TOPLINE: 

Early empirical antifungal treatment in patients admitted to the ICU with influenza-associated acute respiratory distress syndrome (ARDS) reduced the 30-day incidence of influenza-associated pulmonary aspergillosis (IAPA), but it did not improve 30-day survival rates.

METHODOLOGY:

• Researchers conducted a retrospective observational study across nine centers to investigate the role of empirical administration of mold-active antifungals in critically ill patients with influenza and ARDS.
• They enrolled 172 patients (median age at ICU admission, 65 years; 38% women) with polymerase chain reaction-confirmed influenza A or B admitted to ICUs between September 2016 and March 2025.
• Comprehensive testing for fungal infections was performed and IAPA cases were classified using Fungal Infections in Adult Patients in ICU consensus criteria. Overall, 61 patients received empirical antifungal treatment, most commonly posaconazole (94%), whereas 111 did not.
• The primary outcome was 30-day IAPA incidence, measured from ICU admission to either the first positive IAPA sample or 30-day censoring, and the secondary outcome was 30-day overall survival in the ICU.

TAKEAWAY:

• IAPA was diagnosed in 24 cases, with a median onset of 2 days after ICU admission.
• The 30-day IAPA incidence was significantly lower in patients who received empirical antifungals than in those who did not (7.7% vs 20.4%).
• No significant difference was observed in 30-day ICU survival between those who received empirical antifungals and those who did not (P = .073).
• Patients who developed IAPA had significantly worse 90-day ICU mortality.

IN PRACTICE:

"[The findings highlight] the need for future research to identify patients who may benefit from early empirical antifungal treatment or later prophylaxis as part of an ICU influenza care bundle," the authors wrote.

"In our hypothesis-generating analysis, patients with severe respiratory failure appeared to potentially benefit the most from this strategy, though further research is needed to confirm this observation," they added.

SOURCE:

The study was led by Stefan Hatzl, MD, PhD, Department of Internal Medicine, Medical University of Graz, Graz, Austria. It was published online on September 15, 2025 in Clinical Infectious Diseases.

LIMITATIONS: 

The study had limitations, including nonrandomized antifungal use, ICU variability between groups, and possible underreporting of adverse events. Mortality rates remained higher in the treatment group despite lower IAPA rates, possibly due to unmeasured confounders or because IAPA may be a marker of disease severity rather than a direct cause of death.

DISCLOSURES:

The study did not receive any funding. Two authors reported receiving financial aid from or engaging in collaborations with pharmaceutical companies. One of these authors was listed as a co-inventor on a patent relating to influenza virus vaccines and influenza virus therapeutics.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.