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.
Keywords
Introduction
This is the third fungal diagnosis and management clinical guideline published in cooperation with various European scientific societies [
1
, 2
, 3
, 4
, 5
, 6
, 7
, 8
, 9
]. This part of the guideline regarding invasive and chronic aspergillosis is a condensation of all the recommendations made by the guideline subcommittees and is presented in tables for easier and faster reading. More details on how the recommendations were arrived at are planned in supplementary publications. This Aspergillus guideline will follow the style of other guidelines by including diagnostic and therapeutic guidance. Other scientific groups have published guidelines on this topic previously and all follow the common goal to provide clinicians with best guidance in their everyday working environment. Our goal was to provide a comprehensive European guideline focusing on the life-threatening diseases caused by Aspergillus spp.Methods
Author panel recruitment and organization was similar to what was done previously [
10
]. In brief, experts in the field were nominated by the three societies: European Society for Clinical Microbiology and Infectious Diseases (ESCMID), the European Confederation of Medical Mycology (ECMM) and the European Respiratory Society (ERS). The total of 53 authors were grouped into their special fields of expertise. Subgroup coordinators were responsible for the first draft of recommendations. There were two face-to-face meetings followed by numerous electronic exchanges. Some of the first recommendations were presented at ECCMID 2014. This summary was reviewed and approved by all authors and sent to the ESCMID guideline director for public review. Then the final version was submitted to Clinical Microbiology and Infection for additional peer review and subsequent publication. Only the rationale of the chronic pulmonary aspergillosis (CPA) guideline was published ahead of time [11
].Questions were predefined and modified where appropriate and the strength of recommendation and quality of evidence was slightly modified (Table 1) [
12
]. Diagnostic tests are regarded as interventions.- Cornely O.A.
- Cuenca-Estrella M.
- Meis J.F.
- Ullmann A.J.
European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Fungal Infection Study Group (EFISG) and European Confederation of Medical Mycology (ECMM) 2013 joint guidelines on diagnosis and management of rare and emerging fungal diseases.
Clin Microbiol Infect. 2014; 20: 1-4
Table 1Strength of recommendation and quality of evidence
| Strength of recommendation | Definition |
| Grade A | Societies strongly support a recommendation for use |
| Grade B | Societies moderately support a recommendation for use |
| Grade C | Societies marginally support a recommendation for use |
| Grade D | Societies support a recommendation against use |
| Quality of evidence | Definition |
| Level I | Evidence from at least one properly∗ designed randomized, controlled trial (oriented on the primary end point of the trial) |
| Level II | Evidence from at least one well-designed clinical trial (including secondary end points), without randomization; from cohort or case–controlled analytic studies (preferably from more than one centre); from multiple time series; or from dramatic results of uncontrolled experiments |
| Level III | Evidence from opinions of respected authorities, based on clinical experience, descriptive case studies, or reports of expert committees |
| Added index | Source of Level II evidence |
| r | Meta-analysis or systematic review of randomized controlled trials |
| t | Transferred evidence, i.e. results from different patients‘ cohorts, or similar immune-status situation |
| h | Comparator group: historical control |
| u | Uncontrolled trials |
| a | Published abstract presented at an international symposium or meeting |
∗ Poor quality of planning, inconsistency of results, indirectness of evidence etc. would lower the Strength of recommendation.
Summary of recommendations
Diagnostic procedures
Early diagnosis of invasive aspergillosis (IA) is a challenge and should be based on the integration of clinical, radiological and microbiological data.
