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

Effect of Interpretation of Positive Metagenomic Next-Generation Sequencing Reports on the Infection Diagnosis in Patients With Hematological Disorders

Background

Metagenomic next-generation sequencing (mNGS) has become a crucial diagnostic tool for infectious diseases in patients with hematological disorders. However, despite the abundant microbial information provided by positive mNGS reports, interpreting these results remains challenging due to the lack of standardized criteria.

Methods

We surveyed 92 clinicians to identify common challenges in understanding mNGS reports. Microbiologists then provided additional "report interpretation cards" (RICs) for positive mNGS results alongside original reports. The aim of using RICs was to determine whether each detected microorganism was likely cause of infection. After a 3-month period, a panel of clinical experts retrospectively reviewed 281 cases, involving 728 detected microorganisms, to assess RIC accuracy.

Results

In total, 82.6% of clinicians (76 of 92) experienced difficulties in interpreting mNGS reports. After receiving RICs, 97.8% of clinicians (90 of 92) reported satisfaction. The overall concordance rates between interpretation and adjudication in the 281 cases was 79.0% (222 of 281). In 203 cases in which multiple microorganisms were detected, 37.9% (77 of 203) and 37.4% (76 of 203) were interpreted and adjudicated as mixed infections. Among the 728 microorganisms, interpretation and adjudication revealed concordance rates of 93.9% (154 of 164), 95.7% (88 of 92), and 72.3% (339 of 469) for bacterial, fungal, and viral infections, respectively. In 68.7% of the cases (193 of 281), mNGS positively influenced pathogen diagnosis.

Conclusions

Not all microorganisms detected by mNGS are responsible for infection, and appropriate interpretation is essential. The provision of interpretations by microbiologists aids clinicians in accurately using mNGS for infection diagnosis.

Invasive Mould Infections Following Combat-Related Injuries-A Retrospective Cohort Study

BACKGROUND

Available data on combat wound-related invasive mould infections (IMIs) are limited.

OBJECTIVES

We aimed to describe the characteristics and outcomes of IMIs in casualties of a recent conflict.

PATIENTS/METHODS

A retrospective study including hospitalised patients with combat-related injuries, fulfilling criteria for wound-related IMI based on Trauma Infectious Disease Outcomes Study definitions. Patient and injury characteristics, management and outcomes are described and compared to previous cohorts. Mould isolates and susceptibility testing results, including the novel agent manogepix, are reported.

RESULTS

Overall, 31 patients (69 mould isolates) were included-resulting in an IMI incidence rate of 1.9%. Blast was the most common injury mechanism (71%), with limb amputations and abdominoperineal injuries in 35% and 45%, respectively. Mould cultures, obtained mostly from lower extremities wounds (62%), were positive in all patients. Most (68%) had poly-mould infections, with Aspergillus and Fusarium species predominating. Overall, non-susceptibility rates of > 50% to newer azoles and 38% to amphotericin B reflected the high proportion of Fusarium spp., A. terreus and A. flavus, with the lowest azole minimal inhibitory concentrations demonstrated with posaconazole. Manogepix displayed good in-vitro activity against all isolates, except for Mucorales species. Two patients (6.5%) died of disseminated IMIs and 19% required amputations. Patients with Mucorales had poorer outcomes (40% mortality/amputation vs. 19% for non-Mucorales).

CONCLUSIONS

Combat wound-related IMIs are uncommon but carry significant morbidity and mortality. High susceptibility rates to manogepix were observed. Further studies are needed to evaluate optimal surgical approaches and the role of antifungal susceptibility testing in this setting.

Pulmonary Coinfection of Pneumocystis jirovecii and Aspergillus Species

In this multicenter study of 387 patients who were immunocompromised, 4.5% with invasive pulmonary aspergillosis also had Pneumocystis jirovecii pneumonia. Predictors of coinfection included elevated β-D-glucan and prolonged corticosteroid use. Coinfection correlated with reduced 30-day survival (22% vs 57%), suggesting that early identification and prophylaxis may improve outcomes.

Invasive fungal infections in patients with liver disease: immunological and clinical considerations for the intensive care unit

Patients with liver disease in the intensive care unit (ICU) face a unique susceptibility to infection due to the complex immune dysfunction resulting from hepatic failure. Bacterial infections are commonly present in these patients upon arrival to the hospital, often being the primary reason for ICU admission. In contrast, invasive fungal infections (IFIs) afflict a smaller percentage of patients and are usually discovered in the course of the ICU stay. IFI diagnosis in the ICU, particularly in patients with liver disease, is often delayed or overlooked, contributing to the extremely high ICU mortality associated with IFI in these patients despite the availability of effective (and largely safe) antifungal therapy. Thus, to improve outcomes, it is crucial for intensive care clinicians to be vigilant for IFIs in patients with liver disease. This review aims to contribute to the intensive care literature in this regard. We begin with an overview of normal antifungal immunity followed by a summary of how it may become compromised in the setting of hepatic dysfunction. Next, a general discussion of IFIs in liver disease is presented and then the three most relevant fungal pathogens, namely Candida, Aspergillus, and Cryptococcus, are individually examined. This review concludes by highlighting key knowledge and practice gaps that require attention by the scientific and clinical communities in the coming years.

Shifting sands: Unveiling the changes in respiratory comorbidities and fungal pathogens in Saudi Arabia

OBJECTIVES

To investigate epidemiological changes in respiratory fungal infections (RFI), including fungal isolation and colonization, at one of the main centers in Medina. The incidence of RFI is rising due to an increase in the number of immunocompromised individuals, a higher prevalence of respiratory viral infections, and an aging population.

METHODS

A retrospective cross-sectional study was conducted by extracting data of patients with fungal-positive respiratory cultures from King Fahad Hospital (KFH), Al Madinah Al Munawwarah from 2013 to 2023.

RESULTS

A total of 352 episodes of fungal-positive cultures were identified in 79 patients, reflecting a 12-fold increase in RFI prevalence. The most frequent fungus was Candida albicans 43% (n=150), followed by C. tropicalis at 34% (n=119), C. glabrata at 7% (n=25), C. parapsilosis at 5% (n=18), C. dubliniensis at 3.4% (n=12), and Aspergillus fumigatus at 3.4% (n=12). Bronchoalveolar lavage was performed 52 times, with 19 cultures growing C. albicans and 8 cultures positive for A. fumigatus. None of the 58 lung biopsy samples grew mold. Only one patient had 2 C. glabrata isolates resistant to voriconazole and fluconazole. The most prevalent comorbidities were respiratory diseases (30%) and lower limb injuries and diabetes (16%).

CONCLUSION

Candida albicans was the leading cause of RFI. Continuous monitoring, improved diagnostics, and targeted interventions are crucial to address existing challenges and emerging threats. The growing recognition of fungal infections necessitates increased research and education for healthcare professionals.

A Novel Giant Magnetoresistance-Enabled Multiplex Polymerase Chain Reaction Assay for the Diagnosis of Invasive Fungal Infection

Background

Despite advances in clinical microbiology, the diagnosis of invasive fungal infections remains challenging. Giant magnetoresistance (GMR) is a novel technology that enables the detection of trace amounts of cell-free DNA (cfDNA). We evaluated a high-multiplex molecular diagnostic assay coupled with GMR-enabled lab-on-a-chip technology that can detect 18 different fungal species.

Methods

Analytical performance was evaluated in spiked plasma samples. After amplification, cfDNA was digested. Residual single-stranded DNA was flowed over a GMR sensor that was surface-coated with probes specific to different fungal species. After hybridization, magnetic beads bound to the probe complexes produced a GMR signal that was detected by the sensors. Clinical performance was determined using residual serum samples collected before the initiation of antifungal treatment from 20 patients with infection.

Results

The limit of detection of the assay ranged from 5 to 50 copies per polymerase chain reaction (PCR) reaction. Nonspecific signals were not observed in the spiked samples. Fungal cfDNA was detected in 80% of patients with invasive candidiasis (3/4 with candidemia, 5/6 with invasive candidiasis without candidemia), all 3 cases of invasive pulmonary aspergillosis, and all 3 cases of disseminated histoplasmosis. cfDNA was not detected in 2 patients with cryptococcosis (both had negative blood cultures) and 2 patients with Pneumocystis pneumonia.

Conclusions

We developed a novel GMR-enabled multiplex PCR assay detecting fungal pathogens that have been prioritized for public health action. Clinical sensitivity was highest in cases of presumed angioinvasion and dissemination. This technology has the potential for use in the clinical microbiology laboratory setting.

How accurate is high-resolution computed tomography of the chest in differentiating between pulmonary invasive fungal infections and other pulmonary infections in children with cancer?

BACKGROUND

Pulmonary invasive fungal infections pose a serious risk for immunocompromised patients. Although diagnostic imaging plays an important role in the early detection of pulmonary invasive fungal infections, radiological differentiation between invasive fungal infection and other pulmonary infections is challenging.

OBJECTIVE

The aim of this study was to assess the accuracy of chest high-resolution computed tomography (HRCT) in the differentiation between pulmonary invasive fungal infections and other pulmonary infections in paediatric cancer patients.

MATERIALS AND METHODS

In this retrospective study, baseline HRCTs of patients with probable or proven invasive fungal infections and other pulmonary infections were blindly assessed by two radiologists, followed by a consensus reading. The scoring form included imaging characteristics and radiological invasive fungal infection probability assessment. Inter-rater reliability was determined with Cohen's kappa.

