European Organization For Research And Treatment Of Cancer/Mycoses Study Group Research Articles

Invasive fungal infections are rare in pediatric and young adult autologous hematopoietic stem cell transplant patients.

Pediatric and young adult patients undergoing autologous hematopoietic stem cell transplant (auto-HSCT) face a crucial, yet understudied, risk of invasive fungal infections (IFI), especially compared to allogeneic transplants. This gap underscores the need for research in pediatric patients undergoing auto-HSCT. Our objective was to evaluate the incidence of IFI in pediatric and young adult patients during the first year after auto-HSCT. We conducted a single-center retrospective analysis of 150 pediatric and young adult auto-HSCT patients who underwent transplant from January 2013 to January 2023. We focused on IFI incidence within the first-year post transplant, using the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria for IFI identification. Among the 150 patients analyzed, with 240 unique transplant episodes, the primary indication was neuroblastoma (37.3%), and micafungin was extensively used for prophylaxis (82.7%). There was an absence of IFI from yeast and mold species, suggesting a low IFI risk in this cohort. The incidence of IFI in pediatric auto-HSCT recipients receiving micafungin primary antifungal prophylaxis is rare. The findings advocate for further research to refine prophylaxis guidelines and highlight the need for individualized risk assessment to optimize post-transplant care.

Clinical Features and Outcomes of Invasive Fusariosis in Pediatric Patients with Acute Lymphoblastic Leukemia (ALL): A Case Series in a Single Tertiary Center in North-Eastern Mexico

Abstract Background Fusariosis is a pathology that is of great clinical concern in certain at-risk patient groups. Pediatric patients with ALL are in the greatest at-risk population as they are frequently in a post-chemotherapy state. The diagnosis for IFIs can be carried out by the criteria established in the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) and the notable intrinsic resistance of the Fusarium species to most of the antifungal agents available lead to high mortality rates in immunocompromised patients. Starting in 2002, the use of voriconazole was approved as empiric monotherapy as a first line therapy for the treatment of disseminated fusariosis. Other options are liposomal amphotericin B (LAB), Posaconazole or Isavuconazole. There are a few reports combined antifungal treatment in a pediatric population. In pediatric patients, the empirical and specific antifungal treatment is mostly inferred from clinical experience in adult patients. Methods We identified six patients with culture-proven fusariosis at a tertiary healthcare center in North-Eastern Mexico from May 2018- August 2021. We reported six cases of fusariosis categorized according to the EORTC/MSG. B cell ALL diagnosis was defined as a positive result in a B-cell leukemia panel. In terms of the descriptive statistics, continuous variables were reported as medians and [Interquartile range], while categorical variables were described via counts, frequencies, and (prevalence). Results The median age was 8 [6-12], 2 of the patients were female. All of the included patients were in the remission induction phase of their therapy and all patients had a confirmed B cell ALL and all patients presented with neutropenia. Four patients had a central venous catheter present, 3 of patients had a bacterial co-infection (E. coli, S. pneumoniae, Klebsiella blee). LAB was given as empirical therapy in 3 of patients while one patient received a combination of amphotericin B and voriconazole and the remaining patient received voriconazole monotherapy. Five patients had resistance to LAB, two patients showed voriconazole resistance. The definitive treatment was LAB plus Voriconazole in 5 (83.3%) patients. Five (83.3%) patients survived. Conclusions There are no clearly established guidelines for treatment options for fusariosis in pediatric patients. The majority of our reported patients presented with LAB-resistance and the combination of LAB with voriconazole has been used to control this pathology. There is still much more to explore and further research is needed into the indicated treatment plan and the susceptibility and therapeutic strategy for this specific population.

Invasive Fungal Infection in Hematopoietic Stem Cell Transplant Recipient from an Indian Oncology Setting

Objective Invasive fungal infections (IFI) are one of the major causes of morbidity and mortality in post-hematopoietic stem cell transplant (HSCT) recipients. Data from India is limited. The objective of this study was to analyze the incidence, risk factors, and outcomes associated with IFI in our center. Materials and Methods Adult patients, who underwent marrow/stem cell transplantation between 2014 and 2018, in an oncology center in India, were included in this single-center retrospective observational study. The revised European Organization for Research and Treatment of Cancer/ Mycoses Study Group (EORTC/MSG) consensus group 2008 definition for IFI was considered to define cases. Incidence, risk factors, and outcomes associated with IFI were analyzed. Statistical Analysis All continuous variables were represented by mean ± standard deviation and categorical variables as percentage. Comparison of categorical variables was done by either the chi-squared test or Fisher's exact test. All “p” values less than 0.05 were considered statistically significant. Results Out of the 126 patients who underwent HSCT between January 2014 and December 2018, 56 (44.4%) patients had allo-HSCT, 64 (50.8%) had auto-HSCT, and 6 (4.8%) had haplo-identical HSCT. Eighty-three (63%) patients were male and 43 (34%) females, and 113 (83.9%) Asians and 13 (10.3%) Africans. Total 111 (88%) patients received myeloablative conditioning and 24 (19%) received total body irradiation. The hematological conditions were acute myeloid leukemia (n = 23; 18.25%), acute lymphoblastic leukemia (n = 16; 12.69%), chronic myeloid leukemia (n = 4; 3.17%), Hodgkin lymphoma (n = 17; 13.4%), non-Hodgkin lymphoma (n = 11; 8.73%), myeloma (n = 35; 27.7%), sickle cell disease (n = 13; 10.31%), etc. Most patients received fluconazole (78; 61.9%) followed by micafungin (23; 18.25%), posaconazole (20; 15.87%), voriconazole (4; 3.17%), and liposomal amphotericin B (1; 0.79%) as antifungal prophylaxis. The overall rate of IFI (possible cases included) was auto-HSCT (n = 5; 7.81%), and allo-HSCT (n = 5; 8.92%). Among auto-HSCT, the IFI was proven = 0, probable n = 1 (1.5%), and possible n = 4 (6.25%) and among allo-HSCT the IFI was proven = 0, probable n = 2 (3.57%), and possible n = 3 (5.35%). No patients in haplo-HSCT had IFI. The 1-year survival rate among the IFI cases was 8/10(80%). A meaningful comparison of the risk factors and the impact of prophylactic regimens were difficult because of the very low number of IFI cases. Conclusions The overall rate of IFI in HSCT patients in our setting was low compared to global data on IFI in HSCT.

