Aspergillus-positive lower respiratory tract samples in patients with the acute respiratory distress syndrome: a 10-year retrospective study
Contou et al. Ann. Intensive Care
Aspergillus-positive lower respiratory tract samples in patients with the acute respiratory distress syndrome: a 10-year retrospective study
Damien Contou 0 2 3
Matthieu Dorison 0 3
Jérémy Rosman 0 3
Frédéric Schlemmer 1
Aude Gibelin 0 3
Françoise Foulet 4
Françoise Botterel 4
Guillaume Carteaux 0 2 3
Keyvan Razazi 0 2 3
Christian Brun‑Buisson 0 2 3
Armand Mekontso Dessap 0 2 3
Nicolas de Prost nicolas.de‑ 0 2 3
0 Groupe Henri Mondor‐Albert Chenevier, Centre Hospitalier Universitaire Henri Mondor, DHU AT‐VB, Service de Réanimation Médicale, Assistance Publique‐ Hôpitaux de Paris , 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex , France
1 Centre Hospitalier Universitaire Henri Mondor, DHU AT‐VB, Antenne de Pneumolo ‐ gie, Assistance Publique‐Hôpitaux de Paris , 94010 Créteil , France
2 Groupe de Recherche CARMAS, Faculté de Médecine de Créteil, Université Paris Est Créteil , 94010 Créteil , France
3 Groupe Henri Mondor‐Albert Chenevier, Centre Hospitalier Universitaire Henri Mondor, DHU AT‐VB, Service de Réanimation Médicale, Assistance Publique‐Hôpitaux de Paris , 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex , France
4 Unité de Mycologie, Département de Biologie‐Pathologie, Centre Hospitalier Universitaire Henri Mondor, DHU VIC, Assistance Publique‐Hôpitaux de Paris , 94010 Créteil , France
Background: The detection of Aspergillus spp. in endotracheal aspirate cultures of mechanically ventilated patients may reflect either colonization or infection. However, little is known about the prevalence and the impact on outcome of respiratory tract sample positive for Aspergillus during the acute respiratory distress syndrome (ARDS). Methods: We conducted a monocentric, retrospective study over a 10‑ year period (January 2006-December 2015) in the ICU of a university hospital. All consecutive adult patients with ARDS were included, and the diagnosis of invasive pulmonary aspergillosis was assessed using a previously validated algorithm. Results: In total, 423 ARDS patients were included with 35 patients [8.3 %, 95 % CI (5.4-10.6)] having at least one respiratory tract sample positive for Aspergillus (Aspergillus+ patients) after a median delay of 3 days (1-11) following ICU admission. Comorbidities did not differ between Aspergillus+ and Aspergillus− patients except for more frequent immunosuppression in Aspergillus+ patients (40 vs. 22 %; p = 0.02). There was no difference between Aspergillus− and Aspergillus+ patients regarding in‑ ICU mortality, ventilator‑ free days at day 28, and incidence of ventilatorassociated pneumonia, but need for renal replacement therapy was higher in Aspergillus+ patients than in others (49 vs. 27 %; p = 0.01). Seventeen [4.0 %, 95 % CI (2.1-5.9)] patients had putative/proven aspergillosis. After adjusting on covariates associated with ICU mortality, putative/proven aspergillosis was associated with in‑ ICU mortality [aOR = 9.58 (1.97-46.52); p = 0.005], while Aspergillus colonization was not [aOR = 0.64 (0.21-1.99); p = 0.44]. Conclusions: Eight percent of ARDS patients had Aspergillus spp.‑ positive respiratory tract cultures. These had a higher risk of mortality only when categorized as having putative or proven invasive pulmonary aspergillosis.
Aspergillus; Invasive pulmonary aspergillosis; Acute respiratory distress syndrome; Immunosuppression
Invasive pulmonary aspergillosis (IPA) has been reported
chiefly in immunocompromised patients with prolonged
neutropenia, organ and allogeneic stem cell
transplantation, prolonged corticosteroids use or severe inherited
]. However, in the past decade,
definite cases of IPA have also been reported in intensive
care unit (ICU) patients having none of the previously
defined host risk factors for IPA [
], but other associated
illnesses including advanced cirrhosis [
Influenza infection  or chronic obstructive pulmonary
disease (COPD) [
]. In one study, the prevalence of IPA
reached 6 % in a cohort of patients without malignancy
hospitalized in a medical ICU . Endotracheal aspirate
cultures growing Aspergillus spp. have been recorded
in 1–2 % of mechanically ventilated ICU patients
having no predisposing factors and may reflect either
colonization or infection [
]. A recent clinical algorithm
developed by Blot et al. demonstrated favorable
operating characteristics to discriminate Aspergillus
respiratory tract colonization from IPA in ICU patients, whereas
the European Organization for Research and Treatment
of Cancer/Mycosis Study Group (EORTC/MSG) criteria
failed to adequately categorize patients in the absence of
conventional risk factors .
