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Coyle V, Forde C, McAuley DF, Wilson RH, Clarke M, Plummer R, Grayson M, McDowell C, Agus A, Doran A, Thomas AL, Barnes RA, Adams R, Chau I, Storey D, McMullan R. Early switch to oral antibiotic therapy in patients with low-risk neutropenic sepsis (EASI-SWITCH): a randomized non-inferiority trial. Clin Microbiol Infect 2024; 30:92-99. [PMID: 37517522 DOI: 10.1016/j.cmi.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To determine whether early switch to oral antibiotic treatment in adults with neutropenic sepsis at low risk of complications is non-inferior to switching later. METHODS This non-inferiority, parallel-group, randomized, open-label clinical trial enrolled UK adults hospitalized with neutropenic sepsis. Participants were randomly assigned to either switch to oral ciprofloxacin plus co-amoxiclav within 12-24 hours or to continue intravenous treatment for at least 48 hours. The primary outcome was a composite measure of treatment failure, 14 days after randomization. The non-inferiority margin was 15%. RESULTS There were 129 participants from 16 centres and 125 were assessed for the primary outcome. Of these, 113 patients completed protocolized treatment and comprised the per-protocol population. In total, 9 (14.1%) of 64 patients in the standard care arm met the primary end point, compared with 15 (24.6%) of 61 in the early switch arm, giving a risk difference of 10.5% (1-sided 95% CI, -∞% to 22%; p 0.14). In the per-protocol population, 8 (13.3%) of the 60 patients in the standard care arm met the primary end point, compared with 9 (17%) of 53 in the intervention arm giving a risk difference of 3.7% (one-sided 95% CI, -∞% to 14.8%; p 0.59). Duration of hospital stay was shorter in the intervention arm (median 2 [inter-quartile range (IQR) 2-3] vs. 3 days [IQR 2-4]; p 0.002). DISCUSSION Although non-inferiority of early oral switch was found in the per-protocol population, the intervention was not non-inferior in the intent-to-treat population.
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Affiliation(s)
- Vicky Coyle
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Caroline Forde
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Richard H Wilson
- Translational Research Centre, University of Glasgow, Glasgow, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen's University Belfast, Belfast, UK; Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ruth Plummer
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | | | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Anne L Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Rosemary A Barnes
- Cardiff University School of Medicine, Centre for Trials Research, Cardiff, UK
| | - Richard Adams
- Cardiff University School of Medicine, Centre for Trials Research, Cardiff, UK; Velindre NHS Trust, Department of medical oncology, Cardiff, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, Gastrointestinal and lymphoma unit, London, UK
| | - Dawn Storey
- The Beatson West of Scotland Cancer Centre, Department of medical oncology, Glasgow, UK
| | - Ronan McMullan
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
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Cruciani M, White PL, Barnes RA, Loeffler J, Donnelly JP, Rogers TR, Heinz WJ, Warris A, Morton CO, Lengerova M, Klingspor L, Sendid B, Lockhart DEA. An Overview of Systematic Reviews of Polymerase Chain Reaction (PCR) for the Diagnosis of Invasive Aspergillosis in Immunocompromised People: A Report of the Fungal PCR Initiative (FPCRI)-An ISHAM Working Group. J Fungi (Basel) 2023; 9:967. [PMID: 37888223 PMCID: PMC10607919 DOI: 10.3390/jof9100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/11/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
This overview of reviews (i.e., an umbrella review) is designed to reappraise the validity of systematic reviews (SRs) and meta-analyses related to the performance of Aspergillus PCR tests for the diagnosis of invasive aspergillosis in immunocompromised patients. The methodological quality of the SRs was assessed using the AMSTAR-2 checklist; the quality of the evidence (QOE) within each SR was appraised following the GRADE approach. Eight out of 12 SRs were evaluated for qualitative and quantitative assessment. Five SRs evaluated Aspergillus PCR on bronchoalveolar lavage fluid (BAL) and three on blood specimens. The eight SRs included 167 overlapping reports (59 evaluating PCR in blood specimens, and 108 in BAL), based on 107 individual primary studies (98 trials with a cohort design, and 19 with a case-control design). In BAL specimens, the mean sensitivity and specificity ranged from 0.57 to 0.91, and from 0.92 to 0.97, respectively (QOE: very low to low). In blood specimens (whole blood or serum), the mean sensitivity ranged from 0.57 to 0.84, and the mean specificity from 0.58 to 0.95 (QOE: low to moderate). Across studies, only a low proportion of AMSTAR-2 critical domains were unmet (1.8%), demonstrating a high quality of methodological assessment. Conclusions. Based on the overall methodological assessment of the reviews included, on average we can have high confidence in the quality of results generated by the SRs.
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Affiliation(s)
| | - P. Lewis White
- Public Health Wales, Microbiology Cardiff, UK and Centre for Trials Research, Division of Infection and Immunity, Cardiff University, Cardiff CF14 4XW, UK;
| | | | - Juergen Loeffler
- Department of Internal Medicine II, University Hospital of Würzburg, 97070 Würzburg, Germany
| | | | - Thomas R. Rogers
- Discipline of Clinical Microbiology, Trinity College Dublin, St. James’s Hospital Campus, LS9 7TF Dublin, Ireland;
| | - Werner J. Heinz
- Medicine Clinic II, Caritas Hospital Bad Mergentheim, 97980 Bad Mergentheim, Germany
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter EX4 4QJ, UK;
| | - Charles Oliver Morton
- School of Science, Western Sydney University, Campbelltown Campus, Campbelltown, NSW 2751, Australia;
| | - Martina Lengerova
- Central European Institute of Technology, Masaryk University, 60177 Brno, Czech Republic
| | - Lena Klingspor
- Department of Laboratory Medicine, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Boualem Sendid
- Inserm U1285, CNRS UMR 8576, UGSF, CHU Lille, Laboratoire de Parasitologie-Mycologie, University of Lille, 59000 Lille, France;
| | - Deborah E. A. Lockhart
- Institute of Medical Sciences, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB24 3FX, UK
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White PL, Alanio A, Brown L, Cruciani M, Hagen F, Gorton R, Lackner M, Millon L, Morton CO, Rautemaa-Richardson R, Barnes RA, Donnelly JP, Loffler J. An overview of using fungal DNA for the diagnosis of invasive mycoses. Expert Rev Mol Diagn 2022; 22:169-184. [PMID: 35130460 DOI: 10.1080/14737159.2022.2037423] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fungal PCR has undergone considerable standardization and together with the availability of commercial assays, external quality assessment schemes and extensive performance validation data, is ready for widespread use for the screening and diagnosis of invasive fungal disease (IFD). AREAS COVERED Drawing on the experience and knowledge of the leads of the various working parties of the Fungal PCR initiative, this review will address general considerations concerning the use of molecular tests for the diagnosis of IFD, before focussing specifically on the technical and clinical aspects of molecular testing for the main causes of IFD and recent technological developments. EXPERT OPINION For infections caused by Aspergillus, Candida and Pneumocystis jirovecii, PCR testing is recommended, combination with serological testing will likely enhance the diagnosis of these diseases. For other IFD (e.g. Mucormycosis) molecular diagnostics, represent the only non-classical mycological approach towards diagnoses and continued performance validation and standardization has improved confidence in such testing. The emergence of antifungal resistance can be diagnosed, in part, through molecular testing. Next-generation sequencing has the potential to significantly improve our understanding of fungal phylogeny, epidemiology, pathogenesis, mycobiome/microbiome and interactions with the host, while identifying novel and existing mechanisms of antifungal resistance and novel diagnostic/therapeutic targets.
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Affiliation(s)
- P Lewis White
- Public Health Wales Microbiology Cardiff, UHW, Cardiff, UK CF14 4XW
| | - Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Lariboisière, Saint-Louis, Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris, France.,Institut Pasteur, CNRS UMR2000, Unité de Mycologie Moléculaire, Centre National de Reference Mycoses invasives et Antifongiques, Paris, France
| | - Lottie Brown
- NHS Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands & Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rebecca Gorton
- Dept. of Infection Sciences, Health Services Laboratories (HSL) LLP, London, UK
| | - Michaela Lackner
- Institute of Hygiene and Medical Microbiology, Department of Hygiene, Medical Microbiology and Publics Health, Medical University Innsbruck, Innsbruck, Austria
| | - Laurence Millon
- Parasitology-Mycology Department, University Hospital of Besançon, 25000 Besançon, France.,UMR 6249 CNRS Chrono-Environnement, University of Bourgogne Franche-Comté, 25000 Besançon, France
| | - C Oliver Morton
- Western Sydney University, School of Science, Campbelltown, NSW 2560, Australia
| | - Riina Rautemaa-Richardson
- NHS Mycology Reference Centre Manchester, ECMM Centre of Excellence, Manchester University NHS Foundation Trust, Wythenshawe Hospital; and Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | | | - Juergen Loffler
- Department of Internal Medicine II, WÜ4i, University Hospital Wuerzburg, Wuerzburg, Germany
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Rocchi S, Scherer E, Mengoli C, Alanio A, Botterel F, Bougnoux ME, Bretagne S, Cogliati M, Cornu M, Dalle F, Damiani C, Denis J, Fuchs S, Gits-Muselli M, Hagen F, Halliday C, Hare R, Iriart X, Klaassen C, Lackner M, Lengerova M, Letscher-Bru V, Morio F, Nourrisson C, Posch W, Sendid B, Springer J, Willinger B, White PL, Barnes RA, Cruciani M, Donnelly JP, Loeffler J, Millon L. Interlaboratory evaluation of Mucorales PCR assays for testing serum specimens: A study by the fungal PCR Initiative and the Modimucor study group. Med Mycol 2021; 59:126-138. [PMID: 32534456 DOI: 10.1093/mmy/myaa036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/14/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
Interlaboratory evaluations of Mucorales qPCR assays were developed to assess the reproducibility and performance of methods currently used. The participants comprised 12 laboratories from French university hospitals (nine of them participating in the Modimucor study) and 11 laboratories participating in the Fungal PCR Initiative. For panel 1, three sera were each spiked with DNA from three different species (Rhizomucor pusillus, Lichtheimia corymbifera, Rhizopus oryzae). For panel 2, six sera with three concentrations of R. pusillus and L. corymbifera (1, 10, and 100 genomes/ml) were prepared. Each panel included a blind negative-control serum. A form was distributed with each panel to collect results and required technical information, including DNA extraction method, sample volume used, DNA elution volume, qPCR method, qPCR template input volume, qPCR total reaction volume, qPCR platform, and qPCR reagents used. For panel 1, assessing 18 different protocols, qualitative results (positive or negative) were correct in 97% of cases (70/72). A very low interlaboratory variability in Cq values (SD = 1.89 cycles) were observed. For panel 2 assessing 26 different protocols, the detection rates were high (77-100%) for 5/6 of spiked serum. There was a significant association between the qPCR platform and performance. However, certain technical steps and optimal combinations of factors may also impact performance. The good reproducibility and performance demonstrated in this study support the use of Mucorales qPCR as part of the diagnostic strategy for mucormycosis.
