Galactomannan Levels Research Articles

Seroprevalence and prognostic value of Aspergillus-specific IgG among non-neutropenic invasive pulmonary aspergillosis patients: a prospective multicenter study

BackgroundThis study aimed to assess the diagnostic and prognostic value of Aspergillus-specific IgG (Asp-IgG) for invasive pulmonary aspergillosis (IPA) in non-neutropenic non-hematologic patients.MethodsBetween November 2019 and February 2022, we recruited 40 non-neutropenic, non-hematologic IPA patients from Taiwan and measured serum Asp-IgG levels using Phadia, Thermofisher. A positive Asp-IgG test was defined as a level > 40 mgA/L. We evaluated the association between Asp-IgG levels and overall survival, as well 90-day mortality rate of IPA patients.ResultsOf the 40 participants, 11 (27.5%) tested positive for Asp-IgG, while 16 (40%) had positive galactomannan antigen (optical density > 1). Higher Asp-IgG levels were associated with improved overall survival (HR: 0.22, 95% CI: 0.05–0.99, p = 0.035) in multivariable Cox regression. The overall 90-day mortality rate was 65% (26/40). We found that patients with low Asp-IgG levels (≤ 40 mgA/L) had a borderline higher 90-day mortality rate compared to patients with high Asp-IgG levels (OR: 3.15, 95% CI: 0.75–13.28, p = 0.118). Stratifying by serum galactomannan and Aspergillus IgG levels, patients with elevated serum GM and low Asp-IgG had the highest 90-day mortality (80%, 8/10), followed by patients with low serum GM and low Asp-IgG (68.4%, 13/19).ConclusionsAsp-IgG was positive in approximately one-fourth of non-neutropenic IPA patients. Asp-IgG may hold potential as a clinical prognostic factor for IPA. Further studies are required to validate this finding.

Mechanism-Based Pharmacokinetic/Pharmacodynamic Model of Voriconazole for Predicting the Clinical Outcomes of Adult Patients with Invasive Aspergillosis.

Voriconazole is the first-line therapy for invasive aspergillosis (IA). To determine the minimum inhibitory concentration of Aspergillus, a voriconazole pharmacokinetic-pharmacodynamic (PK-PD) model linked to galactomannan response was developed and evaluated, and its clinical correlation for IA treatment was elucidated. Adult patients with probable or definite IA and at least one serum voriconazole measurement were included. A two-compartment voriconazole PK model was linked to a previously described PD model of galactomannan response. PK and PD parameters were estimated using a nonparametric adaptive grid technique. The relationship between the ratio of voriconazole exposure that induced half-maximum galactomannan response (EC50) and the observed terminal galactomannan concentration was evaluated. The factors associated with the PK-PD parameters and mortality were also determined. Between January 2013 and December 2022, 41 patients were prescribed voriconazole for IA. The 30-day mortality rate was 17%. A high correlation was found for the observed-predicted Bayesian posterior estimates of voriconazole and galactomannan levels. Moreover, a nonlinear relationship was identified between AUC:EC50 and terminal galactomannan. The factors associated with higher AUC:EC50 were intravenous administration and intubation. In the survival analysis, higher EC50 tended to be associated with mortality, higher AUC was significantly associated with increased mortality, and higher AUC:EC50 tended to be associated with higher mortality. After adjusting for the intravenous route, higher AUC and AUC:EC50 were not associated with mortality. Individual EC50 estimation can provide insights into in vivo host and organism responses. Elevated EC50 showed comparable and unfavorable trends to higher minimum inhibitory concentration. Thus, determining EC50 might help guide individualized target serum voriconazole levels.

Non-invasive detection of Aspergillosis in ventilated patients: Galactomannan analysis in exhaled breath

This study evaluates the non-invasive diagnosis of Invasive Aspergillosis Pneumonia (IPA) in mechanically ventilated patients by measuring galactomannan (GM) in exhaled breath condensate (EBC). Utilizing a rat model and a novel EBC collection device, we compared GM levels in bronchoalveolar lavage fluid (BALF) and EBC, supplemented by cytokine profiling. Analysis of 75 patients confirmed the device's efficacy, with EBC-GM and BALF-GM showing high diagnostic accuracy (AUC = 0.88). The threshold of 0.235 ng/ml for EBC-GM achieved 92.8 % sensitivity and 66.7 % specificity, with a strong correlation (r = 0.707, P < 0.001) with BALF-GM. This approach offers a safe, effective alternative to invasive diagnostics, enhancing precision with IL-6 and TNF-α measurements.The number registered on clinicaltrails.gov is NCT06333379.

