Bronchoalveolar Lavage Galactomannan Research Articles

A 2-year Review of the Diagnostic Performance of Serum and Bronchoalveolar Lavage Galactomannan Testing in Lung Transplant Recipients in a National Heart and Lung Transplant Centre.

The 2015 International Society for Heart and Lung Transplant (ISHLT) fungal guidelines recommend the use of bronchoalveolar lavage (BAL) galactomannan over serum galactomannan for the diagnosis of invasive aspergillosis (IA) in lung transplant (LTx) recipients, based on limited evidence. Galactomannan testing is costly. A single-center, retrospective cohort study reviewing all 814 serum and BAL galactomannan samples received from 184 LTx recipients in our center between 2021 and 2022 and assessing their diagnostic performance in the diagnosis of IA. Over the study period, 394 serum galactomannan samples were received from 144 patients and 420 BAL galactomannan samples from 143 patients. Using a cut-off of ≥ 1.0 for BAL galactomannan, the sensitivity and specificity were 65.9% and 98.4%, respectively. In total, 30 patients had positive BAL galactomannan. Antifungal therapy was commenced or continued in 29 of these patients either as targeted or pre-emptive treatment. Using a cut-off of ≥ 0.5 for serum galactomannan, the sensitivity and specificity were 9.7% and 99.7%, respectively. In total, four patients had a positive serum galactomannan. All four patients were either already on antifungal treatment for IA or were started before the serum galactomannan result was available, supported by laboratory, clinical, and radiological findings. A positive serum galactomannan was used to monitor treatment response in one patient. Serum galactomannan is not a valuable test in the diagnosis of IA in our LTx recipients, is costly, and does not remove the need for bronchoscopy and BAL galactomannan. This supports the ISHLT recommendation.

The performance of bronchoalveolar lavage Aspergillus PCR testing in solid organ transplant recipients with invasive pulmonary aspergillosis.

Invasive aspergillosis affects solid organ transplant (SOT) recipients, carrying a high risk of mortality and morbidity in this population. Rapid and accurate diagnosis is essential to ensure the initiation of correct antifungal therapy. We aimed to evaluate the performance of the bronchoalveolar lavage (BAL) Eurofins Viracor Aspergillus PCR (AspPCR) in diagnosing invasive pulmonary aspergillosis (IPA) in SOT recipients. We conducted a multicenter retrospective study of SOT recipients in Arizona from February 2019 to December 2022 who had AspPCR done at the time of the clinical encounter. Probable IPA was defined as a positive BAL culture with Aspergillus spp. with clinical and imaging findings of IPA per EORTC/MSGERC criteria. Ninety-nine SOT recipients with 131 encounters with BAL AspPCR testing were included. The median age was 66, the majority were White, non-Hispanics (60%), and males (66%). Among the participants, 93 lung transplant recipients with 87 of the encounters received antifungal prophylaxis active against Aspergillus spp. Sixty-four encounters had BAL galactomannan (GM), all of which had BAL GM <1 OD, and one case had a serum GM of 10 OD. Nine cases met the definition of IPA. The sensitivity of the BAL AspPCR was 67% (95% CI 30%-93%), and the specificity was 98% (95% CI 93%-99%). BAL AspPCR had moderate sensitivity and high specificity in identifying IPA in our cohort of SOT recipients. Further studies in populations with a higher prevalence of IPA are needed to evaluate the performance of this test.

The effect of antifungal treatments on bronchoalveolar lavage galactomannan for the diagnosis of invasive fungal infections in patients with hematological malignancy: Single-center experience

Background Invasive fungal infections (IFI) mainly caused by aspergillus species are one of the leading causes of death in patients undergoing immunosuppressive therapy for hematological malignancies. The presence of galactomannan in bronchoalveolar lavage fluid (BAL GM) is an important diagnostic marker. Some of the factors affecting the BAL GM are still unknown. Antifungal treatment administered before or after BAL also affect BAL GM results. Methods To investigate the effect of BAL GM timing on the diagnosis of IFE, 100 patients receiving immunosuppressive therapy with hematological malignancy at the Uludağ University Faculty of Medicine, Hematology Department, and underwent BAL over a 3-year period with the suspicion of IFE as well as 127 BAL procedures of these patients were examined. Results There were 70 patients who started antifungal therapy before BAL and 30 patients who did not. BAL GM was found positive in 33 (47.1%) of the 70 patients who received antifungal therapy compared to 22 (73.3%) of the 30 patients who did not receive antifungal therapy. There was a significant difference between the two groups in terms of BAL GM positivity (p = 0.016). Subsequently, 127 BAL procedures of these 100 patients were evaluated. When the second, third, and subsequent BAL procedures of the same patients were included in the study, BAL GM was positive in 41 (46.6%) of the 88 procedures in patients who received treatment before BAL and in 25 (64.1%) of the 39 procedures in patients who did not receive treatment before BAL. The rate of BAL GM positivity did not differ between groups (p = 0.068). Conclusions The balance between reducing the risk by initiating early antifungal therapy and maximizing the diagnostic value of BAL GM should be evaluated individually for each patient.