Invasive Fungal Infections in Acute Haematological Malignancies: A Cross-sectional Study

Introduction: Fungal infections are common complications of acute haematological malignancies i.e. acute myeloid and acute lymphoblastic leukaemia. The cells in these two groups are different morphologically and immunologically. Hence the interaction with the different types of fungi may vary. Aim: To identify the acute leukaemia cases and fungal infection among myeloid and lymphoid groups and to find out association of types of invasive fungal infection according to cell line affected. Materials and Methods: A cross-sectional observational hospital-based prospective study was conducted in a risk group of acute haematological malignancy over a period of six months from July 2021 to December 2021 in a tertiary care Hospital, Medical College Kolkata, West Bengal, India. Study tools were questionnaire based on European Organisation for Research and Treatment of Cancer /Mycoses Study Group (EORTC/MSG) criteria, clinical reports and standard laboratory procedures were practiced in Microbiology laboratory. The data was entered in excel spreadsheet and analysed using Statistical Package for the Social Sciences (SPSS) 28th version. Results: A total of 24 cases of Invasive Fungal Infections (IFI) were observed out of the 78 patients included in the study. This corresponds to an IFI prevalence of 30.77%. Patients with proven IFI constituted 8 (33.33%), probable IFI accounted for 15 (62.5%) where as those with possible IFI accounted for 1 (4.2%) of total IFI cases. There were age and sex wise variation in IFI. The prevalence of IFI was found to be higher in Acute Myeloid Leukaemia (AML) (48.5%) patients as compared to Acute Lymphoblastic Leukaemia (ALL) (19.14%). Of all AML patients invasive candidiasis was the most common type followed by aspergillosis. In ALL patients invasive candidiasis also constituted 44.44% followed by dematiaceous mycosis, followed by aspergillosis. Conclusion: AML patients suffer more from IFI than ALL ones. Invasive non albicans candidiasis affected both types but more incidence was seen in AML affected group. Aspergillus spp. affected lungs of both groups but dematiaceous fungi were isolated only from ALL affected paediatric patients and in samples other than pulmonary or blood sample.

Influenza associated pulmonary aspergillosis in california: A case series

• AspICU, IAPA, and EORTC/MSG criteria varied in their ability to capture IAPA cases. • Classic radiographic findings for aspergillosis were not present in these cases. • Few patients in our IAPA case series had traditional aspergillosis risk factors. Invasive pulmonary aspergillosis has been reported to occur in patients who are critically ill with severe influenza. The mortality rate is high. We reviewed electronic medical records from University of California at Los Angeles Health Hospitals for patients who had a positive influenza and Aspergillus test from September 1st, 2019 to May 6th, 2020. We classified cases using definitions from the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG), Aspergillus Intensive Care Unit ( Asp ICU), and Influenza Associated Pulmonary Aspergillosis (IAPA) definition. We identified 8 cases where the patient had both a positive influenza and Aspergillus test. Four (50%) of the 8 patients did not have underlying conditions that were considered typical risk factors for aspergillosis. Seven (87.5%) of the 8 patients were admitted to the intensive care unit and four (50%) of the 8 patients died. One patient met the diagnostic criteria by the EORTC/MSG guidelines, six by the Asp ICU, and seven by the IAPA definition. We found cases of influenza-associated pulmonary aspergillosis in a Los Angeles hospital population. Typical underlying conditions for aspergillosis were absent in four of the 8 cases. The ability to categorize the cases as influenza associated pulmonary aspergillosis varied. Further research and development of more sensitive guidelines to establish a diagnosis of invasive pulmonary aspergillosis in patients critically ill with influenza may be warranted.