The acute respiratory distress syndrome (ARDS) [
occurs in about 10 % of ICU patients and is associated
with a high mortality of 35 % [
]. Respiratory tract
Aspergillus colonization was shown to be more frequent
in ARDS than in other critically ill patients [
autopsy study of 64 patients with ARDS revealed that 8
of them (13 %) had died with pulmonary lesions of IPA
]. However, the burden of IPA during ARDS has been
poorly studied and little is known on the prevalence of
Aspergillus respiratory tract colonization and IPA during
ARDS, as well as on the prognosis of IPA in this setting.
In this monocenter retrospective study we aimed at: (1)
assessing the prevalence, (2) reporting the clinical
characteristics, and (3) evaluating the impact on outcome of
Aspergillus-positive lower respiratory tract specimen in
We conducted a monocenter retrospective study in the
24-bed medical ICU of a tertiary referral center (Henri
Mondor Hospital, Créteil, France). All consecutive adult
(>18 years) patients admitted in the ICU for ARDS
according to the Berlin definition criteria (within 48 h
of admission) and receiving invasive mechanical
ventilation over a 10-year period (January 2006 to
December 2015) were included [
]. Exclusion criteria were
as follows: previously known lung interstitial disease or
tumoral infiltration, chronic respiratory failure requiring
long-term oxygen therapy, pure cardiogenic pulmonary
edema, mild ARDS treated with noninvasive ventilation
only, proven or suspected invasive pulmonary
aspergillosis under antifungal therapy upon ARDS diagnosis and
patients for whom no endobronchial sampling had been
All respiratory tract samples (plugged telescoping
catheter, tracheal aspirate or bronchoalveolar fluid)
performed for microbiological examination were analyzed.
Galactomannan antigen (GM) detection in plasma and
in bronchoalveolar lavage (BAL) fluid was performed
at the discretion of the managing physician. An optical
density ratio of 0.5 or greater for GM in serum and of 1.0
or greater for BAL fluid was considered positive. Chest
CT scan and cerebral or facial scan were not routinely
Definition of infection and categorization of patients
Patients were categorized into two groups: those with
one or more respiratory tract sample positive in
culture for Aspergillus spp. (Aspergillus+ patients) during
the ICU stay and those without such positive sample
(Aspergillus− patients). The former group was further
split into three categories depending on the
probability of IPA according to the clinical algorithm proposed
by Blot et al. [
]: (A) proven IPA (microscopic analysis
on sterile material: histopathologic, cytopathologic or
direct microscopic examination of a specimen obtained
by needle aspiration or sterile biopsy in which hyphae are
seen accompanied by evidence of associated tissue
damage; isolation of Aspergillus from culture of a specimen
obtained by lung biopsy); (B) putative IPA in case of (1)
Aspergillus-positive lower respiratory tract specimen
culture (entry criterion) with (2) compatible signs and
symptoms (one of the following: fever refractory to at least
3 days of appropriate antibiotic therapy, recrudescent
fever after a period of defervescence of at least 48 h while
still on antibiotics and without other apparent cause,
pleuritic chest pain, pleuritic rub, dyspnea, hemoptysis,
worsening respiratory insufficiency in spite of
appropriate antibiotic therapy and ventilatory support) and (3)
abnormal medical imaging by portable chest X-ray or
CT scan of the lungs, and either (4a) a host risk factor
(one of the following conditions: neutropenia (absolute
neutrophil count <500 G/L) preceding or at the time of
ICU admission, underlying hematological or oncological
malignancy treated with cytotoxic agents, glucocorticoid
treatment (prednisone equivalent >20 mg/day),
congenital or acquired immunodeficiency) or (4b) a
semiquantitative Aspergillus-positive culture of BAL fluid (+ or
+++), without bacterial growth together with a
positive cytological smear showing branching hyphae or (C)
Aspergillus respiratory tract colonization when ≥1
criterion necessary for a diagnosis of putative IPA was not
met (Tables 1, 2).