Clinicomycological Study of the Spectrum of Pulmonary Aspergillosis at a Tertiary Care Hospital in Central India.

Knowing the spectrum, prevalence, and modes of diagnosis of pulmonary aspergillosis (PA) will be beneficial to clinicians for its early diagnosis and management. This study aims to estimate the prevalence, spectrum, and role of serological tests and radiological findings in the diagnosis of PA. A total of 150 patients were suspected of having PA after obtaining relevant clinical history and radiological imaging. The patients were grouped into each spectrum of PA as invasive PA (IPA), chronic necrotizing PA (CNPA), aspergilloma, allergic bronchopulmonary aspergillosis (ABPA) based on predisposing factors, clinical and radiological findings, and the guidelines of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG). Samples (bronchoalveolar lavage (BAL), sputum, blood) were collected from these patients and processed in a microbiology lab. BAL and sputum were subjected to microscopy by potassium hydroxide mount, calcofluor white mount, and culture. The serum was separated from blood by centrifugation and subjected to specific serological tests based on the spectrum of PA that the patient was suspected to have. For IPA, serum and BAL galactomannan antigen enzyme-linked immunosorbent assay (ELISA) was performed. For CNPA and aspergilloma, the anti-Aspergillus IgG antibody ELISA was performed. For ABPA, the tests performed were total immunoglobulin E (IgE) ELISA, Aspergillus fumigatus-specific IgE ELISA, and anti-Aspergillus immunoglobulin G (IgG) antibody ELISA. After compiling the clinical, radiological, culture, and serological findings, patients were diagnosed to have a particular spectrum of PA. The prevalence of IPA was 1.4%, CNPA was 4%, ABPA was 3.2%, and aspergilloma was 2.9%. CNPA was the predominant spectrum of PA in our study. Culture positivity for Aspergillus species was seen the highest in aspergilloma patients, followed by IPA, ABPA, and CNPA patients. A. fumigatus was the most common causative agent of PA, except for IPA for which Aspergillus flavus was the most common causative. Aspergillus niger and Aspergillus terreus were less the frequent causes of PA. A combination of radiological, microbiological, and serological tests along with clinical correlation is needed to confirm the diagnosis of PA.

Serial Bronchoalveolar Lavage Fluid Aspergillus Galactomannan and Treatment Response in Invasive Pulmonary Aspergillosis.

We studied patients diagnosed with aspergillosis based on positive bronchoalveolar lavage (BAL) Aspergillus galactomannan (GM) who had follow-up BAL sampling within 180 days. GM trend and clinical outcome were concordant in only 60% (30/50). While useful for the initial diagnosis, BAL GM trending does not always correlate with treatment response.

Effect of volume of instillate on the diagnostic utility of bronchoalveolar lavage galactomannan in patients with suspected chronic pulmonary aspergillosis-A pilot study.

Bronchoalveolar lavage (BAL) galactomannan (GM) is commonly used to diagnose Aspergillus-related lung diseases. However, unlike serum GM, which is measured in undiluted blood, BAL-GM is estimated using variable aliquots and cumulative volume of instillates during bronchoscopy. Since different studies have reported varying diagnostic accuracy and cut-offs for BAL-GM in CPA, we hypothesized that the total volume of instillate and 'order/label' of aliquots significantly affects the BAL-GM values, which was evaluated as part of this study. We obtained 250 BAL samples from 50 patients (five from each) with suspected chronic pulmonary aspergillosis. BAL fluid was collected after instilling sequential volumes of 40 mL of normal saline each for the first four labels and a fifth label was prepared by mixing 1 mL from each of the previous labels. The GM level of each label was measured by PLATELIA™ ASPERGILLUS Ag enzyme immunoassay. This study measured the discordance, level of agreement, diagnostic characteristics (sensitivity, specificity and AUROC) and best cut-offs for BAL-GM in the different aliquots of lavage fluid. The study population, classified into CPA (28%) and non-CPA (72%) groups, based on ERS/ESCMID criteria (excluding BAL-GM) were not different with respect to clinico-radiological characteristics. The discordance of BAL-GM positivity (using a cut-off of >1) between the serial labels for the same patient ranged between 10% and 22%, while the discordance between classification using BAL-GM positivity (using a cut-off of ≥1) and clinic-radio-microbiological classification ranged between 18% and 30%. The level of agreement for serial labels was at best fair (<0.6 for all except one 'label'). The AUROC for the serial samples ranged between 0.595 and 0.702, with the '40 mL and the 'mix' samples performing the best. The best BAL-GM cut-off also showed significant variation between serial labels of varying dilutions (Range:1.01 - 4.26). This study highlights the variation in BAL-GM measured and the 'positivity' between different 'labels' of aliquots of BAL, with the first aliquot and the mixed sample showing the best performances for diagnosis of CPA. Future studies should attempt to 'standardise' the instilled volume for BAL-GM estimation to standardise the diagnostic yield.

