Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium

Clinical Features of Invasive Fungal Disease in China Tertiary Hospital: A Prospective, Multicenter Study

Invasive fungal disease (IFD) has high morbidity and mortality, the spectrum of pathogenic fungi and high-risk groups have also changed. Fewer literature focus on the overall incidence of IFD in various departments of general hospitals. Among the adult inpatients in four Chinese tertiary hospitals located in Beijing, Shanghai, Nanning and Nanchang, proven or probable cases of IFD were included prospectively in this study between May 1, 2021 and May 1, 2022. The clinical data were collected and analyzed. A total of 330 patients (342 episodes) with 278 of proven and 64 of probable IFDs were included, including invasive candidiasis (IC) (132, 40.0%), cryptococcosis (64, 19.4%), invasive aspergillosis (IA) (54, 16.4%), Talaromyces marneffei (TsM) infection (43, 13.0%), Pneumocystis pneumonia (PCP) (16, 4.8%), mixed fungal infection (10, 3.0%), other mold or yeast infection. 37.9% occurred in elderly patients (age ≥ 65 years). Nosocomial infection accounted for 44.5%, the proportion of nosocomial infection was highest in patients with IC (81.8%). Diabetes (19.7%) was the most common underlying disease. 83.9% of the 342 episodes of IFD had evidence of fungal culture, while the proportion of microscopic examination and histopathology as mycological evidence was 26.9% and 3.5%, respectively. The cumulative all-cause mortality at 180 days after diagnosis of IFD was 38.5%. Age ≥ 65 years old (HR = 1.670, P = 0.009), ICU (HR = 2.002, P = 0.001), nosocomial infection (HR = 1.630, P = 0.016) and diabetes (HR = 1.679, P = 0.013) were associated with increased death in IFD patients. The prognosis of IFD patients was poor. Doctors should pay attention to nosocomial fungal infection especially in old and diabetes.

Evaluation of the Loop-Mediated Isothermal Amplification Assay (LAMP) Eazyplex®Pneumocystis jirovecii

A commercially available loop-mediated isothermal amplification assay (LAMP) for the detection of Pneumocystis jirovecii (P. jirovecii) has been evaluated for the diagnosis of Pneumocystis pneumonia (PcP) in critically ill patients. Altogether, 109 lower respiratory tract specimens from 95 patients with a positive P. jirovecii test in routine diagnostics were collected from five distinct university hospitals in Germany. All samples were tested with a qPCR and eazyplex® LAMP assay. qPCR was set as the gold standard and was evaluated beforehand with samples from 100 patients categorized to have proven, probable, and possible PcP according to the EORTC/MSGERC guidelines. The sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of the LAMP were assessed. Sensitivity was 68%, specificity was 86%, and PPV and NPV were 99% and 16%, respectively. All patients with proven PcP were positive in the LAMP. There was a weak correlation between the time to positivity and the fungal load (squared Pearson correlation coefficient (r2) = 0.5653). A positive result in the LAMP indicates a PcP. Because of the low sensitivity, negative results do not rule out an infection and should be clarified with further molecular methods. The LAMP should be used in patients in whom a PcP is expected, not for screening only.

Invasive Fungal Infections in Pediatric Hematology-Oncology: A 12-year Single-center Observational Study and the Need for a Clinical Classification System

Pediatric patients undergoing chemotherapy or allogeneic hematopoietic stem cell transplantation are at high risk for invasive fungal infections (IFIs). Diagnosing IFIs is challenging due to nonspecific clinical presentations, invasiveness of diagnostic procedures, and the low sensitivity of microbiological assays. This retrospective 12-year observational study examines incidence, diagnostic challenges, fungal pathogens, and course of IFI cases in pediatric patients with hematologic malignancies or receiving allogeneic hematopoietic stem cell transplantation at the University Children's Hospital of Basel. Of the 163 patients reviewed, 39 (23.9%) received antifungal therapy based on clinical suspicion of IFI. Applying the EORTC/MSGERC diagnostic classification system, only 19 cases (11.6% cumulative incidence) were confirmed as proven or probable IFIs. Within this subgroup, a mortality rate of 21% underscores the severe consequences associated with advanced disease and profound immunosuppression. In addition, we introduce a novel clinical classification system to complement the EORTC/MSGERC criteria, with the aim of enhancing early diagnosis and risk stratification in this high-risk population. Our findings highlight the diagnostic challenges in pediatric patients, including the low specificity of radiologic findings and the limited utility of microbiological tests in guiding treatment decisions. Addressing these gaps is crucial for improving outcomes and advancing care for children with IFIs.

Clinical significance and antifungal susceptibility profile of 103 clinical isolates of Scedosporium species complex and Lomentospora prolificans obtained from NIH patients

Reduced susceptibility to antifungals is common among members of genera Scedosporium and Lomentospora, with optimal treatments still not fully defined. In vitro antifungal susceptibility results and clinical data do not comprehensively account for the advent of new Scedosporium species identified by molecular phylogenetics. Using Clinical and Laboratory Standards Institute (CLSI) methodology, we tested a total of 103 clinical isolates obtained from patients at the NIH Clinical Center. The most frequent species were Scedosporium apiospermum (63%) and Scedosporium boydii (11%), followed by Lomentospora prolificans (7%). The novel antifungal olorofim showed the lowest MICs against all Scedosporium spp. and L. prolificans, followed by micafungin. Among the triazoles, voriconazole showed lower MICs against Scedosporium spp. Amphotericin B and posaconazole demonstrated species-specific and inter-species variable activity. Itraconazole, isavuconazole, and terbinafine had higher MIC values against Scedosporium spp. and L. prolificans. Clinical data were retrospectively reviewed for 90 isolates, of which nine patients (28 isolates) had active disease/infection and received antifungal treatment that included voriconazole or posaconazole. Five of these patients (56%) died, while three patients (33%) with chronic granulomatous disease were cured following hematopoietic cell transplantation. In 24 patients (62 isolates), the presence of the fungus was considered airway colonization. In conclusion, our data support the existence of species-specific and inter-species differences in the antifungal susceptibility patterns among members of genera Scedosporium and L. prolificans. The novel investigational antifungal olorofim may be a promising therapy. Our clinical data suggest that host status and administration of antifungal therapy most effective for each Scedosporium species complex are important determinants of outcomes.IMPORTANCEUnderstanding the epidemiology and clinical spectrum of infections caused by Scedosporium species complex and Lomentospora prolificans is integral to improving outcomes, particularly in severely ill and immunocompromised patients. In vitro antifungal susceptibility testing can provide an estimate of antifungal activity against fungal pathogens. Our study showed that species-specific and inter-species differences exist in the distribution of antifungal susceptibility patterns between Scedosporium and L. prolificans. Our clinical data also highlight that host status, along with effective antifungal therapy, plays a crucial role in determining treatment outcomes.

CD3 + CD4 + T cells counts reflect the severity and prognosis of invasive pulmonary aspergillosis in patients with connective tissue disease-associated interstitial lung disease

OBJECTIVES

Invasive pulmonary aspergillosis (IPA) is a potentially fatal complication in patients with connective tissue disease-associated interstitial lung disease (CTD-ILD). The aim of this study is to investigate the clinical significance of CD3 + CD4 + T cells counts in CTD-ILD with IPA patients.

METHODS

This retrospective study included 152 CTD-ILD patients admitted to a single center in China between January 2018 and June 2020. A total of 54 CTD-ILD patients with IPA were assigned to the CTD-ILD with IPA group, while 98 uninfected CTD-ILD patients were assigned to the control group. Serum CD3 + CD4 + T cells counts were compared between the above-mentioned two groups, and the correlations between CD3 + CD4 + T cells counts and the clinical features, mortality of CTD-ILD with IPA were also evaluated.

RESULTS

CTD-ILD patients with IPA had significantly lower CD3 + CD4 + T cells counts than those with CTD-ILD without IPA (P < 0.001). The area under the receiver operating characteristic curve (AUROC) of discriminating CTD-ILD with IPA from CTD-ILD without IPA was 0.800 (95% CI, 0.722-0.878, P < 0.001). Correlation analyses showed that serum CD3 + CD4 + T cells counts were positively correlated with PaO2/FiO2 ratio(r = 0.317, P = 0.034) and negatively correlated with C reactive protein (CRP) (r = - 0.358, P = 0.009), erythrocyte sedimentation rate (ESR) (r = - 0.346, P = 0.014), and lactate dehydrogenase (LDH) (r = - 0.306, P = 0.026). In addition, 30 decedents with CTD-ILD infected IPA exhibited lower values of CD3 + CD4 + T cells compared with 24 survivors (P = 0.041). Furthermore, CD3 + CD4 + T cells counts were a prognostic factor and also associated with a higher mortality rate (log-rank test, P = 0.003).

CONCLUSION

CD3 + CD4 + T cells counts could be a useful serum indicator associated with occurrence of IPA in CTD-ILD. Moreover, decreased CD3 + CD4 + T cells counts were associated with a poor survival of IPA in CTD-ILD patients. Key Points • CTD-ILD patients with IPA had significantly lower CD3+CD4+T cells counts than those with CTD-ILD without IPA. • Correlation analyses showed that serum CD3+CD4+T cells counts were positively correlated with PaO2/FiO2 ratio and negatively correlated with C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and lactate dehydrogenase (LDH). • Decreased CD3+CD4+T cells counts were associated with a poor survival of IPA in CTD-ILD patients.