Thoracic imaging
In patients at risk for IA with fever of unknown origin or clinical symptoms of lower respiratory tract infection who remain febrile despite broad-spectrum antibacterial treatment, thin-section chest computed tomography (multidetector (MDCT), multislice (MSCT), spiral CT, high resolution CT) at optimized dose (according to the ALARA (‘As Low As Reasonably Achievable’) principle) is the imaging modality of choice (AII) [
13
, 14
, 15
, 16
, 17
, 18
, 19
, 20
, 21
, 22
, 23
]. Pulmonary CT angiography may be of interest in the early diagnosis of IA by depicting directly vessel occlusion at the level of a suspicious fungal lesion with a potential high negative predictive value regarding imaging evaluation [24
, 25
, 26
], and is required in case of haemoptysis (AII). In selected patients where CT is not wanted or not feasible, magnetic resonance imaging (MRI) of the lungs may represent an alternative imaging to thin-section MSCT [27
, 28
, - Maschmeyer G.
- Carratala J.
- Buchheidt D.
- Hamprecht A.
- Heussel C.P.
- Kahl C.
- et al.
Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the infectious diseases working party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO).
Ann Oncol. 2015; 26: 21-33
29
, 30
, 31
, 32
], positron emission tomography-CT being of modest interest in the diagnostics of IA [33
, 34
].No CT scanning technique is 100% sensitive or specific for pulmonary IA [
35
, 36
, 37
]. Classical CT findings of angioinvasive aspergillosis include macronodule(s) >1 cm, which may be surrounded by a halo of ground-glass attenuation (halo sign, early phase, inconstant) [36
, 38
, 39
, 40
], pleural based wedge-shaped areas of consolidation [41
], alveolar consolidations [36
, 42
, 43
], masses (especially in solid organ transplant (SOT) recipients) [15
, 38
], internal low attenuation [44
], reverse halo sign [45
], cavity or air-crescent sign (delayed finding), ground glass opacities and pleural effusion [17
, 35
, 46
]. Bronchoinvasive forms may appear as tracheal or bronchial wall thickening, centrilobular nodules with tree in bud appearance [14
] in a patchy distribution, predominant peribronchial areas of consolidation [47
] or bronchopneumonia [46
] (Table 2).Table 2Recommendations for imaging and bronchoalveolar lavage
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Neutropenia, fever or clinical symptoms of pneumonia, empiric antibiotics failing to achieve defervescence, e.g. FUO | To detect pulmonary infiltrates | Chest CT and thin section multi-detector CT (MDCT) | A | II | Dose optimization recommended | 21 , 31 , 35 , 366 |
| To identify vessel occlusion | Chest angio-CT/pulmonary CT angiography | B | II | 24 , 25 , 26 | ||
| Haemoptysis | To identify vessel erosion | Chest angio-CT/pulmonary CT angiography | A | II | 367 , 368 | |
| Any, with infiltrate | To identify possible underlying fungal or other infectious disease | BAL | A | II | 21 , 49 , 50 , 51 , 52 , 53 , 54 | |
| Any, with infiltrate | To obtain appropriate specimens for microscopy, culture and PCR | CT-guided BAL | A | III | 55 , 56 |
Abbreviations: BAL, bronchoalveolar lavage; CT, computed tomography; FUO, fever of unknown origin; PCR, polymerase chain reaction; QoE, Quality of evidence; SoR, Strength of recommendation.
a Diagnostic tests are interventions.
Bronchoalveolar lavage and biopsies
Other diagnostic procedures include early bronchoalveolar lavage (BAL) (AII) [
48
, 49
, 50
, 51
, 52
, 53
, 54
], guided by CT findings [55
, 56
], and less frequently CT-guided transthoracic biopsies, video-assisted thoracoscopic surgery, open lung biopsies, transbronchial biopsies or convex endobronchial ultrasound transbronchial needle aspiration, the latter technique appearing to be a promising procedure in this setting [28
, - Maschmeyer G.
- Carratala J.
- Buchheidt D.
- Hamprecht A.
- Heussel C.P.
- Kahl C.
- et al.
Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the infectious diseases working party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO).
Ann Oncol. 2015; 26: 21-33
57
, 58
, 59
, 60
, 61
, 62
, 63
, - Carrafiello G.
- Lagana D.
- Nosari A.M.
- Guffanti C.
- Morra E.
- Recaldini C.
- et al.