Collection of data and definitions
Demographics and clinical characteristics upon ICU
admission and during ICU stay were abstracted from
the medical charts of all patients. Immunosuppression
was defined by one of the following conditions:
neutropenia (absolute neutrophil count <500 G/L) preceding or
at the time of ICU admission, underlying hematological
or oncological malignancy treated with cytotoxic agents,
glucocorticoid treatment (prednisone equivalent >20 mg/
ARDS acute respiratory distress syndrome, COPD chronic obstructive pulmonary disease; continuous variables are shown as median (interquartile range 25–75);
categorical variables are shown as n (%)
day for more than 4 weeks), congenital (e.g., chronic
granulomatous disease, hyper-IgE syndrome [
acquired (e.g., AIDS [
]) immunodeficiency. Patient
initial severity was assessed using the Simplified Acute
Physiology Score II (SAPS II) [
] and Logistic Organ
Dysfunction (LOD) [
] scores. ARDS was categorized as
mild, moderate or severe according to the lowest PaO2/
FiO2 ratio obtained within 48 h of ICU admission [
Shock was defined as need for vasopressor (epinephrine
or norepinephrine) at a dose higher than 1 mg/h for more
than 2 h. Outcome variables included the use of adjuvant
therapies for ARDS (i.e., neuromuscular blocking agents,
nitric oxide inhalation, prone positioning or venovenous
extracorporeal membrane oxygenation), the need for
renal replacement therapy or vasopressors, the
administration of corticosteroids, the number of ventilator-free
days at day 28, the duration of ICU stay, the incidence of
ventilator-associated pneumonia and in-ICU mortality.
All chest CT scans performed in Aspergillus+ patients
were reviewed by two pulmonologists (FS and NDP)
blinded to the final Aspergillus classification and
outcome. Elementary lesions including alveolar
consolidation, lung nodules, ground-glass opacities, halo sign,
cavitation and pleural effusion were recorded.
ARDS patients received mechanical ventilation using
a standardized protective ventilation strategy [
Tracheal suction was performed using a closed system.
Other treatments including neuromuscular blocking
], nitric oxide inhalation, prone positioning
] and venovenous extracorporeal membrane
oxygenation were administered depending on the severity of
Antifungal therapy (voriconazole, caspofungin or
liposomal amphotericin B) was administered at the
a Hematological malignancies (n = 7, including lymphoma (n = 5), acute leukemia (n = 2), one of whom required allogeneic bone marrow transplant), solid organ
transplant (n = 6), gastric cancer (n = 1), HIV infection (n = 1), neutropenia of unknown cause (n = 1) and connective tissue disease under corticosteroid treatment
(n = 1)
b p = 0.018 and c p = 0.015 (Fisher’s exact test) for comparison between immunosuppressed and non-immunosuppressed patients; continuous variables are shown
as median (interquartile range 25–75); categorical variables are shown as n (%)
discretion of the managing physician and not initiated on
the sole basis of a positive GM in serum or in BAL fluid.
Continuous variables are reported as median [25th–75th
percentiles] or mean ± standard deviation (SD) and
compared as appropriate. Categorical variables are reported
as numbers and percentages [95 % confidence interval
(95 % CI)] and compared as appropriate. There was no
imputation for missing data, except for data missing from
comorbidities, which were then considered as absent.
Factors associated with ICU mortality were
determined by univariable and multivariable backward
logistic regression analyses. Independent variables with a p
value <0.10 in univariable analysis were entered into the
multivariable model, with backward elimination of
variables displaying a p value greater than 0.05. Interactions
between variables were assessed using the
Mantel–Haenszel test. Analyses were conducted using the SPSS Base
21.0 statistical software package (SPSS Inc., Chicago, IL).
Prevalence of Aspergillus+ respiratory tract samples during ARDS
Over the 10-year study period, 423 patients were
admitted for ARDS, of whom 35 [8.3 %, 95 % CI (5.4–10.6)] had
at least one respiratory tract sample positive for
Aspergillus spp. (Aspergillus+ patients) (Fig. 1; Table 1).
