Decoding CAPA: A Comparative Study of Aspicu, Isham, and Eortc Criteria in Critical COVID-19 Patients Requiring Mechanical Ventilation

Background: COVID-19-associated pulmonary aspergillosis (CAPA) is a frequent and severe complication among critically ill patients with COVID-19 (1). The absence of a clear diagnostic gold standard and the multiplicity of proposed definitions (EORTC/MSG (2), AspICU (3), and ISHAM (4)) complicate its diagnosis and therefore the early treatment of these patients. Objectives: This study aimed to compare the performance of the EORTC/MSG, AspICU, and ISHAM classifications in diagnosing CAPA among mechanically ventilated COVID-19 patients and to assess their correlations with clinical outcomes. Methods: We conducted a retrospective, monocentric study including all adult COVID-19 patients requiring invasive mechanical ventilation admitted in the ICUs of CHU-Charleroi Chimay between March 2020 and December 2021. Patients were classified on probable or possible CAPA according to EORTC/MSG, AspICU, and ISHAM criteria. Demographics, comorbidities, management, and outcomes were compared across groups. Results: 405 patients were included during the four waves. The mean incidence of probable or possible CAPA during the study period varied widely: 6.1% with EORTC/MSG, 9.7% with AspICU, and 15.1% with ISHAM criteria. The distribution of aspergillosis cases across the four COVID-19 waves varied depending on the classification system used, especially for the AspICU and ISHAM criteria (from 7.6 to 11.9 % at the third wave for AspICU criteria and 12.3 to 18.6 % for the ISHAM criteria at the fourth wave). These variations could be secondary to changes in management practices of COVID-19 disease, particularly the use of corticosteroids. ICU mortality was significantly higher among patients with positive Aspergillus culture (50 compared to 40.5% in patients with negative culture), Conclusion: The choice of CAPA diagnostic criteria has a major impact on incidence estimates and patient management. Variations among diagnostic criteria emphasize the need for a unified and pragmatic definition. Prospective validation of CAPA definitions, integrating multiple mycological criteria, is urgently needed to guide clinical decision-making and antifungal therapy. Keywords: COVID-19, pulmonary aspergillosis, CAPA, AspICU, ISHAM, EORTC, invasive fungal infections, critical care.