Gastrointestinal and Intra-Abdominal Mucormycosis in Non-Haematological Patients-A Comprehensive Review

Intra-abdominal and gastrointestinal mucormycosis are less frequent than rhino-orbito-cerebral and pulmonary mucormycosis, but highly lethal. Their diagnosis remains challenging due to the non-specific clinical presentation. We collected English-language cases of intra-abdominal and gastrointestinal mucormycosis in non-haematological and non-neonatal patients published up to October 2024. This review analysed the epidemiological, clinical, and therapeutic charts of 290 cases. A proportion of 53.4% were reported from India and the USA. The main predisposing conditions were diabetes, solid organ transplant, ICU, and corticosteroid treatment. The most common site was the stomach (53.8%). Gastrointestinal perforation, skin breakdown, and abdominal wall infection were sources of intra-abdominal localisation. The most common symptoms were abdominal pain, vomiting, and gastrointestinal bleeding. The diagnosis relied on histology (93.8%), mycology with microscopy and culture (38.8%), and molecular methods (9.9%). Mortality (52.9%) was lower when treatment was intravenous amphotericin B, combined or not with surgery. Prompt treatment, essential for a favourable outcome, relies on early suspicion and diagnosis. Gastrointestinal and intra-abdominal mucormycosis should also be suspected in patients admitted in ICU with ventilation/nasogastric tube and corticosteroids and those with abdominal trauma or surgery, presenting abdominal distension, pain, and GI bleeding. Mycological diagnosis including direct examination, culture and Mucorales qPCR on tissue should assist with rapid diagnosis and thus treatment.

Optimizing fungal DNA extraction and purification for Oxford Nanopore untargeted shotgun metagenomic sequencing from simulated hemoculture specimens

Long-read metagenomics provides a promising alternative approach to fungal identification, circumventing methodological biases, associated with DNA amplification, which is a prerequisite for DNA barcoding/metabarcoding based on the primary fungal DNA barcode (Internal Transcribed Spacer (ITS) region). However, DNA extraction for long-read sequencing-based fungal identification poses a significant challenge, as obtaining long and intact fungal DNA is imperative. Comparing different lysis methods showed that chemical lysis with CTAB/SDS generated DNA from pure fungal cultures with high yields (ranging from 11.20 ± 0.17 µg to 22.99 ± 2.22 µg depending on the species) while preserving integrity. Evaluating the efficacy of human DNA depletion protocols demonstrated an 88.73% reduction in human reads and a 99.53% increase in fungal reads compared to the untreated yeast-spiked human blood control. Evaluation of the developed DNA extraction protocol on simulated clinical hemocultures revealed that the obtained DNA sequences exceed 10 kb in length, enabling a highly efficient sequencing run with over 80% active pores. The quality of the DNA, as indicated by the 260/280 and 260/230 ratios obtained from NanoDrop spectrophotometer readings, exceeded 1.8 and 2.0, respectively. This demonstrated the great potential of the herein optimized protocol to extract high-quality fungal DNA from clinical specimens enabling long-read metagenomics sequencing.

IMPORTANCE

A novel streamlined DNA extraction protocol was developed to efficiently isolate high molecular weight fungal DNA from hemoculture samples, which is crucial for long-read sequencing applications. By eliminating the need for labor-intensive and shear-force-inducing steps, such as liquid nitrogen grinding or bead beating, the protocol is more user-friendly and better suited for clinical laboratory settings. The automation of cleanup and extraction steps further shortens the overall turnaround time to under 6 hours. Although not specifically designed for ultra-long DNA extraction, this protocol effectively supports fungal identification through Oxford Nanopore Technology (ONT) sequencing. It yields high molecular weight DNA, resulting in longer sequence fragments that improve the number of fungal reads over human reads. Future improvements, including adaptive sampling technology, could further simplify the process by reducing the need for human DNA depletion, paving the way for more automated, bioinformatics-driven workflows.

Incorporating microbial cell-free DNA testing into healthcare-associated invasive fungal infection surveillance: benefits and challenges

Surveillance by clinical epidemiology teams for invasive fungal infections (IFIs) in healthcare settings can be challenging due to several factors including low sensitivity of noninvasive conventional microbiologic diagnostics, nonspecific clinical presentation, and complex patient populations. Recently, availability of microbial cell-free DNA testing (cfDNA) via the Karius Test has shown promise for increased diagnostic sensitivity of IFIs. However, how to best incorporate cfDNA results into IFI surveillance remains a vexing challenge. Herein, we provide perspectives on the benefits and challenges of use of cfDNA for IFI surveillance.

Longitudinal assessment of the effect of invasive fungal infections on transplant success in kidney transplant recipients

Invasive fungal infections (IFIs) significantly impact morbidity and mortality in kidney transplant recipients (KTRs), but their effect on allograft function remains poorly defined. This retrospective study examined adult KTRs transplanted at Johns Hopkins from 2012 to 2018, with follow-up through 2023. The association of IFIs with a composite outcome of graft failure and mortality was assessed using negative binomial regression. The association of IFI exposure on composite outcome was quantified by matching using a stochastic extension stratification method, followed by Cox regression. Among 1453 KTRs, 79 were diagnosed with proven/probable IFIs, predominantly invasive candidiasis (46.8%). KTRs with IFIs had worse outcome-free survival with higher composite outcome rates (53/79 [67.1%] vs 411/1338 [30.7%]; P < .001). The composite outcome incidence rate was 4.61-fold higher when IFIs occurred in the first 6 months posttransplant and decreased to 2.13-fold higher after 36 months (P < .001). IFI exposure was associated with 3.45-fold increased hazard of composite outcome (95% CI, 1.54-7.70; P < .01) and a 3.23-fold increased hazard of all-cause mortality (95% CI, 1.53-6.83; P < .01). The association of IFIs with increased risk of poor kidney transplant outcomes, particularly in the early posttransplant period, highlights the need for improved strategies for early IFI detection and management in KTRs.

Association of obesity on short- and long-term survival in patients with moderate to severe pneumonia-related ARDS: a retrospective cohort study

BACKGROUND

The incidence of obesity among patients admitted to the intensive care unit (ICU) is increasing, and pneumonia remains the leading cause of acute respiratory distress syndrome (ARDS). The association of obesity on both short- and long-term outcomes in patients with pneumonia-induced ARDS has been the subject of only limited research.

METHODS

We conducted a retrospective analysis of a prospective cohort consisting of ARDS patients who had microbiologically confirmed pneumonia and a PaO2/FiO2 ratio ≤ 150 mmHg. Patients were assessed for mortality at 28 days, 90 days, and at 1 year from the diagnosis of ARDS and compared between obese defined by a body mass index (BMI) ≥ 30 kg.m2 and non-obese patients. Models were adjusted for age, sex, COPD, coronary artery disease, immunodepression, severity score and acute kidney injury on admission to the ICU, severity of ARDS (PaO2/FiO2 ratio ≤ 100 mmHg), severe hypercapnia (PaCO2 ≥ 50 mmHg), ventilatory ratio and plateau pressure the first day of ARDS, influenza, COVID-19, pneumocystosis, and bacteria involved in pneumonia. We also investigated the continuous spectrum of BMI on the risk of mortality.

RESULTS

Of 603 patients, 227 patients (37.6%) were obese. Obesity was associated with female gender (p = 0.009), hypertension (p < 0.001), diabetes mellitus (p < 0.001), COVID-19 pneumonia (p = 0.008), and PaO2/FiO2 ratio ≤ 100 mmHg (p = 0.006). Obesity was independently associated with lower mortality at 28 days (adjusted Odds Ratio (OR) 0.55, 95% confident interval (CI) 0.33-0.90, p = 0.02) but not at 90 days (adjusted OR 0.70, 95% CI 0.45-1.09, p = 0.11) nor at 1 year from the diagnosis of ARDS (adjusted OR 0.73, 95% CI 0.47-1.13, p = 0.16). Mortality at 28 days was significantly lower in obese patients than in non-obese patients when propensity score matching was used (15.2% versus 22%, p = 0.04). BMI was also independently associated with lower mortality at 28 days (p = 0.038) but not with mortality at 90 days (p = 0.12) and 1 year (p = 0.12).

CONCLUSION

Our results suggest that in patients with pneumonia-related ARDS, obesity is independently associated with better survival at 28 days but not at 90 days and 1 year from the diagnosis of ARDS.

A Laboratory-Developed Assay for the Simultaneous Detection of Aspergillus fumigatus and Pneumocystis jirovecii Pulmonary Pathogens

Invasive fungal diseases are a significant threat in immunocompromised patients, underscoring the need for rapid and accurate diagnostics. This study describes the development and validation of a real-time PCR-based laboratory-developed assay (LDA) on the Panther Fusion system for the simultaneous detection of Aspergillus fumigatus (AF) and Pneumocystis jirovecii (PJ) in bronchoalveolar lavage fluid (BALF) samples. The assay was evaluated using 239 clinical BALF samples, including cases confirmed positive for AF or PJ by reference mycological methods. Rigorous optimization ensured compatibility with the automated workflow of the Panther Fusion system, which addresses challenges such as BALF viscosity and fungal DNA recovery. No cross-reactivity with non-target fungal species was observed, and the assay demonstrated high analytical sensitivity and specificity. Only two false-negative results were reported, which could plausibly be reclassified as true negatives when interpreted alongside the serum beta-d-glucan and galactomannan assay results. For PJ detection, the assay showed excellent concordance with the OLM PneumID assay, supporting its reliability in clinical settings. The dual-target approach facilitates the simultaneous detection of both pathogens within a single workflow, improving diagnostic efficiency. The AF/PJ LDA represents a robust and scalable alternative to existing molecular assays, with the potential to enhance routine diagnostics for pulmonary fungal infections.