Among 17 (49 %) immunocompromised Aspergillus+
patients, one had proven IPA, 11 had putative IPA, and
5 were categorized as having respiratory tract
colonization. Conversely, among 18 (51 %)
non-immunocompromised Aspergillus+ patients, 5 had putative IPA and
13 had colonization (Fig. 1; Table 2). The overall
prevalence of proven/putative aspergillosis was 4.0 % [95 % CI
Presentation of ARDS patients with Aspergillus‑positive respiratory tract samples
Comorbidities did not differ between Aspergillus+
and Aspergillus− patients except for more frequent
ARDS patients over a 10-year period
N = 423
Aspergillus + patients
N = 35 (8%)
Aspergillus – patients
N = 388 (92%)
N = 17
Proven IPA n = 1
Putative IPA n = 11
Aspergillus respiratory tract colonization n = 5
N = 18
Proven IPA n = 0
Putative IPA n = 5
Aspergillus respiratory tract colonization n = 13
immunosuppression in the former group (Table 1). The
two groups did not differ regarding clinical presentation
and severity of illness upon ICU admission, as assessed
by SAPS II, LODS and ARDS severity. Regarding the
main ARDS risk factors retrieved, infective pneumonia
was significantly more frequent (while aspiration
pneumonitis was less frequent) in Aspergillus+ patients than
in others (Table 1).
Among the 35 patients of the Aspergillus+ group,
27 (77 %) had a GM measurement performed in both
plasma and BAL fluid. Plasma GM measurements were
not significantly different between patients with proven/
putative IPA and those with Aspergillus spp. colonization
(7/15, 47 % vs. 2/12, 17 %, p = 0.22). In contrast, when
measured in BAL fluid, GM was more frequently
positive in patients with proven/putative IPA than in those
with Aspergillus colonization (8/15, 53 % vs. 0/12, 0 %,
p = 0.003) (Table 3).
Chest CT scans were obtained in 60 % (n = 21/35)
of patients of the Aspergillus+ group during ICU stay
(Table 4; Fig. 2) and displayed no significant difference
between patients categorized as having
proven/putative aspergillosis (n = 13/21) and those with Aspergillus
colonization (n = 8/21). Of note, while lung nodules were
observed in 67 % of cases, other chest CT scan patterns
suggestive of IPA, including lung cavitation and halo sign,
were detected in only 14 % of cases. Alveolar
consolidations, consistent with the underlying ARDS, were present
in 90 % of cases.
Management and outcome of ARDS patients with Aspergillus‑positive respiratory tract samples
The median number of collected samples was 3 (2–7) per
patient, and the median delay between ICU admission
and the first respiratory tract sample positive for
Aspergillus spp. was 3 days (1–11) (Table 5). There were no
differences between Aspergillus− and Aspergillus+ patients
regarding duration of ICU stay, in-ICU mortality,
number of ventilator-free days at day 28 and incidence of
ventilator-acquired pneumonia and of shock. In contrast,
the need for renal replacement therapy was almost twice
as high in Aspergillus+ patients than in others (Table 5).
Within the Aspergillus+ group, fifteen patients received
an antifungal treatment during ICU stay (voriconazole,
n = 12; liposomal amphotericin B, n = 3; caspofungin,
n = 2; combination therapy, n = 3), including the sole
BAL bronchoalveolar lavage
a p value comes from the Fisher exact test; an optical density (OD) ratio of 0.5 or greater for galactomannan antigen in serum and 1.0 for BAL fluid was considered
patient with proven IPA, 10 over 16 patients with
putative IPA and 4 over 18 patients with Aspergillus
respiratory tract colonization.
The association between Aspergillus status, as
categorized with the Blot et al. algorithm, and in-ICU
mortality was assessed by logistic regression analysis. Both in
univariable analysis [OR = 7.98 (1.80–35.36), p = 0.006)]
and after adjusting for covariates significantly associated
with ICU mortality, putative/proven IPA was strongly
associated with in-ICU mortality [aOR = 9.58 (1.97–
46.52), p = 0.005], while Aspergillus colonization was not
[aOR = 0.64 (0.21–1.99), p = 0.44] (Table 6). Of note,
within the putative/proven IPA subgroup (n = 17), 10/12
immunocompromised and 5/5
non-immunocompromised patients died in the ICU.
We herein report Aspergillus-positive lower respiratory
tract specimen culture in an 8 % prevalence of patients
with ARDS, half of whom had putative or proven IPA.
