Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation

Abstract

To identify the incidence, risk factors and impact on long-term survival of invasive pulmonary aspergillosis (IPA) and Aspergillus colonisation in patients receiving vv-extracorporeal membrane oxygenation (ECMO). A retrospective evaluation was performed of patients receiving vv-ECMO at a tertiary hospital in Manchester (UK) between January 2012 and December 2016. Data collected included epidemiological data, microbiological cultures, radiographic findings and outcomes. Cases were classified as proven IPA, putative IPA or Aspergillus colonisation according to a validated clinical algorithm. One hundred thirty-four patients were supported with vv-ECMO, median age of 45.5 years (range 16.4–73.4). Ten (7%) patients had putative IPA and nine (7%) had Aspergillus colonisation. Half of the patients with putative IPA lacked classical host risk factors for IPA. The median number of days on ECMO prior to Aspergillus isolation was 5 days. Immunosuppression and influenza A infection were significantly associated with developing IPA in a logistic regression model. Cox regression model demonstrates a three times greater hazard of death associated with IPA. Overall 6-month mortality rate was 38%. Patients with putative IPA and colonised patients had a 6-month mortality rate of 80 and 11%, respectively. Immunosuppression and influenza A infection are independent risk factors for IPA. IPA, but not Aspergillus colonisation, is associated with high long-term mortality in patients supported with vv-ECMO.

Invasive Pulmonary Aspergillosis in Nonimmunocompromised Hosts

“…21 Finally, in the sickest ARDS patients undergoing extracorporeal membrane oxygenation (ECMO), 8 to 14% of patients are found with colonization and 2.5 to 8% are reported with IPA. 54,55 Expectedly, IPA case fatality in this setting is 70%. 56 Beside chronic lung disease, with or without steroids, acute pulmonary illnesses like influenza infection predispose to IPA, as suggested in several case series.…”

Review of influenza-associated pulmonary aspergillosis in ICU patients and proposal for a case definition: an expert opinion

“…There is little evidence on the impact of ECMO on antifungal drug exposure [56]. For the echinocandins, an impact of ECMO is not expected.…”

Occurrence of Invasive Pulmonary Fungal Infections in Patients with Severe COVID-19 Admitted to the ICU

“…Invasive aspergillosis is now a well-recognized complication that can affect immunocompetent patients during an ICU stay, whether or not it is associated with influenza pneumonia and ECMO support ( 26 , 27 ). In a recent study, 7% of patients receiving vv-ECMO had putative aspergillosis, and 7% had Aspergillus colonization ( 28 ). In our series, however, vv-ECMO support was not related to IPMI, and its potential association with fungal colonization and/or clinically irrelevant mycological test warrants further study.…”