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2016 guideline strategies for the use of antifungal agents in patients with hematological malignancies or hematopoietic stem cell transplantation recipients in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:287-301. [PMID: 28781151 DOI: 10.1016/j.jmii.2017.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/12/2017] [Indexed: 12/11/2022]
Abstract
The Infectious Diseases Society of Taiwan (IDST), the Hematology Society of Taiwan, the Taiwan Society of Blood and Marrow Transplantation, Medical Foundation in Memory of Dr. Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines cooperatively published this guideline for the use of antifungal agents in hematological patients with invasive fungal diseases (IFDs) in Taiwan. The guideline is the first one endorsed by IDST focusing on selection of antifungal strategies, including prophylaxis, empirical (or symptom-driven) and pre-emptive (or diagnostic-driven) strategy. We suggest a risk-adapted dynamic strategy and provide an algorithm to facilitate decision making in population level as well as for individual patient. Risk assessment and management accordingly is explicitly emphasized. In addition, we highlight the importance of diagnosis in each antifungal strategy among five elements of the antimicrobial stewardship (diagnosis, drug, dose, de-escalation and duration). The rationale, purpose, and key recommendations for the choice of antifungal strategy are summarized, with concise review of international guidelines or recommendation, key original articles and local epidemiology reports. We point out the interaction and influence between elements of recommendations and limitation of and gap between evidences and daily practice. The guideline balances the quality of evidence and feasibility of recommendation in clinical practice. Finally, this version introduces the concept of health economics and provides data translated from local disease burdens. All these contents hopefully facilitate transparency and accountability in medical decision-making, improvements in clinical care and health outcomes, and appropriateness of medical resource allocation.
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Mercier T, Maertens J. Clinical considerations in the early treatment of invasive mould infections and disease. J Antimicrob Chemother 2017; 72:i29-i38. [PMID: 28355465 DOI: 10.1093/jac/dkx031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Different therapeutic strategies for invasive fungal diseases have been explored, each with particular strengths and weaknesses. Broad-spectrum antifungal prophylaxis seems logical, but selective use is important due to its substantial disadvantages, including interference with diagnostic assays, selection for resistance, drug toxicity and drug-drug interactions. Antimould prophylaxis should be restricted to high-risk groups, such as patients undergoing intensive chemotherapy for acute myeloid leukaemia or myelodysplastic syndrome, allogeneic HSCT patients with prior invasive fungal infection, graft-versus-host-disease or extended neutropenia, recipients of a solid organ transplant, or patients with a high-risk inherited immunodeficiency. An empirical approach, whereby mould-active therapy is started in neutropenic patients with fever unresponsive to broad-spectrum antibiotics, is widely applied but incurs the clinical and cost penalties associated with overtreatment. A benefit for all-cause mortality using empirical therapy has not been shown, but it is recommended for high-risk patients who remain febrile after 4-7 days of broad-spectrum antibiotics and in whom extended neutropenia is anticipated. There is growing interest in delaying antifungal treatment until an invasive fungal infection is confirmed ('pre-emptive' or 'diagnostics-driven' management), prompted by the development of more sensitive diagnostic techniques. Comparisons of empirical versus pre-emptive regimens are sparse, particularly with modern triazole agents, but treatment costs are lower with pre-emptive therapy and the available evidence has not indicated reduced efficacy. Pre-emptive treatment may be appropriate in neutropenic patients who remain febrile after administration of broad-spectrum antibiotics but who are clinically stable. Further work is required to define accurately the specific patient subgroups in which each management approach is optimal.
