Infection prevention
pointed out that invasive Aspergillus infection (IA) is the most significant fungal infection problem globally – with around 1.8 million deaths. The annual number of people affected is around 2.1 million.
Fungal infections and COPD Prof. Denning explained that patients with smoking-related lung disease (COPD), patients in intensive care, and patients with lung cancer and leukaemia are all at increased risk of severe fungal infections caused by IA. There is a very high mortality among this cohort and the reason is primarily due to a lack of diagnosis, he explained. “We do not suspect the patient has the disease; we do not ask for the right tests; or – if we do – it’s too late,” he commented. Research suggests that the number of patients with COPD (Gold stage II-IV) is around 551,800,000 and there are around 57,938,000 admissions to hospital (10.5% annually). It is not just hospital-acquired infection that is an issue; community acquisition of IA is also a significant problem – research from Singapore and Vancouver (Tiew et al, 2024) has highlighted the problem of residential exposure to Aspergillus spp, associated with exacerbations in COPD.1 A study by Hammond et al (2020) indicates
that, in Spain, there are 760,000 IA cases in COPD patients at a 1.3% rate, while in China there are 2,272,000 IA cases in patients with COPD, at a rate of 3.9%.2
Prof. Denning explained that this
means that, on a ward round, you can expect to see one of these patients every two or three weeks. “This is a very big problem, and it needs to
be addressed,” he warned. The clues to the diagnosis of IA include: l GOLD stage 3 or 4 l Excess wheezing (consider tracheobronchitis)
l Worsening infiltrates in an ‘exacerbation’ (66%)
l Bilateral infiltrates (55%) l Culture of Aspergillus l High corticosteroid exposure recently l Do NOT expect fever (38%), chest pain or haemoptysis3
Research by Loughlin et al (2020) indicates that 1-5% of medical ICU patients develop IA.4 “In intensive care, an estimated 500 million people get invasive Aspergillus infection. Some of this is influenza or COVID driven, but most of it is just medical patients ending up on ICU with an episode of sepsis, diabetes or COPD. It is not the surgical patients; it’s the medical ones,” said Prof. Denning. “If you perform bronchoscopy on ICU, you double the chance of diagnosis. So, one of the pieces of advice, which has come from work in Belgium and Holland, is that new emergency medical admissions to ICU should have a bronchoscopy. It should be a routine procedure, looking for fungus and looking at the airway. Although many of these patients are very sick and oxygen dependant, you can do a quick bronchoscopy,” he continued. “This needs to be part of routine care in this country and it isn’t.” Prof. Denning pointed out that a study of 25
years of autopsy cases from ICU patients in Spain found 2.8% had IA (approximately 1 in 40).5 Furthermore, a prospective study (UK) found 12.5% of ICU patients with ventilator-assisted pneumonia had IA.4
“This is a group that needs
particular attention,” Prof. Denning exclaimed. From a diagnostic perspective, he added that
radiology is “not very distinctive” and therefore not very helpful.
Invasive candida The second largest group of fungal infections is invasive candida infection. The global incidence is around 1.5 million, with 1 million deaths. It
affects many different types of patients – from premature babies, through to patients undergoing cancer chemotherapy; people with diabetes; patients who have undergone major surgery; patients who have experienced major trauma or burns, patients with renal failure, and people who have received excess antibiotics. “If you have been given three classes of
antibiotics, you triple the risk of invasive candida infection,” he asserted. Antibiotic stewardship is an important prevention factor, while hospital transmission via healthcare worker’s hands is another risk factor that needs to be addressed. A significant problem in terms of diagnosis is that blood cultures are only 40% sensitive.
Chronic pulmonary aspergillosis Chronic pulmonary aspergillosis (CPA) is similar to TB in presentation. However, key tests are Aspergillus IgG or precipitins and high-volume fungal culture. High-volume culture and PCR are much more sensitive than conventional culture for CPA and Allergic Bronchopulmonary Aspergillosis (ABPA) patients. The incidence of CPA is around 1.8 million, with 340,000 deaths. It is associated with patients with TB, smoking- related lung disease (COPD), asthma, and lung surgery, etc. Although mortality is lower for CPA, morbidity is high and patients are very “poorly,” Prof. Denning explained; often they are unable to work and cough up blood.
Candida auris Candida auris has been spreading across the world since 2008 and is now the 3rd most common cause of candidaemia.6,7 from Pakistan (Moin et al, 2021)8
A study compared
candidaemia due to Candida auris and other
non-C.auris cases in hospitalised COVID-19 patients, over a period of 9 months, at a healthcare organisation. The researchers found 86 cases of Candida bloodstream infections (April – December 2020); 10 cases (12%) were Candida auris and all cases were fluconazole resistant, with an overall mortality of 67%. “In the UK, we have seen a gradual increase in the number of isolations for Candida auris. It comes in waves and is very much a hospital outbreak problem. This organism behaves like MRSA. It colonises the environment; it colonises the skin; we need to think of this, not as the old-style Candida found only in our blood and gut, but as an MRSA ‘lookalike’…It is a multi-drug- resistant infection, like MRSA, which seems to be South-East London focused. It is also now a notifiable disease,” he commented. Other severe fungal diseases total 1 million – accounting for around 614, 000 mortality. These infections are associated with patients with AIDS, diabetes, severe asthma and patients
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www.clinicalservicesjournal.com I August 2025
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