Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Table 5. : diagnosis of CAPA according to EORTC, ISHAM and ASPICU criterias through waves 177 and overall.  (I would bold the sub-headers of all diagnostic criteria, right now only EORTC is bolded)

Very interesting paper, compared/contrasted diagnostic criteria well. Interesting how GM in BAL was low, and only increased in 4th wave, any explanation to this?

 

In table 2 "Immunosuppression" is listed under co-morbidities, is this meant both primary and secondary immunosuppressive illnesses? Does it include immunocompetent ICU patients receiving tocilizumab as part of COVID? need clarification on definition. 

 

What steroid dosages were used? was it more than 2mg/kg/day?

 

How were patients designated in each group category treated? who were started on systematic anti-fungals as empiric therapy? 

Author Response

Comment 1:

Table 5: diagnosis of CAPA according to EORTC, ISHAM and ASPICU criterias through waves and overall. (I would bold the sub-headers of all diagnostic criteria, right now only EORTC is bolded)

Response 1:

Thank you for this helpful suggestion. We agree that consistency in formatting improves readability. Therefore, we have revised Table 5 to ensure that all diagnostic criteria sub-headers (EORTC, AspICU, and ISHAM) are uniformly bolded.

This change can be found in the revised manuscript.

Comments 2:

Very interesting paper, compared/contrasted diagnostic criteria well. Interesting how GM in BAL was low, and only increased in 4th wave, any explanation to this?

Response 2:

We thank the reviewer for this insightful comment. We have expanded the discussion to provide potential explanations for the observed increase in BAL galactomannan positivity during later waves.

Specifically, we now discuss:

• The increased use of corticosteroids and immunomodulatory therapies (e.g., after the RECOVERY trial), potentially predisposing patients to fungal infections.
• A shift toward more systematic and earlier mycological screening practices in later waves.
• Improved awareness of CAPA among clinicians, leading to increased diagnostic yield.

Comments 3:

In table 2 “Immunosuppression” is listed under co-morbidities, is this meant both primary and secondary immunosuppressive illnesses? Does it include immunocompetent ICU patients receiving tocilizumab as part of COVID? need clarification on definition.

Response 3:

We appreciate this important request for clarification.

We have clarified the definition of “immunosuppression” in the Methods section to specify that it includes:

• Primary immunosuppressive conditions (e.g., hematological malignancies, solid organ transplantation),
• Chronic immunosuppressive therapies (e.g., long-term corticosteroids, immunosuppressive drugs).

We also explicitly state that:

• Acute immunomodulatory treatments administered for COVID-19 (such as tocilizumab or short-term corticosteroids) were not considered as baseline immunosuppression, but were analyzed separately under treatment variables.

This clarification has been added in the Methods section.

Comments 4:

What steroid dosages were used? was it more than 2mg/kg/day?

Response 4:

Thank you for raising this important point.

We have added details regarding corticosteroid regimens in the Methods and Results sections. Specifically:

• Most patients received dexamethasone according to standard COVID-19 protocols (e.g., 6 mg/day).
• A minority of patients received higher doses (e.g., methylprednisolone), depending on clinical severity and physician discretion.

We confirm that doses exceeding 2 mg/kg/day were not routinely used in our cohort.

These details are now specified in the revised manuscript.

Comments 5:

How were patients designated in each group category treated? who were started on systematic anti-fungals as empiric therapy?

Response 5:

We thank the reviewer for this relevant question.

We have clarified antifungal treatment strategies in the revised manuscript. Specifically:

• Empirical antifungal therapy was generally initiated in patients with clinical deterioration and at least one positive mycological criterion (corresponding mainly to Group 3 – probable CAPA).
• Patients classified as colonization (Group 1) were typically not treated unless clinical worsening occurred.
• Treatment decisions were left to the discretion of the treating physicians and were not protocolized due to the retrospective nature of the study.

These clarifications have been added in the Methods and Discussion sections in red.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses an important and timely topic: the diagnosis of COVID-19-associated pulmonary aspergillosis (CAPA) in critically ill patients, comparing three commonly used classification systems (EORTC/MSG, AspICU, and ISHAM). The relatively large cohort (n = 405) and focus on mechanically ventilated ICU patients are strengths. However, several aspects require clarification and improvement to enhance scientific rigor and clarity.