The Utility of Galactomannan and Polymerase Chain Reaction Assays in Bronchoalveolar Lavage for Diagnosis of Chronic Pulmonary Aspergillosis.

The diagnosis of chronic pulmonary aspergillosis (CPA) is established by combined clinic-radio-microbiological criteria. Out of the different microbiological criteria, a positive serology for Aspergillus-specific IgG levels is the cornerstone of diagnosis. Alternatively, other microbiological evidence are sometimes sought viz., positive Aspergillus antigen (broncho-alveolar lavage fluid,i.e., BALF galactomannan ≥ 1.0), histopathological demonstration of the fungi following lung biopsy or resection, demonstration of hyaline septate hyphae in direct microscopy resembling Aspergillus spp. or its growth on arespiratory specimen. However, the exactroles of BALF- GM and the newer BALF-PCR have not been confirmed by studies till date. This study enrolled 210 patients with suspected CPA. Of the participants, 88 patients met the criteria for CPA, whereas 122 patients had an alternative diagnosis. The sensitivity-specificity of AsperGenius® PCR and "in-house" PCR were 52.27(36.69-67.54) %-33.78 (23.19-45.72) % and 36.36 (22.41-52.23) %-39.19 (28.04-51.23) % respectively. The sensitivity/specificity of BALF (> 1.0) and serum galactomannan (> 1.0) were 46.55% (33.34-60.13)/64.08% (54.03-73.3) and 29.82% (22.05-37.6)/86.84% (81.1-92.59) respectively. The optimal cut-off values for BALF-Galactomannan and serum galactomannan in diagnosing CPA were found to be 0.69 (sensitivity: 64%; specificity: 53%) and 0.458 (sensitivity: 67%; specificity: 64%) respectively. This results of this study suggeststhatAspergillus PCR from BAL may not be a good "rule-in" test for diagnosing CPA. While the performances of GM in BAL and serum may be better than PCR, it should be best used in conjunction with other clinical, radiological, and other microbiological characteristics.

Aspergillus coinfection in critically Ill patients with severe dengue

In 2014–2015, a significant outbreak of dengue fever occurred in southern Taiwan, with a subsequent decline in dengue incidence. Despite this, there is emerging concern about virus-associated aspergillosis, yet limited research has explored coinfections involving dengue and aspergillosis. We conducted a retrospective study at a single center in Southern Taiwan, specifically focusing on dengue patients admitted to the intensive care unit during the period between July and November 2015. Among the 142 dengue patients studied, only 8.06 % (10/142) underwent serum galactomannan testing, with a single patient undergoing bronchoalveolar lavage (BAL) galactomannan assay. Out of those tested, 20 % (2/10) returned positive serum galactomannan results. Herein, we present two consecutive cases of coinfection involving dengue and pulmonary aspergillosis in immunocompetent patients.

Diagnosis and Outcomes of Fungal Co-Infections in COVID-19 Infections: A Retrospective Study.

The SARS-CoV-2 pandemic has resulted in a public health emergency with unique complications such as the development of fungal co-infections. The diagnosis of fungal infections can be challenging due to confounding imaging studies and difficulty obtaining histopathology. In this retrospective study, 173 patients with COVID-19 receiving antifungal therapy due to concern for fungal co-infection were evaluated. Patient characteristics, clinical outcomes, and the utility of fungal biomarkers were then evaluated for continuation of antifungal therapy. Data were collected from the electronic health record (EPIC) and analyzed using SPSS (version. 28, IBM, Inc., Armonk, NY, USA) Data are presented as mean ± SD or percentages. A total of 56 COVID-19 patients were diagnosed with fungal co-infection and 117 COVID-19 + patients had no fungal infection. Significantly fewer female patients were in the fungal+ group compared to COVID-19 control patients (29% in fungal+ compared to 51% in controls p = 0.005). Fungal diagnostics were all significantly higher in fungal+ patients. These include 1,4-beta-D-glucan (BDG), fungal culture, and bronchoalveolar lavage galactomannan (BAL GM). Intensive care unit hospitalization, mechanical ventilation, and mortality in fungal+ patients with COVID-19 were significantly higher than in control patients. Finally, significantly more fungal+ patients received voriconazole, isavuconazonium, or amphotericin B therapies, whereas control patients received significantly more short-course fluconazole. COVID-19+ patients with fungal co-infection were significantly more likely to be in the ICU and mechanically ventilated, and they result in higher mortality compared to control COVID-19 patients. The use of fungal diagnostics markers were helpful for diagnosis.

