Incidence, mortality and risk factors of invasive pulmonary aspergillosis in critically ill patients during the COVID-19 era: a global systematic review and meta-analysis.

Authors

Zijing Zhou, Bin Luo, Xiwen Zhang, Qing Li, Yingzi Huang, Yi Yang, Haibo Qiu, Ming Xue, Jianfeng Xie

Published in

Annals of clinical microbiology and antimicrobials. Jul 10, 2026. Epub Jul 10, 2026.

Abstract

Invasive pulmonary aspergillosis (IPA) represents a growing threat to critically ill patients, with mortality rates exceeding 50%. The burden of IPA has been exacerbated during the COVID-19 era due to prolonged ICU stays and widespread use of immunosuppressive therapies. This systematic review and meta-analysis aimed to synthesize global evidence on the incidence, mortality, and risk factors of IPA in ICU patients.
Observational studies reporting IPA incidence, mortality, or risk factors in ICU settings from their inception between November 1, 2019 to October 11, 2024 for eligible studies were retrieved from PubMed, Embase, Web of Science, and Cochrane Library. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses were performed using R software to calculate pooled estimates with 95% confidence intervals (CI). Multiple subgroup analysis was conducted.
Fifty-six studies involving 15,385 ICU patients (2,381 IPA cases) were included. The pooled incidence of IPA was 11.9% (95% CI: 9.7-14.6%). Subgroup analyses revealed higher incidence in mechanically ventilated patients (15.0%, 95% CI: 11.7-19.0%). Factors associated with an increased risk of IPA included male sex (OR = 1.29), smoking history (OR = 1.52), chronic lung diseases (OR = 1.30), chronic kidney disease (OR = 1.70), chronic liver disease (OR = 1.79), heart disease (OR = 1.20), malignant tumor (OR = 1.75), hematological malignancy (OR = 2.65), glucocorticoids use before ICU (OR = 2.13), immunosuppression (OR = 2.26), EORTC host factors (OR = 2.13), vasopressor use (OR = 3.28), mechanical ventilation (OR = 3.69), and renal replacement therapy (OR = 2.31). The overall mortality rate was 59.6% (95% CI: 55.0-64.0%), escalating to 61.9% in mechanically ventilated patients. Mortality-associated factors included age ≥ 65 years (OR = 2.85), ICU-administered glucocorticoids (OR = 1.95) and mechanical ventilation (OR = 1.93).
During the COVID-19 era, IPA remains a life-threatening complication in critically ill patients, particularly those with COVID-19, and is associated with immunosuppression, organ dysfunction, and invasive therapies. Our findings, predominantly reflecting CAPA epidemiology, generate the hypothesis that early screening in high-risk populations and tailored antifungal strategies warrant prospective evaluation to determine whether they improve outcomes.
Ethical approval and patient consent were not required for this meta-analysis, as it was based on previously published studies. The protocol for this meta-analysis was registered on PROSPERO: International prospective register of systematic reviews (CRD42025631579).

PMID:
42432685
Bibliographic data and abstract were imported from PubMed on 11 Jul 2026.

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