Prevalence, Risk Factors, and Mortality of Invasive Pulmonary Aspergillosis in Patients with Anti-MDA5+ Dermatomyositis: A Retrospective Study in China.

To investigate the prevalence, risk factors and prognosis of invasive pulmonary aspergillosis (IPA) in patients with anti-melanoma differentiation-associated gene 5 positive dermatomyositis (anti-MDA5+ DM). A retrospective analysis was conducted in anti-MDA5+ DM patients diagnosed between January 2016 and March 2023. Patients with lower respiratory tract specimens were categorized into IPA+ and IPA- groups based on the presence of IPA and their clinical characteristics and prognoses then compared. Of the 415 patients diagnosed with anti-MDA5+ DM, 28 cases had IPA (prevalence rate of 6.7%) with Aspergillus fumigatus being the most common species. The patients were categorized into IPA+ (n=28) and IPA- (n=98) groups, with no significant age or gender-related differences (P>0.05). The IPA+ group had a lower lymphocyte count, particularly the CD4+ T-cell count, and reduced serum albumin and higher serum ferritin levels (P all<0.05). An elevated bronchoalveolar lavage fluid (BALF) galactomannan level was found to be the sole independent risk factor for the occurrence of IPA (adjusted OR=2.191, P=0.029) with a cut-off value of 0.585 and area under the curve of 0.779. The mortality rate in the IPA+ group was 25%. Compared to survivors, non-survivors in this group exhibited a higher incidence of rapidly progressive interstitial lung disease, lower lymphocyte counts, and increased co-infection with Pneumocystis jirovecii (P all<0.05). IPA was not rare in patients with anti-MDA5+ DM, with elevated BALF galactomannan levels being an independent risk factor for IPA occurrence. Clinicians must exercise vigilance to identify patients exhibiting the aforementioned risk factors.

Evaluation of interleukin-8 levels in the diagnosis of invasive pulmonary aspergillosis in patients with haematological malignancies.

This study aimed to determine the level of interleukin (IL)-8 in diagnosing of invasive pulmonary aspergillosis (IPA). We conducted this study with 50 controls and 25 IPA patients with haematological malignancies. Demographic data, haematological diagnoses, chemotherapy regimen, galactomannan level, fungal culture, and computed tomography findings of the patients were evaluated prospectively. IL-8 levels were studied with the ELISA method. The mean age of patients in the case group was 60.84±15.38 years, while that of the controls was 58.38±16.64 years. Of the patients, 2/25 were classified as having 'proven', 13/25 as 'probable', and 10/25 as 'possible' invasive aspergillosis (IA). Serum IL-8 levels were found to be significantly higher in the case group compared to the controls. There was a negative correlation between serum IL-8 levels and neutrophil counts and a positive correlation with the duration of neutropenia. A significant cutoff value for serum IL-8 parameter in detecting IPA disease was obtained as ≥274 ng/l; sensitivity was 72%; specificity was 64%; PPV was 50%; and NPV was 82%. In the subgroup analysis, there was no significant difference in serum IL-8 levels between the case group and the patients in the neutropenic control group, while a significant difference was found in with the patients in the non-neutropenic control group. Serum IL-8 levels in neutropenic patients who develop IPA are not adequate in terms of both the diagnosis of the disease and predicting mortality. New, easily applicable methods with high sensitivity and specificity in diagnosing IPA are still needed.

Successful management of Aspergillosis in post renal transplant patient: A case report

This case describes a 60-year-old man with a history of diabetes and hypertension who underwent a kidney transplant in September 2023. The patient presented with fever, cough for 5 days, empirical antibiotics were started but complaints were not resolved so fungal markers were sent, which showed elevated galactomannan levels, necessitating the initiation of voriconazole therapy. X Ray chest showed patch along with cavitatory lesion which was further confirmed by CT Scan Chest which confirmed a cavitatory lesion. This case report emphasizes the importance of considering fungal infection as a differential diagnosis in immunocompromised patients and achieving good results with appropriate treatment.

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.