Systematic review and meta-analysis of galactomannan antigen testing in serum and bronchoalveolar lavage for the diagnosis of chronic pulmonary aspergillosis: defining a cutoff.

A clear cutoff value of galactomannan (GM) has not been established for chronic pulmonary aspergillosis (CPA) and is frequently extrapolated from invasive pulmonary aspergillosis. We performed a systematic review and meta-analysis to evaluate the diagnostic performance of serum and bronchoalveolar lavage (BAL) GM, and to propose a cutoff. We extracted from the studies the cutoff of serum or/and BAL GM associated with true positives, false positives, true negatives, and false negatives. We performed a multi-cutoff model and a non-parametric random effect model. We estimated the optimal cutoff and the area under the curve (AUC) for GM in serum and BAL samples. Nine studies from 1999 to 2021 were included. Overall, the optimal cutoff of serum GM was 0.96 with a sensitivity of 0.29 (95%CI: 0.14-0.51); specificity of 0.88 (95%CI: 0.73-0.95); and AUC of 0.529 (with a CI: [0.415-0.682] [0.307-0.713]). The AUC for the non-parametric ROC model was 0.631. For BAL GM the cutoff was 0.67 with a sensitivity of 0.68 (95%CI: 0.51-0.82), specificity of 0.84 (95%CI: 0.70-0.92), and AUC of 0.814 (with a CI: [0.696-0.895] [0.733-0.881]). The AUC for the non-parametric model was 0.789. The diagnosis of CPA requires the assessment of a combination of mycological and serological factors, as no single serum and/or BAL GM antigen test is adequate. BAL GM performed better than serum, with better sensitivity and excellent accuracy.

A Pathology-based Case Series of Influenza- and COVID-19-associated Pulmonary Aspergillosis: The Proof Is in the Tissue.

Invasive pulmonary aspergillosis has emerged as a frequent coinfection in severe COVID-19, similarly to influenza; yet the clinical invasiveness is more debated. We investigated the invasive nature of pulmonary aspergillosis in histology specimens of influenza and COVID-19 intensive care unit (ICU) fatalities in a tertiary care center. In this monocentric, descriptive, retrospective case series we included adult ICU patients with PCR-proven influenza/COVID-19 respiratory failure that underwent postmortem examination and/or tracheobronchial biopsy during ICU admission from September 2009 until June 2021. Diagnosis of probable/proven viral-associated pulmonary aspergillosis (VAPA) was made based on the ICM-IAPA and ECMM/ISHAM-CAPA consensus criteria. All respiratory tissues were independently reviewed by two experienced pathologists. In the 44 patients of the autopsy-verified cohort, 6 proven influenza-associated and 6 proven COVID-19-associated pulmonary aspergillosis diagnoses were identified. Fungal disease was identified as missed-diagnosis upon autopsy in 8% of proven cases (n=1/12), yet most frequently found as confirmation of probable antemortem diagnosis (n=11/21, 52%) despite receiving antifungal treatment. Bronchoalveolar lavage galactomannan testing showed highest sensitivity for VAPA diagnosis. Among both viral entities, an impeded fungal growth was the predominant histologic pattern of pulmonary aspergillosis. Fungal tracheobronchitis was histologically indistinguishable in influenza (n=3) and COVID-19 (n=3) cases, yet macroscopically more extensive at bronchoscopy in influenza setting. Proven invasive pulmonary aspergillosis diagnosis was found regularly and with a similar histological pattern in influenza and in COVID-19 ICU case-fatalities. Our findings highlight an important need for VAPA awareness with an emphasis on mycological bronchoscopic work-up. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Sensitivity of Antigen, Serology, and Microbiology Assays for Diagnosis of the Subtypes of Chronic Pulmonary Aspergillosis at a Teaching Hospital in São Paulo, Brazil.

Chronic pulmonary aspergillosis (CPA) is divided into five subtypes. The diagnosis of CPA is complicated due to poor sensitivity of the laboratory tests. Diagnostic performance of different antigen, serological, and microbiological methods in subtypes of CPA is unknown. The purpose of this study was to evaluate the diagnostic performance in different subtypes of CPA. A total of 91 participants with CPA were included, and the study was performed at Hospital das Clínicas of University of São Paulo. Bronchoalveolar lavage galactomannan (73%, 11/15), serology by immunodiffusion test (81%, 61/75), and histology (78%, 39/50) had the best sensitivity. The counterimmunoelectrophoresis (CIE) titers had a significant statistical difference between the CPA subtypes (P < 0.001), in which the forms chronic fibrosing pulmonary aspergillosis (CFPA) and subacute invasive aspergillosis (SAIA) had higher titers: 1/64 (interquartile range [IQR]: 1/32-1/256) and 1/64 (1/32-1/128). C-reactive protein generally presented lower values (median 15 mg/L, IQR: 6-33), with higher values in SAIA and lower values for Aspergillus nodule. Overall, we found a low diagnostic sensitivity of current tests. Regarding the CPA subtypes, we did not find great differences in the performance of the tests, but it is observed that the inflammatory markers and CIE titers tend to be higher in forms of the more extensive lung parenchyma involvement, such as SAIA and CFPA.