Utility of computed tomography (ct) and of fine needle aspiration biopsy (fnab) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients.
La Radiologia Med. 2006; 111: 33-41
64
, 65
, 66
, - Georgiadou S.P.
- Sampsonas F.L.
- Rice D.
- Granger J.M.
- Swisher S.
- Kontoyiannis D.P.
Open-lung biopsy in patients with undiagnosed lung lesions referred at a tertiary cancer center is safe and reveals noncancerous, noninfectious entities as the most common diagnoses.
Eur J Clin Microbiol Infect Dis. 2013; 32: 101-105
67
, 68
, 69
, 70
, 71
, 72
]. Contraindications to these techniques need to be considered.Imaging of other sites
Moreover, according to clinical symptoms, paranasal CT, CT or MRI of the central nervous system (CNS) as well as abdominal CT may also be required. In particular, findings of sinusitis with bone erosion may be observed, intracranial and/or intraorbital extension of the disease being best evaluated by MRI [
73
, 74
, 75
]. In the brain, due to direct spread from paranasal sinuses or haematogenous dissemination, meningeal enhancement or empyema, cerebral abscess, mycotic aneurysms as well as haemorrhagic lesions and rarely stroke may be seen [76
, 77
, 78
, 79
].Microscopy and culture
Both microscopy and culture should be attempted on appropriate specimens from patients at risk for IA (AII) with a priority for culture in most cases where insufficient material is available. Demonstrating tissue invasion by hyphae through microscopic examination of biopsy or autopsy material provides a diagnosis of proven invasive fungal infection. However, the sensitivity of microscopy for IA is 50% at best [
80
]. Specimens may be examined as a wet mount preparation with or without the addition of 10% potassium hydroxide. Fluorescent dyes such as Calcofluor White™ or Blancophor™ have the advantages of increased sensitivity, rapid turnaround time and broad applicability but are not specific for Aspergillus (AII). Gomori's methenamine silver stain (GMS) and periodic acid-Schiff (PAS) can be applied to histological sections and smears and should be conducted in all cases in which IA is considered a possibility (Table 3). Respiratory secretions from patients with suspected aspergillosis must be processed rapidly for culture to prevent overgrowth by bacteria and yeasts. To achieve optimal recovery of Aspergillus from BAL fluid, centrifugation of the sample is advised with investigation of the sediment (AIII). It is recommended that cultures of high volume untreated sputum and BAL should be performed as opposed to culturing small volumes of digested, liquefied samples [81
] (Table 4). Specific media to support fungal growth are recommended. Species identification to the complex level should be carried out for clinically relevant isolates from patients who need antifungal treatment, and for epidemiological purposes (AIII) (Table 5).Table 3Microscopic examinations
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Any | To identify fungal elements in histological sections and stains | Histological examination Gomori's methenamine silver stain Periodic acid–Schiff | A | III | Histopathology is an essential investigation Inability to definitively distinguish other filamentous fungi GMS: removes cellular background; more sensitive to hyphal elements PAS: advantage of counter stain to check cellular detail | 61 , 80 , 369 , 370 |
| Any | To identify fungal elements in histological sections and stains | Fluorescent dyes: Calcofluor white™, Uvitex 2B, Blancophor™ | A | II | Not specific to Aspergillus but high sensitivity and the micromorphology may provide information on the fungal class (e.g. Aspergillus: typically dichotomous and septate, Mucorales: pauci-septate and 90° angle branching, yeast: budding) Rapid turnaround time Broad applicability May be applied to frozen sections, paraffin-embedded tissue | 371 , 372 , 373 , 374 , 375 |
| Any | To identify fungal elements in histological sections and stains | Immunohistochemistry Monoclonal antibody WF-AF-1 or EB-A1 In situ hybridization | B | II | Have the potential to provide genus- and species-specific data Commercially available monoclonal antibodies WF-AF-1 is specific for Aspergillus fumigatus, Aspergillus flavus, and Aspergillus niger Time consuming and not broadly available | 371 , 372 , 373 , 374 , 375 |
| Any | To identify fungal elements in fresh clinical specimens (e.g. BAL) | Application of fluorescent dyes Calcofluor white™ or Uvitex 2B or Blancophor™ | A | II | Essential investigation Not specific for Aspergillus species High sensitivity Rapid turn-around time Broad applicability No species identification but the micromorphology may provide information on the fungal class (e.g. Aspergillus: typically dichotomous and septate, Mucorales: pauci-septate and 90° angle branching, yeast: budding) | 61 , 80 , 376 |
Abbreviations: BAL, bronchoalveolar lavage; CNS, central nervous system; GMS, Gomori's methenamine silver stain; HE, haematoxylin-eosin; PAS, Periodic acid–Schiff; QoE, Quality of evidence; SoR, Strength of recommendation.