Invasive Aspergillosis in Chronic Lymphocytic Leukemia: Therapy and Outcomes

Background: Despite the introduction of novel non-cytotoxic therapies (such as ibrutinib, idelalisib and venetoclax) for the treatment of patients with CLL, opportunistic fungal infections such as Pneumocystis jiroveci and aspergillosis are reported in these patients (Ahn, Blood, 2016; Lionakis, Cancer Cell, 2017). The clinical characteristics and outcomes of chronic lymphocytic leukemia (CLL) patients (pts) who develop invasive aspergillosis (IA) are not well described in the literature.Methods: The Mayo Clinic CLL database was queried to identify CLL pts who had either a positive aspergillus culture or a positive galactomannan antigen test result between 1/1995-12/2016. We applied the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria to categorize pts to have either proven or probable IA. Patients who developed IA after an allogeneic stem cell transplant were excluded. The Mayo Clinic IRB approved this study.Results: 123 CLL pts met the inclusion criteria for this study with either a positive aspergillus culture or a positive galactomannan antigen test. Among these, 93 pts had asymptomatic antigenemia or colonization and were not included in the analysis. Thirty pts (34%) had a diagnosis of clinically significant aspergillosis, 14 pts with proven IA and 16 pts with probable IA. The baseline characteristics at the time of IA diagnosis are shown in Table 1. At the time of IA diagnosis, the median serum IgG was 332 mg/dL and median ANC was 1.5 x109/L.The median time from CLL diagnosis to IA diagnosis was 7.1 years (range: 0.15-17.59 years). The diagnosis of IA was made via both culture and antigen (Ag) in 7/30 pts (23%), culture alone in 18/30 pts (60%) and Ag alone in 6/30 pts (20%). Invasive pulmonary aspergillosis was the most frequent syndrome, seen in 28 pts (93%). In addition, there were 3 pts with invasive sinus aspergillosis, including one case with both pulmonary and sinus infection.Among those who received prior chemotherapy (N=23), the median time from last documented CLL directed therapy to diagnosis of IA was 3.5 months (range: 0.3-53.1 months). The most recent CLL treatment prior to IA diagnosis included: chemoimmunotherapy in 9 pts (39%), chemotherapy alone in 4 pts (17%), rituximab with high dose steroids in 3 pts (13%), alemtuzumab in 2 pts (9%), and ibrutinib in 5 pts (22%). Of the 5 patients diagnosed with IA while on Ibrutinib, 3 pts had proven IA and 2 pts had probable IA. The median duration between initiation of ibrutinib and diagnosis of IA was 2.5 months (0.03-21 months).No patient received antifungal prophylaxis prior to the diagnosis of IA. Therapy for IA consisted of voriconazole monotherapy in 16 pts (53%), 5 pts (17%) received voriconazole in combination with caspofungin, 4 pts (13%) voriconazole in combination with amphotericin, 2 pts (7%) amphotericin alone, and 3 pts (7%) died prior to receiving anti-fungal therapy. The median overall survival from IA diagnosis was 11.2 months. After a median follow-up of 9.3 months, 20 pts (67%) died: 9 pts (45%) died secondary to uncontrolled IA infection, 4 (20%) due to Pseudomonas aeruginosa bacteremia, 4 (20%) due to CLL progression, 2 (10%) due to concomitant fungal infections (Cryptococcus and Mucor), and 1 (6%) due to respiratory failure. None of the CLL specific prognostic markers were associated with OS.Conclusion: Invasive aspergillosis is a rare but devastating complication in CLL patients. In this large retrospective study, median overall survival following IA diagnosis is <1 year. Better tools at identifying potential risk factors and prophylaxis are important to prevent IA infection among CLL patients, to improve outcomes. [Display omitted] DisclosuresDing:Merck: Research Funding. Kay:Pharmacyclics: Research Funding; Gilead: Research Funding; Agios: Membership on an entity's Board of Directors or advisory committees; Tolero Corporation: Research Funding. Shanafelt:Genentech: Research Funding; GlaxoSmithKline: Research Funding; Celgene: Research Funding; AbbVie: Research Funding; Hospira: Research Funding; Jannsen: Research Funding; Pharmacyclics: Research Funding. Parikh:Pharmacyclics: Research Funding; Pharmacyclics: Honoraria; AstraZeneca: Honoraria.

#25: Survival and Risk Factors Associated with Mortality due to Invasive Aspergillosis in Pediatric Oncology Patients in Mexico City

Abstract Background Invasive Aspergillosis (IA) has been reported as the most frequent life-threatening opportunist mold infectious disease in immunocompromised subjects, mainly in oncology patients Its incidence has been increasing over the years, with a reported mortality from 35% to 70%. Risk factor for IA mortality has been poorly described in middle-income settings. We aimed to identify risk factors associated with IA mortality and to report the survival in a middle-income setting. Methods Case–control study at Hospital Infantil de México Federico Gómez (HIMFG) in Mexico City from January 2004 to April 2017. We identified patients &amp;lt;18 years old with cancer and diagnosis of proven or probable IA, according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. Neutropenia, chemotherapy, use of steroids, hematopoietic stem cell transplantation (HSCT), graft vs. host disease (GVHD) and disseminated disease (defined as the affection of 2 or more sites) were compared between surviving and deceased patients with IA. Fisher exact test or Student’s t-test were performed to identify independent risk factors for IA-related mortality, and a binary logistic regression model was used. Kaplan–Meier analysis was performed to calculate survival rates at days 30 and 90 after IA diagnosis. Results Seventy-four IA events in 72 patients were identified. The mean age was 8.4 years, 63% were male. 89% of IA presented in hematologic malignances, being ALL the most frequent diagnosis in 54% of cases; 8.1% (6) were in HSCT patients (5 allogeneic HSCT). Of the 74 IA, 42% and 58% were classified as proven and probable AI respectively. Localized disease (76%) was more frequent than disseminated. Lungs were the most frequent sites of primary infection (84%) but an unusual site of infections, such as heart, pericardium, pulmonary artery, bowel, skin, and spleen, were reported by histopathology. Aspergillus flavus was the most frequent species isolated (42%) followed by A. fumigatus (27%). Voriconazol was first line of therapy in 95% of cases, while combined therapy was used during the course of infections in 53% of cases. The disseminated disease was an independent risk factor associated with IA mortality (OR 4.2 95% CI, 1.5 – 15.2, P = 0.007). Overall mortality was 64%; however, directed IA-related mortality was 35%. On day 30 and day 90 after IA diagnosis, overall survival was 66% and 32%, respectively. Two IA were diagnosed post mortem. IA-related mortality was 67% in HSCT (P = 0.009). All HSCT patients which death was associated with IA presented GVHD. Conclusions In our population, IA-related mortality (35%) was similar to that reported globally, nevertheless IA-related mortality in HSCT was high (67%). Disseminated disease and neutropenia were identified as risk factors for mortality due to IA. Efforts should be made to early identification of IA and prompt start of antifungal treatment, to reduce the incidence and consequences of disseminated disease.