Prevalence, Risk Factors, Treatment, Outcome, and Diagnosis of COVID-19-Associated Pulmonary Aspergillosis Using a Serum Galactomannan Assay

Background: Coronavirus-associated pulmonary aspergillosis (CAPA) is defined as invasive pulmonary aspergillosis (IPA) occurring in patients with COVID-19 infection. Objectives: This study aimed to identify CAPA patients and describe their clinical-epidemiological characteristics in Ahvaz, Iran, from the third to the fifth COVID-19 waves. Methods: The serum galactomannan (GM) antigen assay was used to detect CAPA in 257 COVID-19 hospitalized patients according to the EORTC/MSGERC (European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium) 2020 criteria. The demographic and clinical data, host risk factors, lung radiographic imaging, laboratory findings, antifungal agents used, and the outcomes of the patients were extracted in cases that were available. All findings were statistically analyzed. Results: Of the 257 patients, 114 (44.35%) were positive for GM levels (CAPA cases). The demographic and clinical information of 51 cases showed that diabetes mellitus (25.5%) was the most common underlying condition, followed by oropharyngeal candidiasis (22%) and hypertension (21.6%). In both surviving and deceased patients, the frequency of CAPA in older ages was statistically significant (r = 0.519; P &lt; 0.0001). In surviving individuals, GM had a significant relationship with age (r = 0.520; P = 0.032), blood glucose (BS; r = 0.497; P = 0.043), diagnosis of hyperglycemia during hospitalization (P = 0.039), and diabetes mellitus (P = 0.039). In deceased patients, the frequency of CAPA in older ages was statistically significant (r = 0.503; P = 0.002). Galactomannan had a significant association with the variables of age (r = 0.503; P = 0.002) and suspicion of fungal infection (P = 0.003). Conclusions: The prevalence of CAPA was high in critically ill patients with COVID-19. Diabetes mellitus, hyperglycemia, and old age are the main factors that predispose COVID-19 patients to IPA.

Performance of the Aspergillus galactomannan lateral flow assay with a digital reader for the diagnosis of invasive aspergillosis: a multicenter study

PurposeThe objective of this multicenter study was to compare the diagnostic performance of lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) to detect the Dynamiker Aspergillus Galactomannan levels in serum and bronchoalveolar lavage fluid (BALF) samples for I.MethodsWe registered 310 clinically suspected Aspergillus infection patients from December 2021 to February 2023 and classified them into subgroups as the “IA group” and “non-IA group” based on the latest EORTC/MSG guidelines. The immunoassays were analyzed by LFA and ELISA respectively.ResultsGalactomannan was examined using LFA, and serum and BALF samples demonstrated sensitivities of 82.57% and 89.47%, specificities of 90.76% and 92.00%, PPVs of 89.11% and 96.23%, and NPVs of 85.04% and 79.31%, respectively. Galactomannan was observed using two assays in serum and BALF samples and showed PPAs of 95.11% and 93.33%, NPAs of 89.19% and 96.30%, and TPAs of 92.47% and 94.25%, respectively. The ROC curve demonstrated that LFA had optimum diagnostic value when the index value (I value) = 0.5, the sensitivity was 84.94%, and the specificity was 90.97%.ConclusionCompared to the ELISA method, the LFA has shown excellent performance for the diagnosis of IA in serum and BALF sample and can be used as an assay for the early diagnosis of patients with IA. The dynamic change in galactomannan levels may be useful for assessing treatment response.

Incidence of Invasive Fungal Infections in CAR T-Cell Therapy Recipients: A Single-Center Retrospective Analysis