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Springer J, Lackner M, Ensinger C, Risslegger B, Morton CO, Nachbaur D, Lass-Flörl C, Einsele H, Heinz WJ, Loeffler J. Clinical evaluation of a Mucorales-specific real-time PCR assay in tissue and serum samples. J Med Microbiol 2016; 65:1414-1421. [PMID: 27902424 DOI: 10.1099/jmm.0.000375] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Molecular diagnostic assays can accelerate the diagnosis of fungal infections and subsequently improve patient outcomes. In particular, the detection of infections due to Mucorales is still challenging for laboratories and physicians. The aim of this study was to evaluate a probe-based Mucorales-specific real-time PCR assay (Muc18S) using tissue and serum samples from patients suffering from invasive mucormycosis (IMM). This assay can detect a broad range of clinically relevant Mucorales species and can be used to complement existing diagnostic tests or to screen high-risk patients. An advantage of the Muc18S assay is that it exclusively detects Mucorales species allowing the diagnosis of Mucorales DNA without sequencing within a few hours. In paraffin-embedded tissue samples this PCR-based method allowed rapid identification of Mucorales in comparison with standard methods and showed 91 % sensitivity in the IMM tissue samples. We also evaluated serum samples, an easily accessible material, from patients at risk from IMM. Mucorales DNA was detected in all patients with probable/proven IMM (100 %) and in 29 % of the possible cases. Detection of IMM in serum could enable an earlier diagnosis (up to 21 days) than current methods including tissue samples, which were gained mainly post-mortem. A screening strategy for high-risk patients, which would enable targeted treatment to improve patient outcomes, is therefore possible.
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Affiliation(s)
- Jan Springer
- Department for Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Michaela Lackner
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Christian Ensinger
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Brigitte Risslegger
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | | | - David Nachbaur
- University Hospital of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Hermann Einsele
- Department for Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Werner J Heinz
- Department for Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Juergen Loeffler
- Department for Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
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Ceesay MM, Kordasti S, Rufaie E, Lea N, Smith M, Wade J, Douiri A, Mufti GJ, Pagliuca A. Baseline cytokine profiling identifies novel risk factors for invasive fungal disease among haematology patients undergoing intensive chemotherapy or haematopoietic stem cell transplantation. J Infect 2016; 73:280-8. [PMID: 27343564 DOI: 10.1016/j.jinf.2016.04.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/16/2016] [Accepted: 04/20/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Invasive fungal disease (IFD) is a disease of immunocompromised hosts. Cytokines are important mediators of innate and adaptive immune system. The aim of this study was to identify cytokine profiles that correlate with increased risk of IFD. METHODS We prospectively enrolled 172 adult haematology patients undergoing intensive chemotherapy, immunosuppressive therapy, and haematopoietic stem cell transplantation. Pro-inflammatory cytokine profiling using 30-plex Luminex assay was performed at baseline and during treatment. Nine single nucleotide polymorphisms (TLR1, TLR2, TLR3, TLR4.1, TLR4.2, TLR6, CLEC7A, CARD9, and INFG) were investigated among transplant recipients and donors. FINDINGS The incidence of IFD in this cohort was 16.9% (29/172). Median baseline serum concentrations of IL-15, IL-2R, CCL2, and MIP-1α were significantly higher whilst IL-4 was lower in patients with proven/probable IFD compared to those with no evidence of IFD. Baseline high IL-2R and CCL2 were associated with increased risk of IFD in the multivariate analysis (adjusted hazard ratio 2.3 [95% CI 1.1-5.1; P = 0.037], and hazard ratio 2.7 [95% CI 1.2-6.1; P = 0.016], respectively). However, these differences were not significant in follow up measurements. Similarly, no significant independent prognostic value was associated with baseline cytokine profile. INTERPRETATION High baseline IL-2R and CCL2 concentrations were independent indicators of the risk of developing IFD and could be used to identify patients for enhanced prophylaxis and early antifungal therapy.
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Affiliation(s)
- M Mansour Ceesay
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom.