S2.3c High-resolution digital DNA melting: a breakthrough in diagnosing IMI?

S2.3 Novel diagnostic tools for invasive mold infection, September 21, 2022, 3:00 PM - 4:30 PMInvasive mold infections (IMIs) such as Aspergillosis, Mucormycosis, Fusariosis, and Lomentosporiosis have emerged as important pathogens in immunocompromised patients, with mortality rates as high as 50% to nearly 80% for these infections. Outcomes can be substantially improved with early initiation of appropriate antifungal therapy, yet early diagnosis remains difficult to establish and often requires multidisciplinary teams evaluating clinical and radiological findings plus supportive microbiologic findings. Conventional fungal culture and PCR techniques are limited by low sensitivity, long turn-around time, and are insufficient for differentiating between infection and colonization. Other non-culture-based tests, such as the Galactomannan test, are available only for invasive aspergillosis and are limited by imperfect test performance. Better and more rapid diagnostics are needed to enable early diagnosis and targeted treatment of IMIs and improve survival. We have developed a new technology called digital high resolution melting analysis (dHRM) to enable a rapid and robust diagnosis of IMI. This technology accomplishes fast genotyping of fungal genomic sequences in clinical samples by: (1) conducting broad-based amplification of fungal genes in a digital PCR format, and (2) conducting high-resolution melting of the DNA amplicons in each digital reaction. High resolution melting measures the fluorescence of a saturating intercalating dye as dPCR-amplified fungal DNA fragments are rapidly heated and disassociated, producing sequence-defined melt curves in a closed reaction format. These melt curves serve as unique fungal ‘fingerprints’, which allows us to correctly identify disease-causing pathogen(s) with an accuracy of 99%-100% through the use of machine learning methods trained to tolerate variations in reaction conditions. This approach provides a simple, low-cost, fast, and robust method for pathogen identification. Here, we will present the performance of this new technology on clinical bronchoalveolar lavage (BAL) samples from patients with and without IMI. A total of 75 patient BAL samples were tested, coming from 30 patients with proven (n = 1), probable (n = 25), or putative (n = 4) invasive pulmonary aspergillosis (IPA) infections, and from 45 patients classified as not having IPA (n = 4 possible IPA and n = 41 no IPA). Our results show that dHRM was able to reliably differentiate between different Aspergillus spp. and was also able to identify Aspergillus spp. in BAL samples from patients with probable IPA where qPCR had resulted in negative. In a few instances, it also detected rare molds in culture-negative samples and multiple Aspergillus spp. within one BAL sample, a phenomenon that has been previously described in cultures. Interestingly, there was no clear correlation between dHRM results and BAL galactomannan levels, suggesting that dHRM may serve as an independent method allowing for a combined diagnostic approach. While further validation and optimization are needed, these results suggest that dHRM is a promising new diagnostic technology capable of providing clinically relevant information within 2-3 h.

Tracheal Aspirate Galactomannan Testing in COVID-19-Associated Pulmonary Aspergillosis.

Among critically ill patients, COVID-19-associated pulmonary aspergillosis (CAPA) is a challenging complication. The recommended diagnostic methods for this disease are bronchoalveolar lavage (BAL) culture and galactomannan (GM) testing, which were not widely available during the pandemic. There is scarce information regarding GM testing in other respiratory specimens. Our objective was to compare the agreement of GM between BAL and tracheal aspirate (TA) samples. We selected patients with COVID-19 and those with suspected CAPA who were admitted in the intensive care unit (ICU). GM was routinely done in BAL. We performed GM in TA samples and compared the results. The agreement was evaluated with Cohen's Kappa coefficient. GM was considered positive when an OD index ≥ 1 in BAL and ≥ 2 in TA were found. Probable CAPA was considered when the ECMM/ISHAM criteria were met. A descriptive analysis of clinical characteristics and mortality was made. We included 20 patients with suspected CAPA from 54 patients with critical COVID-19, of which 5 (9%) met the probable category. Aspergillus fumigatus was the most frequent isolate. We found moderate agreement between BAL and TA GM (Kappa = 0.47, p = 0.01, 95% CI.04-0.9), whereas TA GM had 75% sensitivity (95% CI 19.4-99.4%), 81.2% specificity (95% CI 54.4-95.9%), 50% positive predictive value (95% CI 23.8-76.3%),] and 92.8% negative predictive value (95% CI 70.1-98.6%), and 80% accuracy (95% CI 56.3-94.3%). Lastly, three (60%) patients with CAPA died during hospitalization compared to 40% (6/15) without CAPA (p = 0.4). In conclusion, a moderate agreement between TA GM and BAL was found. Therefore, TA testing may aid in ruling out CAPA due to high negative predictive value when bronchoscopies are unavailable.