Mucormycosis in Hematopoietic Cell Transplant Recipients and in Patients With Hematological Malignancies in the Era of New Antifungal Agents.

BackgroundThe survival benefit of combination antifungal therapy for invasive mucormycosis (IM) in patients with hematologic malignancy (HM) and hematopoietic cell transplant (HCT) is not well defined.MethodsThis multicenter, retrospective study included HM and HCT recipients with proven or probable IM between January 1, 2007 and December 31, 2017 from 10 transplant centers across North America.ResultsSixty-four patients with proven (n = 47) or probable (n = 17) IM defined by 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) consensus definitions were included. Thirty-nine (61%) were HCT recipients (95% allogeneic). Sites of infection included rhino-orbital-cerebral (33), pulmonary (30%), disseminated (19%), gastrointestinal (3%), and cutaneous (3%). Surgical debridement was performed in 66%. Initial antifungal treatment consisted of the following: lipid formulation of amphotericin B (AmB) alone (44%), AmB + posaconazole (25%), AmB + echinocandin (13%), AmB + isavuconazole (8%), posaconazole alone (5%), and isavuconazole alone (3%). All-cause mortality at 30 days and 1 year were 38% and 66%, respectively. Initial treatment with AmB plus posaconazole or isavuconazole (n = 28) was associated with a trend toward lower treatment failure compared with AmB (n = 21) (42% vs 64%, P = .136).ConclusionsLong-term survival with IM among HM and HCT populations remains poor. However, initial use of AmB + azole in conjunction with surgery may result in less treatment failure. More evidence from prospective controlled studies is needed to confirm this observation.

Invasive pulmonary aspergillosis in the COVID-19 era: An expected new entity.

ObjectivesInformation on the recently COVID‐19‐associated pulmonary aspergillosis (CAPA) entity is scarce. We describe eight CAPA patients, compare them to colonised ICU patients with coronavirus disease 2019 (COVID‐19), and review the published literature from Western countries.MethodsProspective study (March to May, 2020) that included all COVID‐19 patients admitted to a tertiary hospital. Modified AspICU and European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria were used.ResultsCOVID‐19‐associated pulmonary aspergillosis was diagnosed in eight patients (3.3% of 239 ICU patients), mostly affected non‐immunocompromised patients (75%) with severe acute respiratory distress syndrome (ARDS) receiving corticosteroids. Diagnosis was established after a median of 15 days under mechanical ventilation. Bronchoalveolar lavage was performed in two patients with positive Aspergillus fumigatus cultures and galactomannan (GM) index. Serum GM was positive in 4/8 (50%). Thoracic CT scan findings fulfilled EORTC/MSG criteria in one case. Isavuconazole was used in 4/8 cases. CAPA‐related mortality was 100% (8/8). Compared with colonised patients, CAPA subjects were administered tocilizumab more often (100% vs. 40%, p = .04), underwent longer courses of antibacterial therapy (13 vs. 5 days, p = .008), and had a higher all‐cause mortality (100% vs. 40%, p = .04). We reviewed 96 similar cases from recent publications: 59 probable CAPA (also putative according modified AspICU), 56 putative cases and 13 colonisations according AspICU algorithm; according EORTC/MSG six proven and two probable. Overall, mortality in the reviewed series was 56.3%.ConclusionsCOVID‐19‐associated pulmonary aspergillosis must be considered a serious and potentially life‐threatening complication in patients with severe COVID‐19 receiving immunosuppressive treatment.