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Affiliation(s)
- S Rocchi
- Parasitology - Mycology, University Hospital Besançon, Besançon, France.,UMR6249 CNRS Chrono-Environnement, University of Bourgogne Franche-Comté, Besançon, Besançon, France
| | - E Scherer
- Parasitology - Mycology, University Hospital Besançon, Besançon, France.,UMR6249 CNRS Chrono-Environnement, University of Bourgogne Franche-Comté, Besançon, Besançon, France
| | - C Mengoli
- Molecular Medicine, University of Padova, Padova, Italy
| | - A Alanio
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals (NRCMA), Molecular Mycology Unit, UMR2000, Paris, France.,Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, France
| | - F Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine de Créteil, 8 rue du Général Sarrail 94010 Créteil, France.,Unité de Parasitologie - Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, AP-HP, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - M E Bougnoux
- Parasitology-Mycology Unit, Necker Enfants Malades Hospital, APHP, Paris, France.,Fungal Biology and Pathogenicity Unit - INRA USC 2019. Institut Pasteur, Paris, France
| | - S Bretagne
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals (NRCMA), Molecular Mycology Unit, UMR2000, Paris, France.,Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, France
| | - M Cogliati
- Lab. Medical Mycology, Dip. Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy
| | - M Cornu
- Inserm U1285, Univ. Lille, UMR CNRS 8576- UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, F-59000, Lille, France
| | - F Dalle
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, Dijon France.,UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - C Damiani
- Laboratoire de Parasitologie et Mycologie Médicales, Centre de Biologie Humaine, CHU Amiens Picardie, France.,Equipe AGIR: Agents Infectieux, Résistance et Chimiothérapie UR4294, Université de Picardie Jules Verne, Amiens, France
| | - J Denis
- Laboratoire de Parasitologie et de Mycologie Médicale, Hôpitaux Universitaires de Strasbourg. 1 Place de l'Hôpital, 67000 Strasbourg, France
| | - S Fuchs
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Gits-Muselli
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, France
| | - F Hagen
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Medical Mycology, Jining No. 1 People's Hospital, Jining, Shandong, People's Republic of China
| | - C Halliday
- Clinical Mycology Reference Laboratory, Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, NSW Health Pathology, Westmead, NSW, 2145, Australia
| | - R Hare
- Mycology Unit, Department for Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - X Iriart
- Service de Parasitologie-Mycologie, CHU Toulouse, Toulouse, France.,Centre de Physiopathologie de Toulouse Purpan (CPTP), Université de Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - C Klaassen
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - M Lackner
- Institut for Hygiene and Medical Microbiology, Medical University of Innsbruck (MUI), Austria
| | - M Lengerova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - V Letscher-Bru
- Laboratoire de Parasitologie et de Mycologie Médicale, Hôpitaux Universitaires de Strasbourg. 1 Place de l'Hôpital, 67000 Strasbourg, France
| | - F Morio
- Laboratoire de Parasitologie-Mycologie, CHU Nantes, Nantes, France.,Département de Parasitologie et Mycologie Médicale, EA1155 - IICiMed, Nantes Université, Nantes, France
| | - C Nourrisson
- Laboratoire de Parasitologie-Mycologie, CHU Clermont-Ferrand, 3IHP, France
| | - W Posch
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - B Sendid
- Inserm U1285, Univ. Lille, UMR CNRS 8576- UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, F-59000, Lille, France
| | - J Springer
- Department of Internal Medicine II, WÜ4i, University Hospital Wuerzburg, Wuerzburg, Germany
| | - B Willinger
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna
| | - P L White
- Mycology Reference Laboratory, Public Health Wales Microbiology, Cardiff, United Kingdom
| | - R A Barnes
- Medical Microbiology and Infectious Diseases, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - M Cruciani
- Infectious Diseases Unit, ULSS 20 Verona, Italy
| | - J P Donnelly
- Division of Infectious Diseases, San Antonio Center for Medical Mycology, San Antonio, Texas, United States of America
| | - J Loeffler
- Department of Internal Medicine II, WÜ4i, University Hospital Wuerzburg, Wuerzburg, Germany
| | - L Millon
- Parasitology - Mycology, University Hospital Besançon, Besançon, France.,UMR6249 CNRS Chrono-Environnement, University of Bourgogne Franche-Comté, Besançon, Besançon, France
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Cruciani M, White PL, Mengoli C, Löffler J, Morton CO, Klingspor L, Buchheidt D, Maertens J, Heinz WJ, Rogers TR, Weinbergerova B, Warris A, Lockhart DEA, Jones B, Cordonnier C, Donnelly JP, Barnes RA. The impact of anti-mould prophylaxis on Aspergillus PCR blood testing for the diagnosis of invasive aspergillosis. J Antimicrob Chemother 2021; 76:635-638. [PMID: 33374010 DOI: 10.1093/jac/dkaa498] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The performance of the galactomannan enzyme immunoassay (GM-EIA) is impaired in patients receiving mould-active antifungal therapy. The impact of mould-active antifungal therapy on Aspergillus PCR testing needs to be determined. OBJECTIVES To determine the influence of anti-mould prophylaxis (AMP) on the performance of PCR blood testing to aid the diagnosis of proven/probable invasive aspergillosis (IA). METHODS As part of the systematic review and meta-analysis of 22 cohort studies investigating Aspergillus PCR blood testing in 2912 patients at risk of IA, subgroup analysis was performed to determine the impact of AMP on the accuracy of Aspergillus PCR. The incidence of IA was calculated in patients receiving and not receiving AMP. The impact of two different positivity thresholds (requiring either a single PCR positive test result or ≥2 consecutive PCR positive test results) on accuracy was evaluated. Meta-analytical pooling of sensitivity and specificity was performed by logistic mixed-model regression. RESULTS In total, 1661 (57%) patients received prophylaxis. The incidence of IA was 14.2%, significantly lower in the prophylaxis group (11%-12%) compared with the non-prophylaxis group (18%-19%) (P < 0.001). The use of AMP did not affect sensitivity, but significantly decreased specificity [single PCR positive result threshold: 26% reduction (P = 0.005); ≥2 consecutive PCR positive results threshold: 12% reduction (P = 0.019)]. CONCLUSIONS Contrary to its influence on GM-EIA, AMP significantly decreases Aspergillus PCR specificity, without affecting sensitivity, possibly as a consequence of AMP limiting the clinical progression of IA and/or leading to false-negative GM-EIA results, preventing the classification of probable IA using the EORTC/MSGERC definitions.
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Affiliation(s)
| | | | | | - J Löffler
- University of Wuerzburg, Wuerzburg, Germany
| | - C O Morton
- Western Sydney University, Sydney, Australia
| | | | | | - J Maertens
- Department of Microbiology, Immunology, and Transplantation, KULeuven, Leuven, Belgium
| | - W J Heinz
- University of Wuerzburg, Wuerzburg, Germany
| | - T R Rogers
- Trinity College Dublin, St James's Hospital Campus, Dublin, Ireland
| | - B Weinbergerova
- Department of Internal Medicine - Haematology and Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | - A Warris
- MRC Centre for Medical Mycology, University of Exeter, UK
| | | | - B Jones
- Institute of Infection, Immunity and Inflammation, University of Glasgow, UK
| | | | - J P Donnelly
- University of Nijmegen, Nijmegen, The Netherlands
| | - R A Barnes
- Cardiff University School of Medicine, Cardiff, UK
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White PL, Posso R, Parr C, Price JS, Finkelman M, Barnes RA. The Presence of (1→3)-β-D-Glucan as Prognostic Marker in Patients After Major Abdominal Surgery. Clin Infect Dis 2020; 73:e1415-e1422. [PMID: 32914187 DOI: 10.1093/cid/ciaa1370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/07/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND While the serological detection of (1→3)-β-D-glucan (BDG) can indicate invasive fungal disease (IFD), false positivity occurs. Nevertheless, the presence of BDG can still be recognized by the host's innate immune system and persistent BDG antigenemia, in the absence of IFD, can result in deleterious proinflammatory immune responses. METHODS During the XXX (INTENSE) study into the preemptive use of micafungin to prevent invasive candidiasis (IC) after abdominal surgery, the serum burden of BDG was determined to aid diagnosis of IC. Data from the INTENSE study were analyzed to determine whether BDG was associated with organ failure and patient mortality, while accounting for the influences of IC and antifungal therapy. RESULTS A BDG concentration >100 pg/mL was associated with a significantly increased Sequential Organ Failure Assessment score (≤100 pg/mL: 2 vs >100 pg/mL: 5; P < .0001) and increased rates of mortality (≤100 pg/mL: 13.7% vs >100 pg/mL: 39.0%; P = .0002). Multiple (≥2) positive results >100 pg/mL or a BDG concentration increasing >100 pg/mL increased mortality (48.1%). The mortality rate in patients with IC and a BDG concentration >100 pg/mL and ≤100 pg/mL was 42.3% and 25.0%, respectively. The mortality rate in patients without IC but a BDG concentration >100 pg/mL was 37.3%. The use of micafungin did not affect the findings. CONCLUSIONS The presence of persistent or increasing BDG in the patient's circulation is associated with significant morbidity and mortality after abdominal surgery, irrespective of IC. The potential lack of a specific therapeutic focus has consequences when trying to manage these patients, and when designing clinical trials involving patients where host-associated BDG concentrations may be elevated. CLINICAL TRIALS REGISTRATION NCT01122368.