Diagnostics of Pulmonary Aspergillosis in Critically Ill Hematological and Non-Hematological Patients in the Intensive Care Unit By Combined Use of Galactomannan, 1-3-Beta-D-Glucan, Aspergillus Specific PCR and Conventional Culture in Concurrent Blood and Bronchoalveolar Lavage Samples — Results of a Multicenter Prospective Pilot Study

Invasive pulmonary aspergillosis (IPA) is a life-threatening infectious complication mainly affecting immunocompromised hematological patients. Therapeutic success requires early and precise diagnostics. Few data are available on the performance of current diagnostic tests in patients admitted to the intensive care unit (ICU) as the majority of diagnostic studies is conducted in hematological patients and results cannot readily be transferred to patients in the ICU setting.In a prospective multicenter study, we evaluated concurrent bronchoalveolar lavage (BAL) samples and concurrent blood samples from 44 patients admitted to the ICU who required mechanical ventilation and therefore underwent a diagnostic work-up including chest CT scan and BAL (NCT01695499). The subsequent diagnostic work-up comprised of conventional methods for direct detection of Aspergillus spp. as well as biomarkers such as galactomannan (GM) and 1-3-beta-D-glucan (BDG) and an Aspergillus specific nested polymerase chain reaction (PCR).14 patients (32%) suffered from a hematological/hematooncological disease, of which 7 had received allogeneic stem cell transplantation. 6 patients (14%) had a solid tumor requiring chemotherapy. The remaining 24 patients (54%) had no hematological or oncological disease. 11 patients were neutropenic with ANC <1.0/nl (10 belonged to the hematooncological group). According to AspICU classification (Blot et al., Am J Respir Crit Care Med 2012) 9 patients (20%) had putative IPA (3 patients with hematological malignancy). Other invasive fungal diseases (IFD) besides IPA were observed: positive growth of Rhizopus microsporus in BAL was seen in one patient. Furthermore, two cases of disseminated candidiasis with positive growth in blood culture (C.albicans, C.krusei) and one case with positive growth in ascites (C.albicans). Additionally, two cases of Pneumocystis jirovecii pneumonia (PcP) were diagnosed.Diagnostic performance of each single test and of test combinations was analyzed. GM and PCR showed superior performance in BAL (sensitivity/specificity of 56%/94% (GM) and 44%/94% (PCR) compared to 33%/97% and 11%/94% in serum). Despite a better sensitivity of 89%, BDG showed a specificity of only 31% in BAL and 26% in serum, reducing the diagnostic odds ratio (DOR) to 3.7 and 2.8, respectively. For hematological patients the mean GM optical density index (ODI) in BAL was 0.97 and in serum 0.58 compared to 0.59 and 0.16 in non-hematological patients. The strength of agreement between GM in BAL and GM in serum as calculated by Cohen's kappa intertest coherence analysis was 0.62 [0.29-0.95], which is considered to be good. BDG levels and performance of the PCR assay did not differ between hematological and non-hematological patients. The combined use of biomarkers in BAL showed a diagnostic performance of sensitivity/specificity/PPV/NPV and DOR of 89%/31%/25%/92% and 3.67. Testing of GM and BDG solely in serum resulted in a combined test performance of 89%/26%/ 24%/ 90% and 2.77. GM (BAL) combined with BDG (serum) showed high joint sensitivity of 100% with specificity of 25% (DOR 6.81). Using PCR instead of GM dropped sensitivity to 89% (specificity 23%, DOR 2.37). Diagnostic performance of combined GM and PCR testing in BAL showed sensitivity/specificity/PPV/NPV and DOR 67%/89%/60%/91% and 15.0. Cohen's kappa for PCR (BAL) vs. GM (BAL) was 0.49 [0.145 to 0.840], which is considered to be moderate. If a diagnostic algorithm defines BDG (serum) as an initial test that is, in case of a positive result, followed by a confirming test combination from BAL with strong or even exclusive specificity for Aspergillus spp. (GM, PCR and culture) a diagnostic performance is achieved with sensitivity/specificity/positive predictive value/negative predictive value of 88%/97%/88%/97% and DOR >100.This study intended as a pilot study underscores the concept of combined testing in serum and BAL for optimized detection of IPA and provides valuable data for the emerging cohort of critically ill patients, both hematological and non-hematological. Further studies with hematological ICU patients in larger cohorts are planned. DisclosuresBoch:Pfizer research grant (WS 2274964): Research Funding. Buchheidt:Pfizer research grant (WS 2274964): Research Funding.

