Table 2.
Mycological workup leading to diagnosis or exclusion of IPA in patients with SARS-CoV-2–associated ARDS undergoing BAL
| Time from ICU Admission/Intubation to BAL (d) | Mycology before BAL |
Mycology (BAL) |
Cytopathology (BAL) | Conclusions |
||||
|---|---|---|---|---|---|---|---|---|
| Serum GM (Index) | Tracheal Aspiration*: Culture/Aspergillus PCR† (Ct Value) | Bronchial Aspiration: Direct Examination/Culture | BAL: Culture | BAL: Aspergillus PCR (Ct Value)† | Direct Examination | Final Consensus Diagnosis | Therapeutic Decision | |
| 5/0 | Neg | Neg/Neg | Neg/Neg | Neg | Aspergillus sp (39) | Neg | Colonization | No AFT |
| 6/6 | Pos (0.8) | Neg/Aspergillus sp (40) | Neg/C. albicans | — | A. fumigatus (32) | Candida-type hyphae | Putative IPA‡ | AFT continuation |
| Aspergillus sp (34) | ||||||||
| 7/7 | Neg | Neg/Neg | Pos/A. fumigatus | A. fumigatus | A. fumigatus (29) | Aspergillus-type hyphae | Putative IPA‡ | Start of AFT |
| Aspergillus sp (29) | ||||||||
| 12/12 | Pos (0.7) | Neg/Neg | Pos/A. fumigatus | A. fumigatus | A. fumigatus (32) | Neg | Putative IPA‡ | AFT continuation |
| Aspergillus sp (32) | ||||||||
| 15/15 | Neg | A. fumigatus/Neg | Neg/A. fumigatus & C. albicans | Neg | Neg | Neg | Colonization | Withdrawal of AFT |
| 20/20 | Neg | Neg/Aspergillus sp (38) | Neg/A. fumigatus & C. albicans | C. albicans | A. fumigatus (37) | Neg | Probable Aspergillus tracheobronchitis§ | AFT continuation |
| Aspergillus sp (37) | ||||||||
| 23/23 | Pos (1.3) | C. albicans/Neg | Neg/C. albicans | C. albicans | Neg | Neg | False positive of serum GM | Withdrawal of AFT |
| 26/26 | Neg | C. albicans/Neg | Neg/A. fumigatus & C. albicans | C. albicans | Aspergillus sp (37) | Neg | Possible IPA‖ | Start of AFT |
Definition of abbreviations: AFT = antifungal therapy; A. fumigatus = Aspergillus fumigatus; BAL = bronchoalveolar lavage; C. albicans = Candida albicans; COVID-19 = coronavirus disease; Ct = threshold cycle; GM = galactomannan; ICU = intensive care unit; IPA = invasive pulmonary aspergillosis; Neg = negative; PCR = polymerase chain reaction; Pos = positive; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
BAL galactomannan detection was not available during the study period due to COVID-19 lab constraints.
Last tracheal aspiration was performed at a median [interquartile range] of 2 [0–3] days before BAL, range (0–7) days.
Aspergillus PCR methods: PCR specifically targeting A. fumigatus by 28S rRNA gene and PCR pan Aspergillus using mitochondrial gene.
Putative IPA diagnosis according to criteria initially proposed by Blot and colleagues (10) and revised by Schauwvlieghe and colleagues (11).
Diagnosis of probable Aspergillus tracheobronchitis was based on the presence of airway plaque and pseudomembrane associated with microbial criteria, as recently proposed for influenza-associated pulmonary aspergillosis (12).