Airway-invasion-associated pulmonary computed tomography presentations characteristic of invasive pulmonary Aspergillosis in non-immunocompromised adults: a National Multicenter Retrospective Survey in China

BackgroundThe European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria are widely used in the diagnosis of invasive pulmonary aspergillosis (IPA), but they only apply to immunocompromised patients. We here aimed to identify clinical characteristics helpful to the diagnosis of IPA in non-immunocompromised patients.MethodsThis is a multicenter retrospective study. Data were collected from adult patients with IPA admitted to 15 tertiary hospitals in China from 2010 to 2016.ResultsWe included 254 patients in the study, of whom 66 (26.0%) were immunocompromised, and 188 (74.0%) were not. Airway-invasion-associated computed tomography (CT) signs including patchy exudation along the airway (67.6% vs. 45.5%, P = 0.001) and thickened airway wall (42.0% vs. 16.7%, P < 0.001) were more common in non-immunocompromised patients than in immunocompromised ones, and angio-invasive CT signs were more common in immunocompromised patients (55.3% vs.72.7%, P = 0.013). Typical angio-invasive CT signs were delayed in non-immunocompromised IPA patients, whereas airway-invasive signs appear earlier. Host immunocompromised condition was associated with ICU admission and/or intubation (OR 1.095; 95% CI 1.461–6.122; P = 0.003). Poor prognosis (35.5% vs. 21.1%, P = 0.005) was more common in immunocompromised patients.ConclusionAirway-invasion-associated CT presentations at early stages of the disease are characteristic of IPA in non-immunocompromised hosts.

Evaluation of a PCR-electrospray ionization mass spectrometry platform for detection and identification of fungal pathogens directly from prospectively collected bronchoalveolar lavage specimens

The incidence of invasive fungal infections is on the rise worldwide due to the growth of the immunocompromised population. We report here the use of a diagnostic assay that utilizes a universal extraction method, broad spectrum PCR amplification and analysis via electrospray ionization mass spectrometry (PCR/ESI-MS) to detect and identify more than 200 pathogenic fungi directly from bronchoalveolar lavage (BAL) specimens in less than 8 hours. In this study, we describe both analytical and clinical performance of the assay, when run with prospectively collected clinical BAL specimens. In 146 patients with probable and possible fungal infections defined by EORTC/MSG (European Organization for Research and Treatment of Cancer/Mycoses Study Group) criteria, the PCR/ESI-MS assay demonstrated a sensitivity of 90.9% (95% CI: 76.4–96.9%) and a specificity of 82.3% (95% CI: 74.2–88.2%). This data demonstrates the utility of a non-culture based broad fungal targets molecular diagnostic tool for rapid and accurate diagnosis of invasive fungal infections in patients at risk of developing fungal diseases.

Polymerase chain reaction blood tests for the diagnosis of invasive aspergillosis in immunocompromised people

This is an update of the original review published in the Cochrane Database of Systematic Reviews Issue 10, 2015.Invasive aspergillosis (IA) is the most common life-threatening opportunistic invasive mould infection in immunocompromised people. Early diagnosis of IA and prompt administration of appropriate antifungal treatment are critical to the survival of people with IA. Antifungal drugs can be given as prophylaxis or empirical therapy, instigated on the basis of a diagnostic strategy (the pre-emptive approach) or for treating established disease. Consequently, there is an urgent need for research into both new diagnostic tools and drug treatment strategies. Increasingly, newer methods such as polymerase chain reaction (PCR) to detect fungal nucleic acids are being investigated. To provide an overall summary of the diagnostic accuracy of PCR-based tests on blood specimens for the diagnosis of IA in immunocompromised people. We searched MEDLINE (1946 to June 2015) and Embase (1980 to June 2015). We also searched LILACS, DARE, Health Technology Assessment, Web of Science and Scopus to June 2015. We checked the reference lists of all the studies identified by the above methods and contacted relevant authors and researchers in the field. For this review update we updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 3) in the Cochrane Library; MEDLINE via Ovid (June 2015 to March week 2 2018); and Embase via Ovid (June 2015 to 2018 week 12). We included studies that: i) compared the results of blood PCR tests with the reference standard published by the European Organisation for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG); ii) reported data on false-positive, true-positive, false-negative and true-negative results of the diagnostic tests under investigation separately; and iii) evaluated the test(s) prospectively in cohorts of people from a relevant clinical population, defined as a group of individuals at high risk for invasive aspergillosis. Case-control and retrospective studies were excluded from the analysis. Authors independently assessed quality and extracted data. For PCR assays, we evaluated the requirement for either one or two consecutive samples to be positive for diagnostic accuracy. We investigated heterogeneity by subgroup analyses. We plotted estimates of sensitivity and specificity from each study in receiver operating characteristics (ROC) space and constructed forest plots for visual examination of variation in test accuracy. We performed meta-analyses using the bivariate model to produce summary estimates of sensitivity and specificity. We included 29 primary studies (18 from the original review and 11 from this update), corresponding to 34 data sets, published between 2000 and 2018 in the meta-analyses, with a mean prevalence of proven or probable IA of 16.3 (median prevalence 11.1% , range 2.5% to 57.1%). Most patients had received chemotherapy for haematological malignancy or had undergone hematopoietic stem cell transplantation. Several PCR techniques were used among the included studies. The sensitivity and specificity of PCR for the diagnosis of IA varied according to the interpretative criteria used to define a test as positive. The summary estimates of sensitivity and specificity were 79.2% (95% confidence interval (CI) 71.0 to 85.5) and 79.6% (95% CI 69.9 to 86.6) for a single positive test result, and 59.6% (95% CI 40.7 to 76.0) and 95.1% (95% CI 87.0 to 98.2) for two consecutive positive test results. PCR shows moderate diagnostic accuracy when used as screening tests for IA in high-risk patient groups. Importantly the sensitivity of the test confers a high negative predictive value (NPV) such that a negative test allows the diagnosis to be excluded. Consecutive positives show good specificity in diagnosis of IA and could be used to trigger radiological and other investigations or for pre-emptive therapy in the absence of specific radiological signs when the clinical suspicion of infection is high. When a single PCR positive test is used as the diagnostic criterion for IA in a population of 100 people with a disease prevalence of 16.3% (overall mean prevalence), three people with IA would be missed (sensitivity 79.2%, 20.8% false negatives), and 17 people would be unnecessarily treated or referred for further tests (specificity of 79.6%, 21.4% false positives). If we use the two positive test requirement in a population with the same disease prevalence, it would mean that nine IA people would be missed (sensitivity 59.6%, 40.4% false negatives) and four people would be unnecessarily treated or referred for further tests (specificity of 95.1%, 4.9% false positives). Like galactomannan, PCR has good NPV for excluding disease, but the low prevalence of disease limits the ability to rule in a diagnosis. As these biomarkers detect different markers of disease, combining them is likely to prove more useful.