Background: CAR T-cell therapy has transformed the treatment of hematologic malignancies, but challenges persist due to toxicities like cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and infections. Rates of invasive fungal infections (IFI) post CAR T-cell therapy are estimated to range from 1% to 7% (Haidar et al. Clin Infect Dis, 2020). Some centers use positive fungal biomarkers, such as serum (1à3)-β-D-glucan (B-DG) and galactomannan (GM), alongside surveillance radiographic imaging to guide preemptive fungal therapy in this population. The objective of the study was to assess the diagnostic performance of surveillance B-DG and GM for the diagnosis of IFI in recipients of BCMA and CD19-directed CAR T for multiple myeloma (MM) and non-Hodgkin lymphoma (NHL), respectively. Methods: We conducted a retrospective analysis on adult patients who received BCMA-directed CAR T therapy for MM or CD19-directed CAR T for NHL at our institution between 2018-2023. IFI was defined using the Revised European Organization for Research and Treatment of Cancer and the Mycoses Study Group (EORTC/MSG) criteria (Donnelly et al. Clin Infect Dis, 2020). Only patients with proven or probable infection were included in the analysis. The choice of antifungal prophylaxis was determined based on the treating physician's discretion. In the most cases, B-DG and GM monitoring was done prior to apheresis, before CAR T infusion, and subsequently every 14 days for a duration of 6 months. All patients were followed until 7/12/2023, or until their data were censored at the last follow-up. The cumulative incidence was calculated using Kaplan-Meier method, considering the time to IFI, with IFI-free death and disease relapse as competing risks. Statistical analysis was performed using IBM SPSS (version 29.0). Result: Among the 148 subjects in this study, 51 patients (34.5%) received BCMA CAR T, and 97 (65.5%) received CD19 CAR T therapy. The median age at CAR T infusion was 66 years (range 36-78) in the BCMA cohort and 65 years (range 27-83) in the CD19 cohort (p=0.64). The BCMA cohort had a higher number of prior therapies, with a median of 6 (range 2-15) compared to the CD19 cohort, which had a median of 4 (range 2-12) (p&amp;lt;0.001). The median follow-up from CAR T infusion was 9.5 months (range 0-63) in both cohorts, with 12 months (range 0-63) in the BCMA cohort and 8 months (range 0-49) in the CD19 cohort. All patients received prophylactic antifungal agents, including anti-yeast (fluconazole, n=95), and anti-mold (micafungin n=5, isavuconazole n=1, or Posaconazole n=52). Among the BCMA cohort, 92% of the patients received anti-yeast prophylaxis, while 8% were given anti-mold prophylaxis. In the CD19 cohort, 49.5% received anti-yeast prophylaxis, while 50.5% received anti-mold prophylaxis. Out of the 148 patients, 21 individuals (14%) exhibited elevated B-DG levels, while only 2 patients (1%) showed elevated GM levels. However, 20 out of 21 (95%) cases with positive B-DG, and all cases with positive GM were deemed to be false positives. Among these false positives, 60% were attributed to IVIG administration, while the cause for the remaining cases remained unknown (Table 1). Only one patient in this study developed IFI. The patient received anti-yeast prophylaxis (Fluconazole) at CAR-T and had a disseminated Rhizopus infection on day 13 post CD19 CAR T, which ultimately resulted in the patient's death. The 1-year cumulative incidence of IFI, considering competing risks, was 0.7% (95% confidence interval [CI], 0- 2.1). The median progression-free survival (PFS) in the overall cohort was 11.7 months (95% CI, 6.9-16.6), with 8.6 months (95% CI, 3.2-13.97) in the BCMA cohort and 14.6 months (95% CI, NR-NR) in the CD19 cohort (p=0.324). The median overall survival (OS) of the study cohort was 32.4 months (95% CI, 16.3-48.4), with 41.4 months (95% CI, 16.74-66.08) in the BCMA cohort and 23.98 months (95% CI, NR-NR) in the CD19 cohort (p=0.260). Conclusion: The rate of IFI in our cohort was low (0.7%) post-CAR T therapy. The diagnostic performance of serial monitoring of B-DG and GM for the diagnosis of IFI is poor in recipients of BCMA-directed CAR T therapy for MM or CD19-directed CAR T for NHL.

Amino sugars influence Aspergillus fumigatus cell wall polysaccharide biosynthesis, and biofilm formation through interfering galactosaminogalactan deacetylation

Aspergillus fumigatus is a ubiquitous fungal pathogen responsible for a significant number of deaths annually due to invasive aspergillosis infection. While the utilization of diverse carbon sources, including amino sugars, has been explored in other fungi, its impact on A. fumigatus remains uncharted territory. In this study, we investigated A. fumigatus responses to glucose (Glc), glucosamine (GlcN) and N-acetylglucosamine (GlcNAc) as carbon sources. GlcN inhibited growth, reduced sporulation and delayed germination, while GlcNAc had no such effects. Both amino sugars induced alterations in cell wall composition, leading to a reduction in glucan and galactomannan levels while increasing chitin and mannan content, rendering A. fumigatus susceptible to cell wall stress and osmotic stress. GlcN repressed biofilm formation via downregulation of galactosaminogalactan (GAG) cluster genes, notably agd3, which encodes a GAG-specific deacetylase. Moreover, GlcN increased biofilm susceptibility to echinocandins, suggesting its potential for enhancing the effectiveness of antifungal treatments. This study sheds light on the multifaceted effects of amino sugars on A. fumigatus, encompassing growth, cell wall biosynthesis, and biofilm formation, offering promising avenues for innovative aspergillosis treatment strategies.