RESULTS

Chest HRCTs (n = 77) of paediatric cancer patients with pulmonary invasive fungal infections (n = 45) and with other pulmonary infections (n = 32) were evaluated. In the consensus reading, nodules with halo sign and wedge-shaped consolidations were observed significantly more in pulmonary invasive fungal infections than in other pulmonary infections (86.7% vs. 34.4% and 28.9% vs. 9.4%), and ground-glass opacities were observed less frequently (61.4% vs. 87.5%). The kappa values for the individual imaging characteristics ranged from 0.121 to 0.408. Sensitivity of the HRCT to diagnose a pulmonary invasive fungal infection ranged from 0.78 to 0.80, and specificity from 0.66 to 0.88.

CONCLUSION

The accuracy of chest HRCTs in differentiating between invasive fungal infections and other pulmonary infections is poor. There are two main reasons for this: no individual imaging characteristic was found to be able to fully distinguish between invasive fungal infections and other pulmonary infections, and the agreement between radiologists was only moderate.

Outcomes in hematopoetic cell transplantation in the setting of mold infections in patients with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a disorder of immunity characterized by phagocyte dysfunction. Mold infections in patients with CGD are often severe and disseminated. We present patient characteristics, microbiological data, and outcomes for 26 patients with CGD who received hematopoietic cell transplantation (HCT) or gene therapy-modified cells (GT) between 2008 and 2019, with proven fungal infection either before or during their transplant. All patients engrafted, and all but one GT recipient had neutrophil recovery and evidence of functional correction. Eighteen patients (69%) are currently alive and 19 patients (73% of total, 90% of patients with repeat imaging performed) had evidence of radiographic improvement. With 3 exceptions, deaths were not principally related to the fungal infection and duration of antecedent infection did not correlate with death. Aspergillus species accounted for the majority of disease (50%), followed by Phellinus species (18%). Osteomyelitis and disseminated disease were common, as only 11 patients (42%) had disease restricted to pneumonia. Triazole therapy was used in all 26 patients, with combination therapy used in 25 (96%). HCT or gene therapy, with appropriate antifungal therapy, are viable therapies for refractory fungal infections in patients with CGD.

Coinfection by Mucoraceae and Aspergillus Species in a Patient With Acute Leukemia: A Clinical Case Report

The concurrent occurrence of invasive mold infections caused by two distinct fungal species in hematologic patients represents a rare and challenging condition. The mortality rate associated with these invasive fungal infections in neutropenic patients is high, underscoring the importance of timely diagnosis and prompt initiation of appropriate treatment to improve clinical outcomes. Herein, we present a concomitant acute invasive fungal rhinosinusitis (AIFR) and invasive pulmonary fungal infection caused by Aspergillus and Mucoraceae species in a patient with pre-B-cell acute lymphoblastic leukemia. This case highlights the need for further research to optimize outcomes in immunocompromised patients.

Breakthrough Invasive Mold Infections in Hematologic Cases: Relevance of the Host's Factors

Background

Breakthrough invasive mold infections (bIMIs) are life-threatening complications in hematologic cases. Most previous studies in this field covered the whole spectrum of fungal pathogens, including yeasts, and antifungal agents.

Methods

We conducted a retrospective study including all hematologic cases of patients diagnosed with a bIMI while receiving a mold-active antifungal agent at our center between January 2017 and June 2022.

Results

Overall 37 patients were diagnosed with bIMI: 6 (16.2%) proven, 18 (48.6%) probable, and 13 (35.1%) possible. The highest incidence rate was found for micafungin (1.31 bIMI episodes per 1000 treatment-days), although with no significant differences across antifungal agents. Most patients (90.9%) for whom therapeutic drug monitoring was performed exhibited adequate through levels. Ten (27.0%) patients had undergone allogeneic hematopoietic stem cell transplantation. Aspergillus species was the most common pathogen in cases with microbiological identification. Regarding risk factors, 67.6% had severe neutropenia at diagnosis and 40.5% had received high-intensity chemotherapy. Rates of clinical response and attributable mortality by day +30 were 64.9% and 23.3%, respectively. Poorer performance status, higher Charlson Comorbidity index, older age, and higher C-reactive protein by day +7 were associated with 30-day attributable mortality.

Conclusions

Aspergillus was the predominant pathogen in our cohort of bIMIs, with a significant proportion of episodes occurring despite adequate triazole levels. Thirty-day attributable mortality was lower than previously reported. Poorer performance status, higher comorbidity burden, and older age had a relevant role in the outcome of bIMI.

Two-transcript signature for differentiation and clinical outcomes in severe fever with thrombocytopenia syndrome (SFTS) patients: a double-blind, multicenter, validation study

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with a high mortality rate that is often underdiagnosed due to the limitations of current laboratory testing. Timely diagnosis and early identification of severe cases are crucial to improving patient outcomes and overall survival rates. This study aimed to evaluate the efficacy of two transcripts, IFI44L and PI3, in the early differentiation between SFTS virus (SFTSV) infection and bacterial sepsis, as well as in the prompt identification of severe cases during epidemic seasons. In a prospective study conducted between 1 May 2021 and 30 September 2022, we enrolled 225 patients who presented with acute fever and thrombocytopenia at four hospitals in Shandong Province, China. The two-transcript signature provided a clear distinction between SFTS and bacterial infection, achieving an area under the receiver operating characteristic curve of 0.961 (95% confidence interval [95% CI] 0.916-0.986), outperforming C-reactive protein (0.810 [95% CI 0.738-0.870]) and procalcitonin (0.764 [95% CI 0.687-0.830]). Importantly, the relative expression of the IFI44L gene was significantly elevated in fatal SFTS cases, with an area under the curve (AUC) of 0.820 (95% CI 0.727-0.914), indicating its potential as an early prognostic marker. Additionally, IFI44L and PI3 were identified as potential biomarkers for distinguishing SFTS patients with and without invasive pulmonary aspergillosis, with AUC values of 0.817 and 0.753, respectively. Our findings demonstrate that the two-transcript signature effectively distinguishes SFTSV infection from bacterial sepsis and helps identify high-risk individuals, guiding appropriate treatment during SFTS outbreak.

Invasive aspergillosis in critically ill patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

In the intensive care unit (ICU), invasive aspergillosis (IA) has a poor prognosis. Some studies report a positive association between diabetes mellitus (DM) and IA in critically ill patients, but the relationship between DM and IA in the ICU remains controversial. We aimed to clarify the relationship between DM and IA among patients in the ICU in a systematic review and meta-analysis.

METHODS

We retrieved all reports published in PubMed, EMBASE, and the Cochrane Library databases before July 12, 2023. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) to evaluate the relationship between DM and IA. Subgroup analyses were conducted to further analyze sources of heterogeneity. Heterogeneity was evaluated using the Cochran's Q test and I2 statistic. Additionally, we evaluated publication bias using funnel plots, Egger's test, and Begg's test. Finally, sensitivity analysis was conducted to evaluate the robustness of the results.

RESULTS

Twenty studies with 6155 participants were included in this meta-analysis. We found a positive association between DM and IA among patients in the ICU (OR = 1.18, 95% CI:1.01 to 1.39; p = 0.04). The heterogeneity was not significant (I² = 5%; p = 0.39) and publication bias was not significant (Egger's test: p = 0.654; Begg's test: p = 0.417). The results of sensitivity analysis supported a stable association between DM and IA. Subgroup analysis indicated that patients' comorbidities might be a potential source of heterogeneity. Additionally, patients with DM had a significantly higher risk of COVID-19-associated pulmonary aspergillosis (CAPA) than those without DM (OR = 1.40, 95% CI: 1.15 to 1.70; p < 0.001). The heterogeneity was not significant (I² = 0%; p = 0.91). In the subgroup with influenza, the OR of the relationship between DM and IA was 0.81 (95% CI: 0.54, 1.23; p = 0.32; heterogeneity: p = 0.36; I² = 8%).

CONCLUSIONS

Patients with DM in the ICU showed a higher risk of developing IA than patients in the ICU without DM. DM was a significant risk factor for IA, with the highest risk observed in critically ill patients diagnosed with CAPA.

A practical approach to investigating nosocomial acquisition of Aspergillus

Invasive mould disease (IMD) has a high mortality in immunosuppressed patients. Invasive aspergillosis (IA) is the most common IMD. A guideline for preventing IA has been published jointly by the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. Use of high-efficiency particulate air filters, adequate air exchange rates, sealing of patient rooms, and preventing exposure to moulds by nursing patients in areas away from construction sites are recommended by the guideline. However, there is limited information in relation to the actions to be undertaken by infection prevention and control teams in the event of one or more cases of nosocomial aspergillosis. In this review, we describe a systematic approach to aspergillosis by defining possible and probable nosocomial acquisition based on the number of days since hospital admission. We advocate an incremental response to the investigation of nosocomial aspergillosis in patients in protective isolation taking into account the number of cases and the likelihood of nosocomial origin. For single cases of nosocomial IA, we suggest that infection control investigations should focus on case surveillance and walk-through inspection escalating in a stepwise manner to enhanced case surveillance, verification of environmental controls, environmental monitoring, genotyping of clinical and environmental isolates, and review of antifungal prophylaxis for multiple cases and outbreaks. Where applicable, the construction site should be inspected with the aim to reduce the dispersal of conidia. Surveillance systems need to be strengthened to better understand the epidemiology of IA.