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Affiliation(s)
- P Lewis White
- Mycology Reference Laboratory, Microbiology Cardiff, Public Health Wales, Cardiff, United Kingdom
| | - Raquel Posso
- Mycology Reference Laboratory, Microbiology Cardiff, Public Health Wales, Cardiff, United Kingdom
| | - Christian Parr
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Jessica S Price
- Mycology Reference Laboratory, Microbiology Cardiff, Public Health Wales, Cardiff, United Kingdom
| | | | - Rosemary A Barnes
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, Cardiff, United Kingdom
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Forde C, McMullan R, Clarke M, Wilson RH, Plummer R, Grayson M, McDowell C, Agus A, Doran A, McAuley DF, Thomas AL, Barnes RA, Adams R, Chau I, Coyle V. Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis (the EASI-SWITCH trial): study protocol for a randomised controlled trial. Trials 2020; 21:431. [PMID: 32460818 PMCID: PMC7251886 DOI: 10.1186/s13063-020-04241-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neutropenic sepsis remains a common treatment complication for patients receiving systemic anti-cancer treatment. The UK National Institute for Health and Care Excellence have not recommended switching from empirical intravenous antibiotics to oral antibiotics within 48 h for patients assessed as low risk for septic complications because of uncertainty about whether this would achieve comparable outcomes to using intravenous antibiotics for longer. The UK National Institute for Health Research funded the EASI-SWITCH trial to tackle this uncertainty. METHODS The trial is a pragmatic, randomised, non-inferiority trial that aims to establish the clinical and cost-effectiveness of early switching from intravenous to oral antibiotics in cancer patients with low-risk neutropenic sepsis. Patients ≥ 16 years, receiving systemic anti-cancer treatment (acute leukaemics/stem cell transplants excluded), with a temperature of > 38 °C, neutrophil count ≤ 1.0 × 109/L, MASCC (Multinational Association of Supportive Care in Cancer) score ≥ 21 and receiving IV piperacillin/tazobactam or meropenem for less than 24 h are eligible to participate. Patients are randomised 1:1 either (i) to switch to oral ciprofloxacin and co-amoxiclav within 12-24 h of commencing intravenous antibiotics, completing at least 5 days total antibiotics (intervention), or (ii) to continue intravenous antibiotics for at least 48 h, with ongoing antibiotics being continued at the physician's discretion (control). Patients are discharged home when their physician deems it appropriate. The primary outcome measure is a composite of treatment failures as assessed at day 14. The criteria for treatment failure include fever persistence or recurrence 72 h after starting intravenous antibiotics, escalation from protocolised antibiotics, hospital readmission related to infection/antibiotics, critical care support or death. Based on a 15% treatment failure rate in the control group and a 15% non-inferiority margin, the recruitment target is 230 patients. DISCUSSION If the trial demonstrates non-inferiority of early switching to oral antibiotics, with potential benefits for patient quality of life and resource savings, this finding will have significant implications for the routine clinical management of those with low-risk neutropenic sepsis. TRIAL REGISTRATION ISRCTN: 84288963. Registered on the 1 July 2015. https://doi.org/10.1186/ISRCTN84288963. EudraCT: 2015-002830-35.
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Affiliation(s)
- Caroline Forde
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
| | - Ronan McMullan
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen’s University Belfast, Belfast, UK
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Ruth Plummer
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | | | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Danny F. McAuley
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | | | | | - Richard Adams
- Cardiff University and Velindre NHS Trust, Cardiff, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Vicky Coyle
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
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8
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Barnes RA, White PL, Morton CO, Rogers TR, Cruciani M, Loeffler J, Donnelly JP. Diagnosis of aspergillosis by PCR: Clinical considerations and technical tips. Med Mycol 2018; 56:60-72. [PMID: 29087518 DOI: 10.1093/mmy/myx091] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/29/2017] [Indexed: 12/25/2022] Open
Abstract
Standardization of Aspergillus polymerase chain reaction (PCR) protocols has progressed, and analytical validity of blood-based assays has been formally established. It remains necessary to consider how the tests can be used in practice to maximize clinical utility. To determine the optimal diagnostic strategies and influence on patient management, several factors require consideration, including the patient population, incidence of invasive aspergillosis (and other fungal disease), and the local antifungal prescribing policy. Technical issues such as specimen type, ease of sampling, frequency of testing, access to testing centers, and time to reporting will also influence the use of PCR in clinical practice. Interpretation of all diagnostic tests is dependent on the clinical context and molecular assays are no exception, but with the proposal to incorporate Aspergillus PCR into the second revision of the consensus guidelines for defining invasive fungal disease the acceptance and understanding of molecular tests should improve.
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Affiliation(s)
| | - P Lewis White
- Public Health Wales Microbiology Cardiff, Cardiff, UK
| | | | | | - Mario Cruciani
- Center of Community Medicine and Infectious Diseases Service, ULSS 20 Verona
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9
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White PL, Posso RB, Gorton RL, Price JS, Wey E, Barnes RA. An evaluation of the performance of the Dynamiker® Fungus (1-3)-β-D-Glucan Assay to assist in the diagnosis of Pneumocystis pneumonia. Med Mycol 2018; 56:778-781. [PMID: 29087494 DOI: 10.1093/mmy/myx097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/08/2017] [Indexed: 11/12/2022] Open
Abstract
The Dynamiker® Fungus (1-3)-β-D-Glucan Assay (D-BDG) has recently become available in the Western Hemisphere for the diagnosis of invasive fungal disease (IFD). Evaluations of its performance for Pneumocystis pneumonia (PcP) are limited. A retrospective evaluation of D-BDG diagnosis of PcP was performed (23 PcP cases and 23 controls). Sensitivity and specificity were 87% and 70%, respectively, reducing the positivity threshold to 45 pg/ml increased sensitivity (96%), whereas a threshold of 300 pg/ml increased specificity (96%). The performance of D-BDG for the detection of PcP is comparable to other IFD, but sensitivity is below that required to confidently exclude PcP.
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Affiliation(s)
- P Lewis White
- UK Clinical Mycology Network (UKCMN) Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, UK
| | - Raquel B Posso
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, UK
| | - Rebecca L Gorton
- UKCMN Regional Laboratory, Department of Microbiology, Health Services Laboratories, London, United Kingdom
| | - Jessica S Price
- UK Clinical Mycology Network (UKCMN) Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, UK
| | - E Wey
- UKCMN Regional Laboratory, Department of Microbiology, Health Services Laboratories, London, United Kingdom
| | - Rosemary A Barnes
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, UK
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10
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White PL, Barnes RA, Gorton R, Cruciani M, Loeffler J, Alanio A, Barnes RA, Bialek R, Bretagne S, Buchheidt D, Buitrago Serna MJ, Caliendo A, Chen S, Clancy N, Cogliati M, Cordonnier C, Crowley B, Cruciani M, Donnelly JP, Gorton R, Guiver M, Hagen F, Halliday C, Hamal P, Heinz W, Jaton K, Johnson E, Jones B, Klingspor L, Hare RK, Lackner M, Lagrou K, Lamoth F, Lengerova M, Linton C, Lockhart D, Loeffler J, Maertens J, Melchers W, Mengoli C, Millon L, Morton O, Nguyen MH, Novak-Frazer L, Paholcsek M, Patterson T, Posch W, Richardson R, Rickerts V, Rogers T, Ruhnke M, Sendid B, Snelders E, Vyzantiadis TA, Warn P, Warris A, Weinbergerova B, White PL, Willinger B. Comment on: T2Candida MR as a predictor of outcome in patients with suspected invasive candidiasis starting empirical antifungal treatment: a prospective pilot study. J Antimicrob Chemother 2018; 74:532-533. [DOI: 10.1093/jac/dky325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- P Lewis White
- Public Health Wales, Microbiology Cardiff, Cardiff, UK
| | | | | | - Mario Cruciani
- Center of Community Medicine and Infectious Diseases Service, ULSS 20 Verona, Verona, Italy
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11
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White PL, Price JS, Posso RB, Barnes RA. An evaluation of the performance of the Dynamiker® Fungus (1-3)-β-D-Glucan Assay to assist in the diagnosis of invasive aspergillosis, invasive candidiasis and Pneumocystis pneumonia. Med Mycol 2018; 55:843-850. [PMID: 28340117 DOI: 10.1093/mmy/myx004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/06/2017] [Indexed: 01/29/2023] Open
Abstract
Invasive fungal disease (IFD) can be caused by a range of pathogens. Conventional diagnosis has the capacity to detect most causes of IFD, but poor performance limits impact. The introduction of non-culture diagnostics, including the detection of (1-3)-β-D-Glucan (BDG), has shown promising performance for the detection of IFD in variety of clinical settings. Recently, the Dynamiker® Fungus (1-3)-β-D-Glucan assay (D-BDG) was released as an IFD diagnostic test. This article describes an evaluation of the D-BDG assay for the diagnosis of invasive aspergillosis (IA), invasive candidiasis (IC) and Pneumocystis pneumonia (PCP) across several high-risk patient cohorts and provides comparative data with the Associates of Cape Cod Fungitell® and BioRad Platelia™ Aspergillus Ag (GM) assays. There were 163 serum samples from 121 patients tested, from 21 probable IA cases, 28 proven IC cases, six probable PCP cases, one probable IFD case, 14 possible IFD cases and 64 control patients. For proven/probable IFD the mean BDG concentration was 209pg/ml, significantly greater than the control population (73pg/ml; P: <.0001). The sensitivity, specificity, and diagnostic odds ratio for proven/probable IFD was 81.4%, 78.1%, and 15.5, respectively. Significant BDG false positivity (9/13) was associated post abdominal surgery. D-BDG showed fair and good agreement with the Fungitell®, and GM assays, respectively. In conclusion, the D-BDG provides a useful adjunct test to aid the diagnosis of IFD, with technical flexibility that will assist laboratories processing low sample numbers. Further, large scale, prospective evaluation is required to confirm the clinical validity and determine clinical utility.