False positive Aspergillus galactomannan assay results caused by specific parenteral nutrition.

In September 2022, the proportion of clinically false positive results with high index values for the galactomannan (GM) assay increased dramatically in our hospital and remained high until November 2022. We aimed to identify the possible causative agent that led to the dramatic increase in false positivity in GM assay. A case-control-control study was conducted, and patients admitted to two intensive care units between September and November 2022 were included. We defined each time point at which the GM assay was conducted in a patient as an episode and classified episodes into strong-positive (≥10.0 index; case), positive (control), and negative (<0.5 index; control) groups. We compared the medications administered in three groups and measured GM levels in relevant medications, including parenteral nutrition (PN). In total, 118 episodes in 33 patients were classified into three groups. There were 46 negative, 23 positive, and 49 strong-positive episodes, and there was a significant difference in the use of Winuf® PNs (P<.001) between the three groups. Forty episodes (82%) in the strong-positive group received Winuf®, compared with three (6.5%) in the negative group and one (4.3%) in the positive group (P<.001). All samples of Winuf® PNs used in the five patients whose GM results were repeatedly strong-positive were strongly positive for GM. False positivity in GM assay can be caused by the administration of specific PNs. A thorough investigation of prescribed medications should be considered when there is an abrupt increase in the proportion of strong-positive or positive GM results.

Seroprevalence of Galactomannan Aspergillus in COVID-19 patients in Jakarta: A challenge in the pandemic commotion

COVID-19-associated pulmonary aspergillosis (CAPA) is a severe complication of COVID-19 due to Aspergillus infection. However, the clinical manifestation and radiology findings are not typical and require measurement of Aspergillus galactomannan (GM) level to assist in the diagnosis of CAPA. We evaluated the positivity rate of Aspergillus GM level among COVID-19 patients and investigated the correlation between the GM level and the age of patients. This retrospective observational study compiled the GM results from COVID-19 patients’ sera during the early period of the COVID-19 pandemic from March 2020 to December 2021. All samples underwent an ELISA test to measure Aspergillus GM level. There were 96 patients enrolled in this study. The positivity rate was 33%, with the highest (56%) percentage of positivity observed in the age group 40-59 in the positive Aspergillus GM group. The measurement of Aspergillus GM level among COVID-19 patients with risk factors of CAPA is critical to establish CAPA diagnosis. The availability of Aspergillus GM test in Indonesia is still limited and this issue needs to be addressed by all healthcare experts and stakeholders.

COVID-19-associated pulmonary aspergillosis

Abstract Invasive pulmonary aspergillosis (IPA) is now been recognized as a possible secondary infection affecting COVID-19 recovery and increasing mortality. It can be explained due to factors such as direct epithelial injury, hypercoagulable and hyperinflammatory states, and the use of immunosuppressive treatment. We managed five such cases in a post-COVID intensive care unit facility at a tertiary care institute in North India. All patients had high oxygen demand, positive serum galactomannan (GM) index, and significant chest X-ray changes. All patients showed an initial improvement after receiving intravenous antifungal treatment with voriconazole. Systemic markers were suboptimal for the diagnosis of COVID-19-associated pulmonary aspergillosis (CAPA) with a sensitivity of less than 50%. GM assay has been validated in BAL and serum in numerous studies. Serum GM is a sensitive marker for IPA in patients with neutropenia; however, in nonneutropenic critically ill patients, serum GM exhibited a sensitivity of 25%, although a negative serum result cannot exclude the diagnosis of CAPA. The diagnosis of CAPA is challenging, and in patients with severe COVID-19 pneumonia may be associated with a worse prognosis. GM levels can be used for the diagnostic purpose of probable CAPA cases and administration of prophylactic treatment with voriconazole is still under debate.

