High index of suspicion, early diagnosis and appropriate treatment can improve outcome in these patient. Future large multicenter studies are required to assess the risk factors and role of antifungal prophylaxis to improve the outcome of influenza-associated aspergillosis.
References: Schauwvlieghe A, Rijnders BJA, Philips N, DutchBelgian Mycosis study group et al. Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study. Lancet Respir Med 2018. Huang L, Zhang N, Huang X, et al. Invasive pulmonary aspergillosis in patients with influenza infection: A retrospective study and review of the literature. Clin Respir J. 2019 Apr;13(4):202-211.
Full conference title:
- TIMM (2019)