| | - Shahram Kordasti
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom
| | - Eamaan Rufaie
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom
| | - Nicholas Lea
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom
| | - Melvyn Smith
- Department of Virology, King's College Hospital NHS Foundation Trust, SE5 9RS, United Kingdom
| | - Jim Wade
- Department of Microbiology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, United Kingdom
| | - Abdel Douiri
- Department of Public Health Science, King's College London and NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and King's College London, London, SE5 9RS, United Kingdom
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Lichtheimia Infection in a Lymphoma Patient: Case Report and a Brief Review of the Available Diagnostic Tools. Mycopathologia 2016; 181:561-6. [PMID: 27115610 DOI: 10.1007/s11046-016-0010-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/17/2016] [Indexed: 10/21/2022]
Abstract
We describe the case of a patient with a T-lymphoblastic lymphoma whose disseminated mucormycosis was diagnosed with delay, and we address the diagnostic and therapeutic decision-making process and review the diagnostic workup of patients with potential IFD. The diagnosis was delayed despite a suggestive radiological presentation of the patient's pulmonary lesion. The uncommon risk profile (T-lymphoblastic lymphoma, short neutropenic phases) wrongly led to a low level of suspicion. The diagnosis was also hampered by the lack of indirect markers for infections caused by Mucorales, the low sensitivity of both fungal culture and panfungal PCR, and the limited availability of species-specific PCR. A high level of suspicion of IFD is needed, and aggressive diagnostic procedures should be promptly initiated even in apparently low-risk patients with uncommon presentations. The extent of the analytical workup should be decided on a case-by-case base. Diagnostic tests such as the galactomannan and β-D-glucan test and/or PCR on biological material followed by sequencing should be chosen according to their availability and after evaluation of their specificity and sensitivity. In high-risk patients, preemptive therapy with a broad-spectrum mould-active antifungal agent should be started before definitive diagnostic findings become available.
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Kontoyiannis DP, Lewis RE. Treatment principles for the management of mold infections. Cold Spring Harb Perspect Med 2014; 5:cshperspect.a019737. [PMID: 25377139 DOI: 10.1101/cshperspect.a019737] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Survival rates among immunocompromised patients with invasive mold infections have markedly improved over the last decade with earlier diagnosis and new antifungal treatment options. Yet, increasing antifungal resistance, breakthrough infections with intrinsically resistant fungi, and potentially life-threatening adverse effects and drug interactions are becoming more problematic, especially with prolonged therapy. Evidence-based recommendations for treating invasive aspergillosis and mucormycosis provide excellent guidance on the initial workup and treatment of these molds, but they cannot address all of the key management issues. Herein, we discuss 10 general treatment principles in the management of invasive mold disease in immunocompromised patients and discuss how these principles can be integrated to develop an effective, individualized treatment plan.
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Affiliation(s)
| | - Russell E Lewis
- Department of Medical Sciences and Surgery, University of Bologna, 40138 Bologna, Italy
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Desoubeaux G, Bailly É, Chandenier J. Diagnosis of invasive pulmonary aspergillosis: Updates and recommendations. Med Mal Infect 2014; 44:89-101. [DOI: 10.1016/j.medmal.2013.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 09/15/2013] [Accepted: 11/18/2013] [Indexed: 01/26/2023]
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Desoubeaux G, Jourdan ML, Valera L, Jardin B, Hem S, Caille A, Cormier B, Marchand-Adam S, Bailly É, Diot P, Chandenier J. Proteomic demonstration of the recurrent presence of inter-alpha-inhibitor H4 heavy-chain during aspergillosis induced in an animal model. Int J Med Microbiol 2013; 304:327-38. [PMID: 24360996 DOI: 10.1016/j.ijmm.2013.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 11/07/2013] [Accepted: 11/25/2013] [Indexed: 11/30/2022] Open
Abstract
Invasive pulmonary aspergillosis remains a matter of great concern in oncology/haematology, intensive care units and organ transplantation departments. Despite the availability of various diagnostic tools with attractive features, new markers of infection are required for better medical care. We therefore looked for potential pulmonary biomarkers of aspergillosis, by carrying out two-dimensional (2D) gel electrophoresis comparing the proteomes of bronchial-alveolar lavage fluids (BALF) from infected rats and from control rats presenting non-specific inflammation, both immunocompromised. A bioinformatic analysis of the 2D-maps revealed significant differences in the abundance of 20 protein spots (ANOVA P-value<0.01; q-value<0.03; power>0.8). One of these proteins, identified by mass spectrometry, was considered of potential interest: inter-alpha-inhibitor H4 heavy-chain (ITIH4), characterised for the first time in this infectious context. Western blotting confirmed its overabundance in all infected BALF, particularly at early stages of murine aspergillosis. Further investigations were carried on rat serum, and confirmed that ITIH4 levels increased during experimental aspergillosis. Preliminary results in human samples strengthened this trend. To our knowledge, this is the first description of the involvement of ITIH4 in aspergillosis.