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Affiliation(s)
- P Lewis White
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, UK
| | - Jessica S Price
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, UK
| | - Raquel B Posso
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, UK
| | - Rosemary A Barnes
- Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, UK
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12
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 786] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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13
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Morton CO, White PL, Barnes RA, Klingspor L, Cuenca-Estrella M, Lagrou K, Bretagne S, Melchers W, Mengoli C, Caliendo AM, Cogliati M, Debets-Ossenkopp Y, Gorton R, Hagen F, Halliday C, Hamal P, Harvey-Wood K, Jaton K, Johnson G, Kidd S, Lengerova M, Lass-Florl C, Linton C, Millon L, Morrissey CO, Paholcsek M, Talento AF, Ruhnke M, Willinger B, Donnelly JP, Loeffler J. Determining the analytical specificity of PCR-based assays for the diagnosis of IA: What is Aspergillus? Med Mycol 2018; 55:402-413. [PMID: 28339744 DOI: 10.1093/mmy/myw093] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 09/27/2016] [Indexed: 11/14/2022] Open
Abstract
A wide array of PCR tests has been developed to aid the diagnosis of invasive aspergillosis (IA), providing technical diversity but limiting standardisation and acceptance. Methodological recommendations for testing blood samples using PCR exist, based on achieving optimal assay sensitivity to help exclude IA. Conversely, when testing more invasive samples (BAL, biopsy, CSF) emphasis is placed on confirming disease, so analytical specificity is paramount. This multicenter study examined the analytical specificity of PCR methods for detecting IA by blind testing a panel of DNA extracted from a various fungal species to explore the range of Aspergillus species that could be detected, but also potential cross reactivity with other fungal species. Positivity rates were calculated and regression analysis was performed to determine any associations between technical specifications and performance. The accuracy of Aspergillus genus specific assays was 71.8%, significantly greater (P < .0001) than assays specific for individual Aspergillus species (47.2%). For genus specific assays the most often missed species were A. lentulus (25.0%), A. versicolor (24.1%), A. terreus (16.1%), A. flavus (15.2%), A. niger (13.4%), and A. fumigatus (6.2%). There was a significant positive association between accuracy and using an Aspergillus genus PCR assay targeting the rRNA genes (P = .0011). Conversely, there was a significant association between rRNA PCR targets and false positivity (P = .0032). To conclude current Aspergillus PCR assays are better suited for detecting A. fumigatus, with inferior detection of most other Aspergillus species. The use of an Aspergillus genus specific PCR assay targeting the rRNA genes is preferential.
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Affiliation(s)
| | | | | | | | | | - Katrien Lagrou
- University Hospitals Leuven, Department of Laboratory Medicine and National Reference Center for Mycosis, Leuven, Belgium, Belgium
| | - Stéphane Bretagne
- Paris Diderot, Sorbonne Paris Cité University, Faculty of Medicine, Paris, France
| | | | | | - Angela M Caliendo
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island and Aspergillus Technology Consortium, USA
| | - Massimo Cogliati
- Dip. Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | | | | | - Ferry Hagen
- Canisius-Wilhelmina Hospital, Nijmegen. The Netherlands
| | - Catriona Halliday
- Clinical Mycology Reference Laboratory, Pathology West, Westmead, Australia
| | - Petr Hamal
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | | | - Katia Jaton
- Institute of Microbiology, University Hospital of Lausanne, Switzerland
| | - Gemma Johnson
- Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, United Kingdom
| | - Sarah Kidd
- National Mycology Reference Centre, SA Pathology, Adelaide. Australia
| | - Martina Lengerova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Chris Linton
- UK Mycology Reference Lab, Public Health England, Bristol, United Kingdom
| | - Laurence Millon
- Laboratoire de Parasitologie-Mycologie Centre Hospitalier Universitaire, Besançon, France
| | | | - Melinda Paholcsek
- University of Debrecen Medical and Health Science Center, Debrecen. Hungary
| | - Alida Fe Talento
- Department of Clinical Microbiology, Trinity College, Dublin, Ireland
| | - Markus Ruhnke
- Charité Medical School, University of Berlin, Berlin. Germany
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Wattal C, Chakrabarti A, Oberoi JK, Donnelly JP, Barnes RA, Sherwal BL, Goel N, Saxena S, Varghese GM, Soman R, Loomba P, Tarai B, Singhal S, Mehta N, Ramasubramanian V, Choudhary D, Mehta Y, Ghosh S, Muralidhar S, Kaur R. Issues in antifungal stewardship: an opportunity that should not be lost. J Antimicrob Chemother 2017; 72:969-974. [PMID: 27999053 DOI: 10.1093/jac/dkw506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Many countries have observed an increase in the incidence of invasive fungal infections (IFIs) over the past two decades with emergence of new risk factors and isolation of new fungal pathogens. Early diagnosis and appropriate antifungal treatment remain the cornerstones of successful outcomes. However, due to non-specific clinical presentations and limited availability of rapid diagnostic tests, in more than half of cases antifungal treatment is inappropriate. As a result, the emergence of antifungal resistance both in yeasts and mycelial fungi is becoming increasingly common. The Delhi Chapter of the Indian Association of Medical Microbiologists (IAMM-DC) organized a 1 day workshop in collaboration with BSAC on 10 December 2015 in New Delhi to design a road map towards the development of a robust antifungal stewardship programme in the context of conditions in India. The workshop aimed at developing a road map for optimizing better outcomes in patients with IFIs while minimizing unintended consequences of antifungal use, ultimately leading to reduced healthcare costs and prevention development of resistance to antifungals. The workshop was a conclave of all stakeholders, eminent experts from India and the UK, including clinical microbiologists, critical care specialists and infectious disease physicians. Various issues in managing IFIs were discussed, including epidemiology, diagnostic and therapeutic algorithms in different healthcare settings. At the end of the deliberations, a consensus opinion and key messages were formulated, outlining a step-by-step approach to tackling the growing incidence of IFIs and antifungal resistance, particularly in the Indian scenario.
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Affiliation(s)
- Chand Wattal
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | | | - Jaswinder Kaur Oberoi
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | | | - Rosemary A Barnes
- Department of Medical Microbiology & Infectious Diseases, Division of Infection & Immunity, School of Medicine, Cardiff University, UK
| | - B L Sherwal
- Rajendra Institute of Medical Sciences, Ranchi, India
| | - Neeraj Goel
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | - Sonal Saxena
- Department of Medical Microbiology, Lady Hardinge Medical College, New Delhi, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | | | - Poonam Loomba
- G. B. Pant Institute of Post Graduate Medical Education & Research, New Delhi, India
| | | | | | - Naimish Mehta
- Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - V Ramasubramanian
- Infectious Diseases & Tropical Medicine, Apollo Hospitals, Infectious Diseases, Sri Ramachandra Medical College & Research Institute, Infectious Diseases, MGR Medical University, Chennai, India
| | | | - Yatin Mehta
- Medanta (The Medicity), Medanta Institute of Critical Care and Anesthesiology, Gurgaon, Haryana, India
| | - Supradip Ghosh
- Department of Critical Care Medicine, Fortis-Escorts Hospital, Faridabad, Haryana, India
| | - Sumathi Muralidhar
- Apex Regional STD Teaching Training & Research Centre, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi, India
| | - Ravinder Kaur
- Department of Medical Microbiology, Lady Hardinge Medical College, New Delhi, India
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Abstract
INTRODUCTION Pneumocystis jirovecii is a ubiquitous fungus, which causes pneumonia in humans. Diagnosis was hampered by the inability to culture the organism, and based on microscopic examination of respiratory samples or clinical presentation. New assays can assist in the diagnosis and even aid with the emergence of resistant infections. Areas covered: This manuscript will provide background information on Pneumocystis pneumonia (PcP). Diagnosis, from radiological to non-microbiological (e.g. Lactate dehydrogenase) and microbiological investigations (Microscopy, PCR, β-D-Glucan) will be discussed. Recommendations on prophylactic and therapeutic management will be covered. Expert commentary: PcP diagnosis using microscopy is far from optimal and false negatives will occur. With an incidence of 1% or less, the pre-test probability of not having PcP is 99% and testing is suited to excluding disease. Microscopy provides a high degree of diagnostic confidence but it is not infallible, and its lower sensitivity limits its application. Newer diagnostics (PCR, β-D-Glucan) can aid management and improve performance when testing less invasive specimens, such as upper respiratory samples or blood, alleviating clinical pressure. Combination testing may allow PcP to be both diagnosed and excluded, and molecular testing can assist in the detection of emerging resistant PcP.