Impact of an institutional antifungal stewardship program on antifungal usage and outcomes in patients with invasive fungal infections

Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

Invasive aspergillosis caused by cryptic species in transplant recipients: A review

The clinical and microbiological characteristics of invasive aspergillosis (IA) caused by cryptic Aspergillus species have not been well-defined in transplant settings. However, IA is among the most common mould infections in solid organ and hematopoietic stem cell transplant recipients. Among 55 causative isolates in the 53 reported cases, Aspergillus calidoustus, A. lentulus, A. tubingensis, and A. udagawae were the four most common causative cryptic Aspergillus species. Newer diagnostic modalities, such as matrix-assisted laser desorption ionization-time of flight mass spectrometry, may help diagnose these cryptic species. Of the 24 cases with detailed clinical information, 13 had antifungal breakthrough infections. The 12-week mortality rates of all 24 cases, 7 cases of A. calidoustus, and 7 cases of A. lentulus were 46%, 43%, and 43%, respectively. Based on antifungal susceptibility profiles obtained from previous studies, an empiric antifungal regimen such as liposomal amphotericin B with or without echinocandin is recommended for A. calidoustus. A combination of an anti-mould azole and liposomal amphotericin B with or without an echinocandin is suggested for A. lentulus and A. udagawae. Additionally, any one of voriconazole, isavuconazole, or posaconazole with or without liposomal amphotericin B with or without an echinocandin is indicated for A. tubingensis. Newer antifungal agents may have more significant activity against Aspergillus cryptic species.

Utility of Mucorales polymerase chain reaction to diagnose Rhizomucor infections in neutropenic patients

Mucormycoses are life-threatening infections related to fungi from the Mucorales order. Based on fungal culture, the most frequently involved genera are Rhizopus spp., Mucor spp., or Lichtheimia spp. However, since the introduction of Mucorales polymerase chain reaction (PCR), many diagnoses have been made without positive fungal culture, biasing mucormycosis epidemiology. We conducted a single-centre retrospective observational study on invasive mucormycosis cases diagnosed between April 2020 and December 2022. Cases were classified according to EORTC/MSGERC definitions, adding a 'PCR-only' category for patients with a positive Mucorales PCR as the only mycological evidence. Genus/species identification was obtained by sequencing the Mucorales 18S rDNA directly on Mucorales PCR-positive samples. We identified 35 cases of mucormycosis, including 6 proven, 7 probable, and 22 'PCR-only'. Genus/species identification was achievable in 34 cases and surprisingly revealed the genus Rhizomucor as the main aetiological agent (n = 14, 41.2%). Interestingly, all the Rhizomucor infections, except one, were classified as 'PCR-only', while fungal culture was positive in 11/20 (55%) for other Mucorales genera (P <.001). Moreover, in comparison with other genera, the genus Rhizomucor was significantly more associated with neutropenia (11/14 [78.6%] vs. 2/20 [10%], P < .0001) and pulmonary localizations (11/14 [78.6%] vs. 6/20 [30%], P = .01). Our study reveals the changing epidemiology of mucormycosis in our centre with the use of Mucorales PCR and underlines the importance of the genus Rhizomucor, especially in neutropenic patients. This highlights the benefits of using Mucorales PCR in clinical practice for mucormycosis diagnosis in high-risk patients and the need to include it in diagnostic criteria.

Comprehensive Review of Environmental Surveillance for Azole-Resistant Aspergillus fumigatus: A Practical Roadmap for Hospital Clinicians and Infection Control Teams

As azole-resistant Aspergillus fumigatus emerges globally, healthcare facilities face mounting challenges in managing invasive aspergillosis. This review synthesizes worldwide azole resistance data to reveal profound regional variability, demonstrating that findings from other regions cannot be directly extrapolated to local settings. Consequently, hospital-level environmental surveillance is crucial for tailoring interventions to local epidemiology and detecting resistant strains in real-time. We outline practical approaches-encompassing sampling site prioritization, diagnostic workflows (culture-based and molecular), and PDCA-driven continuous improvement-so that even resource-limited facilities can manage resistant isolates more effectively. By linking real-time surveillance findings with clinical decisions, hospitals can tailor antifungal stewardship programs and swiftly adjust prophylaxis or treatment regimens. Our approach aims to enable accurate, ongoing evaluations of emerging resistance patterns, ensuring that institutions maintain efficient and adaptive programs. Ultimately, we advocate for sustained, collaborative efforts worldwide, where facilities adapt protocols to local conditions, share data through international networks, and contribute to a global knowledge base on resistance mechanisms. Through consistent application of these recommendations, healthcare systems can better preserve azole efficacy, safeguard immunocompromised populations, and refine infection control practices in the face of evolving challenges.

The Antimicrobial Resistance of Candida: A 5-Year Retrospective Analysis at a Tertiary Hospital in Jordan

Candida infections are a global health concern, increasingly complicated by rising antimicrobial resistance (AMR). This study analyzed the prevalence and AMR patterns of circulating Candida species in Amman, Jordan, using electronic records from a tertiary teaching hospital's microbiology lab (from 2017 to 2022). Complete records of Candida isolates (n = 2673) were assessed by sample type, species, and AMR. Among positive blood samples, C. albicans accounted for the majority (38.7%), followed by C. tropicalis (19.0%), C. parapsilosis (18.3%), Nakaseomyces glabratus (14.6%), and Pichia kudriavzevii (9.5%). Non-albicans species demonstrated higher resistance to Caspofungin, notably P. kudriavzevii (23.1%), N. glabratus (30.0%), and C. parapsilosis (32.0%), compared to C. albicans (1.9%). In high vaginal swabs, C. albicans was most prevalent (63.7%), with N. glabratus also notable (28.6%); Fluconazole resistance in C. albicans remained low (2.0%). Across all pooled isolates, AMR was similar between inpatients and outpatients, except for Micafungin, where inpatient resistance was significantly higher. In conclusion, non-albicans species predominated in blood infections and demonstrated pronounced AMR. Micafungin resistance was notably higher among inpatients. Variations in Candida species and AMR by sample type suggest that aggregating samples in registry studies may obscure critical patterns.

Lateral flow assay as radiological prognosis factor of pulmonary cryptococcosis: a single center retrospective study in China

Background

Lateral flow assay (LFA) has demonstrated high sensitivity and specificity for diagnosing cryptococcosis. However, its role in predicting therapeutic efficacy for pulmonary cryptococcosis (PC) remains underexplored.

Methods

We conducted a retrospective analysis of HIV-negative patients with PC to describe the clinical profile and identify potential predictors of radiological prognosis.

Results

All the 168 participants received antifungal therapy with a triazole agent. Of these, 84.5% experienced partial or complete absorption of pulmonary lesions. The results of the gamma test, chi-square trend test, and ordinal logistic regression all indicated that both baseline LFA and changes in LFA after treatment were significant predictors of imaging prognosis. The degree of radiological improvement was inversely associated with the baseline LFA positive grade(P for linear-by-linear association: 0.011, Spearman correlation coefficient = -0.17; γ= -0.368, P = 0.045). Patients with a decrease in LFA after therapy had significantly better radiological outcomes compared to those with equal or increased LFA(linear-by-linear association, P = 0.014, Spearman correlation coefficient = 0.188; γ = 0.371, P = 0.012). Additionally, favorable outcomes were more likely in patients with lesions confined to the right lung.

Conclusions

LFA shows potential of monitoring radiological outcomes in pulmonary cryptococcosis.

Epidemiology of Coronavirus Disease 2019-Associated Fungal Infections in the Intensive Care Unit: A Single-Center Retrospective Study

INTRODUCTION

Invasive fungal disease (IFD) is a morbid superinfection that can arise in critically ill patients with COVID-19 infection. Studies evaluating the full spectrum of COVID-19-associated fungal infections remain limited.

METHODS

Single-center retrospective study assessing IFD in patients with COVID-19, hospitalized for ≥ 72 h in the intensive care unit (ICU) between 02/25/20 and 02/28/22 (n = 1410). IFD was assessed using consensus criteria (EORTC/MSGERC or ISHAM/ECMM criteria). T- and chi-square tests compared demographic/clinical characteristics between IFD and non-IFD patients. Cox proportional hazards regression estimated risk factors for in-hospital mortality.

RESULTS

Of 1410 patients with severe COVID-19, 70 (5%) had a diagnosis of COVID-19-associated fungal infection with invasive candidiasis occurring in 3%, and invasive aspergillosis in 2%. Other fungal infections were rare. Patients with IFD had longer ICU stays (26 vs. 13 days; p < 0.001); increased rates of mechanical ventilation (99% vs. 70%; p < 0.001); and a higher risk of in-hospital death (69% vs. 36%; p < 0.001). On multivariable analysis, COVID-associated fungal infections were associated with an increased risk of in-hospital mortality.

CONCLUSIONS

This real-world study of critically ill patients with COVID-19 demonstrated a low incidence of COVID-19-associated fungal infections with invasive candidiasis occurring most frequently. Fungal infections were associated with an increased risk of in-hospital mortality in this population.

Clinical Impact of Bronchoalveolar Lavage in Pediatric and Young Adult Patients With Cancer and Suspected Respiratory Infections

BACKGROUND

Respiratory infections cause a significant amount of morbidity and mortality in pediatric and young adult patients with malignancy. Bronchoscopy with bronchoalveolar lavage (BAL) is frequently utilized in the diagnostic process, but which patients would most benefit is poorly understood.

METHODS

A retrospective study from 2013 to 2022 examined patients with active malignancy who underwent bronchoscopy with BAL. Positive and negative clinical impacts were assessed by 3 independent reviewers according to predetermined criteria. Mixed-effects logistic regression was performed to identify factors associated with positive and negative clinical impact.

