• Paul E Verweij, BrüggemannRoger J MRJM0000-0002-7618-725XRadboudumc-CWZ Center of Expertise for Mycology, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medica, Elie Azoulay, Matteo Bassetti, Stijn Blot, Jochem B Buil, Thierry Calandra, Tom Chiller, Cornelius J Clancy, Oliver A Cornely, Pieter Depuydt, Philipp Koehler, Katrien Lagrou, Dylan de Lange, Cornelia Lass-Flörl, Russell E Lewis, Olivier Lortholary, Peter-Wei Lun Liu, Johan Maertens, M Hong Nguyen, Thomas F Patterson, RijndersBart J ABJA0000-0003-3343-9610Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands., Alejandro Rodriguez, Thomas R Rogers, Jeroen A Schouten, Joost Wauters, Frank L van de Veerdonk, and Ignacio Martin-Loeches.
• Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, PO box 9101, 6500 HB, Nijmegen, The Netherlands. paul.verweij@radboudumc.nl.
• Intensive Care Med. 2021 Aug 1; 47 (8): 819-834.

PurposeInvasive pulmonary aspergillosis (IPA) is increasingly reported in patients with severe coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). Diagnosis and management of COVID-19 associated pulmonary aspergillosis (CAPA) are challenging and our aim was to develop practical guidance.MethodsA group of 28 international experts reviewed current insights in the epidemiology, diagnosis and management of CAPA and developed recommendations using GRADE methodology.ResultsThe prevalence of CAPA varied between 0 and 33%, which may be partly due to variable case definitions, but likely represents true variation. Bronchoscopy and bronchoalveolar lavage (BAL) remain the cornerstone of CAPA diagnosis, allowing for diagnosis of invasive Aspergillus tracheobronchitis and collection of the best validated specimen for Aspergillus diagnostics. Most patients diagnosed with CAPA lack traditional host factors, but pre-existing structural lung disease and immunomodulating therapy may predispose to CAPA risk. Computed tomography seems to be of limited value to rule CAPA in or out, and serum biomarkers are negative in 85% of patients. As the mortality of CAPA is around 50%, antifungal therapy is recommended for BAL positive patients, but the decision to treat depends on the patients' clinical condition and the institutional incidence of CAPA. We recommend against routinely stopping concomitant corticosteroid or IL-6 blocking therapy in CAPA patients.ConclusionCAPA is a complex disease involving a continuum of respiratory colonization, tissue invasion and angioinvasive disease. Knowledge gaps including true epidemiology, optimal diagnostic work-up, management strategies and role of host-directed therapy require further study.© 2021. The Author(s).

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