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Affiliation(s)
- P Lewis White
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Matthijs Backx
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Rosemary A Barnes
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK.,b Infection, Immunity and Biochemistry , Cardiff University, School of Medicine, UHW , Cardiff , UK
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16
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Abstract
PCR can aid in the diagnosis of invasive fungal disease (IFD). While the large number of "in-house" methodologies drives technological diversity, providing robustness, they make it difficult to identify optimal strategies, limiting standardization, and widespread acceptance. No matter how efficient, PCR utility will be limited by the quality of extracted nucleic acid. This chapter highlights benefits and limitations affecting the nucleic acid extraction process, before focusing on recent recommendations that through multicenter evaluation have provided optimal and standardized methodology.
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Affiliation(s)
- P Lewis White
- Public Health Wales Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - Rosemary A Barnes
- Public Health Wales Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.,Department of Infection and Immunity, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
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17
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Shahin J, Allen EJ, Patel K, Muskett H, Harvey SE, Edgeworth J, Kibbler CC, Barnes RA, Biswas S, Soni N, Rowan KM, Harrison DA. Predicting invasive fungal disease due to Candida species in non-neutropenic, critically ill, adult patients in United Kingdom critical care units. BMC Infect Dis 2016; 16:480. [PMID: 27612566 PMCID: PMC5016930 DOI: 10.1186/s12879-016-1803-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/23/2016] [Indexed: 01/08/2023] Open
Abstract
Background Given the predominance of invasive fungal disease (IFD) amongst the non-immunocompromised adult critically ill population, the potential benefit of antifungal prophylaxis and the lack of generalisable tools to identify high risk patients, the aim of the current study was to describe the epidemiology of IFD in UK critical care units, and to develop and validate a clinical risk prediction tool to identify non-neutropenic, critically ill adult patients at high risk of IFD who would benefit from antifungal prophylaxis. Methods Data on risk factors for, and outcomes from, IFD were collected for consecutive admissions to adult, general critical care units in the UK participating in the Fungal Infection Risk Evaluation (FIRE) Study. Three risk prediction models were developed to model the risk of subsequent Candida IFD based on information available at three time points: admission to the critical care unit, at the end of 24 h and at the end of calendar day 3 of the critical care unit stay. The final model at each time point was evaluated in the three external validation samples. Results Between July 2009 and April 2011, 60,778 admissions from 96 critical care units were recruited. In total, 359 admissions (0.6 %) were admitted with, or developed, Candida IFD (66 % Candida albicans). At the rate of candidaemia of 3.3 per 1000 admissions, blood was the most common Candida IFD infection site. Of the initial 46 potential variables, the final admission model and the 24-h model both contained seven variables while the end of calendar day 3 model contained five variables. The end of calendar day 3 model performed the best with a c index of 0.709 in the full validation sample. Conclusions Incidence of Candida IFD in UK critical care units in this study was consistent with reports from other European epidemiological studies, but lower than that suggested by previous hospital-wide surveillance in the UK during the 1990s. Risk modeling using classical statistical methods produced relatively simple risk models, and associated clinical decision rules, that provided acceptable discrimination for identifying patients at ‘high risk’ of Candida IFD. Trial registration The FIRE Study was reviewed and approved by the Bolton NHS Research Ethics Committee (reference: 08/H1009/85), the Scotland A Research Ethics Committee (reference: 09/MRE00/76) and the National Information Governance Board (approval number: PIAG 2-10(f)/2005). Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1803-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jason Shahin
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK.,McGill University, Montreal, Canada
| | - Elizabeth J Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishna Patel
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Hannah Muskett
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Sheila E Harvey
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | | | | | | | | | - Neil Soni
- Chelsea and Westminster Hospital, London, UK
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK.
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18
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Sands KM, Wilson MJ, Lewis MAO, Wise MP, Palmer N, Hayes AJ, Barnes RA, Williams DW. Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation. J Crit Care 2016; 37:30-37. [PMID: 27621110 DOI: 10.1016/j.jcrc.2016.07.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/10/2016] [Accepted: 07/24/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients. MATERIALS AND METHODS Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay. RESULTS A "microbial shift" occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms. CONCLUSIONS To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens.
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Affiliation(s)
- Kirsty M Sands
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK.
| | - Melanie J Wilson
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
| | - Michael A O Lewis
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Nicki Palmer
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Anthony J Hayes
- Bioimaging Hub, School of Biosciences, Cardiff University, Cardiff, Wales, UK
| | - Rosemary A Barnes
- Cardiff Institute of Infection & Immunity, School of Medicine, Heath Park, Cardiff, Wales, UK
| | - David W Williams
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
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19
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Barnes RA, White PL. PCR Technology for Detection of Invasive Aspergillosis. J Fungi (Basel) 2016; 2:jof2030023. [PMID: 29376940 PMCID: PMC5753136 DOI: 10.3390/jof2030023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/20/2016] [Accepted: 07/26/2016] [Indexed: 11/16/2022] Open
Abstract
The application of molecular technologies to aid diagnosis and management of infectious diseases has had a major impact and many assays are in routine use. Diagnosis of aspergillosis has lagged behind. Lack of standardization and limited commercial interest have meant that PCR was not included in consensus diagnostic criteria for invasive fungal disease. In the last ten years careful evaluation and validation by the Aspergillus European PCR initiative with the development of standardized extraction, amplification and detection protocols for various specimen types, has provided the opportunity for clinical utility to be investigated. PCR has the potential to not only exclude a diagnosis of invasive aspergillosis but in combination with antigen testing may offer an approach for the early diagnosis and treatment of invasive aspergillosis in high-risk populations, with the added benefit of detection of genetic markers associated with antifungal resistance.
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Affiliation(s)
- Rosemary A Barnes
- Department of Medical Microbiology and Infectious Diseases, Cardiff University School of Medicine, Cardiff CF14 4XN, UK.
| | - P Lewis White
- Public Health Wales Microbiology, Cardiff CF14 4 XW, UK.
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20
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Forde C, McMullan R, Clarke M, Wilson RH, Plummer ER, Thomas AL, Barnes RA, Adams RA, Chau I, Grayson M, McDowell C, Agus A, Brown E, Storey DJ, McAuley D, Coyle V. The EASI-SWITCH trial: Early switch to oral antibiotic therapy in patients with low risk neutropenic sepsis. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.tps10143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Caroline Forde
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, United Kingdom
| | - Ronan McMullan
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, United Kingdom
| | - Mike Clarke
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Richard H. Wilson
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, United Kingdom
| | | | | | | | | | - Ian Chau
- Royal Marsden NHS Foundation Trust, London and Sutton, United Kingdom
| | - Margaret Grayson
- Northern Ireland Cancer Research Consumer Forum, Belfast, United Kingdom
| | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Ewan Brown
- Western General Hospital, Edinburgh, United Kingdom
| | | | - Danny McAuley
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Victoria Coyle
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, United Kingdom
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21
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White PL, Wingard JR, Bretagne S, Löffler J, Patterson TF, Slavin MA, Barnes RA, Pappas PG, Donnelly JP. Aspergillus Polymerase Chain Reaction: Systematic Review of Evidence for Clinical Use in Comparison With Antigen Testing. Clin Infect Dis 2015; 61:1293-303. [PMID: 26113653 PMCID: PMC4583581 DOI: 10.1093/cid/civ507] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/13/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Aspergillus polymerase chain reaction (PCR) was excluded from the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal disease because of limited standardization and validation. The definitions are being revised. METHODS A systematic literature review was performed to identify analytical and clinical information available on inclusion of galactomannan enzyme immunoassay (GM-EIA) (2002) and β-d-glucan (2008), providing a minimal threshold when considering PCR. Categorical parameters and statistical performance were compared. RESULTS When incorporated, GM-EIA and β-d-glucan sensitivities and specificities for diagnosing invasive aspergillosis were 81.6% and 91.6%, and 76.9% and 89.4%, respectively. Aspergillus PCR has similar sensitivity and specificity (76.8%-88.0% and 75.0%-94.5%, respectively) and comparable utility. Methodological recommendations and commercial PCR assays assist standardization. Although all tests have limitations, currently, PCR is the only test with independent quality control. CONCLUSIONS We propose that there is sufficient evidence that is at least equivalent to that used to include GM-EIA and β-d-glucan testing, and that PCR is now mature enough for inclusion in the EORTC/MSG definitions.