Immunosuppression and pneumonia were more frequent
among patients having at least one positive sample for
Aspergillus. Immunocompromised ARDS patients were
more frequently categorized as having putative or proven
IPA, while non-immunocompromised patients were
more likely categorized as having Aspergillus
respiratory tract colonization. Importantly, patients with one
or more positive respiratory tract sample for
Aspergillus had a worse outcome than others only when
categorized as having putative/proven IPA according to the Blot
The current series is, to the best of our knowledge, the
largest one to focus on Aspergillus-positive respiratory
tract samples in ARDS patients. The 8 % prevalence of
patients having at least one positive sample for
Aspergillus, in our population with ARDS, is significantly higher
than the 1 % rate prospectively reported by Bassetti et al.
in unselected mechanically ventilated patients,
suggesting ARDS is a risk factor for Aspergillus respiratory
colonization and/or infection [
]. Four percent of our ARDS
patients (n = 17/423) were eventually classified as having
proven or putative IPA, which is less than the 13 %
prevalence of proven IPA that was previously reported in an
autopsy study of 64 patients with ARDS [
], likely due to
differences in case-mix and methods between this study
and ours. Such figures are consistent with the fact that
the Blot et al. algorithm was previously shown to have
61 % specificity and positive predictive value and 92 %
sensitivity and negative predictive value, implying that
its ability to exclude IPA might be better than in
diagnosing it [
]. Strikingly, the median delay between
the first respiratory sample positive for Aspergillus spp.
and mechanical ventilation initiation was 3 days,
consistent with a previous study in mechanically ventilated
non-ARDS patients , suggesting that respiratory tract
colonization by Aspergillus spores had occurred prior
to ARDS onset. The combination of ARDS-associated
alveolar damage and associated local immune
], together with sepsis-induced
], might, through alterations in innate immunity
and antigen presentation processes [
], account for the
development of IPA in previously colonized patients.
Other previously described conditions at risk of IPA in
critically ill non-immunosuppressed patients include
COPD, present in only 11 % of our Aspergillus+ group, as
compared to 31 % in a large series and, to a lesser extent,
cirrhosis and corticosteroids, observed in less than 10 %
of cases [
]. Surprisingly, however, corticosteroid
administration was not associated with mortality in a recent
series of mechanically ventilated patients with proven
or putative Aspergillosis [
]. Although we found a trend
toward more high-dose steroids administration in the
ECMO extracorporeal membrane oxygenation, BAL bronchoalveolar lavage
a Hydrocortisone 200 mg/day
b Prednisone equivalent >1 mg/kg/day; continuous variables are shown as median (interquartile range 25–75); categorical variables are shown as n (%)
IPA invasive pulmonary aspergillosis
a As prescribed for a suspicion of invasive pulmonary aspergillosis; the Hosmer–Lemeshow goodness of fit test showed good calibration of the model (p = 0.28); the
area under the curve of the model is 0.78 (0.73–0.82); OR (95 % CI), odds ratio (95 % confidence interval); aOR, adjusted odds ratio
Aspergillus+ group, their relationship with subsequent
IPA and death could not be assessed in our study due to
its limited statistical power.
The recent clinical algorithm proposed by Blot et al.
for discriminating between ICU patients with Aspergillus
respiratory tract colonization and those with IPA, allows
for categorizing non-immunocompromised patients as
having putative IPA, provided semiquantitative culture
of BAL fluid is positive for Aspergillus, together with a
positive cytological smear showing branching hyphae
]. This criterion (4b) becomes indeed crucial in
nonimmunocompromised ARDS patients who all meet, by
definition, the radiological criterion of the Blot algorithm
(criterion 3), while both the relevance and reproducibility
of several of the clinical criteria (e.g., dyspnea, pleuritic
chest pain, pleuritic rub) can be questioned in critically
ill mechanically ventilated patients. Nevertheless, and
as expected, immunosuppression was strongly
associated with proven/putative IPA in our series; however, it
is noteworthy that non-immunocompromised patients
accounted for one-third of patients classified as having
probable infection, all of whom (n = 5/5) eventually died,
suggesting putative IPA portends a dismal prognosis even
in non-immunocompromised patients.
Although the purpose of our study was not to evaluate
the performance value of GM antigen measurement, our
results suggest that its detection is more efficient in BAL
fluid than in plasma to discriminate between proven/
putative IPA and Aspergillus colonization, in line with
a previous prospective study conducted in non-ARDS
critically ill patients [
]. In the context of ARDS patients
with a positive culture for Aspergillus, a positive GM test
in BAL fluid may be a helpful tool to reinforce the
diagnostic suspicion of IPA and may thus incite clinicians to
start antifungal therapy.
