Diagnosis, clinical features and survival analysis of invasive pulmonary aspergillosis among critically ill patients: a retrospective cohort study based on updated criteria

Objective To evaluate the incidence, diagnostic performance, clinical characteristics, and prognostic determinants of invasive pulmonary aspergillosis (IPA) in critically ill patients, using updated EORTC/MSG and FUNDICU criteria. Methods We retrospectively analyzed a heterogenous ICU pneumonia cohort between Jan 2022 and Jun 2025. All included patients underwent at least one mycological assessment. IPA was diagnosed based on integrated EORTC/MSG and FUNDICU criteria. Diagnostic accuracy of mycological assays was evaluated, and clinical profiles were compared between IPA and non-IPA patients. Independent risk factors for mortality were identified via multivariate Cox regression. Results Among 1835 patients, the IPA incidence was 7.1% (n=131). Of all mycological assays, bronchoalveolar lavage fluid galactomannan (BALF GM) demonstrated the highest sensitivity (85.5%) with robust specificity (82.9%). Molecular testing combined with BALF GM yielded a sensitivity of 64.4% and a specificity of 80.0%. Serum GM exhibited the lowest sensitivity (41.7%) but the highest specificity (89.2%); its combination with culture or molecular methods further enhanced specificity to >95%. Although patchy infiltrates were the most frequent radiological findings in both groups, consolidation (63.4% vs. 40.3%, P < 0.001), nodules (22.9% vs. 9.1%, P = 0.014), cavities (17.6% vs 3.9%, P = 0.004), and tree-in-bud signs (9.9% vs. 1.3% , P = 0.019) were significantly more prevalent in IPA patients. IPA patients experienced longer ICU stays (median 20 vs. 16 days) and significantly higher ICU mortality (55.0% vs 26.0%). Multivariable analysis identified IPA (HR: 2.064, 95% CI = 1.211-3.518, P = 0.008) and a prolonged interval from admission to the first positive mycological test (HR: 1.017, 95% CI = 1.004-1.031, P = 0.011) as independent risk factors for death. Conversely, anti- Aspergillus therapy (HR: 0.489, 95% CI = 0.275-0.871, P = 0.015) and tracheostomy (HR: 0.351, 95% CI = 0.222-0.557, P < 0.001) were associated with improved survival. Conclusion IPA is a common and lethal complication in ICU pneumonia patients, serving as an independent predictor of mortality. BALF GM, particularly when integrated with molecular testing, is the most effective mycological diagnostic method. Reducing the diagnostic window, initiating timely antifungal therapy, and proactive airway management (e.g., tracheostomy) may significantly improve clinical outcome for these critically ill patients.