Invasive pulmonary aspergillosis in cirrhotic patients: analysis of a 10-year clinical experience

Abstract

Background Cirrhosis is not recognised as one of the main risk factors of invasive pulmonary aspergillosis (IPA), although its prevalence is increasing. The aim of our study was to identify factors for IPA in such patients with a positive Aspergillus sp. culture in respiratory samples and to evaluate its impact on outcome. Methods We conducted a monocentric retrospective study between January 2005 and December 2015. All cirrhotic patients hospitalised in our liver ICU with a positive Aspergillus sp. respiratory sample were included. These patients were case-matched with cirrhotic patients without positive Aspergillus respiratory sample. Finally, the patients were classified as having putative aspergillosis or colonisation according to the criteria described previously. Results In total, 986 cirrhotic patients were admitted to ICU during the study period. Among these, sixty patients had a positive Aspergillus sp. respiratory sample. Chronic obstructive pulmonary disease (COPD) comorbidity and organ supports were significantly associated with Aspergillus colonisation. Seventeen patients (28%) were diagnosed as proven or putative IPA and 43 were considered as colonised by Aspergillus sp. The median delay between ICU admission and an IPA diagnosis was 2 [2–24] days. Only COPD was predictive of the presence of IPA (OR 6.44; 95% CI 1.43–28.92; p = 0.0151) in patients with a positive Aspergillus sp. culture. The probability of in-hospital mortality was 71% in the IPA group versus 19% in the colonisation group ( p = 0.0001). Conclusion Patients with cirrhosis can be at risk of IPA, especially with COPD. Antifungal agents should be given as soon as possible mainly in cirrhotic patients with COPD.

Invasive Pulmonary Aspergillosis

“…Several studies have been conducted in intensive care units and identified, in the absence of malignancy, HSCT, or solid organ transplantations, the following risk factors for IA: severe chronic obstructive pulmonary disease, steroid therapy, HIV infection, influenza virus infection (especially H1N1), chronic renal replacement therapy, liver failure, near-drowning, prolonged period of mechanical ventilator dependency. 25,[97][98][99][100][101][102][103][104][105][106][107][108][109][110][111][112][113] Irrespective of these comorbidities, immune paralysis (also called compensatory antiinflammatory response syndrome) induced by severe sepsis can by itself be a risk factor for IA. 114,115 Recently several cases of IA have been reported in patients suffering from severe fever with thrombocytopenia syndrome virus infection, a tick-born disease present in China, Korea, Vietnam, and Japan.…”

Concomitant Presence of Aspergillus Species and Mycobacterium Species in the Respiratory Tract of Patients: Underestimated Co-occurrence?

“…When M. tuberculosis complex was isolated, the diagnosis of pulmonary TB was established. Regarding Aspergillus, cases were classified as CPA according to ESCMID guidelines (Denning et al, 2016) or IPA according to EORTC criteria for immunocompromised patients or Blot modified criteria for critically ill patients (De Pauw et al, 2008;Blot et al, 2012;Ullmann et al, 2018;Levesque et al, 2019). If patients were not included in these definitions, they were classified as colonized (Figure 1).…”

Invasive fungal infection before and after liver transplantation

“…Indeed, they encompass several risk factors, such as a profound immune-dysfunction, prolonged hospitalization, hepatic and extra-hepatic failure(s), indwelling (vascular) catheters, and long-term antibiotic therapies[ 3 , 10 ]. According to available studies on this specific population[ 11 - 16 ], the prevalence of IFD ranges between 1% and 47% (depending on diagnostic criteria and surveillance policies), significantly affecting short-term survival. Nevertheless, heterogeneous selection criteria have not allowed a refinement of risk stratification to date (Table 1 ).…”

“…For the sickest patients who are waiting for a graft, surveillance protocols are mandatory, and antifungal prophylaxis has been advocated in selected cases. For instance, Gustot et al [ 27 ] suggested ICU admission and a baseline MELD score > 24 as factors for considering a prophylaxis against IA in patients with acute alcoholic hepatitis[ 16 , 27 ], but more data are needed before considering it as a standard practice. After diagnosis of IFD, consultation by expert Infectious Disease specialists should be always considered, in order to establish the best targeted antifungal treatment and its length.…”