Mucormycosis coinfection in patients with proven aspergillosis

Data on the coinfection of molds are limited. Therefore, we systematically investigated mucormycosis coinfection in patients with morphologically proven aspergillosis. The medical records of adult patients with proven aspergillosis and available formalin-fixed paraffin-embedded (FFPE) tissue sections were retrospectively reviewed at a tertiary hospital between January 2019 and July 2024. The fungal culture results were reviewed and polymerase chain reaction (PCR) was performed to detect Aspergillus- and Mucorales-specific DNA using FFPE tissues. A positive Mucorales PCR test was confirmed when positive results were obtained for both the 18S and 28S targets. A total of 49 patients with proven aspergillosis were analyzed. The sterile specimen was not found to contain Mucorales. However, fungal cultures from a non-sterile site (endotracheal aspirate) revealed the presence of Aspergillus niger and Cunninghamella spp. in 1 (2%) of 49 patients (Patient A). A positive Mucorales-specific PCR result was obtained for one patient (2%) while positive Aspergillus- and Mucorales-specific PCR results were obtained for five patients, including Patient A (10%). Overall, 6 (12%) of the 49 patients with proven aspergillosis were found to be coinfected with mucormycosis. Coinfection with mucormycosis was significantly more associated with rhino-paranasal sinuses (33% vs. 2%, P = .03). In-hospital mortality was not found to significantly differ between patients with mucormycosis coinfection and those with aspergillosis alone (33% [2/6] vs. 14% [6/43], P = .24). Approximately one-tenth of patients with proven aspergillosis had molecular or microbiologic evidence of mucormycosis coinfection. Further studies are needed to highlight the clinical implications of the molecular evidence of mucormycosis coinfection in patients with proven aspergillosis.

Assessing the appropriateness of antifungal prescribing: key results from the implementation of a novel audit tool in Australian hospitals

OBJECTIVES

To utilize the Antifungal National Antimicrobial Prescribing Survey (Antifungal NAPS), a novel tool utilizing international consensus metrics for antifungal stewardship, to assess the quality of systemic antifungal prescribing in Australian hospitals, in order to identify quality improvement targets.

METHODS

Participating hospitals were directed to audit all systemic antifungals or focus on a specific antifungal drug or class. Data entry into the Antifungal NAPS online portal occurred between October 2022 and June 2023. The data collection tool comprised patient details, reasons precluding use of antifungals, prescription details (guideline compliance, appropriateness, and reasons for inappropriate prescribing) and patient outcomes. Descriptive statistics were used to analyse the data.

RESULTS

Eleven hospitals contributed data for 516 prescriptions for 438 patients. Of these, 77.1% of prescriptions were appropriate, with the highest appropriateness for prophylactic (189/222; 85.1%), followed by directed (105/130; 80.8%) and empirical therapy (104/164; 63.4%). Fluconazole was the most commonly prescribed agent, which had the lowest rate of appropriateness (132/209; 63.2%). The most common reasons for inappropriate prescribing were no antifungal required (35/105; 33.3%), incorrect dose or frequency (30/105; 28.6%) and incorrect duration (19/105; 18.1%). Compliance with guidelines was 73.6%.

CONCLUSIONS

This study outlines the successful implementation of the Antifungal NAPS, a standardized electronic audit tool for the assessment of antifungal prescribing quality. Key areas for quality improvement identified were the overuse of empirical fluconazole for urinary tract and intra-abdominal infections, the importance of invasive fungal infection risk assessment to guide prophylaxis prescribing and greater infectious diseases and antifungal stewardship oversight of antifungal prescribing to guide optimal prescribing.

Cryptococcus albidus fungemia and probable meningitis in very preterm newborn: a case report and review of the literature

BACKGROUND

In pediatric and neonatal age groups, infections from non-neoformans Cryptococcus species, notably Cryptococcus albidus, are rarely encountered. C. albidus is an emerging fungal pathogen that causes severe diseases in immunosuppressed patients; furthermore, it has rarely been reported to cause diseases in immunocompetent patients. Several cases have been described in adults who were severely immunosuppressed. Importantly, the clinical symptoms in these reported cases include fungemia, meningitis, keratitis, pulmonary and cutaneous infections. Individuals at risk include neutropenic patients, those with indwelling intravenous devices, those on prolonged steroid or antibiotic use, and those with impaired immune systems and prematurity. The susceptibility of preterm infants with low birth weight to infections, particularly fungal ones, remains a significant concern. This report presents a rare case of fungemia and meningitis due to C. albidus in a preterm neonate, emphasizing the clinical significance and potential implications for future treatment and management. This report aims to alert physicians of the rarity of C. albidus infections in pediatric patients and to review the clinical significance, pathology, treatment, and outcomes.

CASE PRESENTATION

We report the first case of C. albidus fungemia and meningitis in a very low-birth-weight, preterm infant of 31 weeks. Notably, the patient was admitted for lifesaving treatment from the Alleith Hospital due to prematurity. The patient received surfactant due to ARDS, TPN, and fluconazole prophylaxis. On day 11, features of sepsis were observed and the blood culture grew C. albidus, which was sensitive to liposomal agents. CSF evaluation suggested meningitis. The patient improved following a six-week treatment regimen with liposomal formulations of amphotericin B at a dosage of 5 mg/kg body weight once daily, notably administered without 5-fluorocytosine, and experienced no sequelae.

CONCLUSIONS

This case report underscores the importance of early diagnosis and appropriate antifungal treatment for managing rare fungal infections in vulnerable populations, such as preterm infants. Moreover, it highlights the need for improved diagnostic platforms and comprehensive management protocols for rare pathogens in neonatal settings.

Genetic relationships of Aspergillus fumigatus in hospital settings during COVID-19

The transmission pathways and risks of COVID-19-associated pulmonary aspergillosis (CAPA) remain unclear. This study investigated the genetic relationships of Aspergillus fumigatus isolates from patients with and without COVID-19 and environmental air samples to suggest possible transmission patterns. We conducted a prospective study from March 2020 to December 2022, collecting clinical and environmental isolates from a tertiary hospital. Isolates from patients with and without COVID-19 were compared with those from air samples at four hospital locations. The genetic analysis included internal transcribed spacer and β-tubulin A sequencing, with azole resistance assessed via cyp51A gene analysis. Multiple locus variable-number tandem repeat analysis was performed to elucidate genetic relationships. A total of 155 isolates (19 from COVID-19 patients, 104 from non-COVID-19 patients, and 32 from environmental samples) were identified and genotyped, revealing 131 sequence types (Simpson Diversity Index 0.9972). Four CAPA clinical strains genetically related to environmental strains were isolated from the COVID-19 intensive care unit (ICU), while two CAPA clinical strains sharing multiple locus variable-number tandem repeat sequence types and azole-resistant mutations were isolated in the same COVID-19 ICU 4 months apart. All but one of these strains were isolated from patients requiring mechanical ventilation. The observed genetic similarities between strains from critically ill patients with COVID-19 and those from the environment, as well as within the same ICU, raise the possibility of nosocomial acquisition via contaminated air or environmental sources. These findings highlight the risks of CAPA associated with negative pressure rooms and the need for enhanced environmental infection control measures.IMPORTANCEThis study reveals genetic links between Aspergillus fumigatus in patients with COVID-19 and environmental sources, suggesting nosocomial transmission and urging a reevaluation of universal negative pressure isolation practices in hospitals, especially for critically ill patients.

Relationship between posaconazole concentrations and clinical outcomes in paediatric cancer and haematopoietic stem cell transplant recipients

BACKGROUND

Posaconazole is used to prevent and treat invasive fungal infections (IFIs) in immunocompromised children, including those undergoing cancer treatment or HSCT. Despite differences in pharmacokinetics and IFI epidemiology between children and adults, therapeutic targets established in adult studies are often applied to children.

OBJECTIVES

This systematic review evaluated the correlation between serum posaconazole concentrations and clinical outcomes of IFI prophylaxis and treatment in children with malignancies or HSCT recipients.

METHODS

Four databases (Cochrane, Embase, MEDLINE and PubMed) were searched for studies involving children (≤18 years old) receiving cancer treatment or HSCT that reported posaconazole serum concentrations and treatment outcomes. Animal studies, those primarily in adult (>18 years old) populations, non-malignant conditions (excluding HSCT), case reports, letters, editorials, conference abstracts and narrative reviews were excluded. Bias was assessed using the Newcastle-Ottawa scale.

RESULTS

Nineteen studies were included: 12 reported outcomes of posaconazole prophylaxis; two of treatment; and five of both. For prophylaxis, breakthrough IFIs occurred in 1%-12% of children. All but one occurred with serum concentrations of ≤0.7 mg/L. For treatment, no clear association was observed between a trough concentration of >1.0 mg/L and treatment efficacy, with poor outcomes reported for serum concentrations ranging between 0.2 and 4.8 mg/L. Overall, quality of evidence was poor (medium to high risk of bias for 18 papers, low risk for 1 paper) and there was variation in IFI definitions across studies.

CONCLUSIONS

This review supports current recommendations for posaconazole prophylaxis in paediatric oncology and HSCT recipients. The absence of a clear correlation found between serum trough concentrations and treatment efficacy highlights the need for further studies to determine optimal therapeutic targets for treatment.