RESULTS

In total, 145 bronchoscopies met inclusion criteria with a median patient age of 12 years (interquartile range 5-17). A total of 30.3% of bronchoscopies had a positive clinical impact with 17.2% leading to a new diagnosis, most commonly Pneumocystis jirovecii pneumonia (PJP) (7.6%). Comparatively, 18.6% had a negative clinical impact, most commonly from a procedural complication (13.1%). Trimethoprim-sulfamethoxazole (TMP-SMX) initiation for treatment of suspected PJP prior to BAL (adjusted odds ratio [aOR] 11.20, 95% CI 1.32-95.29) was associated with positive clinical impact. Requirement for ICU-level care (aOR 18.85, 95% CI 3.60-98.69) or oxygen supplementation by nasal cannula prior to BAL (aOR 18.41, 95% CI 4.78-70.95) were associated with negative clinical impact while prior invasive ventilation (aOR 0.09, 95% CI 0.01-0.58) was associated with the absence of negative clinical impact.

CONCLUSIONS

Patients with potential respiratory infections with high clinical suspicion for PJP who had been started on treatment TMP-SMX prior to BAL benefit most from bronchoscopy with BAL. Patients intubated prior to BAL who were deemed clinically safe for bronchoscopy tolerated the procedure better than those in the ICU not requiring intubation or those requiring supplemental oxygen via nasal cannula.

Invasive Aspergillosis in the Intensive Care Unit

Invasive aspergillosis (IA) is a fungal infection, which has traditionally been associated with neutropenia and immunosuppressive therapies. Our understanding of invasive aspergillosis has been evolving and, in the past few decades, IA among ICU patients has been recognized as a common infection and has become more widely recognized. The diagnosis and management of invasive aspergillosis in the ICU is particularly challenging, due to the unstable clinical condition of the patients, lack of diagnostic markers, increased risk of further clinical deterioration, multiple comorbidities, and a need for early assessment and treatment. In this article, we will discuss the challenges and pitfalls of the diagnosis and management of invasive aspergillosis in an ICU setting, along with a review of the current literature that is pertinent and specific to this population.

Safety and recommendation of voriconazole for invasive pulmonary aspergillosis in severe liver disease patients: a retrospective cohort study

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a common opportunistic infection in patients with severe liver disease (SLD), which increases the mortality of patients. The aim of this study was to evaluate the efficacy and safety of voriconazole for IPA in patients with SLD and explore an optimal antifungal regimen.

METHODS

This was a retrospective cohort study of SLD patients diagnosed with proven or probable IPA at Beijing Youan Hospital, Capital Medical University between January 1, 2012 to January 31, 2023. Univariate and multivariate logistic regression analysis were performed to identify the impact of voriconazole on outcomes of SLD patients with IPA.

RESULTS

A total of 142 patients were enrolled and categorized into voriconazole group (n = 92), echinocandins group (n = 26) and a combination of voriconazole and echinocandins group (n = 24). The 28-day all-cause mortality was lower in voriconazole group compared to the other groups (p = 0.033). Voriconazole monotherapy was associated with lower short-term mortality (OR 0.223, 95%CI 0.070-0.650, p = 0.008) and did not seem to exacerbate hepatic function deterioration in SLD patients with IPA (OR 0.259, 95%CI 0.094-0.674, p = 0.007) when compared to echinocandins monotherapy. Among the three subgroups of voriconazole monotherapy, no-loading dose regime demonstrated a superior response to IPA therapy compared to the standard-dose regimen (OR 0.264, 95%CI 0.068-0.845, p = 0.035).

CONCLUSION

Voriconazole monotherapy demonstrated good tolerability with lower mortality in SLD patients with IPA. A no-loading dose voriconazole regimen is proposed for IPA treatment in SLD patients, yet pharmacokinetic studies combined with prospective studies are needed for further validation.

Aspergillus identification through bronchoscope in intensive care unit - a retrospective, databased cohort study

Introduction

Invasive pulmonary aspergillosis (IPA) increases the risk of mortality of critically ill patients. Diagnostic criteria specifically targeting patients in intensive care units(ICUs) have been developed to improve diagnostic sensitivity. This study investigated health outcomes among patients in ICUs with Aspergillus isolates identified using bronchoscopy.

Methods

This retrospective cohort study obtained data from the Chang Gung Research Database of Chang Gung Memorial Hospital. Patients admitted to the ICU between January 2017 and December 2022 who received bronchoalveolar lavage were enrolled. Patients with a fungus culture yielding Aspergillus spp. isolates or who had an Aspergillus galactomannan antigen index value of >1.0 were categorized into the Aspergillus-positive group.

Results

A total of 2372 patients were enrolled, and 146 patients (6.16%) tested positive for Aspergillus. Of the patients who tested positive for Aspergillus, 37.67% had a positive culture result, and 77.4% had a positive galactomannan antigen result. Patients with Aspergillus isolates were more likely to have a recent influenza infection, concurrent bacterial sepsis, and a cavitation and to die in hospital (in-hospital mortality rate 58.9% vs. 48.57%, P = 0.016).

Discussion

Identifying Aspergillus through bronchoscopy in the ICU is associated with higher mortality rates than in patients who test negative for Aspergillus. Galactomannan antigen from bronchoalveolar lavage may provide higher diagnostic sensitivity.

Diagnostic Approach to Pneumonia in Immunocompromised Hosts

In immunocompromised patients, pneumonia presents a diagnostic challenge due to diverse etiologies, nonspecific symptoms, overlapping radiological presentation, frequent co-infections, and the potential for rapid progression to severe disease. Thus, timely and accurate diagnosis of all pathogens is crucial. This narrative review explores the latest advancements in microbiological diagnostic techniques for pneumonia in immunocompromised patients. It covers major available microbiological tools for diagnosing both community-acquired and hospital-acquired pneumonia, encompassing a wide spectrum of pathogens including bacterial, viral, fungal, and parasitic. While traditional culture methods remain pivotal in identifying many pneumonia-causing etiologies, their limitations in sensitivity and time to results have led to the rise of non-invasive antigen tests and molecular diagnostics. These are increasingly employed alongside cultures and microscopy for more efficient diagnosis, mainly in viral and fungal infections. Lastly, we report the future of pneumonia diagnostics, exploring the potential of metagenomics and CRISPR/Cas13a for more precise and rapid pathogen detection in immunocompromised populations.

Invasive Sino-Orbital Aspergillosis and Tinea Corporis Co-Infection in a Returned Traveler from Flooded Sylhet, Bangladesh

We report a case of co-infection with Aspergillus fumigatus causing invasive sino-orbital aspergillosis and Trichophyton interdigitale tinea corporis in a returned traveler from flooded Sylhet region, Bangladesh. Anthropogenic climate change may lead to increased extreme weather-associated fungal infections. Travel to a flooded area should be considered a risk factor for fungal infection.

A MALDI-TOF MS-based multiple detection panel of drug resistance-associated multiple single-nucleotide polymorphisms in Candida tropicalis

Candida tropicalis is one of the main causes of invasive candidiasis. Rapid identification of antifungal resistance is crucial for selection of an appropriate antifungal to improve patient outcomes. Mutations at specific loci are strongly correlated with resistance to antifungal agents. In this study, we developed a multi-single-nucleotide polymorphism (SNP) panel to accurately identify 36 mutation sites across seven genes of C. tropicalis that are associated with resistance to azoles and/or echinocandins. Ten isolates were selected to test repeatability, and another 20 isolates of C. tropicalis were selected to validate consistency. Intra-assay and inter-assay repeatability of the panel was 100%, with the loci accuracy being 99.44% (716 of 720). Furthermore, 109 isolates were examined for clinical research, and the most commonly detected mutations were G751A and A866T of UPC2, A491T of TAC1, and A395T and C461T of ERG11. The G751A and A866T mutations of UPC2 as well as the A395T and C461T mutations of ERG11 co-existed. The SNP panel enables identification of specific mutations at critical sites of drug-resistant strains to facilitate the rapid selection of appropriate antifungal agents and efficient monitoring of the regional epidemiological trends of resistance of C. tropicalis.IMPORTANCEC. tropicalis infections pose a growing global public health challenge, with mortality rates approaching 40%. C. tropicalis is one of the top four Candida spp. responsible for candidiasis, particularly in the Asia-Pacific region and Latin America, notably affecting patients with neutropenia and malignancies. The azole resistance rate of C. tropicalis ranges from 0% to 30%. Between 2009 and 2018, the China Hospital Invasive Fungal Surveillance Network reported an increase in fluconazole and voriconazole resistance from 5.7% to ~30%. Although resistance to echinocandins and amphotericin B remains low, multi-resistance to echinocandins and azoles has been observed. Current methods for detecting drug resistance are limited by the long turnaround time of antifungal susceptibility testing, low throughput of Sanger sequence to target resistance mutations, complex data analysis, and high costs of second-generation sequencing. We developed and validated a rapid, high-throughput, and cost-effective panel to detect and monitor drug-resistance mutations of C. tropicalis.

Invasive fungal disease in the immunocompromised host: changing epidemiology, new antifungal therapies, and management challenges

BACKGROUND

Invasive fungal disease (IFD) causes morbidity and mortality in immunocompromised hosts (ICHs). Based on increasing recognition of the impact of IFD on human disease, a recent WHO priority list identified key areas of need.

OBJECTIVES

This review examines changes in the epidemiology of IFD, in particular the emergence of antifungal-resistant pathogens and the current availability of rapid diagnostic tests and antifungal treatment options.