New Concepts in Diagnostics for Invasive Mycoses: Non-Culture-Based Methodologies.

Non-culture-based diagnostics have been developed to help establish an early diagnosis of invasive fungal infection. Studies have shown that these tests can significantly impact the diagnosis of infection in high risk patients. Aspergillus galactomannan EIA testing is well-recognized as an important adjunct to the diagnosis of invasive aspergillosis and can be detected in serum, bronchoalveolar lavage and other fluids. Galactomannan testing used along with PCR testing has been shown to be effective when integrated into care paths for high risk patients for both diagnoses and as a surrogate marker for outcome when used in serial testing. Beta-d-glucan assays are non-specific for several fungal genera including Aspergillus and Candida and in high risk patients have been an important tool to augment the diagnosis. Lateral flow technology using monoclonal antibodies to Aspergillus are available that allow rapid testing of clinical samples. While standard PCR for Candida remains investigational, T2 magnetic resonance allows for the rapid diagnosis of Candida species from blood cultures. Aspergillus PCR has been extensively validated with standardized approaches established for these methods and will be included in the diagnostic criteria in the revised European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC-MSG) definitions. Finally, these non-culture-based tests can be used in combination to significantly increase the detection of invasive mycoses with the ultimate aim of establishing an early diagnosis of infection.

Micafungin use in a UK tertiary referral hospital.

Here we sought to describe the real-life usage of micafungin in a UK tertiary referral hospital. A prospective, non-interventional, observational surveillance study was performed. Micafungin was commenced in 174 courses involving 148 patients to treat invasive candidiasis and candidaemia (132 courses) and aspergillosis in situations where alternatives such as voriconazole or liposomal amphotericin B could not be used (42 courses). Fungal infection was defined as proven as per European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) guidelines in 84 courses (48.3%). Micafungin was well tolerated; 10 patients (6.8%) developed a rise in alanine aminotransferase (ALT) and only 1 patient stopped therapy due to this. Therapy was rationalised to fluconazole in 77 courses (44.3%). There were no differences in intensive care unit admission or deaths when comparing all 174 courses where patients received micafungin for Aspergillus and Candida infection, respectively [49% vs. 42% (P=0.82) and 24% vs. 15% (P=0.186)]. One patient developed disseminated mucormycosis and four patients had recurrent candidaemia (attributed to poor source control) while receiving micafungin. Micafungin was clinically effective for the treatment of invasive Candida and Aspergillus infections, and usage did not increase the risk of liver dysfunction even in patients with abnormal ALT at baseline.

Local retrospective analysis of galactomannan cut-off values in bronchoalveolar lavage fluids for diagnosis of invasive aspergillosis.

Galactomannan antigen (GM) testing has been used for decades to screen immunocompromised patients for invasive aspergillosis (IA). Recent publications suggested that using a higher cut-off value than 0.5 in bronchoalveolar lavage fluid (BALF) could be more discriminant for hematology patients. We retrospectively analyzed the values of GM in BALF over 7years (from 2010 to 2016). Performance indicators of the GM in BALF, according to three different cut-off values (0.5, 0.8, 1.5), were calculated using Stata 14.1. IA classification for hematology patients was based on European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, as defined in 2008. A number of 716 GM were performed on BALF from 2010 to 2016 (597 patients) and 66 were positive (> 0.5). Among these 597 patients, 27 IA were diagnosed, 13 with a positive GM in BALF, 9 with a negative GM in BALF, and 5 unclassified IA (ICU patients). The analysis of performance indicators, based on our local data, did not demonstrate any significant difference using a higher cut-off value of GM in BALF. This result may be explained by the local recruitment of patients and by pre-analytic variations during BALF realization.