Optimization of cutoff values for (1→3)-β-d-glucan and galactomannan assays in cerebrospinal fluid for the diagnosis of non-cryptococcal fungal infections of the central nervous system

Fungal infections of the central nervous system (FI-CNS) pose substantial diagnostic challenges, owing to their diverse clinical presentations and the limited sensitivity of conventional diagnostic tests. Although serum (1→3)-β-d-glucan (BDG) and galactomannan (GM) assays are FDA-approved for the diagnosis of invasive fungal infections (IFIs), their effectiveness in cerebrospinal fluid (CSF) remains underexplored, and optimal cutoff values in CSF are not well established. This study aimed to assess the utility of BDG and GM assays in CSF for diagnosing non-cryptococcal FI-CNS. We conducted a prospective observational study at the National Institute of Mental Health and Neuro Sciences in India from January 2022 to December 2023, including CSF samples from patients suspected of fungal meningitis. The cases were categorized as proven, probable, or possible FI-CNS based on the revised EORTC/MSGERC criteria. Among 61 suspected cases, 2 were proven, 48 were probable, and 11 were possible FI-CNS. The control group included 23 patients without FI-CNS suspicion. BDG and GM testing in CSF followed manufacturers' guidelines for serum. At the manufacturer's recommended cutoff of 80 pg/ml, sensitivity of BDG was 94% and specificity was 78.3%. For GM, using the manufacturer's recommended cutoff of 0.5 optical density index (ODI), sensitivity was 42% and specificity was 100%. Receiver operating characteristic curve analysis indicated optimal cutoffs of 72 pg/ml for BDG (sensitivity 96%, specificity 78.3%) and 0.47 ODI for GM (sensitivity 44%, specificity 100%). Combining both biomarkers increased sensitivity to 97.8%, suggesting that combined BDG and GM testing in CSF could significantly enhance the diagnostic accuracy and management of FI-CNS.

Diagnostic tests performance in detecting Pneumocystis jirovecii: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Pneumocystis jirovecii (Pj) pneumonia (PJP) is a life-threatening opportunistic infection primarily affecting immunocompromised individuals. Detecting Pj is challenging, particularly in distinguishing between Pj colonization (PJC) and infection. We aimed to systematically evaluate the diagnostic accuracy of various tests in differentiating Pj colonization from infection.

METHODS

Systematic reviews and meta-analyses were performed. Searches were conducted in PubMed, Embase, and Web of Science. Original clinical studies reporting sensitivity and specificity data for diagnostic tests such as quantitative polymerase chain reaction (qPCR), nested PCR, (1,3)-Beta-D glucan (BDG), metagenomic next-generation sequencing (mNGS), and digital PCR (ddPCR) to differentiate PJC from PJP were included. Quality assessment was performed using QUADAS-2 tool, and data processing followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Diagnostic performance was evaluated using either a random-effects or fixed-effects model.

RESULTS

Twenty-eight studies (2,550 patients, 1,445 with PJP) were included, with moderate methodological quality. The pooled sensitivity of these diagnostic tests was 0.80 (95% CI 0.77-0.82) and specificity was 0.83 (95% CI 0.81-0.85), with a diagnostic odds ratio (DOR) of 23.12. Among the individual tests, BDG (5 studies) showed high pooled sensitivity (0.83, 95% CI 0.77-0.88) but lower specificity (0.78, 95% CI 0.69-0.85). mNGS (3 studies) had the highest performance, with pooled sensitivity and specificity both at 0.87 (95% CI 0.80-0.92 and 95% CI 0.77-0.94, respectively), and the highest DOR of 41.57. qPCR (19 studies) demonstrated adequate pooled sensitivity (0.78, 95% CI 0.76-0.81) and high specificity (0.83, 95% CI 0.81-0.86), with a DOR of 20.44.

CONCLUSION

While BDG has low specificity and mNGS is costly with no standardized interpretation, along with the limited number of relevant studies in BDG and mNGS, this meta-analysis concluded that qPCR remains valuable for distinguishing P. jirovecii infection from colonization. A well-designed randomized clinical trial that standardizes the technical aspects of the qPCR protocol is needed to assess its effectiveness and provide a solid basis for clinical diagnosis.

Incidence, risk factors, and outcomes of transplant-associated thrombotic microangiopathy in pediatric patients after allogeneic hematopoietic cell transplantation: a single-institution prospective study

Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication in hematopoietic cell transplantation (HCT). Given the rarity of prospective pediatric studies on TA-TMA, this study aimed to evaluate the incidence, survival outcomes, and risk factors for predicting early the development of TA-TMA in a pediatric population following allogeneic HCT. We conducted a prospective analysis of 173 pediatric patients to evaluate the incidence, survival outcome, and risk factors of TA-TMA. The cumulative incidence of TA-TMA at one-year post-HCT was 4.7% (95% CI, 2.2-8.6%). Patients with TA-TMA showed significantly poorer 1-year overall survival (OS) rate, 50.0% ± 17.7% compared to 85.4% ± 2.8% in those without TA-TMA (p = 0.008). Additionally, the non-relapse mortality (NRM) rate was higher in the TA-TMA group at 12.5% (95% CI, 3.7-55.8%) versus 7.0% (95% CI, 2.8-10.1%) (p = 0.598). A urine protein/creatinine ratio ≥ 1 mg/mg on day 30 post-HCT was significantly associated with TA-TMA occurrence (adjusted HR, 9.5; [95% CI], 1.28-70.39; p = 0.028). This study showed the significantly unfavorable clinical outcomes associated with TA-TMA in pediatric patients and emphasized the importance of early identification of patients at risk. Further research is needed to explore additional strategies for early detection and intervention to improve outcomes.

Revisiting the Real-World Prognosis of Intensive Chemotherapy in Elderly Acute Myeloid Leukemia Patients: A Retrospective Analysis from Tokyo

We investigated whether reduced intensity-chemotherapy (IC) is associated with decreased toxicity and longer overall survival (OS) in elderly AML patients. Age-dependent dose-reduced IC was administered to 110 AML patients between 2004 and 2021. We assessed myelosuppressive toxicity, clinical efficacy, and safety of our regimen using the depth index (D-index). Patients of 66-79 years of age (younger elderly [YE], n = 52) and ≥ 80 years (older elderly [OE], n = 19) were compared to a control group of patients of ≤ 65 years of age (n = 39). Although no significant differences were observed in the number of days with neutrophil count < 500/µl, the D-index, or the onset of sepsis among the groups, OS significantly differed (median OS: control, 578 days [317 days-NA]; YE, 281 days [158-515 days]; OE, 185 days [72-373 days]; p = 0.0001). IC for elderly AML patients achieved negative treatment outcomes despite a reduction in myelosuppressive toxicity, with no data beyond a median OS of 14.7 months for Azacytidine + Venetoclax therapy in a phase 3 VIALE-A trial. Although the findings were negative, the present results provide insights into appropriate IC regimens for elderly AML patients in the future.

Rapid Differentiation of False Positives of Galactomannan Related to Contaminated Intravenous Fluids via a Pharmacokinetics Model and Innovative Web-Based Tool

This study developed a pharmacokinetic model and web-based tool to distinguish true invasive aspergillosis from false positives caused by contaminated fluids. By analyzing galactomannan kinetics, false positives were identified within 24 hours, improving diagnostic accuracy and aiding clinicians in early decision making while minimizing unnecessary interventions.

Invasive fungal disease in a large cohort of hospitalized children with inborn errors of immunity in China

BACKGROUND

Invasive fungal disease (IFD) is a common complication observed in inborn errors of immunodeficiency (IEI) patients, and little is known about the overall prevalence of IFD in IEI patients. We aimed to summarize the fungal spectrum and outcomes of IFDs in a Chinese cohort of hospitalized patients with IEI.

METHODS

In this retrospective study, 607 IEI patients hospitalized from January 2018 to June 2022 were included. Demographic, clinical, and fungal infection data and IEI patient characteristics were collected and analyzed according to the IEI classification.

RESULTS

One hundred and two IEI patients were diagnosed with proven or probable IFD. The overall prevalence of IFD was 17% (102/607). There were 29 different genotypes, among which CYBB (25%), CD40LG (9%), and RAG1 (7%) mutations were the most common. Most IFD infections (87/102) were caused by one fungus. Invasive Aspergillus, Pneumocystis jirovecii pneumonia, and Penicillium infections were more commonly observed in patients with congenital defects in phagocytes, immunodeficiencies affecting cellular and humoral immunity, and defects in innate immunity, respectively. Most IFDs observed in IEI patients were single-site infections, most of which were lung infections (74%). Seventeen patients were diagnosed with disseminated IFDs, nine of which were caused by Penicillium. All patients received antifungal treatments. Eight patients (8%) died within 3 months of IFD diagnosis.

CONCLUSIONS

IFD occurrence suggests the presence of immunity impairment. The IFD fungal profile may indicate different types of IEI. Early recognition of immunodeficiency and optimal timing of antifungal therapy can reduce fatality in IEI patients.

Diagnostic test accuracy of the Fungitell serum (1→3)-β-D-glucan assay for the diagnosis of Pneumocystis jirovecii pneumonia: a systematic review and meta-analysis

BACKGROUND

The diagnosis of Pneumocystis jirovecii pneumonia (PCP) can be challenging because of diagnostic tests that are imperfect and/or invasive. The Fungitell serum (1 → 3)-β-D-glucan (BDG) assay is a noninvasive blood test studied for PCP; however, the manufacturer-recommended cut-off of 80 pg/mL is not well validated for this disease.

OBJECTIVES

We conducted a systematic review and meta-analysis to determine the diagnostic test accuracy of the Fungitell BDG assay for the diagnosis of PCP.

