July 19, 2023
COVID-19–Associated Pulmonary Aspergillosis and Corticosteroid DurationBy Erica Kaufman West, MD
The RECOVERY trial established the benefit of treating hospitalized, hypoxic patients with COVID-19 pneumonia with 10 days of corticosteroids. While reducing inflammatory pathways, steroids also suppress the immune system and increase the risk of secondary infections.
Influenza-associated pulmonary aspergillosis has been a well-described entity, and we can now add SARS-CoV-2 to influenza on the list of viruses linked with aspergillosis. Shah et al. evaluated whether the duration of steroids given affected patients’ risk of COVID-19–associated pulmonary aspergillosis (CAPA). They evaluated 278 patients in a retrospective cohort study with the incidence of CAPA as the primary endpoint. There were 169 patients who received steroids for ≤10 days and 109 patients who received steroids for >10 days. The groups were well-matched except for more acute kidney injury in the short-course group (24.3% vs. 8.3%) and prior solid transplant and prior steroid use in the long-course group (1.8% vs. 7.3% and 5.9% vs. 20.2%, respectively). The long-course group also had a higher baseline severity of illness by SOFA score (6 points vs. 8 points) and tocilizumab usage (6% vs. 17%). Median duration of steroid use was 6 days and 18 days in the short- and long-course group, respectively.
Overall, 20 patients developed proven, probable or possible aspergillosis (7.2%) with more in the long-course group (11.9% vs. 4.1%). Interestingly, the only other independent risk factor in the multivariate analysis for CAPA was tobacco use. Patients with a longer course of corticosteroids also had fewer ventilator-free days and higher inpatient mortality (77.1% vs. 43.2%). Total corticosteroid exposure and dose did not carry an increased risk of CAPA. This study, like others, found higher CAPA-associated mortality, but CAPA did not emerge as an independent predictor of mortality. While the risks and rewards of treating CAPA remain unclear, this study shows that treating patients with the shortest course of steroids possible provides benefit.