Lateral flow assay (LFA) in the diagnosis of COVID-19-associated pulmonary aspergillosis (CAPA): a single-center experience

BackgroundInvasive pulmonary aspergillosis (IPA) is seen during coronavirus-2019 (COVID-19), has been reported in different incidences, and is defined as COVID-19-associated pulmonary aspergillosis (CAPA). Detection of galactomannan antigen is an important diagnostic step in diagnosing IPA. Enzyme-linked immunoassay (ELISA) is the most frequently used method, and lateral flow assay (LFA) is increasingly used with high sensitivity and specificity for rapid diagnosis. The present study aimed to compare the sensitivity of LFA and ELISA in the diagnosis of CAPA in COVID-19 patients followed in our hospital's ICU for pandemic (ICU-P).MethodsThis study included patients with a diagnosis of COVID-19 cases confirmed by polymerase chain reaction and were followed up in ICU-P between August 2021 and February 2022 with acute respiratory failure. The diagnosis of CAPA was based on the European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology 2020 (ECMM/ ISHAM) guideline. Galactomannan levels were determined using LFA and ELISA in serum samples taken simultaneously from the patients.ResultsOut of the 174 patients followed in the ICU-P, 56 did not meet any criteria for CAPA and were excluded from the analysis. The rate of patients diagnosed with proven CAPA was 5.7% (10 patients). A statistically significant result was obtained with LFA for the cut-off value of 0.5 ODI in the diagnosis of CAPA (p < 0.001). The same significant statistical relationship was found for the cut-off value of 1.0 ODI for the ELISA (p < 0.01). The sensitivity of LFA was 80% (95% CI: 0.55–1.05, p < 0.05), specificity 94% (95% CI: 0.89–0.98, p < 0.05); PPV 53% (95% CI: 0.28–0.79, p > 0.05) and NPV was 98% (95% CI: 0.95–1.01, p < 0.05). The risk of death was 1.66 (HR: 1.66, 95% CI: 1.02–2.86, p < 0.05) times higher in patients with an LFA result of ≥ 0.5 ODI than those with < 0.5 (p < 0.05).ConclusionsIt is reckoned that LFA can be used in future clinical practice, particularly given its effectiveness in patients with hematological malignancies and accuracy in diagnosing CAPA.

Impact of revised EORTC/MSGERC 2020 criteria on diagnosis and prognosis of invasive pulmonary aspergillosis in patients with hematological malignancies undergoing bronchoscopy.

The first consensus definitions for invasive fungal diseases (IFD) were published in 2002. Advances in diagnostic tests and a clear need for improvement in certain areas led to a revision of these definitions in 2008. However, growing data on Aspergillus galactomannan (GM) thresholds and the introduction of new polymerase chain reaction-based diagnostic tests resulted in a further update by EORTC and Mycoses Study Group Education and Research Consortium (MSGERC) in 2020. Compared to the 2008 version, the 2020 EORTC/MSGERC criteria have stricter definitions, especially regarding GM levels, which should lead to improved specificity. Thus, our study aimed to evaluate diagnostic changes, based on GM levels, resulting from these new definitions and ascertain the impact of the new classification on mortality rates. Patients hospitalized in a single tertiary care center with hematologic malignancies and undergoing bronchoscopy for suspected IPA between April 2004 and December 2019 were included in this retrospective study. The study population consisted of 327 patients with 31 patients (nine patients with proven IPA and 22 patients with no IPA) excluded from the study. 194 patients were classified as probable IPA cases according to 2008 EORTC/MSG criteria. However, 53 (27.3%) of these patients were re-classified as possible IPA according to 2020 EORTC/MSGERC criteria, due to novel galactomannan cut-off levels. Compared to re-classified possible IPA patients, those remaining in the probable IPA category experienced a higher incidence of septic shock (34.0% vs 16.9%, p=0.02), and required more non-invasive (12.0% vs 0.0%, p=0.004) and invasive (44.6 vs 24.5%, p=0.01) mechanical ventilation. There was a higher in-hospital mortality rate in probable IPA patients than in the re-classified possible IPA group (42.5% vs 22.6%, p=0.01). Patients reassigned to possible IPA had similar underlying diseases, radiological features and prognosis to patients already classified as possible IPA. Independent risk factors for mortality were classification as probable IPA according to 2020 EORTC/MSGERC criteria, lack of remission from hematologic malignancy, and number of nodules in Thorax CT. The use of 2020 EORTC/MSGERC criteria resulted in a 27.3% significant reduction in probable IPA diagnoses and created a more homogeneous category of patients with respect to treatment response, prognosis and mortality. Therefore, 2020 EORTC/MSGERC criteria afford more reliable mortality prediction than 2008 EORTC/MSG criteria.