METHODS

.

DATA SOURCES

A search strategy of MEDLINE and Embase from a previous meta-analysis on BDG was updated to 31 January 2024.

STUDY ELIGIBILITY CRITERIA

Observational studies.

PARTICIPANTS

Patients with risk factors for PCP. TEST: Fungitell BDG assay.

REFERENCE STANDARD

One or more of lung biopsy, bronchoalveolar lavage, induced sputum, or nasopharyngeal swab specimens tested for PCP by histopathology, microscopy using immunofluorescence or staining, or PCR.

ASSESSMENT OF RISK OF BIAS

The Quality Assessment of Diagnostic Accuracy Studies-2 tool.

METHODS OF DATA SYNTHESIS

Diagnostic test accuracy data of the Fungitell serum BDG assay across all reported cut-offs were pooled by meta-analysis. We then evaluated a categorical approach using <80 pg/mL as a rule-out threshold and ≥400 pg/mL as a rule-in threshold.

RESULTS

A total of 26 articles were included comprising 5111 patients and 1150 PCP cases. At the conventional cut-off of 80 pg/mL, the overall pooled sensitivity and specificity were 83.5% (95% 95% CI, 72.8-90.6) and 75.5% (95% CI, 66.0-83.0), respectively. At a pretest probability of <20% and a BDG <80 pg/mL, the post-test probability would be <5% (negative predictive value > 95%). At 400 pg/mL, sensitivity was reduced to 63.5% (95% CI, 45.8-78.1) with specificity increased to 93.6% (95% CI, 88.6-96.5). At a pretest probability of 47.5%, a BDG >400 pg/mL would have a post-test probability of >90%.

DISCUSSION

A categorical approach using <80 pg/mL to rule-out and >400 pg/mL to rule-in PCP may allow for a more nuanced interpretation based on pretest probability. More accurate estimates of pretest probability and further external validation are required.

Fungal biomarkers in HIV-associated disseminated histoplasmosis: a multicenter diagnostic accuracy study on the Guiana shield

OBJECTIVES

Diagnosis of HIV-associated histoplasmosis remains challenging. Our objective was to compare the performances of (1→3)-β-D-Glucan (BDG) and aspergillus galactomannan (GM) antigen for the diagnosis of HIV-associated histoplasmosis.

METHODS

We performed a diagnostic accuracy study using frozen primary serum specimens issued from consecutive hospitalized people living with HIV (PLWH) and blindly tested for BDG and GM using FungitellⓇ and PlateliaTMAspergillus, respectively.

RESULTS

We included 121 sera with 92 HIV-associated histoplasmosis cases and 29 negative controls. At thresholds of 150 pg/ml and 0.5 for BDG and GM, the sensitivity and specificity were 95% (85-100) vs 90% (77-100) and 52% (34-70) vs 83% (69-97), respectively. The receiver operating characteristics (ROC) curves showed area under the curves of 0.82 (0.68-0.91) vs 0.92 (0.80-0.98) for BDG and GM, respectively. Post-test probabilities showed best performances at lowest thresholds for a negative testing of BDG and GM and at the 0.7 threshold for a positive GM test.

CONCLUSIONS

If BDG alone may rule out histoplasmosis when negative, GM alone, either positive or negative, showed the best performances for the diagnosis of histoplasmosis. Given the poorer performances of BDG and GM than Histoplasma antigen detection assays commercially available, they should be considered as an alternative in settings where Histoplasma antigen detection assays remain unavailable. However, this study essentially provides insights in the performances of fungal biomarkers in disseminated histoplasmosis and does not represent recommendations for best practices.

Clinical Characteristics, Risk Factors and Outcomes of Invasive Fungal Disease in Critically III Patients with Hematological Malignancy: A Retrospective Study

BACKGROUND

Invasive fungal disease (IFD) poses significant challenges for critically ill patients with hematological malignancies (HMs). However, there is limited research on the clinical characteristics, risk factors, and outcomes of IFD within this population.

METHOD

A retrospective study was conducted at a tertiary center in China. The study focused on patients with HMs admitted to the intensive care unit (ICU) between 2014 and 2022.

RESULTS

A total of 239 patients were enrolled, among whom 105 (43.9%) were diagnosed with IFD. Further classification revealed that 64.8%, 31.4%, and 3.8% were classified as possible, probable, and proven IFD, respectively. Patients with IFD had significantly prolonged ICU stays compared to those without IFD (median: 4.9 vs. 2.9 days, P < .001). Notably, there was no statistically significant difference in 28-day mortality between the patients with and without IFD (44.8% vs. 54.5%, P = .907). Hypertension, mechanical ventilation (MV) duration exceeding 48 hours, and an extended interval between deterioration and ICU admission emerged as independent risk factors for IFD.

CONCLUSION

IFD is a common complication in critically ill patients with HM and is associated with prolonged length of ICU stay. Additionally, hypertension, prolonged MV duration and delayed ICU transfer are independent risk factors of IFD in these patients.

Sensitivity and Specificity of Plasma and Bronchoalveolar Lavage Fluid PCR for Diagnosing Pulmonary Mucormycosis in Subjects With Diabetes Mellitus

BACKGROUND

Mucorales polymerase chain reaction (PCR) is used to diagnose pulmonary mucormycosis (PM) among neutropenic individuals. However, data on the utility of PCR in patients with diabetes mellitus, another major risk factor for PM, are limited.

OBJECTIVE

The primary objective was to assess the diagnostic performance of a commercial real-time PCR assay (MucorGenius) in plasma and bronchoalveolar lavage fluid (BALF) for diagnosing PM (proven and probable cases only) in patients with suspected invasive mould disease (IMD). For the secondary objective, we evaluated the performance of the MucorGenius assay in all PM (proven, probable, and possible) cases.

METHODS

We prospectively enrolled patients with suspected IMD and assessed the performance of MucorGenius PCR (index test) in plasma and BALF samples. A multidisciplinary team assigned the final diagnosis of IMD (reference standard) based on microscopy, histopathology, cytology, and culture. We report the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI).

RESULTS

We enrolled 103 patients, of whom 43 (41.7%) were confirmed to have PM. Plasma PCR showed a sensitivity of 18.6% (95% CI: 8.4-33.4), specificity of 90.7% (95% CI:77.9-97.4), PPV of 66.7%, and NPV of 52.7%. Including possible PM/IMD cases improved the plasma PCR sensitivity to 30.0% (95% CI: 18.9-43.2) and retained specificity at 90.7%. BALF PCR had better sensitivity (47.4%) but poorer specificity (69.6%), with a PPV of 56.3% and NPV of 61.5%.

CONCLUSION

Plasma and BALF MucorGenius PCR have poor diagnostic performance for diagnosing PM among individuals with diabetes mellitus. Further multicenter studies are needed to validate these findings.

Fatal pneumonia with repeated detection of Talaromyces columbinus two years after haploidentical transplantation

Talaromyces columbinus was previously reported in two patients with lung infections under the name Penicillium piceum and one case of dual infection with Aspergillus calidoustus was recently reported.; currently, no treatment has been established. We identified a 61-year-old woman with fatal pneumonia with repeated detection of T. columbinus that developed two years after haploidentical transplantation using alemtuzumab for chronic myeloid leukemia in the blast phase. Seven months after transplantation, her minimal residual disease (MRD) turned positive. Thus, ponatinib was restarted, which resulted in MRD becoming negative again. Nine months after transplantation, she developed autoimmune hemolytic anemia (AIHA); treatment with prednisone (PSL) 35 mg was started. PSL was discontinued one year ten months after transplantation, but was resumed at 5 mg after relapse one year eleven months after transplantation. Two years after transplantation, she developed cough, and a CT scan showed bilateral pulmonary infiltrates. Initiation of antibiotics, voriconazole (VRCZ), posaconazole (PSCZ) and liposomal amphotericin B (L-AMB) did not improve her condition. Sputum culture detected Penicillium species, which was identified as T. columbinus by polymerase chain reaction (PCR). Since the minimal inhibitory concentration (MIC)/minimal effective concentration (MEC) ratio was lower for echinocandins, micafungin (MCFG) was added to L-AMB. However, the patient died of respiratory failure on day 38 of admission. This is the first reported case of T. columbinus infection in Japan. Managing this infection is challenging due to the lack of established diagnostic methods and treatments. Proactive diagnostic testing and case accumulation are needed.

Non-experimental rapid identification of lower respiratory tract infections in patients with chronic obstructive pulmonary disease using multi-label learning

BACKGROUND AND OBJECTIVE

Microbiological culture is a standard diagnostic test that takes a long time to identify lower respiratory tract infections (LRTI) in patients with chronic obstructive pulmonary disease (COPD). This study entailed the development of an interactive decision-support system using multi-label machine learning. It is designed to assist clinical medical staff in the rapid and simultaneous diagnosis of various infections in these patients.

METHODS

Clinical health record data were collected from inpatients with COPD suspected of having a LRTI. Two major categories of multi-label learning frameworks were integrated with various machine learning algorithms to create 23 predictive models to identify four categories of infection: fungal, gram-negative bacterial, gram-positive bacterial, and multidrug-resistant organism infections. The predictive power of the individual models was tested. Subsequently, the model with the highest comprehensive performance was selected and integrated with SHAP technology to construct a decision support system.

RESULTS

Three-thousand-eight-hundred-one subjects participated in this study. LP-RF recorded the highest overall performance, with a Hamming loss of 0.158 (95 %CI: 0.157-0.159) and a samples-precision of 0.894 (95 %CI: 0.891-0.896). The developed diagnostic decision support system generates predicted probability output for each infection category in a specific patient and displays the interpreted output results.