SOURCES

Literature between 2000 and January 2024 regarding fungal epidemiology, diagnostic tests, antifungal resistance, emerging fungal pathogens, and novel antifungal agents in both adult and paediatric ICH were reviewed.

CONTENT

We describe the changing epidemiology and continued burden and mortality of IFD in ICH. Furthermore, we discuss the emergence of antifungal-resistant organisms driven by new immunosuppressed populations, climate change, and antifungal exposure in the individual and environment. We highlight novel antifungal agents and how they will address current unmet needs.

IMPLICATIONS

The changing epidemiology and increased population at risk for IFD, lack of recognition or quantification of risks for IFD with new therapies, current gaps in the availability of rapid diagnostic tests, and the imminent availability of novel antifungals with distinct spectra of activity argue for improved availability of and access to rapid diagnostics, antifungal stewardship programmes, and global access to antifungal agents.

A Systematic Literature Review to Determine Gaps in Diagnosing Suspected Infection in Solid Organ Transplant Recipients

Background

Improved diagnostic testing (DT) of infections may optimize outcomes for solid organ transplant recipients (SOTR), but a comprehensive analysis is lacking.

Methods

We conducted a systematic literature review across multiple databases, including EMBASE and MEDLINE(R), of studies published between 1 January 2012-11 June 2022, to examine the evidence behind DT in SOTR. Eligibility criteria included the use of conventional diagnostic methods (culture, biomarkers, directed-polymerase chain reaction [PCR]) or advanced molecular diagnostics (broad-range PCR, metagenomics) to diagnose infections in hospitalized SOTR. Bias was assessed using tools such as the Cochrane Handbook and PRISMA 2020.

Results

Of 2362 studies, 72 were eligible and evaluated heterogeneous SOT populations, infections, biospecimens, DT, and outcomes. All studies exhibited bias, mainly in reporting quality. Median study sample size was 102 (range, 11-1307). Culture was the most common DT studied (N = 45 studies, 62.5%), with positive results in a median of 27.7% (range, 0%-88.3%). Biomarkers, PCR, and metagenomics were evaluated in 7, 19, and 3 studies, respectively; only 6 reported sensitivity, specificity, and positive/negative predictive values. Directed-PCR performed well for targeted pathogens, but only 1 study evaluated broad-range PCR. Metagenomics approaches detected numerous organisms but required clinical adjudication, with too few studies (N = 3) to draw conclusions. Turnaround time was shorter for PCR/metagenomics than conventional diagnostic methods (N = 4 studies, 5.6%). Only 6 studies reported the impact of DT on outcomes like antimicrobial use and length of stay.

Conclusions

We identified considerable evidence gaps in infection-related DT among SOT, particularly molecular DT, highlighting the need for further research.

Pretransplant Minimal Pleural and Peritoneal Effusion Is a Potential Poor Prognostic Indicator in Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

Pleural effusion and ascites developing after allogeneic hematopoietic stem cell transplantation (allo-SCT) are generally associated with inferior overall survival (OS); however, the prognostic value of pretransplant effusion on transplant outcomes remained unclear.

METHODS

We retrospectively evaluated minimal pleural effusion and ascites detected by computed tomography in 248 consecutive adult patients who underwent their first allo-SCT from January 2007 to December 2022.

RESULTS

Forty-eight patients demonstrated minimal pleural effusion or ascites within 100 days before transplantation (Effusion group) and the other 200 had no effusion (No effusion group). Serum albumin level was significantly lower in the Effusion group than in the No effusion group (median 3.8 vs. 3.4 g/dL, p < 0.001). Performance status (PS) was significantly inferior and refined disease risk index tended to be higher in the Effusion group. The 2-year OS rate after transplantation was significantly worse in the Effusion group (57.1% vs. 36.7%, p < 0.001). The Effusion group had a significantly lower cumulative incidence of neutrophil and platelet engraftment and higher hepatic veno-occlusive disease. Moreover, a tendency toward higher cumulative incidence of relapse and non-relapse mortality was shown in the Effusion group. In multivariate analysis, the Effusion group had a significantly inferior OS with a hazard ratio of 1.848 (95% confidence interval 1.231-2.774), even after adjustment for disease risk, serum albumin level, PS, and Hematopoietic Cell Transplant-Comorbidity Index points.

CONCLUSION

Reflecting high disease activity and impaired general condition, pretransplant effusion can be a complementary indicator for poor prognosis in allo-SCT.

Real-World Effectiveness and Safety of Isavuconazole Versus Amphotericin B for Patients with Invasive Mucormycosis

BACKGROUND

Invasive mucormycosis (IM) poses a substantial morbidity and mortality burden among immunocompromised patients.

OBJECTIVES

We aim to compare the real-world effectiveness and safety of isavuconazole with those of amphotericin B in patients with IM.

PATIENTS AND METHODS

In this observational cohort study, we enrolled patients who were diagnosed with IM and treated with either isavuconazole or amphotericin B.

RESULTS

A total of 106 patients met the study criteria. Of these, 47 received isavuconazole, and 59 received amphotericin B as the primary treatment. The two cohorts had similar baseline characteristics, including a history of malignancy, use of immunosuppressants, infection sites, and pathogens. The amphotericin B group demonstrated a significantly greater incidence of renal disorders (p < 0.001) and hypokalemia (p < 0.001) than the isavuconazole group. The proportion of patients who received salvage therapy was greater in the amphotericin B group than in the isavuconazole group (42% vs. 6%, p < 0.001). Eighteen patients in the amphotericin B group discontinued treatment because of adverse events, whereas no patients in the isavuconazole group discontinued treatment because of adverse events. A significant difference in the primary therapeutic response between the isavuconazole and amphotericin B groups was noted (p = 0.013), with a higher treatment failure rate in the amphotericin B group (68% vs. 36%, p = 0.001). However, there were no significant differences in all-cause mortality or mucormycosis-attributable mortality rates between the two groups.

CONCLUSIONS

Isavuconazole outperformed amphotericin B as a first-line treatment option for IM in terms of its clinical effectiveness and safety.

Prevalence and Outcomes of Infections in Critically-ill Paediatric Oncology Patients: A Retrospective Observation Study

PURPOSE

The survival of paediatric oncology patients has improved substantially in the past decades due to advances in the field of oncology. Modern cancer treatments often come with life-threatening complications, of which infection is one of the most common causes in this patient population. This study aims to investigate the prevalence and outcomes of common infections in haemato-oncology patients during their stay in paediatric intensive care unit (PICU) and to identify any factors associated with these infections.

METHODS

A retrospective observational study was conducted on all children with a haemato-oncology diagnosis or who underwent haematopoietic stem cell transplantation (HSCT) and who were admitted to the Hong Kong Children's Hospital PICU over a one-year period. Infection characteristics and patient outcomes were evaluated and compared between different sub-groups. Univariable and multi-variable analyses were employed to identify risk factors associated with the development of active infection.

RESULTS

Forty-five (36.3%) of 124 critically ill haemato-oncology admissions to PICU were associated with infections, of which 31 (25%) admissions involved bacterial infections, 26 (20.9%) involved viral infections and 6 (4.8%) involved fungal infections. Bloodstream infection was the most common type of infection. More than half (61.3%) of the bacterial infections were due to an antibiotic-resistant strain. After adjusting for confounding variables, post-HSCT status and neutropenia were significantly associated with active infections.

CONCLUSION

Infections in critically-ill haemato-oncological patients are associated with post haematopoietic stem cell transplant status and neutropenia. Further study is warranted to review effective strategies that may mitigate the likelihood of infection in this patient population.

Is galactomannan a useful tool for triage and diagnosis of oral invasive aspergillosis?

OBJECTIVE

To evaluate the accuracy of the galactomannan serum test in diagnosing oral invasive aspergillosis.

METHODS

This prospective observational study included oncohematological neutropenic patients with suspected invasive aspergillosis, but without signs of pulmonary involvement. These patients underwent nasofibroscopy, biopsy, galactomannan serum testing, and maxillofacial high-resolution computed tomography to diagnose invasive aspergillosis. Patients were divided into two groups: Group 1 consisted of those with proven invasive aspergillosis, while Group 2 included patients without proven invasive aspergillosis. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

Thirteen patients were included in Group 1 and four in Group 2. The sensitivity, specificity, positive predictive and negative predictive values were 0.69, 1.0, 1.0 and 0.5, respectively. Sensitivity was higher in cases with Aspergillus sinusitis than in cases with exclusive oral lesions (0.77 versus 0.5, respectively). The galactomannan serum test optical density index was higher in Group 1 (2.4; range 0.2-3.5) than in Group 2 (0.2; range: 0.1-0.3; P-value = 0.007.

CONCLUSIONS

The galactomannan serum test is a valuable tool for screening invasive aspergillosis, especially in cases with nasal or sinus involvement, but biopsy is still the gold standard for diagnosis.

Epidemiological characteristics of invasive Aspergillus isolates: Morphology, drug susceptibility, and mutations in azole drug targets

BACKGROUND

The global epidemiology of aspergillosis varies and is influenced by various factors. To elucidate the disease burden and identify effective control strategies, the epidemiological characteristics of Aspergillus infections have to be investigated. The aim of this study was to assess the epidemiological characteristics of various Aspergillus species, including their morphological features, species identification, and in vitro susceptibility to nine antifungal agents in a large tertiary hospital in northern China.

