Influenza A-associated pulmonary aspergillosis in critically ill patients in the post-COVID-19 era: a multicenter cohort study from China - Scorecard - MDSpire
Clinical Scorecard: Pulmonary Aspergillosis Linked to Influenza A in Critically Ill Patients During the Post-COVID-19 Period: A Multicenter Cohort Analysis from China
Influenza-induced epithelial injury and immune dysregulation can compromise mucosal barriers and impair neutrophil-mediated fungal clearance, facilitating Aspergillus invasion.
Target Population
Adults aged ≥18 years with acute respiratory failure due to laboratory-confirmed influenza A pneumonia.
Care Setting
Twenty-one ICUs across Jiangsu Province, China.
Key Highlights
Aspergillosis was diagnosed in 179 of 542 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; the difference persisted after propensity score matching.
Renal replacement therapy, diabetes, bacterial coinfection, pre-ICU systemic glucocorticoids, and ICU steroid use were independently associated with aspergillosis.
Clinician-directed testing means the reported frequency reflects clinically detected disease rather than true prevalence.
Guideline-Based Recommendations
The source is a retrospective cohort study using consensus diagnostic criteria. Its testing practices and follow-up period are study methods rather than clinical recommendations.
Diagnosis
The study used the 2024 FUNDICU criteria, requiring compatible clinical and radiological findings plus mycological evidence.
Mycological criteria included a positive bronchoalveolar lavage fluid culture for Aspergillus, a lavage galactomannan index ≥1.0, or a serum galactomannan index ≥0.5.
Classic immunocompromising host factors were not required.
Management
The authors call for protocolized screening and timely diagnostic strategies rather than reliance solely on clinician-directed testing.
Diagnosis should integrate clinical, radiological, and microbiological findings to help distinguish invasive infection from colonization.
Monitoring & Follow-up
The study followed patients until 60 days after ICU admission or death.
This observation period does not establish a recommended clinical follow-up schedule.
Risks
Aspergillosis was associated with higher mortality, but the analysis does not establish mortality directly attributable to infection.
Among patients with aspergillosis, hematologic disorders and higher C-reactive protein levels were independently associated with mortality.
Patient & Prescribing Data
The study included adults admitted between November 2024 and February 2025. Pre-ICU corticosteroid exposure was defined as ≥14 consecutive days of systemic glucocorticoid therapy or a daily prednisone-equivalent dose >7.5 mg.
Antifungal therapy was administered to 136 of 179 patients with aspergillosis (76.0%). Comparable mortality between treated and untreated patients should not be interpreted as evidence against antifungal therapy.
Clinical Best Practices
Maintain diagnostic vigilance for fungal coinfection in critically ill patients with influenza A pneumonia.
Integrate chest imaging and mycological evidence with the clinical presentation.
Interpret findings cautiously because selective testing introduces detection bias and some patients meeting FUNDICU criteria may have had colonization.
Treat matched mortality differences as associations, given potential immortal time bias.
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.