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Affiliation(s)
- P. Lewis White
- Public Health Wales, Microbiology Cardiff, United Kingdom
| | | | | | | | - Thomas F. Patterson
- University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio
| | - Monica A. Slavin
- Peter MacCallum Cancer Centre, University of Melbourne, Australia
| | - Rosemary A. Barnes
- Infection, Immunity and Biochemistry, Cardiff University, United Kingdom
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22
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Smyth K, Burdon D, Atkins JP, Barnes RA, Elliott M. Renewables-to-reefs: Response to Fowler et al. Mar Pollut Bull 2015; 98:372-374. [PMID: 26277603 DOI: 10.1016/j.marpolbul.2015.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/03/2015] [Indexed: 06/04/2023]
Affiliation(s)
- K Smyth
- Institute of Estuarine & Coastal Studies (IECS), University of Hull, Hull HU6 7RX, UK.
| | - D Burdon
- Institute of Estuarine & Coastal Studies (IECS), University of Hull, Hull HU6 7RX, UK
| | - J P Atkins
- The Business School, University of Hull, Hull HU6 7RX, UK
| | - R A Barnes
- The Law School, University of Hull, Hull HU6 7RX, UK
| | - M Elliott
- Institute of Estuarine & Coastal Studies (IECS), University of Hull, Hull HU6 7RX, UK
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23
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Loeffler J, Mengoli C, Springer J, Bretagne S, Cuenca-Estrella M, Klingspor L, Lagrou K, Melchers WJG, Morton CO, Barnes RA, Donnelly JP, White PL. Analytical Comparison of In Vitro-Spiked Human Serum and Plasma for PCR-Based Detection of Aspergillus fumigatus DNA: a Study by the European Aspergillus PCR Initiative. J Clin Microbiol 2015; 53:2838-45. [PMID: 26085614 PMCID: PMC4540929 DOI: 10.1128/jcm.00906-15] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/12/2015] [Indexed: 12/04/2022] Open
Abstract
The use of serum or plasma for Aspergillus PCR testing facilitates automated and standardized technology. Recommendations for serum testing are available, and while serum and plasma are regularly considered interchangeable for use in fungal diagnostics, differences in galactomannan enzyme immunoassay (GM-EIA) performance have been reported and are attributed to clot formation. Therefore, it is important to assess plasma PCR testing to determine if previous recommendations for serum are applicable and also to compare analytical performance with that of serum PCR. Molecular methods testing serum and plasma were compared through multicenter distribution of quality control panels, with additional studies to investigate the effect of clot formation and blood fractionation on DNA availability. Analytical sensitivity and time to positivity (TTP) were compared, and a regression analysis was performed to identify variables that enhanced plasma PCR performance. When testing plasma, sample volume, preextraction-to-postextraction volume ratio, PCR volume, duplicate testing, and the use of an internal control for PCR were positively associated with performance. When whole-blood samples were spiked and then fractionated, the analytical sensitivity and TTP were superior when testing plasma. Centrifugation had no effect on DNA availability, whereas the presence of clot material significantly lowered the concentration (P = 0.028). Technically, there are no major differences in the molecular processing of serum and plasma, but the formation of clot material potentially reduces available DNA in serum. During disease, Aspergillus DNA burdens in blood are often at the limits of PCR performance. Using plasma might improve performance while maintaining the methodological simplicity of serum testing.
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Affiliation(s)
| | | | | | | | | | | | - Katrien Lagrou
- National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | | | | | | | | | - P Lewis White
- Public Health Wales Microbiology Cardiff, Cardiff, United Kingdom
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24
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Wise MP, Barnes RA, Baudouin SV, Howell D, Lyttelton M, Marks DI, Morris EC, Parry-Jones N. Guidelines on the management and admission to intensive care of critically ill adult patients with haematological malignancy in the UK. Br J Haematol 2015; 171:179-188. [PMID: 26287443 DOI: 10.1111/bjh.13594] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Matt P Wise
- Cardiff University and University of Wales Hospital Cardiff, Cardiff, UK
| | | | - Simon V Baudouin
- Royal Victoria Infirmary and Newcastle University, Newcastle upon Tyne, UK
| | - David Howell
- University College London NHS Foundation Trust, London, UK
| | | | - David I Marks
- University Hospitals of Bristol NHS Trust, Bristol, UK
| | - Emma C Morris
- University College London, Royal Free Hospital, London, UK
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25
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Affiliation(s)
| | | | | | | | - Ken Haynes
- University of Exeter, Exeter EX4 4QD, UK.
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26
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Affiliation(s)
- M Backx
- Specialist Registrar in Infectious Diseases and Medical Microbiology
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27
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Perry MD, White PL, Barnes RA. Comparison of four automated nucleic acid extraction platforms for the recovery of DNA from Aspergillus fumigatus. J Med Microbiol 2014; 63:1160-1166. [PMID: 24987100 DOI: 10.1099/jmm.0.076315-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Invasive aspergillosis is a significant cause of morbidity and mortality within at-risk groups. Directed antifungal chemotherapy, guided by effective screening algorithms that incorporate reliable and validated molecular assays, reduces the morbidity associated with empirical administration and allows earlier diagnosis. The efficient extraction of nucleic acid from Aspergillus fumigatus is the main limiting factor for successful Aspergillus PCR from clinical specimens. With the integration of automated extraction platforms, assessment of the suitability of these platforms for specific targets is of paramount importance. In this study, four extraction robots (Applied Biosystems MagMAX, bioMérieux easyMAG, Qiagen EZ1 and Roche MagNA Pure LC) were evaluated for their ability to extract clinically significant levels of A. fumigatus from blood. All of the platforms could detect 10(1) c.f.u. ml(-1) from EDTA whole blood, although only the easyMAG, EZ1 and MagNA Pure had 100 % reproducibility at this level. Despite good analytical sensitivity, contamination associated with the easyMAG platform excluded its use for diagnostic Aspergillus PCR. The EZ1 and MagNA Pure platforms demonstrated equivalent high sensitivity and negative predictive values (97.4-100 %), essential for screening assays.
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Affiliation(s)
- Michael D Perry
- Public Health Wales Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, UK
| | - P Lewis White
- Public Health Wales Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Rosemary A Barnes
- Department of Infection, Immunity and Biochemistry, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
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Bhagavatula S, Vale L, Evans J, Carpenter C, Barnes RA. Scedosporium prolificans osteomyelitis following penetrating injury: A case report. Med Mycol Case Rep 2014; 4:26-9. [PMID: 24855598 PMCID: PMC4024514 DOI: 10.1016/j.mmcr.2014.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/07/2014] [Accepted: 03/12/2014] [Indexed: 11/30/2022] Open
Abstract
Scedosporium prolificans are opportunistic moulds that can cause mycetoma following penetrating injuries. This fungus is more virulent than other species and treatment options are limited. Here we describe the first known case in the UK of S. prolificans osteomyelitis, in a 4 year old following penetrating injury. Successful outcome with limb salvage and foot function is achieved after repeated surgical debridement, and combination chemotherapy with voriconazole/terbinafine.
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Affiliation(s)
- S Bhagavatula
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
| | - L Vale
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
| | - J Evans
- Department of Paediatrics and Child Health, University Hospital of Wales, Cardiff, United Kingdom
| | - C Carpenter
- Department of Paediatric Orthopedics, University Hospital of Wales, Cardiff, United Kingdom
| | - R A Barnes
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
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Ashbee HR, Barnes RA, Johnson EM, Richardson MD, Gorton R, Hope WW. Therapeutic drug monitoring (TDM) of antifungal agents: guidelines from the British Society for Medical Mycology. J Antimicrob Chemother 2013; 69:1162-76. [PMID: 24379304 DOI: 10.1093/jac/dkt508] [Citation(s) in RCA: 457] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The burden of human disease related to medically important fungal pathogens is substantial. An improved understanding of antifungal pharmacology and antifungal pharmacokinetics-pharmacodynamics has resulted in therapeutic drug monitoring (TDM) becoming a valuable adjunct to the routine administration of some antifungal agents. TDM may increase the probability of a successful outcome, prevent drug-related toxicity and potentially prevent the emergence of antifungal drug resistance. Much of the evidence that supports TDM is circumstantial. This document reviews the available literature and provides a series of recommendations for TDM of antifungal agents.
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Affiliation(s)
- H Ruth Ashbee
- Mycology Reference Centre, Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
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Abstract
The range of opportunist pathogens in cancer and transplant patients continues to increase. New treatment modalities and forms of immunosuppression following transplantation have improved survival from the underlying disease but can lead to prolonged immunosuppression and increased risk of infection. NICE guidelines for the management of neutropenic sepsis are now available but have aroused some controversy, particularly over the recommendation for quinolone prophylaxis in high-risk patient groups. In addition to neutropenia, long-term defects in cell-mediated immunity are exposing patients to risk of chronic, viral, protozoal and fungal infection. Advances in diagnostic techniques have the potential to improve management and limit unnecessary empirical treatment, allowing a move towards a diagnosis-driven strategy. However, interpreting the clinical validity and utility of some of these assays can be difficult, particularly for low-prevalence infection where the positive predictive value of any diagnostic test is likely to be low and prompt empirical antibacterial therapy is still indicated in neutropenic patients.
