Repeated Aspergillus isolation in respiratory samples from non-immunocompromised patients not selected based on clinical diagnoses: colonisation or infection?

BACKGROUND: Isolation of Aspergillus from lower respiratory samples is associated with colonisation in high percentage of cases, making it of unclear significance. This study explored factors associated with diagnosis (infection vs. colonisation), treatment (administration or not of antifungals) and prognosis (mortality) in non-transplant/non-neutropenic patients showing repeated isolation of Aspergillus from lower respiratory samples. METHODS: Records of adult patients (29 Spanish hospitals) presenting ≥ 2 respiratory cultures yielding Aspergillus were retrospectively reviewed and categorised as proven (histopathological confirmation) or probable aspergillosis (new respiratory signs/symptoms with suggestive chest imaging) or colonisation (symptoms not attributable to Aspergillus without dyspnoea exacerbation, bronchospasm or new infiltrates). Logistic regression models (step-wise) were performed using Aspergillosis (probable + proven), antifungal treatment and mortality as dependent variables. Significant (p < 0.001) models showing the highest R2 were considered. RESULTS: A total of 245 patients were identified, 139 (56.7%) with Aspergillosis. Aspergillosis was associated (R2 = 0.291) with ICU admission (OR = 2.82), congestive heart failure (OR = 2.39) and steroids pre-admission (OR = 2.19) as well as with cavitations in X-ray/CT scan (OR = 10.68), radiological worsening (OR = 5.22) and COPD exacerbations/need for O2 interaction (OR = 3.52). Antifungals were administered to 79.1% patients with Aspergillosis (100% proven, 76.8% probable) and 29.2% colonised, with 69.5% patients receiving voriconazole alone or in combination. In colonised patients, administration of antifungals was associated with ICU admission at hospitalisation (OR = 12.38). In Aspergillosis patients its administration was positively associated (R(2) = 0.312) with bronchospasm (OR = 9.21) and days in ICU (OR = 1.82) and negatively with Gold III + IV (OR = 0.26), stroke (OR = 0.024) and quinolone treatment (OR = 0.29). Mortality was 78.6% in proven, 41.6% in probable and 12.3% in colonised patients, and was positively associated in Aspergillosis patients (R2 = 0.290) with radiological worsening (OR = 3.04), APACHE-II (OR = 1.09) and number of antibiotics for treatment (OR = 1.51) and negatively with species other than A. fumigatus (OR = 0.14) and aspergillar tracheobronchitis (OR = 0.27). CONCLUSIONS: Administration of antifungals was not always closely linked to the diagnostic categorisation (colonisation vs. Aspergillosis), being negatively associated with severe COPD (GOLD III + IV) and concomitant treatment with quinolones in patients with Aspergillosis, probably due to the similarity of signs/symptoms between this entity and pulmonary bacterial infections.

Clinical features of invasive pulmonary aspergillosis vs. colonization in COPD patients distributed by gold stage.

OBJECTIVE: To explore clinical features of invasive pulmonary aspergillosis (IPA) vs. colonization among hospitalized COPD patients. METHODS: Records of COPD patients with two respiratory cultures yielding Aspergillus were retrospectively reviewed. Cases categorized as proven/probable IPA or colonization was analyzed. RESULTS: 118 patients were identified: 70 (59.3%) colonized, 48 (40.7%) with IPA (42 probable, 6 proven). Higher percentage of IPA patients (vs. colonized) presented GOLD III + IV (77.1% vs. 57.1%, p = 0.025). IPA patients presented higher Charlson index (3.5 ± 2.5 vs. 2.6 ± 2.2, p = 0.027), higher rate of ICU admission (27.1% vs. 4.3%, p = 0.001) and worse prognosis (McCabe rapidly fatal category: 31.3% vs. 7.1%, p = 0.001). GOLD-I IPA patients presented risk factors other than COPD. Before hospitalization, 66.7% IPA and 28.6% colonized patients were taking steroids (p < 0.001). Antifungals were administered to 83.3% IPA and 21.4% colonized patients (p < 0.001). Mortality was higher among IPA vs. colonized patients, both in global (58.3% vs. 10.0%, p < 0.001), GOLD-I (75.0% vs. 10.0%, p = 0.041), GOLD-II (42.9% vs. 5.0%, p = 0.042) and GOLD-III patients (54.2% vs. 0.0%, p < 0.001), but not in GOLD-IV patients (69.2% vs. 31.3%, p = 0.066). CONCLUSIONS: IPA should be suspected not only in GOLD-III and GOLD-IV COPD patients, with higher mortality in IPA vs. colonized patients for GOLD-II and -III COPD patients.

Fibrilación ventricular en mujer de 73 años con espondilodiscitis / Ventricular fibrillation in a 73-year-old woman with spondylodiscitis

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