CONCLUSION

The developed multi-label decision support system enables effective prediction of four categories of infections in patients with a history of COPD, and has the potential to curb the overuse of antimicrobial drugs. This system is highly explainable and interactive, providing real-time support in the simultaneous diagnosis of multiple infection categories.

Invasive Fungal Infection by Scedosporium apiospermum with Cerebral Involvement in a Pediatric Patient Affected by Chronic Granulomatous Disease After Hematopoietic Cell Transplant

A 5-year-old boy affected by chronic granulomatous disease (CGD) underwent two allogeneic hematopoietic cell transplants (HCT) from the same unrelated donor. The first HCT was complicated by prolonged fever and primary graft failure. While fully aplastic, the patient developed a disseminated infection by Scedosporium apiospermum involving the knee and parasternal skin (day +34 and +40 post-HCT). The patient was treated with voriconazole and granulocyte transfusions followed by a second HCT 80 days after the first HCT. At day +105, the patient developed fever, headache, and altered level of consciousness associated with multiple bilateral cerebral abscesses at magnetic resonance imaging. The serum B-D-glucan test was positive. Micafungin was added to voriconazole. Despite an initial clinical improvement, the patient developed hydrocephalus. Scedosporium apiospermum was cultured from cerebrospinal fluid. Liposomal amphotericin B, instead of micafungin, was combined with voriconazole as salvage therapy. Unfortunately, the patient developed uncal herniation and died at day +193 from HCT. This case shows that the prognosis of scedosporiosis remains poor despite adequate antifungal treatment. Noteworthy, the B-D-Glucan test is confirmed useful as a non-invasive marker for early diagnosis and may help the differential diagnosis of mycoses.

Comparison of Patients With or Without COVID-19 and Without Hematological Diseases Treated for Invasive Pulmonary Aspergillosis: A 5-Year Retrospective Cohort Study with Propensity-Based Adjustment

Background

Our aim was to compare epidemiological, clinical and treatment characteristics, and outcomes between patients with diagnoses of coronavirus disease 2019-associated pulmonary aspergillosis (CAPA) or putative invasive pulmonary aspergillosis (PIPA), without hematological cancers.

Methods

Retrospective, monocentric comparative observational cohort study, including nonhematological patients treated for invasive pulmonary aspergillosis between 2018 and 2022. Primary study end points were risk factors for 30-day mortality and clinical failure. To account for the imbalance in antifungal treatment allocation, a propensity score weighting approach was adopted.

Results

A total of 209 patients were included, 93 (44.5%) with CAPA and 116 (55.5%) with PIPA; 144 (68.9%) we admitted to the intensive care unit. Patients with PIPA had higher Charlson Comorbidity Index values (mean [SD], 5.8 [2.6]; range, 0-14) and higher prevalences of chronic obstructive pulmonary disease (30.7%), solid cancer (36.8%), liver cirrhosis (12.3%), and concomitant immunosuppressive therapies (26.1%). Patients with CAPA received more invasive mechanical ventilation (70.5%) and corticosteroids (90.1%), more frequently had positive galactomannan (GM) results with bronchoalveolar lavage (80.5%), and had longer mean hospital stays (62.7 [SD, 52.1; range, 8-276] days) and intensive care unit stays (36 [30.7; 2-168] days). No differences in clinical cure or mortality rates were observed between groups. In multivariable analysis, isavuconazole was the only independent factor for clinical cure, reported also in the propensity score matching analysis (odds ratio, 0.41 [95% confidence interval, .16-1.03]; P = .06). A positive serum GM result was independently associated with 30-day mortality (hazard ratio, 1.78 [95% confidence interval, 1.02-3.10]; P = .04).

Conclusions

Patients with CAPA have fewer comorbid conditions and higher fungal burden than those with PIPA, but clinical outcomes are similar between groups. Isavuconazole was an independent predictor for clinical cure, and serum GM positivity an independent predictor for 30-day mortality.

Evaluation of the multiplex PCR combined with capillary electrophoresis technique for detecting pathogenic bacteria and antibiotic resistance genes in bone infections

OBJECTIVE

Orthopedic wound infection is a difficult problem in the clinic. Accurate and rapid microbiological test results are essential for case management, antibiotic therapy, and infection control.

METHODS

We retrospectively evaluated 1285 specimens (puncture fluid, catheter, secretions, joint fluid, lavage fluid, extraction fluid, blood culture, drainage fluid, cerebrospinal fluid, bone, prosthesis tissue, etc.) from 739 patients who received orthopedic diagnosis and treatment, using routine conventional method (RCM)s as a reference method to evaluate the performance of multiplex PCR combined with capillary electrophoresis (mPCR-CE) for detecting pathogens and antibiotic resistance genes associated with bone infection.

RESULTS

Among the 1285 samples analyzed, 1045 samples were consistent with the results of the RCM, with an agreement rate of 81.32%. Among the 155 inconsistent results, 13 (1.01%) were mPCR-CE negative but RCM positive, 142 (11.05%) was mPCR-CE positive but RCM negative. Compared with RCM, mPCR-CE demonstrated positive percentage and negative percentage agreement values of 65.37% and 98.35%, respectively. Moreover, the detection rate of multidrug-resistant bacteria by the mPCR-CE method was generally better than that by the RCM method. The detection rate of methicillin-resistant Staphylococcus aureus (MRSA) by the mPCR-CE method is relatively high. The traditional drug-sensitive culture method is more inclined to detect extended-spectrum β-lactamases (ESBLs). The mPCR-CE method has obvious advantages in terms of timeliness.

CONCLUSION

This study revealed that mPCR-CE is a new and effective diagnostic method that can significantly reduce the identification time of bacterial identification and drug resistance, and has the potential to improve the management of orthopedic infections.

Fungal Infections in People Who Use Drugs

Illicit drug use in the United States continues to rise, alongside an increasing number of severe infections associated with drug use. Surveillance studies report that 28%-34% of candidemia cases are linked to intravenous drug use, with Candida albicans being the most commonly isolated species, followed by Candida parapsilosis and Candida glabrata. Marijuana use is associated with lung infections caused by Aspergillus and the Mucorales, showing a 3.5-fold increased risk of mold infections and a 2.2-fold increased risk for other fungal infections. Intravenous drug use also presents a recognized risk factor for Aspergillus and Mucorales infections. Additionally, substances like cannabis, methamphetamines, and opioids share metabolic pathways with triazoles, a class of antifungal, and terbinafine through the CYP enzyme system. These antifungal drugs strongly inhibit CYP3A4 and CYP2D6, leading to potential drug interactions, adverse effects, overdose risks, and even death.

Effectiveness of combined proton pump inhibitors and posaconazole prophylaxis against invasive fungal infections in patients with hematologic malignancies: a retrospective study

BACKGROUND

Posaconazole is widely recommended for preventing and treating invasive fungal infections (IFIs) in immunocompromised patients, especially those with prolonged neutropenia. However, the concentration of the oral suspension formulation can be affected by factors such as co-administration with acid-suppressing medications, influencing its efficacy and safety.

AIM

This study examined the impact of proton pump inhibitors (PPIs) and other factors on posaconazole concentrations and the concentration-to-dose ratio (C/D) while also evaluating adverse drug reactions in patients with hematologic malignancies.

METHOD

We conducted a retrospective analysis of patients who received posaconazole for IFI prophylaxis or treatment, assessing demographic and clinical data, adverse reactions, treatment outcomes, and drug concentration assays. The study focused on the effects of PPIs on Cmin and C/D.

RESULTS

Data from 283 posaconazole Cmin measurements in 86 patients were analyzed. The incidence of probable or proven IFIs was 6.4% (5/78). PPI use reduced posaconazole Cmin levels but did not significantly impact prophylactic efficacy. Esomeprazole and rabeprazole were explicitly associated with decreased Cmin. Hepatotoxicity was linked to the co-administration of hepatotoxic drugs, indicating that posaconazole was not the sole contributor.

CONCLUSION

Co-administration of esomeprazole or rabeprazole lowers posaconazole plasma concentrations without compromising prophylactic efficacy against IFIs. Nonetheless, caution is advised when combining these drugs in high-risk immunocompromised patients.

Comparative Analysis of Chemiluminescence Immunoassay (CLIA)-Based Tests in the Diagnosis of Invasive Aspergillosis in Patients With Hematologic Malignancies

BACKGROUND AND AIM

Rapid chemiluminescence immunoassays (CLIA) have emerged as a promising alternative to traditional serological methods for the diagnosis of invasive aspergillosis (IA). The aim of this study was to compare the diagnostic performance of rapid CLIA tests in IA.

METHODS

Patient group consisted of 17 patients who were diagnosed with probable IA according to EORTC/MSG criteria. Patients without invasive fungal infection (IFI) were defined as the control group, whereas healthy volunteers were also included. A total of 93 serum samples were used in this study. Platelia Aspergillus Ag test and Dynamiker Aspergillus Ag Kit, CLIA tests Aspergillus Galactomannan Detection Kit and Fungus (1-3) ꞵ-D-Glucan Detection Kit, were used. Specificity, sensitivity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. Receiver operating characteristic (ROC) curve was used to evaluate the overall diagnostic performance of CLIA tests comparing FDA-approved GM ELISA test.