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Affiliation(s)
- Guillaume Desoubeaux
- CHU de Tours, Service de Parasitologie - Mycologie - Médecine tropicale, Tours, France; Université François Rabelais, CEPR UMR-INSERM U1100/E.A. 6305, Faculté de Médecine, Tours, France.
| | - Marie-Lise Jourdan
- CHU de Tours, Service d'Hématologie Biologique, Tours, France; Université François Rabelais, INSERM U1069/N2C, Faculté de Médecine, Tours, France
| | - Lionel Valera
- Sysdiag, CNRS UMR 3145 Bio-Rad, Cap Delta, Montpellier, France
| | | | - Sonia Hem
- Plateforme de spectrométrie de masse protéomique - MSPP, Laboratoire de Protéomique Fonctionnelle, INRA UR1199, Montpellier, France
| | - Agnès Caille
- CHU de Tours, Centre d'Investigation Clinique, Tours, France; Université François Rabelais, INSERM 202, Faculté de Médecine, Tours, France
| | - Bénédicte Cormier
- CHU de Tours, Service d'Anatomie et Cytologie Pathologiques, Tours, France
| | - Sylvain Marchand-Adam
- Université François Rabelais, CEPR UMR-INSERM U1100/E.A. 6305, Faculté de Médecine, Tours, France; CHU de Tours, Service de Pneumologie, Tours, France
| | - Éric Bailly
- CHU de Tours, Service de Parasitologie - Mycologie - Médecine tropicale, Tours, France
| | - Patrice Diot
- Université François Rabelais, CEPR UMR-INSERM U1100/E.A. 6305, Faculté de Médecine, Tours, France; CHU de Tours, Service de Pneumologie, Tours, France
| | - Jacques Chandenier
- CHU de Tours, Service de Parasitologie - Mycologie - Médecine tropicale, Tours, France; Université François Rabelais, CEPR UMR-INSERM U1100/E.A. 6305, Faculté de Médecine, Tours, France
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Bruyère F, Desoubeaux G, Malavaud S, Fourcade C, Chandenier J, Lachaud L, Guy L, Karsenty G, Bastide C, Lavigne JP, Sotto A. [Non-antibiotic anti-infectious treatments in urology]. Prog Urol 2013; 23:1342-56. [PMID: 24183092 DOI: 10.1016/j.purol.2013.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To define the terms of use of pesticides, antifungal, antiviral and antiseptic treatments in urology. MATERIALS AND METHODS A literature search was conducted on MEDLINE for all these treatments used in urology. The molecules were classified by family. Modes of action, indications in urology and adverse effects have been detailed. Authorisation files were consulted and then complemented by a literature analysis. RESULTS Although parasitic or viral diseases are uncommon in urology, their specific treatment deserves a thorough knowledge of pesticide and antiviral molecules. Antifungal treatments are regularly used in urology with special features to know to improve the efficacy/safety ratio. Antiseptics are used daily in urology and a better understanding of these molecules allows better use. CONCLUSION Beyond antibiotics, antiviral, antiparasitic and antifungal deserve a thorough knowledge. Antiseptic although used daily have features little known.
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Affiliation(s)
- F Bruyère
- Service d'urologie, CHRU Bretonneau, 2, boulevard Tonnellé, 37044 Tours cedex, France; Université François-Rabelais de Tours, PRES Centre Val-de-Loire université, 37000 Tours, France.