P144 The uncommon meets the common: Invasive Aspergillosis and tuberculosis co-infection in non-neutropenic patients— arare association

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground and ObjectiveInvasive aspergillosis (IA) is known to occur in immunocompromised patients including neutropenic patients. But, recently increasing cases have been reported in patients with non-classical risk factors and non-neutropenic patients like diabetes mellitus, chronic lung disease, HIV infection, critically ill patients, etc. According to ISHAM these non-classical risk factors should be included in EORTC/MSG host criteria for diagnosis of invasive aspergillosis.India has a high tuberculosis (TB) burden, and this is always considered as the first differential for any patient with fever, cough, hemoptysis, and weight loss. Post-tubercular chronic pulmonary aspergillosis common reported condition. However, co-infection of active TB and invasive aspergillosis is less reported. This co-infection could be one of the contributors of high morbidity and mortality in cases with tuberculosis.We hereby present a series of five cases of TB concomitant with invasive aspergillosis in non-neutropenic patients.MethodsThis is a prospective observational study, all patients admitted with molecular diagnosis (GeneXpert) of tuberculosis and with at least one non-classical risk factor for invasive aspergillosis were subjected to further evaluation. Diagnosis of invasive aspergillosis was considered in patients who had at least one clinical and one mycological EORTC criteria. Galactomannan level in different samples was measured via PlateliaTM ELISA. The efficacy of different antifungals and outcomes were analyzed.ResultsTotal 57 patients with TB underwent for evaluation of invasive aspergillosis. Among them, five patients were diagnosed to have concomitant TB and invasive aspergillosis, of which three cases of CNS TB and CNS aspergillosis and two had concomitant pulmonary infections. The average age was 31 ± 12 years with a female preponderance (4/5). Two patients were HIV positive, while among non-HIV patients, one had CD4 cytopenia (CD4-171). One patient had no known predisposing factor. Radiologically, most common pulmonary lesions were patchy consolidation with centrilobular nodules with tree in bud appearance, while CNS lesions showed multiple ring-enhancing lesions. All the patients had CBNAAT positive, two from BAL sample, 1 from CSF, and 1 from the lymph node. Rifampicin was sensitive in all, except one who had rifampicin resistance indeterminate. Of these patients, four were probable invasive aspergillosis satisfying the host, mycological and clinical factors as per the EORTC/MSGERC 2021 guidelines. The treatment of coinfection is challenging due to the interaction of rifampicin with voriconazole, which is the drug of choice for invasive aspergillosis. Here, 3 patients were treated with Inj amphotericin B, while the other 2 patients were started on voriconazole with rifampicin sparing regimen for TB. Of the 5 patients, 4 patients survived with excellent response to the treatment, with one fatality.ConclusionThe possibility of concurrent TB and invasive aspergillosis in non-neutropenic hosts should be considered to avoid devastating outcomes. The lack of clinical suspicion may result in misdiagnosis, and most importantly, the chronicity of the infection makes it indistinguishable from TB. Moreover, the co-administration of antifungal and anti-TB medications presents significant therapeutic challenges necessitating thorough evaluation and monitoring.

P263 Invasive Pulmonary Aspergillosis (IPA) Among Non-Intubated COVID-19 Patients—a New Age Fungal Storm

