Decoding CAPA: A Comparative Study of AspICU, ISHAM, and EORTC Criteria in Critical COVID-19 Patients Requiring Mechanical Ventilation

COVID-19-associated pulmonary aspergillosis (CAPA) is a frequent and severe complication among critically ill patients with COVID-19. The absence of a clear diagnostic gold standard and the multiplicity of proposed definitions (EORTC/MSG, AspICU, and ISHAM) complicate its diagnosis. 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. We conducted a retrospective, monocentric study including all adult COVID-19 patients requiring invasive mechanical ventilation admitted to the ICUs of CHU-Charleroi Chimay between March 2020 and December 2021. Patients were classified according to EORTC/MSG, AspICU, and ISHAM criteria. Demographics, comorbidities, management, and outcomes were compared across groups. In total, 405 patients were included during the four waves. The incidence of probable or possible CAPA varied widely: 6.1% with EORTC/MSG, 9.7% with AspICU, and 15.1% with ISHAM criteria. ICU mortality reached approximately 76% among patients with probable CAPA versus 43% in patients without aspergillosis. The frequency of CAPA diagnosis increased across COVID-19 waves, possibly correlating with changes in management, particularly corticosteroid use. The choice of CAPA diagnostic criteria has a major impact on incidence estimates and patient management. Prospective validation of CAPA definitions, integrating multiple mycological criteria, is urgently needed to guide clinical decision-making and antifungal therapy.