Table 4Sample selection and pre-analytical respiratory sample treatment
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Any | To achieve a homogeneous sample of viscous samples such as sputum | Liquefaction using a mucolytic agent, e.g. Pancreatin®, Sputolysin®, or using sonication and 1,4-dithiothreitol | A | III | Essential investigation High-volume sputum culture (entire sample) shown to significantly increase recovery | 81 , 377 |
| Any | To achieve optimal recovery of Aspergillus from BAL by centrifugation and investigation of the sediment | Centrifugation of BALs or bronchial aspirates | A | III | Essential investigation Isolation of Aspergillus dependent on volume cultured | 81 |
Abbreviations: BAL, bronchoalveolar lavage; PCR, polymerase chain reaction; QoE, Quality of evidence; SoR, Strength of recommendation.
Table 5Culture and Aspergillus species identification
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Any | Primary isolation from deep sites samples (e.g. biopsies, blood, CSF) | Culture on SDA, BHI agar, PDA at 30°C and 37°C for 72 h | A | III | Blood inhibits conidiation; BHI can help to recover some isolates; isolation of several colonies or isolation of the same fungus from a repeat specimen enhance significance | 81 , 378 , 379 |
| Primary isolation from non-sterile samples, e.g. sputum, respiratory aspirates | Culture on SDA, BHI agar, PDA with gentamicin plus chloramphenicol at 30°C and 37°C for 72 h | A | III | High-volume sputum culture (entire sample) shown to significantly increase recovery; quantitative cultures are not discriminative for infection or colonization | ||
| Identification of species complex | Macroscopic and microscopic examination from primary cultures | A | II | Colony colour, conidium size, shape and septation. Colour of conidia and conidiophore and conidiogenesis (tease or tape mounts are preferred); expertise needed for interpretation Thermotolerance test (growth at 50°C for species confirmation of A. fumigatus) | ||
| Identification of species complex (and species identification of A. fumigatus specifically) | Culture on identification media at 25–30°C, 37°C and 50°C (2% MEA and Czapek-Dox Agar) and microscopic examination | A | II | |||
| Identification at species level | MALDI-TOF MS identification | B | II | In-house databases are often used to improve identification rates | 380 , 381 , 382 , 383 | |
| Identification at species level | Sequencing of ITS, β-tubulin and calmodulin | A | III | Not necessary in organisms with typical growth, but in cases of atypical growth | 384 , 385 | |
| To study outbreaks | Microsatellite and CSP analysis | C | II | To study outbreaks (which in general may comprise more than one genotype) | 386 , 387 , 388 | |
| B | II | To study colonization patterns | 389 |
Abbreviations: BHI, brain–heart infusion; CSF, cerebrospinal fluid; CSP, cell surface protein; ITS, internal transcribed spacer; MALDI-TOF MS, matrix-assisted laser desorption/ionization time-of-flight mass spectometry identification; MEA, malt extract agar; PDA, potato dextrose agar; QoE, Quality of evidence; SDA, Sabouraud dextrose agar; SoR, Strength of recommendation.