METHODS

Ninety-five clinical isolates of Aspergillus were collected from patients. Aspergillus species identification was performed using conventional morphological methods, MALDI-TOF MS, and gene sequencing. In vitro susceptibility to nine antifungal agents was evaluated using the Sensititre YeastOne system. Target genes (cyp51A and cyp51b) of A. tubinazole were sequenced using the Sanger method.

RESULTS

Aspergillus fumigatus, Aspergillus niger, Aspergillus flavus, Aspergillus tubingensis, and Aspergillus terreus were the most common isolated species. Rare species included Aspergillus tamarii, Aspergillus usamil, Aspergillus versicolor, Aspergillus udagawae, Aspergillus lentulus, Aspergillus sydowii, and Aspergillus quadrilineatus. Pulmonary infections accounted for 86.3 % (82/95) of collected cases, and the in-hospital mortality rate was 22.1 %. The median minimum inhibitory concentration (MIC) range of amphotericin B was 1.5-4 mg/L. The MIC range of triazoles against Aspergillus species, excluding Aspergillus udagawae and Aspergillus lentulus, was 0.12-0.5 mg/L. The median minimum effective concentration range of echinocandins was < 0.008-0.03 mg/L. Non-wild-type resistance to amphotericin B was observed in 29.6 % (16/54) of Aspergillus fumigatus isolates, and non-wild-type resistance to voriconazole was observed in 11.1 % (1/9) of Aspergillus tubingensis isolates. Moreover, CYP51A and CYP51b of Aspergillus tabinensis had 2-29 and 10-13 nucleotide mutations, respectively.

CONCLUSION

Patients with non- Aspergillus fumigatus infection accounted for 43.2 %. The T256A amino acid substitution in CYP51A of Aspergillus tabinensis did not lead to increased azole drug MICs.

A multivariable prediction model for invasive pulmonary aspergillosis in immunocompromised patients with acute respiratory failure (IPA-GRRR-OH score)

PURPOSE

Invasive pulmonary aspergillosis (IPA) is a life-threatening opportunistic infection in immunocompromised patients. The diagnosis is often made late, with mortality reaching 90% when mechanical ventilation is needed. We sought to develop and validate a risk prediction model for the diagnosis of IPA.

METHODS

We used two independent datasets of immunocompromised patients with acute respiratory failure admitted to 12 intensive care units (ICUs). The derivation dataset include 3262 patients. Factors associated with probable or proven IPA were identified, and a risk prediction model was developed. This model was then validated in a prospective dataset (776 patients).

RESULTS

IPA prevalence was 4.5% (146/3262) and 3.3% (26/776), in the derivation and the validation cohorts, respectively. The final model included eight variables constitutive of the IPA-GRRR-OH score: type of immunosuppression, high-dose or long-term corticosteroids, neutropenia, the presence of structural lung disease, time from symptoms onset to ICU admission > 7 days, hemoptysis, focal alveolar pattern on the chest imaging, and viral co-infection. The median score [IQR] was 2 [1-3] in the derivation and 1 [0-3] in the validation cohort. The best cutoff score for IPA diagnosis was 4 (sensitivity 23.1%; specificity 90.5%; negative predictive value 91.4%). Discrimination and calibration were good in both the derivation (AUC 0.72 [0.68-0.76]) and the validation cohort (AUC 0.85 [0.76-0.93]).

CONCLUSION

The IPA-GRRR-OH is a clinical score, easily available at ICU admission, which reliably predicts IPA in immunocompromised patients with acute respiratory failure. Studies to demonstrate benefits from the bedside implementation of this score are warranted.

Fungal Disease Response Centre: Pioneering Diagnostic Approach for Regions With Dispersed Hospital Centres

BACKGROUND

Access to fungal disease diagnosis is crucial for reducing mortality, yet it varies widely across Argentina, especially outside Buenos Aires. In regions like Santa Fe and Paraná, where most healthcare facilities are under 150 beds, maintaining specialised mycology labs is challenging.

OBJECTIVES

This work describes the establishment and first-year results of a centralised Fungal Disease Response Centre (FDRC) and referral network serving this region, covering approximately 1 million inhabitants.

METHODS

The FDRC provided tests from the WHO's Essential Diagnostic List, along with antifungal susceptibility testing and molecular diagnostics. Additionally, we offered continuous training, a courier service and digital tools for service requests and result reporting.

METHODS

In 2023, the FDRC handled samples from 878 patients from 22 institutions, performing 1151 tests on 897 samples. Common tests included Aspergillus galactomannan quantification and molecular diagnostics, diagnosing 101 fungal infections including fungaemias, histoplasmosis, aspergillosis and deep-seated candidiasis. Average turnaround times were 6.2 h for antigen-based tests and 21.5 h for molecular tests.

CONCLUSIONS

This centralised service improved diagnosis speed and quality, overcoming limitations of smaller labs. It also enabled population-based studies, revealing higher-than-expected histoplasmosis prevalence. The FDRC's first-year results demonstrate that regional centralisation can enhance diagnostic quality, improve patient outcomes and advance epidemiological knowledge.

Shift from Widespread to Tailored Antifungal Prophylaxis in Lymphoma Patients Treated with CD19 CAR T Cell Therapy: Results from a Large Retrospective Cohort

Patients undergoing CD19 chimeric antigen receptor (CAR)-T cell therapy exhibit multiple immune deficits that may increase their susceptibility to infections. Invasive fungal infections (IFIs) are life-threatening events in the setting of hematologic diseases. However, there is ongoing debate regarding the optimal role and duration of antifungal prophylaxis in this specific patient population. The objective of this study was to provide a comprehensive overview of the evolution of IFI prophylactic strategies over time and to assess IFI incidence rates in a cohort of patients with relapsed or refractory (R/R) lymphoma treated with CAR-T cell therapy. A single-center retrospective study was conducted on a cohort of patients with R/R B cell lymphoma treated with CD19 CAR-T cell therapy between April 2016 and March 2023. Group A (April 2016-August 2020) consisted of patients primarily treated with fluconazole, irrespective of their individual IFI risk profile. In Group B (September 2020-March 2023) antifungal prophylaxis was recommended only for high-risk patients. Overall, 330 patients were included. Antifungal prophylaxis was prescribed to 119/142 (84%) patients in Group A and 58/188 (31%) in Group B (P < .001). Anti-mold azoles were prescribed to 8 (5.6%) patients in Group A and 21 (11.2%) patients in Group B. In Group A, 42 (29%) patients were switched to another antifungal, 9 (21%) because of toxicity, with 6 cases of transaminitis and 3 cases of prolonged QTc. In Group B, 21 (11.2%) patients were switched to the antifungal drug, mainly from fluconazole or micafungin to a mold-active agent following revised guidelines. No difference was found in liver toxicity between the two groups at infusion, day 10, and day 30. No significant differences were observed between the groups. IFIs following CAR-T cell therapy were rare, with 1 case of cryptococcal meningoencephalitis in group A (.7%) and 1 case of invasive aspergillosis in Group B (.5%), both occurring in patients on micafungin prophylaxis. In this large single-center cohort of patients with R/R lymphoma treated with CAR-T cells, we show that individualized prophylaxis, alongside careful management of CAR-T cell-related toxicities such as CRS, was associated with a very low IFI rate, avoiding the risk of unnecessary toxicities, drug-drug interactions, and high costs.

Universal azole prophylaxis for prevention of coccidioidomycosis among lung transplant recipients transferring care to a center within a highly endemic region

BACKGROUND

Coccidioidomycosis may cause severe disseminated disease and mortality among lung transplant recipients. A strategy of lifelong azole prophylaxis was previously associated with low rates of coccidioidomycosis. Whether lung transplant recipients relocating to the Coccidioides endemic region are also at risk and would benefit from antifungal prophylaxis is unknown.

METHODS

Lung transplant recipients transplanted at an outside center with low Coccidioides endemicity before relocating for post-transplant follow-up at a transplant center in Phoenix, Arizona from January 2013 to March 2024 were included. The primary outcome was proven or probable coccidioidomycosis per Mycoses Study Group consensus definitions.

RESULTS

Forty lung transplant recipients were included, with 62.5% not receiving antifungal prophylaxis at the time of transfer. The median time from transplant to relocation was 34 months. Of those not on prophylaxis, 96% were initiated on azole therapy at the first clinic visit, with 72% prescribed itraconazole. Coccidioides serologic testing was performed in 30% of the cohort, most often in the context of a broad diagnostic work-up for suspected infection during hospitalization. After a median follow-up of 31 months, one case (2.5%) of proven pulmonary coccidioidomycosis was identified, occurring 4.8 years post-transplant and >2 years post-transfer in a cystic fibrosis patient who had a pause in fluconazole prophylaxis for >1 month prior to diagnosis due to gastrointestinal intolerance and access issues. The patient was treated and maintained on isavuconazole without complications.

CONCLUSION

Azole antifungal prophylaxis was associated with a low rate of coccidioidomycosis among lung transplant recipients relocating to the highly endemic region.

Epidemiology of Infections in Lung Transplant Recipients Treated With Belatacept

BACKGROUND

Belatacept is a costimulatory blocker that can be used to prevent and treat rejection in lung transplant recipients (LuTRs). The epidemiology of infections in belatacept-treated LuTRs has not been systematically evaluated.

METHODS

We performed a single-center retrospective study of all adult LuTRs who received belatacept as prevention or treatment of antibody-mediated rejection (desensitization) or as part of maintenance immunosuppression from January 1, 2011, to June 30, 2022. We assessed the epidemiology of infections that occurred within 12 months following the first belatacept dose.