Utility of a serum Aspergillusgalactomannan assay in diagnosis of invasive pulmonary Aspergillosis in HIV/AIDS patients: a prospective analysis

Background: Invasive pulmonary aspergillosis (IPA) is a life threatening infection among immunocompromised patients. A timely and precise diagnosis of this condition is often precluded by lack of sensitive and specific noninvasive diagnostic tools. Detection of galactomannan has emerged as a promising tool in this regard. While the analytical performance of serum galactomannan assay has been extensively evaluated in various high risk groups, its possible utility in HIV/AIDS patients is yet to be explored. The present study was undertaken to evaluate the yield of a serum galactomannan assay for diagnosis of IPA in a cohort of HIV/AIDS patients.Methods: 49 febrile HIV reactive patients with co-existent symptomatic AIDS were prospectively enrolled for the evaluation. Blood samples were drawn from each patient and serum galactomannan screening was performed employing the commercially available serum galactomannan assay, Platelia™ Aspergillus EIA. An optical density index >0.5 for at least two serum samples was considered the defining criteria for a positive result. Furthermore, sputum samples were collected and direct microscopic examination (10% potassium hydroxide wet mount) and fungal cultures were performed.Result: In accordance with the definitions laid down under EORTC/MSG (European Organization for Research and Treatment of Cancer / Mycoses Study Group) criteria, ten cases of probable and 23 cases of possible IPA were diagnosed. The sensitivity, specificity, and positive and negative predictive values of Platelia™ Aspergillus EIA for patients with probable IPA were 90%, 100%, 100% and 94.12 % respectively.Conclusion: Serum galactomannan assay has a high sensitivity and specificity and when complemented with relevant lower respiratory tract symptomatology and imaging findings, can serve as a useful adjunct to conventional modalities for the diagnosis of IPA in HIV/AIDS patients. DOI: 10.21276/APALM.1439

Serological Approaches.

The diagnosis of invasive fungal diseases (IFD) based on clinical, radiological, and conventional microbiological findings is not reliable and is often delayed. Non-culture-based methods with higher sensitivity and specificity may reduce diagnostic time and result in decreased IFD morbidity and mortality. These methods are now increasingly used to manage patients at risk of IFD. Among available biomarkers, fungal antigens have been investigated as an aid to early diagnosis and are predominantly used as screening tests to prompt antifungal treatment mainly in patients with hematological malignancies. The revised version of the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) consensus definitions includes some of these biological markers (galactomannan, 1,3-beta-D-glucan, cryptococcus antigen).

Comparison of galactomannan, beta-D-glucan, and Aspergillus DNA in sera of high-risk adult patients with hematological malignancies for the diagnosis of invasive aspergillosis.

Invasive aspergillosis (IA) is a fatal infection that is difficult to diagnose in immunocompromised patients. In this study, Aspergillus-specific DNA was searched using real-time PCR (RT-PCR) in serum samples. Galactomannan (GM) and/or beta-D-glucan (BDG) tests were previously performed on these samples for 70 neutropenic patients with hematological malignancy. The patients were categorized according to the criteria of the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG). Among the patient serum samples, the first positive GM or BDG test sample and the median sample of GM or BDG test for negative patients were used to detect DNA levels by RT-PCR method (Light Cycler 480, Roche Molecular Biochemicals, Meylan, France) using a commercial kit (Way2Gene Fungi; Genmar, İzmir, Turkey). When the proven and probable IA group were considered as real patients, sensitivity of Aspergillus-specific DNA test was 90%, specificity was 73.3%, positive predictive value was 81.8%, and negative predictive value was 84.6%. This study found that searching for specific DNA by RT-PCR method has a sensitivity as high as the GM test. Although specificity was rather low, it was concluded that it can be used jointly with GM and BDG tests after decreasing contamination by severe laboratory applications.

Polymerase chain reaction blood tests for the diagnosis of invasive aspergillosis in immunocompromised people.

Invasive aspergillosis (IA) is the most common life-threatening opportunistic invasive mould infection in immunocompromised people. Early diagnosis of IA and prompt administration of appropriate antifungal treatment are critical to the survival of people with IA. Antifungal drugs can be given as prophylaxis or empirical therapy, instigated on the basis of a diagnostic strategy (the pre-emptive approach) or for treating established disease. Consequently there is an urgent need for research into both new diagnostic tools and drug treatment strategies. Newer methods such as polymerase chain reaction (PCR) to detect fungal nucleic acids are increasingly being investigated. To provide an overall summary of the diagnostic accuracy of PCR-based tests on blood specimens for the diagnosis of IA in immunocompromised people. We searched MEDLINE (1946 to June 2015) and EMBASE (1980 to June 2015). We also searched LILACS, DARE, Health Technology Assessment, Web of Science and Scopus to June 2015. We checked the reference lists of all the studies identified by the above methods and contacted relevant authors and researchers in the field. We included studies that: i) compared the results of blood PCR tests with the reference standard published by the European Organisation for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG); ii) reported data on false-positive, true-positive, false-negative and true-negative results of the diagnostic tests under investigation separately; and iii) evaluated the test(s) prospectively in cohorts of people from a relevant clinical population, defined as a group of individuals at high risk for invasive aspergillosis. Case-control studies were excluded from the analysis. Authors independently assessed quality and extracted data. For PCR assays, we evaluated the requirement for either one or two consecutive samples to be positive for diagnostic accuracy. We investigated heterogeneity by subgroup analyses. We plotted estimates of sensitivity and specificity from each study in receiver operating characteristics (ROC) space and constructed forest plots for visual examination of variation in test accuracy. We performed meta-analyses using the bivariate model to produce summary estimates of sensitivity and specificity. Eighteen primary studies, corresponding to 19 cohorts and 22 data sets, published between 2000 and 2013 were included in the meta-analyses, with a median prevalence of IA (proven or probable) of 12.0% (range 2.5 to 30.8 %). The majority of people had received chemotherapy for a haematological malignancy or had undergone a hematopoietic stem cell transplant. Several PCR techniques were used among the included studies. The sensitivity and specificity of PCR for the diagnosis of IA varied according to the interpretative criteria used to define a test as positive. The mean sensitivity and specificity were 80.5% (95% CI; 73.0 to 86.3) and 78.5% (67.8 to 86.4) for a single positive test result, and 58.0% (36.5 to 76.8) and 96.2% (89.6 to 98.6) for two consecutive positive test results. PCR shows moderate diagnostic accuracy when used as screening tests for IA in high-risk patient groups. Importantly the sensitivity of the test confers a high negative predictive value (NPV) such that a negative test allows the diagnosis to be excluded. Consecutive positives show good specificity in diagnosis of IA and could be used to trigger radiological and other investigations or for pre-emptive therapy in the absence of specific radiological signs when the clinical suspicion of infection is high. When a single PCR positive test is used as diagnostic criterion for IA in a population of 100 people with a disease prevalence of 13.0% (overall mean prevalence), three people with IA would be missed (sensitivity 80.5%, 19.5% false negatives), and 19 people would be unnecessarily treated or referred for further tests (specificity of 78.5%, 21.5% false positives). If we use the two positive test requirement in a population with the same disease prevalence, it would mean that six IA people would be missed (sensitivity 58.0%, 42.1% false negatives) and three people would be unnecessarily treated or referred for further tests (specificity of 96.2%, 3.8% false positives). Galactomannan and PCR have good NPV for excluding disease but the low prevalence of disease limits the ability to rule in a diagnosis. The biomarkers are detecting different aspects of disease and the combination of both together is likely to be more useful.