RESULTS

The sensitivity of the CLIA galactomannan (CLIA GM) test was 70.6%, specificity 92.1%, PPV 66.7% and NPV 93.3% (p < 0.001), while the sensitivity of the CLIA beta-glucan (CLIA BDG) test was 88.2%, specificity 81.6%, PPV 51.7% and NPV 96.9% (p < 0.001). Using the PlateliaTM Aspergillus Ag Test as the reference method, the areas under the curve (AUC) of the ROC curve were 0.878 for CLIA BDG and 0.869 for CLIA GM.

CONCLUSIONS

CLIA-based tests were evaluated as being rapid diagnostic tests for IA since their NPVs were found to be very high. Integrating CLIA into clinical practice may significantly improve diagnostic efficiency and patient outcomes.

Combined ImmunoCAP and Western Blot for the Diagnosis of Aspergillus Lung Disease

BACKGROUND

Pulmonary aspergillosis is a major global health concern, yet its diagnosis remains challenging. Aspergillus-specific IgG measurement is essential for identifying chronic and allergic forms.

OBJECTIVE

This study aimed to evaluate a quantitative method, the ImmunoCAP assay IgG m3 (ICAP) (Phadia-ThermoFisher Scientific, Waltham, USA), a qualitative method, the Aspergillus IgG Western blot kit (Asp-WB) (LDBio Diagnostics, Lyon, France) and a combination of both methods for the diagnosis of Aspergillus lung disease.

METHODS

A retrospective study was conducted at the University Hospital of Marseille, France, during 1 year. Patients undergoing Aspergillus serology were divided into three groups: Group 1 (G1) with ICAP ≥ 40 mgA/L and positive Asp-WB, Group 2 (G2) with ICAP ≥ 40 mgA/L and negative Asp-WB and Group 3 (G3) with ICAP < 40 mgA/L and positive Asp-WB. Data were collected on demographics, underlying diseases, imaging and biological outcomes. Patients were classified according to their Aspergillus lung disease, whether acute pulmonary aspergillosis, chronic pulmonary aspergillosis (CPA), allergic broncho-pulmonary aspergillosis (ABPA), colonisation or Aspergillus sensitisation.

RESULTS

A total of 536 patients were studied: 173 in G1, 204 in G2 and 200 in G3, with 38 patients found in several groups. The primary underlying disease was cystic fibrosis in 44.6% of patients. Twenty-two patients were diagnosed with ABPA. The number of diagnosed ABPA cases in G1 (20; 11.6%) combining positive ICAP and Asp-WB was significantly higher than that found in the groups with a single positive test result (p < 0.001). Fifteen patients were diagnosed with CPA. Isolated positive Western blot (G3) identified five cases of aspergilloma. Significantly fewer Aspergillus lung diseases were diagnosed in isolated positive ICAP G2 (8.8%) than in G1 (53.8%) and G3 (42.5%) (p < 0.001).

CONCLUSIONS

This study highlights the benefits of combining Asp-WB and ICAP for the diagnosis of Aspergillus lung disease and the relatively high false-positive rate in patients with isolated positive ICAP results.

Incidence and impact of invasive fungal infection comparing post-transplant cyclophosphamide with cyclosporine plus methotrexate GVHD prophylaxis in allogeneic HSCT

BACKGROUND

In recent years, haploidentical hematopoietic stem cell transplantation (haploHSCT) with post-transplant cyclophosphamide (PTCy) has become increasingly prevalent. However, the precise impact of invasive fungal disease (IFD) in relation to graft-versus-host disease (GVHD) prophylaxis and donor type remains to be elucidated.

METHODS

In this study, we analyzed data from 580 HSCT patients, comprising 80 patients who received haploidentical grafts and 500 patients who received grafts from other donor types. PTCy was exclusively administered to haploidentical HSCT recipients, while cyclosporine A (CsA) in combination with short-course methotrexate (scMTX) was used for patients receiving grafts from other donors.

RESULTS

The IFD rate by PTCy and CsA plus scMTX was 15 % and 15.6 %, respectively. At 6 months and 1 year post-transplant, the cumulative incidence of IFD was 9.4 % and 14.8 % for the PTCy group, and 7.9 % and 12.3 % for the CsA plus scMTX group, respectively. Both groups exhibited poor survival outcomes associated with IFD. Identified risk factors for IFD included age ≥ 45 years, disease relapse, and grade III-IV acute GVHD. Aspergillus spp. and Candida spp. were the most commonly isolated pathogens. High rate of cytomegalovirus reactivation was also noticed in PTCy or CsA plus scMTX group, but not a risk factor for IFD.

CONCLUSION

The similar IFD rate between haploHSCT with PTCy and others with CsA plus scMTX was documented, with Aspergillus spp. and Candida spp. as the most common pathogens. Further research is needed to investigate IFD following haploHSCT with PTCy and to explore differences with other types of allogeneic HSCT.

Dynamics of Histoplasma fungal load in people living with HIV with disseminated histoplasmosis under treatment with liposomal amphotericin B

OBJECTIVES

Disseminated histoplasmosis (DH) is a lethal fungal disease in patients living with HIV in endemic regions of the world. Diagnosis relies mainly on microscopy, culture, and antigen detection. Our goal was to evaluate the diagnostic and prognostic role of our RT-quantitative PCR (RT-qPCR) in blood specimens allowing to quantify the whole nucleic acids (WNA) load.

METHODS

We tested RT-qPCR assays on serial blood (n = 325) of 105 DH patients at baseline (day 0 or day 1, D0/1) and during antifungal therapy (day 3, D3; day 4 or day 5, D4/5; day 7, D7; and day 14, D14) collected from a phase II trial comparing three different regimens of liposomal amphotericin B for DH treatment in HIV patients from Brazil.

RESULTS

The RT-qPCR was positive at D0/D1 in 64.2% (63/98) of the patients, but positivity increased to 89% (47/53) in patients with proven infection. Urine antigen was positive in 94.2% (97/103) of DH patients. RT-qPCR positive at or after D7 was significantly associated with higher initial WNA load (Cq = 31 [27-34]) when compared with RT-qPCR negative at D7 (Cq = 38 [33-40]) (p 0.001). The WNA load was equivalent in all treatment arms, and an equivalent decrease in the % of RT-qPCR-positive patients was observed in the three arms. Flat of negative WNA slope (increase of WNA load) was associated with an increased relative risk of death at D7 (relative risk, 8.6; p 0.046) and W12 (relative risk, 3.3; p 0.008). This association was not observed when analysing antigen slopes (p > 0.5).

DISCUSSION

We found in this study an association between the progression of flat Histoplasma WNA load during treatment and early death at D7 and D14. This diagnostic tool should be evaluated specifically in a prospective trial to assess its usefulness in identifying patients with poorer prognosis and adapt their treatment accordingly.

Pathogen spectrum and clinical characteristics of lung cancer patients: A 10-year retrospective study

Infection is the most common non-cancer cause of death in patients with lung cancer (LC). However, original research reports with large sample sizes on the epidemiology, pathogen spectrum, immune status changes, and prognosis of these patients are lacking. A retrospective study of LC patients with infection was performed at Guangxi Medical University Cancer Hospital from 2014 to 2023. In total, 699 LC patients with disease complicated by infection were included in the study. The incidence of infection increased from 4.61% in 2014 to 9.77% in 2023 among patients with LC. A total of 109 types of pathogens were detected. The most prevalent pathogenic organisms in each category were bacteria (Klebsiella pneumoniae and Escherichia coli), fungi (Candida spp. and Aspergillus spp.), viruses (COVID-19 and Epstein-Barr virus), and special pathogens (Mycobacterium tuberculosis and Mycoplasma pneumoniae). Upon diagnosis of infection, the total T lymphocyte, helper T cell, Th/Ts ratio, and B lymphocyte counts decreased, while the natural killer cell and suppressor T-cell counts increased. Infection is a crucial risk factor affecting the prognosis and mortality of patients with LC. The susceptibility of patients with LC to infection may be related to immunodeficiency resulting from antitumor treatment and disease progression.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Incidence of Breakthrough Fungal Infections in Patients With Isavuconazole Prophylaxis: A Systematic Review and Meta-analysis

Background

Isavuconazole (ISA) is a newer triazole that has activity against most mold species and has been utilized for prophylaxis as well as treatment in patients with hematologic malignancies (HM) and hematopoietic stem cell transplant (HSCT). However, several studies have documented breakthrough invasive fungal infections (bIFIs). Thus, we conducted a systematic review and meta-analysis to investigate the incidence of bIFIs among patients receiving ISA prophylaxis.

Methods

We conducted a systematic review and meta-analysis of the published literature using the concept of ISA, HSCT, and HM from 5 search engines. In patients with HSCT and HM, the pooled incidence of bIFI while undergoing ISA prophylaxis was calculated via the DerSimonian-Laird random effect model.

Results

The systematic review and meta-analysis included 35 and 19 studies, respectively. In total, 991 patients were identified as using ISA prophylaxis, and the majority had either acute myeloid leukemia or myelodysplastic syndrome (69.9%). The pooled incidence of proven/probable bIFI was 7% (95% CI, 4%-12%, I2 = 55%). The most common pathogen was Aspergillus species (43.1%), followed by Candida (22.4%) and Mucorales (12.1%). In 19 studies, mortality rates were documented and ranged between 0% and 100%; the majority of which were >50%.

Conclusions

In patients with HM or HSCT, we found a high incidence of bIFI while undergoing ISA prophylaxis, with high mortality. Given the lack of randomized clinical trials evaluating ISA in this indication, its role in prophylaxis remains unclear.