While the number of chest CT scans available in the
current study was limited, our results suggest that, in the
particular context of ARDS, its diagnostic yield to
discriminate between putative aspergillosis and Aspergillus
colonization is limited, most patients exhibiting
non-specific findings such as alveolar consolidations.
In our series, the overall positivity of one or more
respiratory sample for Aspergillus was not significantly
associated with higher in-ICU mortality. Still, the risk
of in-ICU mortality was significantly higher in ARDS
patients with proven/putative IPA, as opposed to those
with Aspergillus colonization, and as compared to those
having no positive respiratory tract culture for
Aspergillus, even after adjusting on significantly associated
covariables. The benefit/risk ratio of antifungal therapy
has not been assessed in ICU patients when categorized
as having proven/putative IPA according to the recently
proposed algorithm [
]. Our findings of a higher in-ICU
mortality among a cohort of ARDS patients suggest that
the initiation of such treatment should be considered in
this specific subgroup, including
non-immunocompromised patients, who also exhibited a strikingly high ICU
mortality (n = 5/5 died). Of note, a previous
observational study in critically ill COPD patients having
putative IPA reported no improvement in ICU and long-term
mortality in patients receiving antifungal treatment as
compared to others, suggesting the severity of the
underlying diseases was a key prognostic factor [
in the current series, six patients of the putative IPA
subgroup (n = 16) did not receive an antifungal treatment,
reflecting the fact that the criteria on which such
treatment should be initiated in patients having Aspergillus
spp.-positive respiratory tract samples are not
Our study has a number of limitations. First, due to its
monocentric design, our results may not be applicable
to other centers, thereby limiting their generalizability,
since risk exposure to Aspergillus, prevalence of
colonization and subsequent IPA may vary between centers.
Moreover, the number and the type of respiratory tract
samples performed were not standardized over the study
period, potentially hampering the isolation of
Aspergillus spp. in patients having had limited microbiological
investigations. Second, this was a retrospective study
with possible associated errors in data abstraction.
However, due to the relatively low frequency of IPA,
prospective studies in the specific subgroup of ARDS patients
would be hardly feasible due to the low rate of
Aspergillus colonization [
]. Third, our patients were admitted
over a 10-year period, with inherently associated
selection bias related to variations in coding habits between
years. Moreover, during this relatively long time period,
exposure to Aspergillus spores might have varied due to
environmental factors. However, we found no association
between the year of ICU admission and the risk of having
one or more respiratory tract sample positive for
Aspergillus spp. Fourth, several known prognostic factors for
ARDS, including pulmonary artery pressure level or right
ventricular dysfunction [
], were not available due to
the retrospective nature of the study. Last, due to the
limited number of patients having had a chest CT scan
performed (n = 21/35), our study does not allow for drawing
definite conclusions regarding the performance of chest
CT scan in discriminating between putative aspergillosis
and Aspergillus colonization in the context of ARDS.
We report a prevalence of 8 % of Aspergillus-positive
lower respiratory tract specimen culture and 4 % of
proven or putative IPA during ARDS.
Immunocompromised ARDS patients were more likely to be categorized
as having a putative or proven IPA, while
non-immunocompromised patients were more frequently classified as
having Aspergillus respiratory tract colonization.
Immunosuppression and pneumonia were associated with
having at least one positive sample for Aspergillus. In this
cohort of ARDS patients, having one or more positive
sample for Aspergillus had no impact on outcome when
classified as a mere respiratory tract colonization. In
contrast, patients classified as having putative/proven IPA
had a higher risk of in-ICU mortality, suggesting
antifungal treatment should be assessed in this subgroup.
ARDS: acute respiratory distress syndrome; ICU: intensive care unit; IPA: inva‑
sive pulmonary aspergillosis.
NDP, MD, JR, FS, FF, FB and AG collected the data; NDP, MD and DC analyzed
the data and wrote the manuscript; and KR, GC, FF, FB, AMD and CBB revised
the manuscript. NDP is the guarantor of the article. All authors read and
approved the final manuscript.
The authors declare they have no competing interests.
This observational, non‑interventional analysis of medical records was
approved by the Institutional Review Board of the French Society for Respira‑
tory Medicine. As per French law, no informed consent was required for this
type of study.
This study did not receive funding from external or internal sources.
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