Presentation and prognosis of cryptococcosis requiring intensive care unit admission in France: the CRYPTO-ICU study.

Abstract

Cryptococcus causes life-threatening opportunistic infections in immunocompromised hosts. Data on the most severe cases requiring ICU admission remain limited. We conducted a retrospective, multicenter study of patients admitted to 30 French ICUs for severe cryptococcosis between 2000 and 2022. Among 151 patients included, 56.9% were patients with HIV. Cases in patients without HIV became increasingly prevalent over time (51.3% in 2012-2022 vs. 32.4% before 2012); 82.5% were receiving immunosuppressive therapy. Central nervous system infection was predominant (91.1%), followed by lung infection (39.7%). Fungemia occurred in 59.8% patients, and 75.2% had disseminated infection. Neurological failure was the leading organ impairment at admission (75.5%) followed by respiratory failure (47.7%), acute kiney injury (41.7%) and shock (24.5%). The median SOFA score was 4 [2-7]. Invasive mechanical ventilation, vasopressors and renal replacement therapy were required in 54.9%, 34.4% and 18.5% of patients, respectively. At day 90, 94% of patients requiring mechanical ventilation and vasopressors were deceased, compared to 38.7% with invasive ventilation alone and 17.2% without any organ support (p<0.001). Overall, 90-day mortality reached 49.6%. SOFA score (HR 1.04 [1.02-1.06]), admission between 2000 and 2012 (HR 2.30 [1.36-3.89]), disseminated infection (HR 2.32 [1.15-4.67]) and initiation of antifungal therapy before ICU admission (HR 0.38 [0.22-0.63]) were independently associated with 90-day mortality, whereas HIV serostatus was not (HR 0.93 [0.47-1.84]). Severe cryptococcosis requiring ICU admission affects an increasing number of patients without HIV and is associated with high, though declining, mortality. Early diagnosis and treatment are mandatory to improve prognosis.