Influenza A-associated pulmonary aspergillosis in critically ill patients in the post-COVID-19 era: a multicenter cohort study from China - Report - MDSpire
Clinical Report: Pulmonary Aspergillosis Linked to Influenza A in Critically Ill Patients
Overview
This retrospective multicenter cohort study examines influenza-associated pulmonary aspergillosis (IAPA) among 542 critically ill adults with influenza A pneumonia in China. Aspergillosis was diagnosed in 33.0% of patients and was associated with higher 60-day mortality. The findings support timely diagnostic evaluation while highlighting uncertainty from selective testing and possible misclassification.
Background
Invasive pulmonary aspergillosis complicating severe influenza is termed IAPA. Historically reported frequencies range from 0% to 45%, reflecting differences in patient populations, diagnostic intensity, and regional factors. The authors suggest that experience with COVID-19-associated pulmonary aspergillosis may have increased clinicians’ vigilance for fungal coinfections in viral pneumonia.
Data Highlights
The study included 542 adults admitted to 21 ICUs in Jiangsu Province between November 2024 and February 2025.
Aspergillosis was diagnosed in 179 patients (33.0%).
The median interval from influenza diagnosis to aspergillosis diagnosis was 2 days.
Sixty-day mortality was 47.5% among patients with aspergillosis versus 32.0% among those without it.
Antifungal therapy was administered to 136 of 179 patients with aspergillosis (76.0%).
Key Findings
Renal replacement therapy, diabetes, bacterial coinfection, pre-ICU systemic glucocorticoid use, and steroid use during ICU admission were independently associated with aspergillosis.
Higher mortality among patients with aspergillosis persisted after propensity score matching.
Among patients with aspergillosis, hematologic disorders and higher C-reactive protein levels were independently associated with mortality.
Diagnosis used the 2024 FUNDICU criteria, which require compatible clinical, radiological, and mycological findings without classic immunocompromising host factors.
Interpretation
The reported frequency represents clinically detected IAPA rather than true disease prevalence. Mortality differences are associations and do not establish mortality directly attributable to aspergillosis. Some patients meeting FUNDICU criteria may have had colonization rather than invasive infection.
Limitations
Mycological testing was performed at clinicians’ discretion, introducing detection bias. Propensity score matching cannot fully eliminate immortal time bias because aspergillosis is a time-dependent exposure. FUNDICU criteria differ from older definitions, limiting historical comparisons. Possible colonization or contamination may also affect diagnostic classification.
Clinical Implications
The authors call for protocolized screening and timely diagnostic strategies in critically ill patients with influenza A pneumonia. Diagnosis should integrate clinical, radiological, and microbiological findings. Comparable mortality between treated and untreated patients should not be interpreted as evidence against antifungal therapy.
Conclusion
Clinically detected IAPA is frequent and associated with higher mortality in this cohort. Standardized diagnostic approaches and better methods to distinguish invasive infection from colonization are needed.
Related Resources & Content
Invasive fungal diseases in adult patients in intensive care unit (FUNDICU): 2024 consensus definitions from ESGCIP, EFISG, ESICM, ECMM, MSGERC, ISAC, and ISHAM — Bassetti M, Giacobbe DR, Agvald-Ohman C, et al. — Intensive Care Medicine, 2024;50(4):502–515.
Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study — Schauwvlieghe AFAD, Rijnders BJA, Philips N, et al. — The Lancet Respiratory Medicine, 2018;6(10):782–792.
Influenza-associated invasive aspergillosis in the ICU: a prospective, multicentre cohort study — Janssen NAF, Vanderbeke L, Jacobs C, et al. — Critical Care, 2025.
Incidence and outcomes of influenza-associated pulmonary aspergillosis and the role of antifungal prophylaxis: a structured literature review — Sedik S, Felber D, Schellongowski P, et al. — Critical Care, 2026;30(1):231.
Fungal fog in viral storms: necessity for rigor in aspergillosis diagnosis and research — Feys S, Hoenigl M, Gangneux JP, Verweij PE, Wauters J — American Journal of Respiratory and Critical Care Medicine, 2024;209(6):631–633.