The Utility of Early Broncholaveolar Lavage in Prolonged Neutropenic Patients with Pulmonary Nodules

▪IntroductionManagement of patients with hematologic malignancies (HM) post induction chemotherapy or allogeneic hematopoietic cell transplant (Allo HSCT) is often complicated by neutropenic fever associated with nodular pulmonary infiltrates, and may result in acute respiratory failure and death. The presence of a halo sign in a neutropenic patient with nodular infiltrates is highly suggestive of invasive pulmonary aspergillosis (IPA).Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) is the preferred procedure for identifying the infectious aetiology of pulmonary infiltrates in post Allo-HSCT or post chemotherapy in HM patients with neutropenic fever. The diagnostic value of FOB with BAL in such patients is controversial, however, it has been suggested that the microbiologic yield from FOB and BAL is higher when bronchoscopy is performed within 24 hours of presentation, allowing subsequent BAL-guided therapeutic adjustment.With a view towards improving health care resource utilization, we re-evaluated this diagnostic strategy.MethodsWe conducted a prospective observational study of 100 participants with the following diagnoses: acute myeloid leukemia (AML), 76%; myelodysplastic syndrome (MDS), 9%; acute lymphoblastic leukemia (ALL), 6%; and acute promyelocytic leukemia (APL), 6%. One hundred sequential patients who underwent FOB after August 2016 and provided informed consent, were enrolled and followed for 30 days. Sixty six percent were admitted for induction chemotherapy; 17% for re-induction chemotherapy; 10% for conditioning pre- Allo- HSCT; 4% for consolidation chemotherapy; and 3% for other therapy.Data collected included patients' demographics, dates of onset of fever and of baseline chest CT scan, findings on CT scan, dates of initiation of empirical antibiotic and antifungal therapy, BAL results, and the impact on antimicrobial choices. Other outcomes included transfer to ICU and death.We assessed the utility of performing early FOB (within 48 hours of performing a low dose chest CT scan) vs Late FOB (after 48 hours from low dose chest CT scan) in post-chemotherapy HM and Allo-HSCT patients.ResultsOf the 100 enrolled participants, 61 and 39 underwent early and late FOB, respectively (Figure-1: Table of results) . A positive BAL Galactomannan was observed in 7 (11.5%) early FOB cases, compared to only 1 (2.6 %) in late FOB case (p=0.15), with a subsequent impact on the choice of antifungal in 6 cases (9.8 %) and 1 case (2.6 %), respectively (p=0.042).BAL culture was positive in 2 cases (3.3%) in the early FOB group, compared to only 1 case (2.6%) in the late FOB group (p=0.99). The choice of antibiotic was influenced by BAL results in 1 of the 2 early FOB cases.Eight (13.3%) and 7 (17.9%) of early and late FOB patients, respectively, were transferred to the ICU (p=0.57); and 6 (9.8%) of the early FOB and 3 (7.7 %) of late FOB patients died (p=0.99).ConclusionThe diagnostic yield of early FOB was greater than that of late FOB, as assessed by GM positivity, and more frequently permitted targeted antifungal therapy. There was no difference in the rate of antibiotic use between the two groups. [Display omitted] DisclosuresGupta:Incyte: Consultancy, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. Schuh:Amgen: Consultancy, Honoraria. Yee:Astex: Research Funding; Oncoethix: Research Funding; Karyopharm: Research Funding; Novartis Canada: Honoraria; Celgene Canada: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Galactomannan and 1, 3-β-D-Glucan Assay in Bronchoalveolar Lavage Fluid for the Diagnosis of Invasive Pulmonary Aspergillosis in Malignant and Non-malignant Patients

BACKGROUND: Serum 1, 3-β-D-glucan (BDG) assay was recommended for diagnosing fungal infections. AIM: We aimed to assess 1, 3-β-D-glucan in bronchoalveolar lavage (BAL) fluid in invasive pulmonary aspergillosis (IPA). METHODS: Out of 104 patients clinically suspected fungal, 45 were probable, 18 possible, and 41 unlikely according to EORTC/MSG 2008 criteria. Measuring BAL BDG and galactomannan were done. RESULTS: The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for BDG were 44%, 71%, 62%, and 54%; for galactomannan 84%, 83%, 84%, and 83%; and 93%, 66%, 75%, and 90%, respectively, when combining both tests. A significant different performance of GM; p = 0.0008 was detected in patients with malignant disorders when compared to non-malignant; but not for BDG; p = 0.121. CONCLUSION: We can conclude that BAL-BDG is helpful if positive in a clinically suspected IFI case, but if negative cannot rule out fungal infection. Thus, combining results of BAL-GM and BAL-BDG are recommended.

Diagnostic yield of a bronchoalveolar lavage fluid galactomannan assay in patients with negative serum galactomannan results suspected to have invasive pulmonary aspergillosis.

