are isolated from lower respiratory tract samples in 0.7%–7% of critically ill patients, with findings suggesting invasive pulmonary aspergillosis in around half of these patients based no criteria including EORTC/MSG criteria and autopsy studies. How often does IA occur in the ICU? Aspergillus spp. The authors confirm that the ethical policies of the journal, as noted on the journal’s author guidelines page, have been adhered to. We will here review the clinical definitions of invasive aspergillosis in the critically ill patient and focus specifically on mycological (which samples, which test) and clinical diagnosis of IA in the ICU setting. 23, 24 In line immunological mechanisms differ between the angio-invasive and the primarily airway-invasive type of Aspergillus disease, 25 as do radiological findings (often atypical findings in the non-neutropenic host), 14, 26, 27 and mycological findings (diagnostics in non-neutropenic host primarily from lung, versus blood testing such as with the Aspergillus galactomannan test in neutropenic host). In contrast with the neutropenic host, where Aspergillus grows angio-invasive within hours, there is an extended bronchial phase in the non-neutropenic host, where Aspergillus invades in an airway-invasive manner, often over the period of many days, prior to the disease become angio-invasive. 8, 20– 22 The immune status, and particularly neutrophil count of the host, determines the pathogenesis of Aspergillus disease, which represents a spectrum ranging from allergic and chronic forms to airway-invasive and angio-invasive disease. 2– 7 In contrast, the prevalence of IA continues to increase in non-neutropenic patients with severe underlying diseases, including those in intensive care units, 8– 12 those with severe viral infections caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or influenza virus, 12– 16 solid organ transplant recipients, 17 those receiving systemic glucocorticoids, 18 those with solid cancers, 8, 19 those with chronic obstructive pulmonary disorder (COPD) and other chronic respiratory disorders, and those who have received ibrutinib. 1 Mould-active prophylaxis has shown some success in reducing IA in patients with traditional risk factors for IA, such as those with underlying haematological malignancy and prolonged neutropenia, although breakthrough infections may occur. Worldwide estimates indicate that over 1.8 million cases of invasive fungal infections occurred in 2017, including around 250,000 cases of invasive aspergillosis (IA).
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