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Affiliation(s)
- Rosemary A Barnes
- is Professor/Honorary Consultant, Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. Competing interests: RAB has served on advisory boards, received sponsorship and travel expenses to attend meetings and received honoraria for lectures/symposia from Merck, Sharp and Dohme, Astellas, Gilead Sciences and Pfizer. In addition, she has received educational grants, scientific fellowship awards and independent researcher grants from Gilead Sciences and Pfizer. She is a member of the European Aspergillus PCR Initiative Working Group of the International Society for Human and Animal Mycology and a board member of the foundation European Aspergillus PCR initiative. She is a member of the Steering Group of the NISCHR funded Microbiology and Translational Infection Research Group. She served on the clinical guideline development group for the NICE Neutropenic sepsis guideline
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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] [What about the content of this article? (0)] [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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Barnes RA, Edghill N, Mackenzie J, Holters G, Ross GP, Jalaludin BB, Flack JR. Predictors of large and small for gestational age birthweight in offspring of women with gestational diabetes mellitus. Diabet Med 2013; 30:1040-6. [PMID: 23551273 DOI: 10.1111/dme.12207] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 12/20/2012] [Accepted: 03/22/2013] [Indexed: 12/17/2022]
Abstract
AIM To identify predictors of large and small for gestational age in women with gestational diabetes mellitus. METHODS A retrospective audit of clinical data analysed for singleton births in women diagnosed with gestational diabetes by Australasian Diabetes in Pregnancy Society guidelines from 1994 to 2009. Exclusions were: incomplete data, delivered at < 36 weeks gestation and/or last recorded weight > 4 weeks pre-delivery. We assessed: pre-pregnancy BMI, ethnicity, total maternal weight gain, weight gain before and after treatment initiation for gestational diabetes, HbA(1c) at gestational diabetes presentation and treatment modality (diet or insulin) and smoking. Birthweight was assessed using customized percentile charts (large for gestational age > 90th; small for gestational age < 10th percentile). Multiple regression analyses were undertaken; statistical significance was p < 0.05. RESULTS There were 1695 women first seen at (mean ± sd) 28.1 ± 5.3 weeks gestation (range 6-39). Ethnic mix was South-East Asian 36.7%, Middle Eastern 27.6%, European 22.4%, Indian/Pakistani 8.6%, Samoan 1.9%, African 1.5% and Maori 1.1%. Therapy was diet 69.1% and insulin 30.9%. Mean total weight gain was 12.3 ± 6.1 kg, the majority (10.6 ± 6.0 kg), gained before dietary intervention. There were 7.9% small for gestational age and 15.2% large for gestational age births. Significant independent large for gestational age predictors were: weight gain before intervention, pre-pregnancy BMI, weight gain after intervention and treatment type, but not HbA1c or smoking. Significant small for gestational age predictors were: weight gain before intervention, weight gain after intervention, but not pre-pregnancy BMI, HbA(1c) or smoking. CONCLUSION Conventional treatment for gestational diabetes mellitus concentrates on management of blood glucose levels. The trends identified here emphasize the need to also address pregnancy weight gain stratified by pre-pregnancy BMI.
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Affiliation(s)
- R A Barnes
- Department of Diabetes and Endocrinology, Bankstown-Lidcombe Hospital, NSW, Australia.
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A. Barnes R. Diagnosis and Treatment of Pulmonary Fungal Infections in Critically Ill Patients. CRMR 2012. [DOI: 10.2174/157339812800493304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lambourne J, Agranoff D, Herbrecht R, Troke PF, Buchbinder A, Willis F, Letscher-Bru V, Agrawal S, Doffman S, Johnson E, White PL, Barnes RA, Griffin G, Lindsay JA, Harrison TS. Association of mannose-binding lectin deficiency with acute invasive aspergillosis in immunocompromised patients. Clin Infect Dis 2010; 49:1486-91. [PMID: 19827955 DOI: 10.1086/644619] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Invasive aspergillosis is a devastating infection with attributable mortality of 40% despite antifungal therapy. In animal models of aspergillosis, deficiency of mannose-binding lectin (MBL), a pattern recognition receptor that activates complement, is a susceptibility factor. MBL deficiency occurs in 20%-30% of the population. We hypothesized that MBL deficiency may be a susceptibility factor for invasive aspergillosis in humans. METHODS Serum MBL concentrations were measured by enzyme-linked immunosorbent assay in 65 patients with proven or probable acute invasive aspergillosis and 78 febrile immunocompromised control subjects. MBL concentrations and the frequency of MBL deficiency were compared. RESULTS The median serum MBL level was significantly lower in patients with aspergillosis than in control subjects (281 ng/mL vs 835 ng/mL; P = .007). MBL deficiency (MBL concentration, <500 ng/mL) was significantly more common in patients with aspergillosis than control subjects (62% vs 32%; P < .001). Frequency of MBL deficiency was similar among patients with aspergillosis irrespective of response to antifungal therapy (P = .10). CONCLUSIONS This study is the first, to our knowledge, to show an association between MBL deficiency and acute invasive aspergillosis in humans. Further study is required to investigate the causal nature of this association and to define whether diagnosis of MBL deficiency may identify immunocompromised patients at increased risk of invasive aspergillosis.
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Affiliation(s)
- Jonathan Lambourne
- Dept of Infection, Division of Cellular and Molecular Medicine, St George's University, Cranmer Terrace, London SW17 0RE, England.
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Abstract
Human protothecosis is a rare infection caused by a member of the genus Prototheca, an ubiquitous alga. Traumatic inoculation can cause infections in the immunocompetent host while disseminated infection is mainly seen in patients with compromised immunity. We report here an unusual case of disseminated infection in a cancer patient. Traumatic removal of a Hickman catheter in this patient, led to the development of a severe skin and subcutaneous tissue infection with algaemia. These infections are often indolent and difficult to treat, with paucity of information available as to guidelines for diagnosis and effective therapeutic options.
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Affiliation(s)
- Soma Gaur
- Microbiology, Royal Gwent Hospital, Newport, Wales NP202UB, UK.
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Saayman AG, Findlay GP, Barnes RA, Wise MP. Bacteraemia following single-stage percutaneous dilatational tracheostomy. Intensive Care Med 2009; 35:1970-3. [PMID: 19644673 DOI: 10.1007/s00134-009-1586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Surgical tracheostomy in critically ill adults has largely been replaced by physicians performing percutaneous dilatational tracheostomy (PDT) at the bedside. Complications associated with this technique include haemorrhage, wound infection, barotrauma, false passage, ruptured tracheal ring and bacteraemia. Prophylactic antibiotics are not generally used with this procedure, however the incidence of bacteraemia following PDT has not been extensively studied. DESIGN Prospective observational study. SETTING Adult intensive care unit of a university medical centre. METHODS Peripheral venous blood cultures were obtained immediately before and after PDT in 118 consecutive patients. Surveillance cultures of potential respiratory pathogens were also recorded using routine non-directed broncholalveolar lavage. RESULTS Forty-three female and 75 male patients underwent PDT. Fifty-seven patients (48.3%) were not receiving antibiotics on the day of PDT, whilst the remaining 61 individuals (51.7%) were on antibiotic therapy at the time of the procedure. Bacteraemia following PDT occurred in six out of 113 patients (5.3%), five of which occurred in patients not receiving antibiotics (9.2%). Unexpected bacteraemia (positive pre-and post PDT blood cultures) was identified in five patients, two of whom were on antibiotic therapy. CONCLUSION The incidence of bacteraemia following a single stage PDT was similar to other manipulations of the aerodigestive tract such as intubation, insertion of an LMA or tooth brushing. We suggest that routine antibiotic prophylaxis is unnecessary for this procedure.
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Affiliation(s)
- A G Saayman
- Adult Critical Care, University Hospital of Wales, Cardiff, CF14 4XW, UK
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Abstract
Despite improvements in medical technology, the definitive diagnosis of invasive fungal disease (IFD) is limited. The prevalence of disease is relatively low but many cases are undiagnosed. With the diagnosis of proven IFD dependent on histopathology or culture from a sterile site, clinicians have become more reliant on noninvasive nonculture diagnostic techniques. PCR technology has the capacity to overcome classical limitations but has its own drawbacks, resulting from an incomplete knowledge of the various disease processes and subsequent shortage of optimal specimens, leading to a lack of methodological standardization. This review will consider the general principles and limitations of fungal PCR before discussing genus-specific PCR applications. It is by no means a systematic review of the literature but is intended, where possible, to provide the reader with access to assays with proficient clinical performance.
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Affiliation(s)
- P Lewis White
- NPHS Microbiology Cardiff, UHW, Heath Park, Cardiff, UK.
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Mengoli C, Cruciani M, Barnes RA, Loeffler J, Donnelly JP. Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis 2009; 9:89-96. [PMID: 19179225 DOI: 10.1016/s1473-3099(09)70019-2] [Citation(s) in RCA: 286] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A systematic review and meta-analysis was done on the use of PCR tests for the diagnosis of invasive aspergillosis. Data from more than 10000 blood, serum, or plasma samples obtained from 1618 patients at risk for invasive aspergillosis were retrieved from 16 studies. Overall, the mean diagnostic odds ratios (DORs) of PCR for proven and probable cases were similar whether two consecutive positive samples were required to define positivity (DOR 15.97 [95% CI 6.83-37.34]) or a single positive PCR test was required (DOR 16.41 [95% CI 6.43-41.88]). Sensitivity and specificity of PCR for two consecutive positive samples were 0.75 (95% CI 0.54-0.88) and 0.87 (95% CI 0.78-0.93), respectively, and if only a single positive sample was required, these values were 0.88 (95% CI 0.75-0.94) and 0.75 (95% CI 0.63-0.84), respectively. Whereas specificity based on a single positive test was significantly lower (p=0.027) than two positive tests, the sensitivity and DOR did not differ significantly. A single PCR-negative result is thus sufficient to exclude a diagnosis of proven or probable invasive aspergillosis. However, two positive tests are required to confirm the diagnosis because the specificity is higher than that attained from a single positive test. Populations at risk varied and there was a lack of homogeneity of the PCR methods used. Efforts are underway to devise a standard for Aspergillus sp PCR for screening, which will help enable formal validation of PCR and estimate its use in patients most likely to benefit.
