Antifungal Prophylaxis and Preemptive Therapy to Prevent COVID-19-Associated Pulmonary Aspergillosis in Patients Requiring Advanced Respiratory Support: A Real-World Cohort Study in China.

Objectives

COVID-19-associated pulmonary aspergillosis (CAPA) is a frequent and life-threatening complication in critically ill patients. However, the role of antifungal prophylaxis and preemptive therapy remains unclear. This study aimed to evaluate the effects and safety of these strategies.

Methods

This single-center, retrospective study included patients with COVID-19 who required advanced respiratory support (high-flow nasal cannula, non-rebreathing mask, mechanical ventilation, or extracorporeal membrane oxygenation) between November 2022 and December 2023. The primary outcome was the incidence of CAPA. The secondary outcome was all-cause in-hospital mortality. Safety outcomes included clinical adverse events and laboratory abnormalities.

Results

Of the 267 patients included, 26 received antifungal prophylaxis, and 21 received preemptive therapy. The incidence of CAPA in the non-prevention group (22.7%) was higher than in the prophylactic (3.8%, P = 0.02) and preemptive (4.8%, P = 0.05) groups. Antifungal prophylaxis was independently associated with a reduced risk of CAPA versus non-prevention (sub-distribution hazard ratio 0.11, 95% CI 0.01-0.92, P = 0.04). In-hospital mortality did not differ significantly among the three groups, with rates of 46.2%, 52.4%, and 44.1% in the prophylactic, preemptive, and non-prevention groups, respectively (P = 0.76). Adverse events were comparable overall, with only five adverse drug reactions (Grade 1) reported.

Conclusions

In patients with COVID-19 requiring advanced respiratory support, antifungal prophylaxis was associated with a significantly reduced incidence of CAPA, and preemptive therapy also showed a reducing trend. Both strategies demonstrated favorable safety profiles, whereas neither improved survival. Further studies are warranted to investigate the clinical utility of these strategies.