Polymerase chain reaction blood tests for the diagnosis of invasive aspergillosis in immunocompromised people.

Invasive aspergillosis (IA) is the most common life-threatening opportunistic invasive mould infection in immunocompromised people. Early diagnosis of IA and prompt administration of appropriate antifungal treatment are critical to the survival of people with IA. Antifungal drugs can be given as prophylaxis or empirical therapy, instigated on the basis of a diagnostic strategy (the pre-emptive approach) or for treating established disease. Consequently there is an urgent need for research into both new diagnostic tools and drug treatment strategies. Newer methods such as polymerase chain reaction (PCR) to detect fungal nucleic acids are increasingly being investigated. To provide an overall summary of the diagnostic accuracy of PCR-based tests on blood specimens for the diagnosis of IA in immunocompromised people. We searched MEDLINE (1946 to June 2015) and EMBASE (1980 to June 2015). We also searched LILACS, DARE, Health Technology Assessment, Web of Science and Scopus to June 2015. We checked the reference lists of all the studies identified by the above methods and contacted relevant authors and researchers in the field. We included studies that: i) compared the results of blood PCR tests with the reference standard published by the European Organisation for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG); ii) reported data on false-positive, true-positive, false-negative and true-negative results of the diagnostic tests under investigation separately; and iii) evaluated the test(s) prospectively in cohorts of people from a relevant clinical population, defined as a group of individuals at high risk for invasive aspergillosis. Case-control studies were excluded from the analysis. Authors independently assessed quality and extracted data. For PCR assays, we evaluated the requirement for either one or two consecutive samples to be positive for diagnostic accuracy. We investigated heterogeneity by subgroup analyses. We plotted estimates of sensitivity and specificity from each study in receiver operating characteristics (ROC) space and constructed forest plots for visual examination of variation in test accuracy. We performed meta-analyses using the bivariate model to produce summary estimates of sensitivity and specificity. Eighteen primary studies, corresponding to 19 cohorts and 22 data sets, published between 2000 and 2013 were included in the meta-analyses, with a median prevalence of IA (proven or probable) of 12.0% (range 2.5 to 30.8 %). The majority of people had received chemotherapy for a haematological malignancy or had undergone a hematopoietic stem cell transplant. Several PCR techniques were used among the included studies. The sensitivity and specificity of PCR for the diagnosis of IA varied according to the interpretative criteria used to define a test as positive. The mean sensitivity and specificity were 80.5% (95% CI; 73.0 to 86.3) and 78.5% (67.8 to 86.4) for a single positive test result, and 58.0% (36.5 to 76.8) and 96.2% (89.6 to 98.6) for two consecutive positive test results. PCR shows moderate diagnostic accuracy when used as screening tests for IA in high-risk patient groups. Importantly the sensitivity of the test confers a high negative predictive value (NPV) such that a negative test allows the diagnosis to be excluded. Consecutive positives show good specificity in diagnosis of IA and could be used to trigger radiological and other investigations or for pre-emptive therapy in the absence of specific radiological signs when the clinical suspicion of infection is high. When a single PCR positive test is used as diagnostic criterion for IA in a population of 100 people with a disease prevalence of 13.0% (overall mean prevalence), three people with IA would be missed (sensitivity 80.5%, 19.5% false negatives), and 19 people would be unnecessarily treated or referred for further tests (specificity of 78.5%, 21.5% false negatives). If we use the two positive test requirement in a population with the same disease prevalence, it would mean that six IA people would be missed (sensitivity 58.0%, 42.1% false negatives) and three people would be unnecessarily treated or referred for further tests (specificity of 96.2%, 3.8% false negatives). Galactamannan and PCR have good NPV for excluding disease but the low prevalence of disease limits the ability to rule in a diagnosis. The biomarkers are detecting different aspects of disease and the combination of both together is likely to be more useful.