Major Comments
1. Study Design and Cohort Definition
The study is described as a retrospective monocentric study, which is appropriate for the research question.
However, important details are missing or insufficiently described:
Inclusion and exclusion criteria are not clearly specified (e.g., were all ventilated COVID-19 patients systematically screened for CAPA?).
It is unclear whether screening for Aspergillus (e.g., galactomannan, cultures, PCR) was performed systematically or only when clinically suspected.
The potential for selection bias should be discussed, especially if testing was not standardized.
2. Application of Diagnostic Criteria
The comparison of EORTC/MSG, AspICU, and ISHAM criteria is the central contribution of the study, but:
The manuscript does not clearly explain how each criterion was operationalized in practice.
Some criteria (e.g., EORTC/MSG) are not designed for ICU COVID-19 populations; this limitation should be more explicitly acknowledged.
A table summarizing the differences between the three criteria would greatly improve clarity.
3. Methods – Microbiological and Diagnostic Workup
The microbiological methods are insufficiently detailed:
Specify thresholds (e.g., galactomannan cut-offs in serum vs BAL).
Clarify timing of sampling relative to ICU admission and mechanical ventilation.
Indicate whether antifungal treatment was initiated empirically or based on diagnostic criteria.
Without these details, reproducibility is limited.
4. Results – Clarity and Structure
The key finding—variation in CAPA incidence (6.1% vs 9.7% vs 15.1%)—is clearly stated, but:
The results section mixes descriptive data with interpretation, reducing clarity.
Mortality data (76% vs 43%) are important but should be:
Adjusted (if possible) for confounders (e.g., severity, comorbidities)
Or clearly stated as unadjusted comparisons
Consider adding:
- A flowchart of patient inclusion and classification
- A comparative table showing overlap between classification systems
5. Statistical Analysis
The statistical methods are not described in sufficient detail:
Which statistical tests were used for comparisons?
Were multivariate analyses performed to assess independent associations with mortality?
Were corrections for multiple comparisons applied?
This is a critical limitation that must be addressed.
6. Interpretation and Conclusions
The conclusion that ISHAM criteria identify more CAPA cases is expected but should be interpreted cautiously:
Does higher sensitivity come at the expense of specificity?
Are these additional cases clinically meaningful or potential overdiagnosis?
The manuscript would benefit from a more critical discussion of diagnostic accuracy vs clinical relevance.

Minor Comments
Introduction
The introduction is generally adequate but could:
Better emphasize the clinical consequences of misclassification (over- vs under-diagnosis)
Include more recent CAPA-related studies

Tables and Figures
Tables summarizing patient characteristics and outcomes are useful but:
Some are dense and difficult to interpret
Consider simplifying or highlighting key comparisons
A visual comparison of classification systems is strongly recommended

Terminology
Ensure consistent use of terms such as:
“probable,” “possible,” and “proven” CAPA
Clarify whether definitions differ across classification systems

Comments on the Quality of English Language

The manuscript is generally understandable but contains:

• Grammatical errors
• Typographical issues (e.g., formatting artifacts in the abstract)
• Professional English editing is recommended

Author Response

Comments: Study Design and Cohort Definition – Inclusion and exclusion criteria are not clearly specified. It is unclear whether screening for Aspergillus was systematic or clinically driven. Potential selection bias should be discussed.

Response: Thank you for this important comment. We agree that clarification of study design and screening strategy is essential. We have revised the Methods section to clearly specify inclusion and exclusion criteria, including the requirement for invasive mechanical ventilation and confirmed SARS-CoV-2 infection. We also clarified that Aspergillus investigations were performed either as part of routine screening in mechanically ventilated patients during later waves or triggered by clinical or radiological deterioration. Finally, we have expanded the Discussion to acknowledge the potential for selection bias related to non-standardized screening practices, particularly during the early pandemic waves.

 

Comments: Application of Diagnostic Criteria – The manuscript does not clearly explain how each criterion was operationalized. Some criteria are not designed for ICU COVID-19 populations; this limitation should be acknowledged.

Response: We thank the reviewer for this insightful remark. We have clarified in the Methods section how each diagnostic criterion was applied in practice. We have also strengthened the Discussion to explicitly acknowledge that EORTC/MSG criteria were not designed for ICU populations and may lead to underdiagnosis. Differences between classification systems are now more clearly described.

 

Comments: Methods – Microbiological workup insufficiently detailed.

Response: We have expanded the Methods section. We now specify that galactomannan testing was performed on BAL and serum according to institutional standards, sampling was performed at ICU admission or during clinical deterioration, and antifungal therapy was initiated based on clinical judgment in the presence of clinical deterioration and positive mycological findings. We acknowledge variability due to retrospective design.

 

Comments: Results – Mixing descriptive data and interpretation; mortality data should be adjusted or clearly stated as unadjusted.

Response: We have revised the Results section to improve clarity and removed interpretative elements. Mortality data are now clearly stated as unadjusted. Patient selection and classification clarity have been reinforced.

 

Comments: Statistical Analysis – insufficient detail; multivariate analysis not described.

Response: We have clarified the statistical methods used. We acknowledge that no multivariate analysis or correction for multiple comparisons was performed due to the descriptive nature of the study, and this is now clearly stated as a limitation.

 

Comments: Interpretation and Conclusions – risk of overdiagnosis with ISHAM.

Response: We have strengthened the Discussion to address the balance between sensitivity and specificity. We now emphasize that ISHAM criteria may increase sensitivity at the expense of specificity and that some additional cases may represent colonization rather than invasive disease.

 

Comments: Introduction – emphasize consequences of misclassification and include recent studies.

Response: We have revised the Introduction to better highlight the consequences of misclassification and updated references with more recent CAPA-related studies.

 

Comments: Tables and Figures – dense and difficult to interpret.

Response: We have improved readability of tables and clarified their presentation. Key findings are now emphasized in the text.

 

Comments: Terminology – ensure consistent use of terms.

Response: We have revised the manuscript to ensure consistent terminology across all classification systems.

 

Comments: English language – grammatical and typographical issues.

Response: The manuscript has been carefully revised to improve grammar and clarity.

 

All modifications have been highlighted in red in the revised manuscript.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Reviewers,

Thank you very much for your detailed and kind reply.