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Affiliation(s)
- Carlo Mengoli
- Department of Histology, Microbiology, and Medical Biotechnology, University of Padua, Padua, Italy
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Barnes RA, White PL, Bygrave C, Evans N, Healy B, Kell J. Clinical impact of enhanced diagnosis of invasive fungal disease in high-risk haematology and stem cell transplant patients. J Clin Pathol 2008; 62:64-9. [DOI: 10.1136/jcp.2008.058354] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Noake T, Kuriyama T, White PL, Potts AJC, Lewis MAO, Williams DW, Barnes RA. Antifungal susceptibility of Candida species using the Clinical and Laboratory Standards Institute disk diffusion and broth microdilution methods. J Chemother 2007; 19:283-7. [PMID: 17594923 DOI: 10.1179/joc.2007.19.3.283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
There are conflicting reports on the agreement between the Clinical and Laboratory Standards Institute disk diffusion (M44-A) and reference broth microdilution (M27-A) methods for determination of antifungal susceptibility of yeasts. The antifungal susceptibility of 541 yeasts, the majority of which were from the oral cavity, was determined using these two methods and the accuracy of the disk diffusion method assessed for clinical testing of various Candida species. Of the strains tested, Candida albicans predominated (390 out of 541). The classification of susceptibility determined by the disk diffusion method was largely in concordance with that obtained using the broth dilution method, regardless of species within Candida genus. The overall observed agreement between these two methods was 94.7% for fluconazole and 96.7% for voriconazole was with a 'very major' discrepancy level of 1.5% and 1.7% respectively. This study demonstrates a strong agreement of the simple disk diffusion method with the more labour intensive 'gold standard' broth microdilution method. These findings would support the use of the disk diffusion method in a routine mycology service.
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Affiliation(s)
- T Noake
- Department of Medical Microbiology, amd NPHS Cardiff, University Hospital of Wales, Cardiff, UK
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White PL, Barton R, Guiver M, Linton CJ, Wilson S, Smith M, Gomez BL, Carr MJ, Kimmitt PT, Seaton S, Rajakumar K, Holyoake T, Kibbler CC, Johnson E, Hobson RP, Jones B, Barnes RA. A consensus on fungal polymerase chain reaction diagnosis?: a United Kingdom-Ireland evaluation of polymerase chain reaction methods for detection of systemic fungal infections. J Mol Diagn 2006; 8:376-84. [PMID: 16825512 PMCID: PMC1867606 DOI: 10.2353/jmoldx.2006.050120] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The limitations of classical diagnostic methods for invasive fungal infections (IFIs) have led to the development of molecular techniques to aid in the detection of IFIs. Despite good published performance, interlaboratory reproduction of these assays is variable, and no consensus has been reached for an optimal method. This publication describes the first multicenter study of polymerase chain reaction methods, for the detection of Aspergillus and Candida species, currently used in the UK and Ireland by distribution and analysis of multiple specimen control panels. All three Candida methods were comparable, achieving a satisfactory level of detection (10 cfu), and the method of preference was dependent on the requirements of the particular laboratory. The results for the five Aspergillus assays were more variable, but two methods (2Asp and 4Asp) were superior (10(1) conidia). Formally, the overall performances of the two Aspergillus assays were comparable (kappa statistic = 0.77). However, on the Roche LightCycler, there was a clear sample-type effect that greatly reduced the detection limit of the 4Asp method when testing whole blood samples. Therefore, the preferred Aspergillus method relied on the amplification platform available to the user. This study represents the initial process to achieve a consensus method for the diagnosis of IFIs.
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Affiliation(s)
- P Lewis White
- Department of Medical Microbiology and NPHS Cardiff, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK.
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Abstract
This report documents a case of sepsis caused by a recently recognized environmental organism and demonstrates the pathogenicity of this bacterium in the clinical setting.
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Affiliation(s)
- A Shetty
- Department of Medical Microbiology/PHL, University of Wales College of Medicine, Heath Park, Cardiff CF4 4XN, UK
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Ullmann AJ, Sanz MA, Tramarin A, Barnes RA, Wu W, Gerlach BA, Krobot KJ, Gerth WC. Prospective Study of Amphotericin B Formulations in Immunocompromised Patients in 4 European Countries. Clin Infect Dis 2006; 43:e29-38. [PMID: 16838223 DOI: 10.1086/505969] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Accepted: 05/08/2006] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Amphotericin B is a widely used broad-spectrum antifungal agent, despite being associated with significant adverse events, including nephrotoxicity. METHODS The present prospective study collected data on outcomes for 418 adult patients treated consecutively with polyenes in hematology and oncology wards in 20 hospitals in Europe. RESULTS Patients initially received amphotericin B deoxycholate (62% of patients), liposomal amphotericin B (27%), or other lipid formulations of amphotericin B (11%). Of the patients initially treated with amphotericin B deoxycholate, 36% had therapy switched to lipid formulations of amphotericin B, primarily because of increased serum creatinine levels (in 45.7% of patients) or other amphotericin B-attributable adverse events (in 41.3% of patients). Nephrotoxicity, which was defined as a > or = 50% increase in the serum creatinine level, developed in 57% of patients with normal kidney function at baseline. Predictors of nephrotoxicity included formulation type and duration of treatment. Compared with patients without nephrotoxicity, patients with nephrotoxicity had a higher mortality rate (24%), and their mean length of stay in the hospital was prolonged by 8.6 days. Slight increases in the serum creatinine level (i.e., > or = 50%) were associated with a significantly longer stay in the hospital. Severe nephrotoxicity (i.e., a > or = 200% increase in the serum creatinine level) was a significant predictor of death, as were severe underlying medical conditions and documented fungal infection. CONCLUSION This prospective study confirmed that, in European hospitals, amphotericin B formulations have a major influence on the length of stay in the hospital and nephrotoxicity-associated mortality.
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Affiliation(s)
- Andrew J Ullmann
- Klinikum Johannes Gutenberg Universität, III. Medizinische Klinik und Poliklinik, Langenbeckstr. 1, 55101 Mainz, Germany.
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White PL, Linton CJ, Perry MD, Johnson EM, Barnes RA. The evolution and evaluation of a whole blood polymerase chain reaction assay for the detection of invasive aspergillosis in hematology patients in a routine clinical setting. Clin Infect Dis 2006; 42:479-86. [PMID: 16421791 DOI: 10.1086/499949] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2005] [Accepted: 09/25/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is associated with high mortality. Successful outcome with treatment is linked to early diagnosis. The utility of classic diagnostic methods, however, is limited. METHODS To aid in the diagnosis of IA, we retrospectively assessed our diagnostic service, using real-time polymerase chain reaction (PCR) and galactomannan sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS A total of 203 patients at risk of invasive fungal infection were screened by PCR, and 116 of the patients were also tested by ELISA. The patient group comprised 176 patients with hematological malignancy and 28 control patients with evidence of invasive candidal infection. Consensus European Organisation for Research and Treatment of Cancer and Mycoses Study Group criteria were used to classify fungal infection, which, by definition, excluded the PCR result. The PCR method was sensitive (up to 92.3% sensitivity) and specific (up to 94.6% specificity) and had good agreement with the galactomannan ELISA (76.7%) and high-resolution computed tomography scan results. CONCLUSIONS A negative PCR result can be used to rule out IA and to limit the need for empirical antifungal therapy; thus, it has a role in diagnosing IA infections, especially in combination with antigen testing. PCR-positive cases classified as "false positives" regularly reflect the limitations of classic microbiological procedures or restricted use of consensus clinical methods employed to classify infection.
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Affiliation(s)
- P Lewis White
- Department of Medical Microbiology, National Public Health Service, Cardiff, United Kingdom.
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Abstract
PCR is a useful tool to aid in the diagnosis of invasive aspergillosis. However, it is essential that an optimal method be agreed to allow inclusion in future consensus diagnosis criteria. It should be used in conjunction with other methods (e.g., galatomannan (GM) ELISA and high resolution computed tomography (HRCT)) to enhance the opportunity for detection of this devastating infection. This manuscript will try to highlight the benefits but mainly the limitations occurring throughout the process of molecular testing. It will focus on real-time methods although many of the points will be relevant to block-based amplification.
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Affiliation(s)
| | - Rosemary A Barnes
- Department of Medical Microbiology, University Hospital of Wales, Cardiff, UK
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White PL, Archer AE, Barnes RA. Comparison of non-culture-based methods for detection of systemic fungal infections, with an emphasis on invasive Candida infections. J Clin Microbiol 2005; 43:2181-7. [PMID: 15872239 PMCID: PMC1153728 DOI: 10.1128/jcm.43.5.2181-2187.2005] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The accepted limitations associated with classic culture techniques for the diagnosis of invasive fungal infections have lead to the emergence of many non-culture-based methods. With superior sensitivities and quicker turnaround times, non-culture-based methods may aid the diagnosis of invasive fungal infections. In this review of the diagnostic service, we assessed the performances of two antigen detection techniques (enzyme-linked immunosorbent assay [ELISA] and latex agglutination) with a molecular method for the detection of invasive Candida infection and invasive aspergillosis. The specificities for all three assays were high (> or = 97%), although the Candida PCR method had enhanced sensitivity over both ELISA and latex agglutination with values of 95%, 75%, and 25%, respectively. However, calculating significant sensitivity values for the Aspergillus detection methods was not feasible due to a low number of proven/probable cases. Despite enhanced sensitivity, the PCR method failed to detect nucleic acid in a probable case of invasive Candida infection that was detected by ELISA. In conclusion, both PCR and ELISA techniques should be used in unison to aid the detection of invasive fungal infections.
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Affiliation(s)
- P Lewis White
- Department of Medical Microbiology and NPHS, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom.
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