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM IntroductionCOVID-19 patients are at higher risk for the development of secondary infections, especially fungal due to multiple risk factors associated with COVID illness and its management. COVID-associated pulmonary aspergillosis (CAPA) is a new clinical entity that is contributing to high morbidity and mortality among immunocompetent COVID-19 patients. Lack of adequate published literature, absence of typical host factors, and lack of specific diagnostic criteria and management algorithms add to the difficulty in early diagnosis and treatment initiation. The scant available data is on CAPA among intubated patients, however, there are no data on CAPA in non-intubated COVID-19 patients.ObjectiveThe aim of our study was to assess the occurrence of IPA among non-intubated COVID-19 patients and its correlation with their demographic profile, risk factors, morbidity, and outcome.MethodsThis observational study included 24 non-intubated CAPA patients and 72 controls (1:3 randomly selected age and sex matched) at our hospital between April-June 2021. CAPA cases were defined as per modified-AspICU criteria. Demographic characteristics, risk factors, treatment, factors contributing to morbidity, and outcomes were evaluated. Descriptive statistics were reported as mean ± SD, median, number, and percentages. The proportion of CAPA was reported as frequencies and percentages. Clinical characteristics were compared between CAPA and control using Chi-squared, independent t-test and Mann-Whitney U test as appropriate. Association of CAPA with mortality was performed using Fisher's exact test. Logistic regression was performed to assess the factors associated with CAPA. P-value ˂5% was considered statistically significant. All analyses were performed using SPSS 25.0.ResultsA total of 4058 COVID patients were admitted during the study period. Respiratory samples of 26 patients yielded Aspergillus species. Two patients were excluded as colonizers based on modified AspICU criteria. In all, 24 CAPA cases 72 controls were studied for all the variables. CAPA occurrence was 0.59% among non-intubated COVID-19 patients (24/4058).Both the groups had a male preponderance (75% CAPA, 80% control), the median age was 52.8 ± 14.3. Demographic data and risk factors were comparable. There were no significant differences in lab parameters between the groups. Association of COVID severity and development of CAPA was not statistically significant (mod:OR 2.25, 95% CI, P-value .48; severe:OR 6.65, 95% CI, P-value .08). Significant associations between the cases and controls included, treatment with a higher dose and longer duration of steroids with development of CAPA (dose:OR 1.009, 95% CI, P-value .002; duration:OR 1.09, 95% CI, P-value .006), longer hospital stay (median of 18.4±10days (P-value .008). All-cause mortality was 16.7% in CAPA group (P-value <.0001).Between CAPA non-survivors and survivors, Serum galactomannan levels (P-value .03), duration of hospital stay (P-value .042), dose and duration of systemic corticosteroid (P-value .001), and duration of oxygen requirement (P-value .05) were found to be statistically significant.ConclusionCAPA is an emerging complication with high morbidity and mortality among immunocompetent COVID-19 patients that requires a high index of clinical suspicion. A standard diagnostic criteria and management protocol for early identification and treatment initiation is the need of the hour. Role of steroids in the development of CAPA and the role of galactomannan in diagnosis and prognosis of CAPA needs to be further investigated.

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.

Invasive Mold Infections in Patients with Hematologic Malignities: The Effects of Environmental Factors

Invasive fungal infections (IFI) continue to be an important cause of morbidity and mortality in patients with hematological malignancies. Candida and Aspergillus species constitute most of the IFI in these patients.. It has been reported that most of the invasive aspergillosis epidemics are related to the construction works in the hospital. In this study, we aimed to investigate the frequency of IFI in the old and the new hospital building after relocation in patients with hematological malignancies. Of 8042 patients who were hospitalized in the Department of Hematology, Ondokuz Mayıs University Faculty of Medicine between January 2015 and September 2019, 412 patients who were initiated antifungal therapy were included in the study. The patients in the hematology clinic, which were moved to the new oncology hospital building in January 2018, were grouped as prior and after relocation, and their demographical data, hematological diagnosis, chemotherapy regimens, mortality, IFI, focus of infection, presence of central venous catheter, antifungal prophylaxis and treatment, galactomannan level, fungal culture and computed tomography (CT) findings were evaluated retrospectively. It was determined that 55% of the patients were male and the median age was 58 (range:18-93). The rate of IFI development was 5.12% (n= 412) and the rate of invasive mold infection was 1.2% (n= 145). The most common hematological disease for which antifungal treatment initiated was acute myeloid leukemia (AML) with a rate of 50% (n= 206/412). Of patients, 73% received induction chemotherapy (42%, first induction, 31% reinduction), 13.4% received consolidation therapy. Invasive mold infection was diagnosed as 40% possible, 59% probable, 1% proven. While patients had similar characteristics such as age, gender, hematological disease, chemotherapy regimens and antifungal prophylaxis prior and after transportation, the rate of development of invasive mold infection was 2.1%, 2.06 / 1000 patient days, before transportation, 1.37% (p= 0.009), 1.15/1000 patient days (p<0.001) after transportation, and it was statistically significantly lower after transportation. The median value of galactomannan antigen was detected as 0.17 (0.02-5.9). Blood cultures revealed 10.3% fungal growth and the most common growth was Candida albicans with 54.8% and Mucor spp. as mold with 3.2%. Large-scale construction works such as renovation, extension and demolition works in old hospital buildings are a permanent condition in different units. Clinicians should be aware of that infections due to opportunistic fungi can be seen in immunosuppressive patients close to such construction sites, and even cause epidemics. It should be kept in mind that these infections, which can progress with serious morbidity and mortality are difficult to treat but can be prevented by infection control measures.