COVID-19-associated-pulmonary-aspergillosis (CAPA) is a severe superinfection mostly affecting critically ill COVID-19 patients. Early diagnosis and clinical management of CAPA remain major clinical challenges.

Here, we evaluated different approaches to classify culture-positive CAPA at its peak season, assessed incidence and mortality, identified risk factors and analysed clinical and laboratory CAPA-management of three German tertiary care hospitals.

A retrospective multi-center analysis was performed. Inclusion criteria were SARS-CoV-2-positivity, Aspergillus-culture-positivity of lower respiratory tract specimen and ARDS. Cases were primarily classified according to ECMM/ISHAM-criteria. Species-ID was confirmed by each center. Susceptibility was assessed by EUCAST-microdilution or VIPcheck-screening. Statistical analysis revealed mortality affecting factors.

95 culture-positive CAPA cases were classified as possible (36/95) or probable (59/95) by ECMM/ISHAM; 54 probable cases matched 2 or 3 additional classifications. Incidence rates were higher in ICU (2020/21: 1.56 %/2.13 % non-ICU vs. 5.14 %/6.77 % ICU). A. fumigatus was the most abundant species (93 %; (88/95)). Most patients received steroids to treat COVID-19-ARDS and required respiratory support (steroids: 71 % (67/95); intubated patients 52 % (49/95); ECMO (48 % (46/95)). Retrospective evaluation showed adherence to ECMM/ISHAM antifungal therapy guideline in 71 % (67/95). Case fatality rate was 60 % (57/95). A significant association between GM indices > 3 in respiratory fluid or nicotine abuse (p = 0.035 FE, OR=0.252, 95 % CI=0.066–0.986) and mortality was observed in univariate analysis. Convalescent plasma therapy was significantly associated with mortality reduction in uni- and multivariate analysis (p = 0.020).

Our data reveal regional differences in prevalence, diagnosis, and treatment of culture-positive CAPA in Germany. We could identify new factors affecting survival or mortality.