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Open Access Research article

Repeated Aspergillus isolation in respiratory samples from non-immunocompromised patients not selected based on clinical diagnoses: colonisation or infection?

Jose Barberan1*, Bernardino Alcazar2, Eduardo Malmierca3, Francisco Garcia de la Llana4, Jordi Dorca5, Daniel del Castillo6, Victoria Villena7, Melissa Hernandez-Febles8, Francisco-Javier Garcia-Perez9, Juan-Jose Granizo10, Maria-Jose Gimenez11, Lorenzo Aguilar11 and on behalf of the ASP Investigator Group

Author Affiliations

1 Infectious Diseases Department, Hospital Central de la Defensa Gómez Ulla, Gta. del Ejército s/n, 28047, Madrid, Spain

2 Pneumology Department, Complejo Hospitalario de Jaen, Jaen, Spain

3 Internal Medicine Department, Hospital Infanta Sofia, San Sebastián de los Reyes, Madrid, Spain

4 Infectious Diseases Department, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain

5 Pneumology Department, Hospital Universitari de Bellvitge, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain

6 Pneumology Department, Hospital de Jerez, Jerez de la Frontera, Cadiz, Spain

7 Pneumology Department, Hospital Universitario 12 de Octubre, Madrid, Spain

8 Microbiology Department, Hospital Universitario de Gran Canaria Dr. Negrin, La Palmas de Gran Canaria, Spain

9 Pneumology Department, Hospital Universitario de la Princesa, Madrid, Spain

10 Grana Datos, Pozuelo de Alarcón, Madrid, Spain

11 Microbiology Department, School of Medicine, Universidad Complutense, Madrid, Spain

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BMC Infectious Diseases 2012, 12:295  doi:10.1186/1471-2334-12-295

Published: 12 November 2012

Abstract

Background

Isolation of Aspergillus from lower respiratory samples is associated with colonisation in high percentage of cases, making it of unclear significance. This study explored factors associated with diagnosis (infection vs. colonisation), treatment (administration or not of antifungals) and prognosis (mortality) in non-transplant/non-neutropenic patients showing repeated isolation of Aspergillus from lower respiratory samples.

Methods

Records of adult patients (29 Spanish hospitals) presenting ≥2 respiratory cultures yielding Aspergillus were retrospectively reviewed and categorised as proven (histopathological confirmation) or probable aspergillosis (new respiratory signs/symptoms with suggestive chest imaging) or colonisation (symptoms not attributable to Aspergillus without dyspnoea exacerbation, bronchospasm or new infiltrates). Logistic regression models (step–wise) were performed using Aspergillosis (probable + proven), antifungal treatment and mortality as dependent variables. Significant (p < 0.001) models showing the highest R2 were considered.

Results

A total of 245 patients were identified, 139 (56.7%) with Aspergillosis. Aspergillosis was associated (R2 = 0.291) with ICU admission (OR = 2.82), congestive heart failure (OR = 2.39) and steroids pre-admission (OR = 2.19) as well as with cavitations in X-ray/CT scan (OR = 10.68), radiological worsening (OR = 5.22) and COPD exacerbations/need for O2 interaction (OR = 3.52). Antifungals were administered to 79.1% patients with Aspergillosis (100% proven, 76.8% probable) and 29.2% colonised, with 69.5% patients receiving voriconazole alone or in combination. In colonised patients, administration of antifungals was associated with ICU admission at hospitalisation (OR = 12.38). In Aspergillosis patients its administration was positively associated (R2 = 0.312) with bronchospasm (OR = 9.21) and days in ICU (OR = 1.82) and negatively with Gold III + IV (OR = 0.26), stroke (OR = 0.024) and quinolone treatment (OR = 0.29). Mortality was 78.6% in proven, 41.6% in probable and 12.3% in colonised patients, and was positively associated in Aspergillosis patients (R2 = 0.290) with radiological worsening (OR = 3.04), APACHE-II (OR = 1.09) and number of antibiotics for treatment (OR = 1.51) and negatively with species other than A. fumigatus (OR = 0.14) and aspergillar tracheobronchitis (OR = 0.27).

Conclusions

Administration of antifungals was not always closely linked to the diagnostic categorisation (colonisation vs. Aspergillosis), being negatively associated with severe COPD (GOLD III + IV) and concomitant treatment with quinolones in patients with Aspergillosis, probably due to the similarity of signs/symptoms between this entity and pulmonary bacterial infections.

Keywords:
Aspergillus; COPD; Clinical management; Aspergillosis