Incidence, mortality and risk factors in COVID-19-associated pulmonary aspergillosis (CAPA): an umbrella review and meta-meta-analyses (2020-2025).

Abstract / Summary

COVID-19-associated pulmonary aspergillosis (CAPA) has emerged as a severe and potentially underrecognised complication in patients with SARS-CoV-2 infection, particularly in intensive care units (ICUs). Existing reviews show substantial heterogeneity in diagnostic criteria, incidence estimates, and reported risk factors, limiting reliable interpretation of the overall evidence base. this umbrella review synthesised systematic reviews and meta-analyses published between 2020 and 2025 to clarify the incidence, mortality, and risk factors associated with CAPA. Searches were conducted in PubMed and Scopus. Eligibility was restricted to articles published in English and Spanish. Pooled estimates were re-calculated through a dedicated meta-metaanalysis. sixteen reviews met the inclusion criteria, nine of them with meta-analysis. The pooled incidence among critically ill patients was 11.3% (95% CI 9.2-13.9), strongly influenced by diagnostic variability and the limited use of bronchoalveolar lavage during the pandemic. Overall mortality reached 51.6% (IQR 48.3-54.5), and CAPA tripled the risk of death compared with non-CAPA patients (OR 3.08; 95% CI 2.73-3.49). Consistent risk factors identified across meta-analyses included advanced age (OR 1.05 per year), chronic obstructive pulmonary disease (OR 1.98), type 2 diabetes mellitus (OR 1.25), systemic corticosteroid exposure (OR 1.72), and IL-6 inhibitors (OR 2.32). the marked heterogeneity observed across studies highlights the urgent need for harmonised and clinically applicable diagnostic criteria. CAPA remains an underdiagnosed condition associated with substantial mortality, underscoring the importance of early recognition strategies and improved diagnostic availability to guide timely management in high-risk patients.

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