Towards a holistic approach to pulmonary infections. Insights from the Sixth Annual Meeting of Spanish Experts 2024

Pneumonia is the leading cause of death from infection in the developed world. In recent years, researchers and healthcare professionals have worked extensively to reduce this burden. Prevention is better than cure, and significant advances have been made in areas such as vaccination and the prevention of nosocomial pneumonia in intensive care units. Comprehensive surveillance programmes and new diagnostic methods have been developed to assess trends in this disease and to identify the infectious agents involved. Clinical presentation can be challenging in elderly patients or those with certain comorbidities, prompting new studies in these populations to address these issues. Correct and early management of severe community-acquired pneumonia represents a major opportunity to reduce its associated mortality. Although fungal pathogens are an uncommon cause of lung infection, they are associated with high morbidity and mortality, highlighting the need for new approaches. Finally, new drugs are available for the treatment of pneumonia, and a thorough understanding of them is key to ensuring their correct use, particularly to combat multi-resistance. To provide an update on these points, a multidisciplinary team of Spanish experts convened at the Sixth Annual Meeting of Pneumonia Day, under the scientific sponsorship of GEIPC-SEIMC. This paper reflects the information shared at this meeting, offering the latest insights on these topics and supporting a holistic approach to pneumonia management.

Empirical versus pre-emptive antifungal therapies for invasive fungal infections in critically ill patients

BACKGROUND

The initiation strategy of antifungal therapy (AT) is among the most discussed practices for patients vulnerable to invasive fungal infections (IFI). In low-resource countries, there are also no appropriate consensus or guidelines for this issue. Given this clinical gap, we aimed to investigate the use of empirical and pre-emptive therapy in an Asian intensive care setting.

METHODS

We conducted a retrospective cohort study (timeframe 2019-2020) on critically ill adults receiving systemic antifungals for ≥ 3 days. The exposure was empirical or pre-emptive therapy of systemic antifungals. The primary outcome was IFI-related mortality (in percentage, including in-hospital death or discharge/transfer with death prognosis). The secondary outcomes included overall rationale of AT (in percentage) and length of AT (LoAT, in days). We used logistic and linear regression to investigate the outcomes and reported the estimates with the 95% confidence interval (95% CI).

RESULTS

During a median follow-up of 27 days, among 157 included patients (median age 68, 48.4% being female), we recorded 77 deaths (49.0% [95% CI 41.0-57.1%]) that were related to IFI (60 [51.7%] in the empirical group; 17 [41.5%] in the pre-emptive group; adjusted odds ratio of IFI-related mortality 1.86 [95% CI 0.74 to 4.63; p = 0.184]). The overall rationale of AT was at 45.2% (95% CI 37.2-53.4%; 41.4% [95% CI 32.3-50.9%] in the empirical group; 56.1% [95% CI 40.0-71.5%] in the pre-emptive group; adjusted odds ratio of receiving rational AT: 0.75 [95% CI 0.31 to 1.87]). The median LoAT was 8 days (IQR 6-14; 8 days [IQR 6-13.3] in the empirical group; 9 days [IQR 6-14] in the pre-emptive group; adjusted mean difference - 1.1 days [95% CI -3.2 to 1.0]).

CONCLUSION

Among critically ill patients on systemic antifungals for ≥ 3 days, the proportion of IFI-related mortality was high. The overall rationale of AT was at a low level, with the median LoAT lower than the generally recommended duration of at least 14 days. There were no significant differences in IFI-related mortality, overall rationale of AT, and LoAT between those receiving empirical and pre-emptive therapy.

CLINICAL TRIAL NUMBER

Not applicable.

Lateral-flow device for the diagnosis of invasive aspergillosis: a systematic review and diagnostic meta-analysis

BACKGROUND

Early diagnosis of invasive aspergillosis (IA) can significantly enhance patient survival rates; however, accurately diagnosing IA remains a formidable challenge. Lateral flow device (LFD), as a non-invasive detection method, have been extensively investigated in numerous clinical studies. The objective of this study was to elucidate the diagnostic accuracy of LFD in detecting IA through a meta-analysis.

METHODS

The PubMed, Embase, and Web of Science database were searched to obtain clinical studies on the diagnosis of IA by LFD. A random-effects meta-analysis with a bivariate hierarchical model was used, the estimates and 95% confidence intervals (CI) were used to present pooled sensitivity, specificity, and summary receiver operating characteristic curves (SROC).

RESULTS

Twenty-five cohort or case-control studies were included. The pooled sensitivity of LFD in the diagnosis of IA was 0.67 (95% CI: 0.57-0.75), specificity was 0.90 (95% CI: 0.85-0.93), diagnostic odds ratio was 15.70 (95% CI: 9.69-25.44), the area under the SROC curve (AUC) was 0.87 (95% CI: 0.82-0.93). Subgroup analysis showed that the sensitivity of bronchoalveolar lavage fluid specimen was higher than serum specimen (0.72, 95% CI: 0.67-0.78 vs. 0.49, 95% CI: 0.41-0.56), bronchoalveolar lavage fluid specimens also have higher diagnostic accuracy (AUC = 0.89).

CONCLUSIONS

LFD is an effective technique for the detection of IA infection, but attention should be paid to the influence of specimen source on the accuracy of this technique.

Pneumonia definition in allogeneic hematopoietic cell transplant recipients: Update and challenges in 2024. Recommendations from the EBMT Infectious Diseases Working Party and Practice Harmonization and Guidelines committee

To optimize and homogenize data on infectious diseases complications, the Infectious Diseases Working Party of the European Society for Blood and Marrow Transplantation (IDWP EBMT) participated in the 2023 EBMT international workshop focusing on the standardization of the definition of specific infections, including respiratory infections [1]. This is pertinent considering that a new software for data collection, including data on post-transplant infectious disease complications, was launched in 2023 and which will remain the main tool for future epidemiological studies. In this report, we briefly discuss our proposals for pneumonia definition, predominately focusing on bacterial and fungal pneumonias. We specifically address definitions of pneumonia diagnosis, infection onset date, resolution, recurrence, and breakthrough infection, and the challenges we encountered as a group to accurately define pneumonia in hematopoietic cell transplant (HCT) recipients (Table 1). Infections with community acquired respiratory viruses and adenovirus are discussed in a separate report [1]. Definitions on CMV pneumonia have been previously described and recently updated and hence not discussed in this paper [2,3].

Diagnosing invasive fungal infections in the laboratory today: It's all good news?

Despite the advances in medical science, invasive fungal infections (IFI) remain a diagnostic challenge. The increasing prevalence of IFI, driven by immunosuppressive therapies, advances in intensive care and emerging pathogens, underscores the need for early and accurate diagnosis. This review evaluates current laboratory methods for the diagnosis of IFI, highlighting their strengths and limitations. Conventional techniques, including fungal culture, direct microscopy, and histopathology, remain the gold standard for the diagnosis of proven IFIs. These methods allow pathogen isolation, species identification and antifungal susceptibility testing. However, these techniques have limitations in terms of sensitivity and turnaround times. Although microscopy is a rapid technique, its sensitivity and species discrimination profile are limited. Modern serological assays, such as β-d-glucan and galactomannan detection, have improved the diagnostic accuracy of probable IFI cases. Integration of these assays with clinical and radiological findings, enables earlier intervention, although this is accompanied by an increased risk of false positives and necessitates careful clinical correlation. Molecular diagnostics, particularly polymerase chain reaction (PCR), allow rapid, species-specific identification directly from clinical samples. The advent of MALDI-TOF mass spectrometry has further improved diagnostic efficiency, particularly for yeast identification, although challenges remain for filamentous fungi. Innovative techniques, such as metagenomic sequencing, lateral-flow assays, and loop-mediated isothermal amplification, offer the potential for rapid and precise detection, even in resource-limited settings. The combination of conventional and innovative methods provides a comprehensive diagnostic framework. The continuous refinement of these tools, in conjunction with multidisciplinary collaboration, is imperative to improve the early diagnostic and targeted treatment of patients with IFI.

Aspergillus After Lung Transplantation: Prophylaxis, Risk Factors, and the Impact on Chronic Lung Allograft Dysfunction

BACKGROUND

Invasive pulmonary aspergillosis (IA) poses significant challenges for lung transplant (LTx) patients, with unclear risk factors and preventive strategies. The effectiveness of nebulized amphotericin B (AmB) or statins for IA prevention and the effect of IA on chronic lung allograft dysfunction (CLAD) and mortality remain questionable.

METHODS

Data were collected from all LTx patients transplanted between December 1, 2013 and January 1, 2022 at the University Medical Center Groningen. IA, was defined according to published criteria. Prespecified risk factors were compared between patients with and without IA post-LTx and were entered in a logistic regression model. Two additional logistic regression models were built with factors that might be associated with statin or AmB prophylaxis and IA. A matched case-control study was conducted for the association between statins and IA, with matching based on follow-up time.

RESULTS

Aspergillus was cultured in 110 /274 (40%) patients post-LTx and 89/110 (81%) were classified as probable IA. MMF use, airway stenosis, Aspergillus cultured pre-LTx, CLAD, and acute rejection (AR), were significantly associated with IA. Statin use was associated with a lower incidence of IA, while AmB prophylaxis showed no significant effect. A significant statin effect could not be confirmed by the case control analysis. There was no significant difference in all-cause mortality between patients with and without IA (34% vs. 29%).

CONCLUSIONS

The high incidence of IA post-LTx necessitates more effective strategies. Key targets for intervention include prior positive cultures, airway stenosis, AR, and the use of MMF. The role of statins remains unclear and requires further research.