About the project

Invasive pulmonary aspergillosis (IPA) is a severe fungal infection typically affecting immunocompromised individuals. However, over the past decade, it has been increasingly recognized in critically ill but immunocompetent patients, particularly those suffering from severe influenza. This form of fungal superinfection, known as Influenza-Associated Pulmonary Aspergillosis (IAPA), has been observed in up to 20% of critically ill influenza patients, as demonstrated in a multicentric study led by the GALActIC coordinator (1).
Despite the availability of antifungal treatments, IAPA remains a high-mortality condition, with an associated mortality of approximately 50%, which is 2-fold higher compared to severe influenza patients without aspergillosis (2). The main reason contributing to this high mortality rate is the challenging diagnosis of the infection, leading to late or insufficient antifungal therapy.
A universal antifungal prophylaxis approach for all critically ill influenza patients has been investigated and showed some reduction in IAPA by approximately 50%, but it failed to reach statistical significance. This underscores the need for a more targeted and personalized approach, focusing on high-risk subpopulations.
Obtaining a proven diagnosis of IAPA requires histological confirmation, which is almost never feasible in living patients (3).
Probable IAPA diagnosis depends on bronchoalveolar lavage (BAL) sampling for mycological testing, an invasive procedure that is not always possible in critically ill, non-mechanically ventilated ICU patients 13.
Given that delayed antifungal treatment significantly increases mortality, and that universal antifungal prophylaxis is not sufficiently effective, there is a critical need for a rapid, blood-based biomarker to identify severe influenza patients at risk of developing IAPA. Such a companion biomarker would allow for a personalized prophylactic strategy, ensuring:

1. Targeted antifungal prophylaxis for high-risk patients, enabling early intervention and improved survival rates
2. Avoidance of unnecessary antifungal prophylaxis in low-risk patients, thereby reducing associated side-effects

• IAPA risk factors remain unclear with no validated genetic or immunological biomarkers for diagnosis
• LGALS3-based mechanisms are poorly understood, limiting risk assessment and targeted interventions

• IAPA diagnosis is difficult leading to delayed antifungal treatment
• Universal prophylaxis is ineffective, highlighting the need for personalized antifungal strategies

• Identification of high-risk patients
• Personalized prophylaxis, reducing mortality
• Reduction of healthcare costs

WP1 is led by P0.
WP1 will confirm the association between the risk of IAPA (Influenza-associated pulmonary aspergillosis) and the presence of a specific genetic variation (rs4644 LGALS3 SNP) in a large, already existing international biobank. By analysing various groups of people in the biobank, WP1 will also look at the LGALS3 gene in more detail by testing related genetic markers. This commonly used strategy is known to make the process of studying complex diseases more efficient and is expected to increase the overall predictive value of our approach, by generating risk score models.

WP2 is led by P3.
WP2 will test the functional consequences of LGALS3 gene variations (WP1) on the immune system. This will be done in a lab setting, using immune cells (monocytes, macrophages, and neutrophils) from 216 healthy volunteers in a special functional genomics cohort led by P3.
By studying these cells, WP2 will be able to understand how variations in LGALS3 affect immune cell behaviour, with at least 20 of the donors carrying the specific gene variation linked to higher disease risk. This will provide strong evidence for the role of LGALS3 in immune response, as it affects about 10% of the general population.

WP3 is led by P2.
WP3 aims to identify how LGALS3 gene variations affect the body using multi-omics approaches, including immunological tests, metabolomics, and microbial profiling. We will expand on existing data from the P0 cohort and include new data from the P0/P2 cohorts using advanced technologies like microbial profiling, proteomics, and metabolomics. To ensure consistency, we’ll use the same methods across all cohorts. The analysis will be done in two stages: first separately for discovery and validation cohorts, and then combined for a more comprehensive view. This approach, proven effective by the P2 group, will help identify immune and metabolic factors linked to LGALS3. These findings will inform WP2’s functional studies on how LGALS3 contributes to IAPA.

WP4 is led by P0.
WP4 focuses on designing an interventional trial using LGALS3 genetic variants as biomarkers to identify severe influenza patients who may benefit from antifungal prophylaxis. This phase is a feasibility study aimed at preparing for a larger, multicentre trial, but it does not involve the trial’s execution. Tasks include designing the trial protocol, defining eligibility criteria, recruiting trial centres, calculating power and budget, and preparing informed consent.
As a second part, WP4 will propose an economic evaluation comparing costs and outcomes between three strategies: (1) LGALS3-targeted prophylaxis, (2) universal prophylaxis, and (3) standard care for IAPA. The evaluation will use a Discrete-Event Simulation (DES) model to simulate different patient care scenarios.
As a third part, the social science partner (P4) will work with two ICU patient organizations to help design the trial and identify factors that influence the acceptance of genetic testing for antifungal prophylaxis. This will involve consulting healthcare providers, patients, and families to understand the reasons behind accepting or refusing genetic testing.

WP5 led by P0.
WP5 will cover all aspects of project management, including scientific and administrative tasks such as legal, financial, and communication responsibilities. It will ensure coordination between work packages (WPs), track objectives and deliverables, manage risks, and oversee data management, while also addressing gender equality and ethical considerations.

WP6 led by P1.
The project’s dissemination strategy has two main goals: sharing research on infectious diseases, intensive care, microbiology, and genetics, and engaging clinicians, industry partners, and recruitment centres for clinical implementation.
Efforts include a website, social media (Instagram, X, Bluesky, LinkedIn, Facebook), and presentations at conferences like ESCMID and ID Week. Findings will be published in high-impact journals and open-access repositories.
Communication activities involve public engagement, media outreach, social media videos, local seminars, school visits, and participation in events like Researchers‘ Night. Targeted outreach to clinicians, industry, and investors will occur at key conferences.
Key actions include forming a dissemination committee, issuing press releases, maintaining online platforms, and engaging with patient representatives.