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Stanzani M, Lewis RE, Fiacchini M, Ricci P, Tumietto F, Viale P, Ambretti S, Baccarani M, Cavo M, Vianelli N. A risk prediction score for invasive mold disease in patients with hematological malignancies. PLoS One 2013; 8:e75531. [PMID: 24086555 PMCID: PMC3784450 DOI: 10.1371/journal.pone.0075531] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/14/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A risk score for invasive mold disease (IMD) in patients with hematological malignancies could facilitate patient screening and improve the targeted use of antifungal prophylaxis. METHODS We retrospectively analyzed 1,709 hospital admissions of 840 patients with hematological malignancies (2005-2008) to collect data on 17 epidemiological and treatment-related risk factors for IMD. Multivariate regression was used to develop a weighted risk score based on independent risk factors associated with proven or probable IMD, which was prospectively validated during 1,746 hospital admissions of 855 patients from 2009-2012. RESULTS Of the 17 candidate variables analyzed, 11 correlated with IMD by univariate analysis, but only 4 risk factors (neutropenia, lymphocytopenia or lymphocyte dysfunction in allogeneic hematopoietic stem cell transplant recipients, malignancy status, and prior IMD) were retained in the final multivariate model, resulting in a weighted risk score 0-13. A risk score of < 6 discriminated patients with low (< 1%) versus higher incidence rates (> 5%) of IMD, with a negative predictive value (NPV) of 0.99, (95% CI 0.98-0.99). During 2009-2012, patients with a calculated risk score at admission of < 6 had significantly lower 90-day incidence rates of IMD compared to patients with scores > 6 (0.9% vs. 10.6%, P <0.001). CONCLUSION An objective, weighted risk score for IMD can accurately discriminate patients with hematological malignancies at low risk for developing mold disease, and could possibly facilitate "screening-out" of low risk patients less likely to benefit from intensive diagnostic monitoring or mold-directed antifungal prophylaxis.
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Affiliation(s)
- Marta Stanzani
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
- * E-mail:
| | - Russell E. Lewis
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mauro Fiacchini
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Ricci
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Fabio Tumietto
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simone Ambretti
- Operative Unit of Microbiology, Department of Hematology, Oncology and Laboratory Medicine, S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Michele Baccarani
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Nicola Vianelli
- Institute of Hematology, Department of Hematology and Clinical Oncology, “Lorenzo e Ariosto Seràgnoli” S’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Barnes RA, Stocking K, Bowden S, Poynton MH, White PL. Prevention and diagnosis of invasive fungal disease in high-risk patients within an integrative care pathway. J Infect 2013; 67:206-14. [DOI: 10.1016/j.jinf.2013.04.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 03/06/2013] [Accepted: 04/26/2013] [Indexed: 10/26/2022]
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Barton RC. Laboratory diagnosis of invasive aspergillosis: from diagnosis to prediction of outcome. SCIENTIFICA 2013; 2013:459405. [PMID: 24278780 PMCID: PMC3820361 DOI: 10.1155/2013/459405] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/14/2012] [Indexed: 06/02/2023]
Abstract
Invasive aspergillosis (IA), an infection caused by fungi in the genus Aspergillus, is seen in patients with immunological deficits, particularly acute leukaemia and stem cell transplantation, and has been associated with high rates of mortality in previous years. Diagnosing IA has long been problematic owing to the inability to culture the main causal agent A. fumigatus from blood. Microscopic examination and culture of respiratory tract specimens have lacked sensitivity, and biopsy tissue for histopathological examination is rarely obtainable. Thus, for many years there has been a great interest in nonculture-based techniques such as the detection of galactomannan, β -D-glucan, and DNA by PCR-based methods. Recent meta-analyses suggest that these approaches have broadly similar performance parameters in terms of sensitivity and specificity to diagnose IA. Improvements have been made in our understanding of the limitations of antigen assays and the standardisation of PCR-based DNA detection. Thus, in more recent years, the debate has focussed on how these assays can be incorporated into diagnostic strategies to maximise improvements in outcome whilst limiting unnecessary use of antifungal therapy. Furthermore, there is a current interest in applying these tests to monitor the effectiveness of therapy after diagnosis and predict clinical outcomes. The search for improved markers for the early and sensitive diagnosis of IA continues to be a challenge.
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Affiliation(s)
- Richard C. Barton
- Mycology Reference Centre, Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds LS1 3EX, UK
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