There are limited data in real clinical practice on the diagnostic value of a bronchoalveolar lavage (BAL) fluid galactomannan (GM) assay in patients with suspected invasive pulmonary aspergillosis (IPA) who had negative serum GM results. Thus, we investigated the diagnostic performance of a BAL GM assay in patients with negative serum GM assay results who were suspected to have IPA. This retrospective study was performed between May 2008 and April 2019 at a tertiary-care hospital in Seoul, South Korea. All patients with suspected IPA whose serum GM assays revealed negative results who sequentially underwent BAL were enrolled in this study. A total of 341 patients with suspected IPA including four cases of proven IPA, 38 cases of probable IPA, 107 cases of possible IPA and 192 patients without IPA were enrolled. Of these 341 patients, 107 (31%) with possible IPA were excluded from the final analysis. Of 42 patients with proven and probable IPA who had initial negative serum GM results, 24 (57%) had positive BAL GM results (n=24) or BAL fungal culture results (n=8). In addition, BAL revealed evidence of other opportunistic infections including Pneumocystis jirovecii pneumonia (14% [26/190]), cytomegalovirus (CMV) pneumonia (5% [9/188]) and respiratory viral pneumonia (6% [12/193]). Sequential BAL in patients with suspected IPA who had initial negative serum GM results provided additional diagnostic yield in approximately half of patients with evidence of another co-infection.

Relationship between anti-fungal effects and lung exposure of PC945, a novel inhaled antifungal agent, in Aspergillus fumigatus infected mice: Pulmonary PK-PD analysis of anti-fungal PC945

PC945 is a novel antifungal agent, optimised for inhaled treatment. In this study, the relationship between antifungal effects of PC945 and its exposure in the lungs was investigated in Aspergillus fumigatus intranasally infected, temporarily neutropenic mice. Mice were given prophylactic PC945 intranasally once daily (0.56 µg/mouse) on either Day -7 to 0 (8 doses) or Day -1 to 0 (2 doses). Lung tissue, plasma and bronchoalveolar lavage (BAL) fluid were collected 24 or 72 h post A. fumigatus inoculation for biomarker and pharmacokinetic analyses. BAL cell pellets and supernatants were prepared separately by centrifugation. 8 prophylactic doses of PC945 were found to demonstrate significantly stronger antifungal effects (lung fungal burden and galactomannan (GM) in BAL and plasma) than prophylaxis with 2 doses. PC945 concentrations were below the limit of detection in plasma but readily measured in lung extracts. The concentrations were much higher after extended prophylaxis (709 and 312 ng/g of lung) than short prophylaxis (301 and 195 ng/g of lung) at 24 and 72 h post last dose, respectively, suggesting PC945 accumulation in whole lung after repeat dosing although it was likely to be a mixture of dissolved and undissolved PC945, meaning that the data should be interpreted with caution. Interestingly, low concentrations of PC945 were detected in BAL supernatant (6.6 and 1.9 ng/ml) whereas high levels of PC945 were measured in BAL cell pellets (626 and 406 ng/ml) at 24 and 72 h post last dose, respectively, in extended prophylaxis. In addition, the PC945 concentrations in BAL cells showed a statistically significant correlation with measured anti-fungal activities. These observations will be pursued, and it is intended that BAL cell concentrations of PC945 be measured in future clinical studies rather than standard measurement in BAL itself. Thus, PC945’s profile makes it an attractive potential prophylactic agent for the prevention of pulmonary fungal infections.

Invasive pulmonary aspergillosis in COVID-19 patients

A retrospective analysis of the medical data of 12 patients with COVID-19 was performed. For the diagnosis of invasive aspergillosis the international criteria ECMM/ISHAM 2020 were used. We analyzed the scientific literature data on the diagnosis and treatment of invasive aspergillosis in patients with COVID-19.Results. Among the 12 examined patients with a severe course of COVID-19, invasive aspergillosis was diagnosed in 5 patients. Four patients (80%) were treated in the ICU. Steroids or interleukin-6 inhibitors were used in 80% patients. Severe lymphocytopenia was in 80% patients, neutropenia 20%. A fever refractory to antibiotic therapy was noted in 80% patients, an increase in respiratory failure – 60%, acute respiratory distress syndrome – 60%. All patients showed negative dynamics of changes in the chest CT scan. Invasive aspergillosis was confirmed with a positive test for galactomannan in bronchoalveolar lavage and / or serum in 100% of cases. All patients received antifungal therapy with voriconazole and/or caspofungin. The overall 12-week survival rate was 80%.Conclusion. In ICU patients with severe COVID-19 and progressive pulmonary symptoms invasive aspergillosis should be excluded. Examination of substrates from the lower respiratory tract (BAL, tracheal aspirate, or nonbronchoscopic lavage) is necessary. Laboratory examination should include microscopy, culture and test for galactomannan. Voriconazole and isavuconazole are drugs of choice for the treatment of invasive aspergillosis in patients with COVID-19.