RESULTS

Fifty-two LuTRs received at least one dose of belatacept as either desensitization (n = 32) or maintenance immunosuppression (n = 20). Among 45 patients who were cytomegalovirus (CMV) donor and/or recipient seropositive, nine (20%) developed CMV infection. Seven (77%) CMV infections occurred despite valganciclovir prophylaxis and four (44%) were associated with antiviral resistance. Three (6%) LuTRs developed Epstein-Barr virus (EBV) associated post-transplant lymphoproliferative disorder (PTLD). Twenty-five (48%) LuTRs developed 43 bacterial infections and five (10%) developed proven or probable invasive fungal disease. Incidence rates of viral, bacterial, and fungal infections were similar between the desensitization and maintenance groups: incidence rate ratios (95% confidence interval) were 0.70 (0.32-1.57), 1.31 (0.70-2.46), and 2.82 (0.31-25.2), respectively. Infection/PTLD prompted belatacept discontinuation in eight (15%) patients.

CONCLUSIONS

In the first year after belatacept initiation, LuTRs commonly developed CMV infections, EBV+ PTLD, and bacterial infections. Multicenter collaborations are needed to better understand infection risks in LuTRs treated with belatacept.

Infectious complications in the paediatric immunocompromised host: a narrative review

BACKGROUND

Infections are a major cause of morbidity in children with primary or secondary immunodeficiency, and have a negative impact on overall outcome.

OBJECTIVES

This narrative review presents select paediatric-specific aspects regarding the clinical impact, diagnosis, management, and follow-up of infectious complications in patients with primary and secondary immunodeficiencies.

SOURCES

PubMed until January 2024 and searched references in identified articles including the search terms: infection, immunodeficiency or cancer, diagnostics, antimicrobial agents, bacteria or fungus or virus, and follow-up.

CONTENT

Major advances have been made in the early detection and management of patients with primary immunodeficiency, and multiple analyses report in children with cancer on risk groups and periods of risk for infectious complications. Although many diagnostic tools are comparable between children and adults, specific considerations have to be applied, such as minimizing the use of radiation. Antimicrobial drug development remains a major challenge in the paediatric setting, which includes the establishment of appropriate dosing and paediatric approval. Last, long-term follow-up and the impact of late effects are extremely important to be considered in the management of immunocompromised paediatric patients.

IMPLICATIONS

Although infectious disease supportive care of immunocompromised children and adolescents has considerably improved over the last three decades, close international collaboration is needed to target the specific challenges in this special population.

The Diagnostic Sensitivity of Beta-D-Glucan Assay in Patients with Chronic Disseminated Candidiasis

Objectives: Chronic disseminated candidiasis (CDC) is a specific syndrome in patients with hematologic malignancies which usually occurs after the recovery of neutrophils due to previous chemotherapy. The beta-D-glucan (BDG) assay has been proposed as an adjunct test for diagnosing invasive fungal infection. However, data on BDG assay in patients with CDC are scarce. We aimed to investigate the diagnostic sensitivity of BDG assay in patients with CDC. Methods: All adult patients who were diagnosed as CDC in a tertiary hospital in Seoul, South Korea, from January 2017 to December 2019 and underwent BDG assay (Gold Mountain River Tech Development, Beijing, China) were retrospectively reviewed. CDC was defined by the demonstration of small, target-like abscesses in the liver or spleen (bull’s-eye lesions) or in the brain at the time of neutrophil recovery after a prolonged phase of neutropenia. The values for BDG over 80 pg/mL were classified as positive. Results: A total of 20 patients were enrolled. The median age was 51 years (IQR 39 – 64). Of these, 13 patients had AML, 3 ALL, 2 MDS, and 1 aplastic anemia. Candida spp. were isolated in 6 patients; 3 were C. tropicalis, 2 C. glabrata, and 1 C. krusei. Of the 20 patients, 10 (50%) revealed positive BDG results. The median BDG value was 174 pg/dL (IQR 137–402). More CDC patients with previous candidemia had positive BDG assay than those without candidemia, but with no statistical significance (4/5 (80%) vs. 6/15 (40%), P = 0.30). In the 7 patients with BDG assay-positive CDC, for whom follow-up BDG results were available, the BDG remained high in 6 patients (86%) for more than 4 weeks after adequate antifungal therapy. All 4 patients who died had a positive BDG assay, and 3 of them showed an increasing trend of BDG values during treatment. Conclusions: Negative BDG assay appears to be not useful to rule out CDC. BDG assay decreased slowly during the adequate treatment of CDC.

Molecular Identification and Antifungal Susceptibility of Fusarium spp. Clinical Isolates

BACKGROUND

Accurate identification of Fusarium species requires molecular identification. Treating fusariosis is challenging due to widespread antifungal resistance, high rates of treatment failure, and insufficient information relating antifungal susceptibility to the clinical outcome. Despite recent outbreaks in Mexico, there is limited information on epidemiology and antifungal susceptibility testing (AST).

OBJECTIVES

We aimed to analyse the distribution of Fusarium species from a referral centre in Mexico with DNA sequencing and to describe AST to the clinical outcome.

METHODS

We conducted a retrospective study on clinical isolates of Fusarium. They were identified by translation elongation factor-1α gene amplification and sequencing. AST was performed to determine minimal inhibitory concentrations (MICs).

RESULTS

A total of 35 Fusarium isolates from 26 patients were included. The most common was Fusarium solani species complex (FSSC) in 51.5%, of which Fusarium petroliphilum and Fusarium oxysporum species complex were the most frequent with 37% and 20%, respectively. AST did not show MICs above the epidemiological cut-off value. Fusariosis was diagnosed in 19 patients, mostly with hematologic neoplasm; the overall mortality rate was 32%.

CONCLUSIONS

Fusarium petroliphilum from the FSSC was found most frequently. Elevated mortality and MICs for all tested antifungals were found, with higher MIC50 among F. solani SC than F. oxysporum SC or F. fujikuroi SC.

MRI differentiation of CNS fungal infections: correlating imaging features with microbiological and histopathological findings

PURPOSE

The study aims to evaluate the magnetic resonance (MR) features of central nervous system (CNS) fungal infections and determine the associations between these findings and the type of fungus. Our main objective was to assess whether imaging can serve as a predictor for identifying the specific group of fungi responsible for the infection using microbiology and histopathology as a benchmark.

MATERIALS AND METHODS

A retrospective analysis was done on 50 patients with proven CNS fungal infections. Fungal type was determined and grouped according to microbial classifications into four subtypes: hyalohyphomycetes, mucorales, yeasts and dematiaceous molds. MR findings were compared with histopathology/microbiology and associations between fungal groups were sought.

RESULTS

A total of 37 males and 13 females with a mean age of 39.3 years were included in the study. Aspergillus spp. infection (48%) was the most common. Most patients (54%) had an underlying risk factor for the infection. Pseudo-tumoral mass-like behavior was observed with Aspergillus, and the presence of meningitis was associated with yeast infections (p < 0.001). Of the 19 abscesses, 9 (47.3%) showed a dual rim sign on susceptibility-weighted imaging (SWI), and 10 (52.6%) showed intracavitary dot-like foci of dropouts on SWI. Both findings were statistically significant with dematiaceous molds (p = 0.04 and p = 0.009, respectively).

CONCLUSION

Although radiological characteristics are non-specific and can overlap with each type of fungi, our study shows that certain MR features can help radiologists point towards the causative type. More specifically, dot-like foci of susceptibility point towards abscesses caused by dematiaceous molds possibly owing to melanin pigment and metal chelation properties.

Acute Infusion-Related Side Effects of Amphotericin B Lipid Complex (ABLC) in Oncohematological Patients: Real-World Data from Brazilian Reference Centers

INTRODUCTION

Amphotericin B lipid complex (ABLC) is an effective antifungal agent for treating invasive fungal infections (IFIs) even though its formulation is associated with potential adverse events, including those related to its infusion. This study aimed to analyze the incidence of acute infusion-related side effects (IRSE) associated with ABLC and their relationship with the profile of patients with oncohematological disease admitted in Brazilian reference tertiary hospitals.

METHODS

This is an observational retrospective study that included clinical records of patients hospitalized, in a period of 6 years, diagnosed with probable or proved IFI and treated with at least two doses of ABLC.

RESULTS

A total of 229 patients were included, with a male prevalence and an average age of 44 years for adults and 10 years for children. Seventy-nine (34.5%) developed some IRSE, 5.1% of which progressed in severe form to discontinuation of treatment. The most prevalent events in adults were fever (66.7%), tremor/chills (53.3%), and tachycardia (24.4%). In children, the most common were fever (64.7%), tremors/chills (50%), and skin rash/itching (17.6%). Statistical significance was found for premedication use from the first dose of ABLC in relation to the onset of infusion reactions (P = 0.006). Multivariate analysis revealed that ABLC, when compared to liposomal AMB (L-AMB), and neutropenia were associated with a higher risk of developing IRSE (odds ratio [OR] 3.04, P = 0.008; and OR 11.02, P = 0.025, respectively).

CONCLUSIONS

The use of premedication was a protective factor against the occurrence of IRSE. Therefore, services providing amphotericin B (AMB) must reinforce protocols or implement new measures that optimize tolerability and safety during the treatment of patients with oncohematological disease, with special attention to patients with neutropenia, prioritizing the liposomal formulation of AMB whenever possible.

Viral reactivations and fungal infections in nonresolving acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a condition affecting 10% of patients requiring admission to the intensive care unit and results from endothelial dysfunction, alveolar epithelial injury and unbalanced inflammation, leading to exudative pulmonary oedema. A significant portion of these patients experience a lung injury that fails to resolve. Persistent or worsening respiratory failure beyond 5 days after the initiation of mechanical ventilation is referred to as nonresolving ARDS. Viral and fungal pathogens can exploit the hyperinflammatory environment and altered immune landscape in ARDS, perpetuating a cycle of ongoing inflammation and lung injury, thereby contributing to the progression towards and persistence of nonresolving ARDS, even in previously immunocompetent patients. This review discusses the significance, pathophysiology, diagnostic challenges and key knowledge gaps concerning various viral and fungal pathogens in nonresolving ARDS, with a particular focus on influenza-associated and COVID-19-associated pulmonary aspergillosis and pulmonary reactivation of Herpesviridae, such as cytomegalovirus and herpes simplex virus. Diagnosing these infections is challenging due to their nonspecific clinical presentation and the inability of current tests to distinguish between fungal colonisation or asymptomatic viral shedding and clinically significant infections or reactivations. A deeper understanding of the complex interplay between these pathogens and the host immune system in the context of ARDS, combined with advances in diagnostic and therapeutic strategies, has the potential to enhance the management and prognosis of patients with nonresolving ARDS.

Invasive Candidiasis in Pediatric Hematologic Malignancy: Increased Risk of Dissemination With Candida tropicalis

BACKGROUND

Candida species are the most common cause of invasive fungal disease, and children with hematologic malignancy are at increased risk. Non- albicans Candida (NAC) now account for more than half of all invasive candidiasis (IC) and carry a worse prognosis. We aimed to compare the epidemiology, risk factors, organ dissemination, biomarkers and outcomes in IC based on the species implicated and evaluate trends in antifungal resistance over time.

METHODS

Patients 0-18 years of age with hematologic malignancy and IC at 2 centers were included. Fifty-three patients from 2011 to 2022 were identified. Information related to demographics, host and risk factors, Candida species and antifungal susceptibilities, treatment and outcomes was collected via retrospective chart review. Data were analyzed at the species level.

RESULTS

The incidence rate of IC was 29 per 1000 patients with leukemia and lymphoma. The median time to infection from diagnosis of malignancy was 38 days. Candida tropicalis (n = 17; 30%) was the most identified species followed by Candida albicans (n = 14; 25%). Patients with C. tropicalis infection were more likely to have dissemination to the eyes ( P = 0.035), spleen ( P = 0.001) and skin ( P = 0.003) than patients with C. albicans or other NAC. Of the 34 patients who underwent dilated retinal examination, 24% (n = 8) had evidence of intraocular candidiasis. Seven of the 8 patients with intraocular disease had prolonged candidemia (3 or more days; P = 0.003). The 12-week crude mortality rate was 16.9%.

CONCLUSIONS

NAC, specifically C. tropicalis , accounted for most of the IC in children with hematological malignancies. Screening for intraocular candidiasis continues to play an important role in patients with IC, and future studies are needed to determine if screening can be limited to patients with select risk factors.

Histoplasma capsulatum var. duboisii: A Case of Histoplasmosis 50 Years After the Exposure

Histoplasmosis is a mycotic infection caused by Histoplasma capsulatum, a thermally dimorphic organism that presents two pathological variants in humans: H. capsulatum var. capsulatum and H. capsulatum var. duboisii. The latter is restricted to Africa, where both variants may coexist. H. capsulatum var. duboisii mainly affects the skin, subcutaneous tissues, and bone, with rare dissemination. Infections can exhibit prolonged latency, reactivating decades after exposure. This report describes a rare case of histoplasmosis due to H. capsulatum var. duboisii, including its laboratory approaches, in a 73-year-old immunocompetent male patient from Portugal who served in Angola in the 1970s. The patient presented with an exophytic gingival lesion that progressed over three months and a lesion on the left wrist joint. This case emphasizes the vital role of microbiological approaches in diagnosing histoplasmosis and highlights the need to consider it in individuals who have been in endemic regions, regardless of the temporal gap since exposure.

Clinical Features of COVID-19 Associated Pulmonary Aspergillosis: A Multicenter, Retrospective Study

OBJECTIVE

This study was conducted to further understand the clinical characteristics of COVID-19 associated pulmonary aspergillosis (CAPA).

METHODS

In this study, we conducted a multicenter retrospective survey, which included patients with COVID-19 from five hospitals in Zhejiang, China. A total of 197 patients with COVID-19 were included in the study. The detailed clinical data of seven patients with CAPA from COVID-19 onset to 28 days after CAPA were collected and analyzed.

RESULTS

In the total of 197 patients, 36 were admitted to the intensive care unit (ICU), 13 received mechanical ventilation; among them, nine received extracorporeal membrane oxygenation (ECMO). All seven cases acquired CAPA in the ICU, six cases during MV, of which five cases received ECMO treatment at the same time, and one case had been off ventilation. The average duration from onset of COVID-19 to CAPA was 25.4 days, from ICU admission to CAPA was 23.4 days, and from MV to CAPA was 22.1 days. All seven patients were diagnosed with CAPA without neutropenia, four with lymphopenia, seven with decreased CD4+ T lymphocyte, and five with decreased CD8+ T lymphocyte. All cases received glucocorticoids before CAPA, with an average duration of 15 days and an average cumulative dose of 762.5 mg prednisolone. In addition, all patients suffered bacterial infections and received antibacterial agents before CAPA, with an average duration of 22.6 days. CAPA was diagnosed according to a positive culture of Aspergillus fumigatus in sputum or bronchoalveolar lavage fluid (BALF) and positive serum 1,3-β-d-glucan in all seven patients; serum galactomannan was positive in three cases. Rhizopus was cultured from BALF of one case during treatment of CAPA. All patients received antifungal therapy, and the 28-day survival rate was 100%.

CONCLUSION

The incidence of CAPA in patients with COVID-19 admitted to the ICU was 19.44%, all patients with CAPA had a history of chronic underlying diseases, and all had a history of high dose glucocorticoid. Patients with CAPA had no specific clinical symptoms and lung imaging manifestations, and diagnosis depended on Aspergillus culture and galactomannan detection. For patients with COVID-19 with these high-risk factors, Aspergillus culture and GM testing should be performed actively to avoid delaying the diagnosis of CAPA.

Metagenomic next-generation sequencing and galactomannan testing for the diagnosis of invasive pulmonary aspergillosis

To evaluate the diagnostic value of metagenomic next-generation sequencing (mNGS) and galactomannan (GM) testing in invasive pulmonary aspergillosis (IPA) and to compare mNGS with other diagnostic approaches (serum/bronchoalveolar lavage fluid (BALF)-GM and conventional microbiological tests (CMTs) including sputum smears and culture, BALF fungal culture, and bronchial brushing). In all, 237 patients were enrolled in this retrospective study, including 120 patients with IPA and 117 with non-IPA pulmonary infections treated at Henan Provincial People's Hospital between June 2021 and February 2024. The diagnostic performance of mNGS was compared to conventional diagnostic methods including serum GM, BALF-GM, sputum smear microscopy, sputum culture, bronchial brushings, and BALF culture. The proportion of patients with underlying diseases was significantly higher in the IPA group than in the non-IPA group (P < 0.05). Compared to conventional diagnostic methods for IPA, mNGS showed higher diagnostic efficacy, with a sensitivity of 92.5% and a specificity of 94.02%. The area under the receiver operating characteristic curve (AUC) for BALF-GM for diagnosing IPA was 0.8, with an optimal cutoff value of 0.546, sensitivity of 66.7%, and specificity of 82.1%. The combination of mNGS and BALF-GM testing further improved diagnostic performance (sensitivity of 96.67% and specificity of 78.63%). mNGS testing has excellent diagnostic efficacy for IPA, which is further enhanced by combining it with BALF-GM testing. This approach has considerable potential for the early diagnosis and targeted treatment of IPA.

Cryptococcus neoformans/gattii and Histoplasma capsulatum var. capsulatum infections on tissue sections: Diagnostic pitfalls and relevance of an integrated histomolecular diagnosis

Cryptococcus neoformans/gattii and Histoplasma capsulatum var. capsulatum may present atypical histopathological features inducing diagnostic errors. We aimed to estimate the frequency of these atypical features in formalin-fixed tissue (FT) samples and to assess the relevance of an integrated histomolecular diagnosis using specific H. capsulatum PCR and panfungal PCR followed by Sanger sequencing and/or targeted massive parallel sequencing (MPS). A total of 27 FT from 23 patients with a histopathological diagnosis of cryptococcosis (n = 16 FT from 13 patients) or histoplasmosis (n = 11 FT from 10 patients) were retrospectively included. All FT were consultation cases. Mycological identifications on equivalent fresh tissue were available for 11/23 (47.8%) patients. The expert pathologist review modified the diagnosis suggested by the initial pathologist in 7/27 (25.9%) FT. Fungal morphology and tissue inflammation were compared between both mycoses. The most discriminant atypical criterion was the presence of dented-looking yeasts, observed in 68.75% (11/16) of C. neoformans/gattii and none (0/11) of H. capsulatum var. capsulatum (P = .002). For the 12/23 (52.2%) patients without mycological identification on fresh tissue, an integrated histomolecular diagnosis on FT using specific PCR or panfungal PCR followed by Sanger sequencing and/or MPS led to fungal identification in 9/12 (75%) cases; for cryptococcosis, the targeted MPS sensitivity was higher than that of Sanger sequencing (P = .041). Thus, because atypical histopathological features may be tricky, integrated histomolecular diagnosis is essential for optimal patient care.