Non-culture based assays
Galactomannan (GM) detection in fluids (especially BAL) is more sensitive than culture for diagnosis of IA. GM is reported as optical density index (ODI). In serum samples an ODI cut-off of 0.5 results in high sensitivity in haematological patients in the absence of mould-active prophylaxis (AI) (Table 6). Serial screening for serum GM in prolonged neutropenia and in allogeneic stem cell transplantation recipients during the early engraftment phase has a high sensitivity and negative predictive value for IA (AII) [
82
]. Serial screening is not recommended in patients on mould-active prophylaxis [83
].Table 6Galactomannan testing in blood samples
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Patients with prolonged neutropenia or allogeneic stem cell transplantation recipients not on mould-active prophylaxis | Prospective screening for IA | GM in blood | A | I | Highest test accuracy requiring two consecutive samples with an ODI ≥0.5 or retesting the same sample Prospective monitoring should be combined with HRCT and clinical evaluation | 82 , 94 , 390 , 391 , 392 , 393 ,
Galactomannan and PCR versus culture and histology for directing use of antifungal treatment for invasive aspergillosis in high-risk haematology patients: a randomised controlled trial. Lancet Infect Dis. 2013; 13: 519-528 394 |
| Draw samples every 3–4 days | C | III | ||||
| Patients with prolonged neutropenic or allogeneic stem cell transplantation recipients on mould active prophylaxis | Prospective screening for IA | GM in blood | D | II | Low prevalence of IA in this setting with consequently low PPV of blood GM test Prophylaxis may have a negative impact on sensitivity of the test or the low yield may be due to decreased incidence of IA | 395 , 396 |
| Patients with a haematological malignancy | To diagnose IA | GM in blood | Significantly lower sensitivity in non-neutropenic patients | 319 , 391 , 397 , 398 | ||
| A | II | ||||
| B | II | ||||
| ICU patients | To diagnose IA | GM in blood | C | II | Better performance in neutropenic than in non-neutropenic patients | 89 , 399 |
| Solid organ recipients | To diagnose IA | GM in blood | C | II | Low sensitivity, good specificity Most data for lung SOT | 319 , 400 , 401 |
| Any other patient | To diagnose IA | GM in blood | C | II | Piperacillin/tazobactam may no longer be responsible for false-positive results according to recent studies Cross-reactivity in case of histoplasmosis, fusariosis, talaromycosis (formerly: penicilliosis) False-positive results reported due to ingestion of ice-pops, transfusions, antibiotics, Plasmalyt® infusion | 398 , 402 , 403 , 404 , 405 , 406 , 407 , 408 , 409 |
| Cancer patients | To monitor treatment | GM in blood | A | II | 85 , 353 , 410 |
Abbreviations: GM, galactomannan; IA, invasive aspergillosis; ICU, intensive care unit; ODI, optical density index; PPV, positive predictive value; QoE, Quality of evidence; SoR, Strength of recommendation; SOT, solid organ transplantation.
a Serum or plasma.
Sensitivity of serum GM testing is significantly lower in non-neutropenic versus neutropenic patients [
84
]. Decrease of the ODI during the first 2 weeks of antifungal therapy is a reliable predictor of a satisfactory response in cancer patients [85
]. GM detection in BAL specimens has an excellent performance with evidence that ODI of 0.5–1.0 has decreased predictive values compared with results of >1.0 [86
] (AII) (Table 7). The test also has diagnostic value in patients undergoing lung transplantation or who are in intensive care [87
, 88
, - Luong M.L.
- Clancy C.J.
- Vadnerkar A.
- Kwak E.J.
- Silveira F.P.
- Wissel M.C.
- et al.
Comparison of an aspergillus real-time polymerase chain reaction assay with galactomannan testing of bronchoalvelolar lavage fluid for the diagnosis of invasive pulmonary aspergillosis in lung transplant recipients.
Clin Infect Dis. 2011; 52: 1218-1226
89
]; a sensitivity of 100% and a specificity of 90.4% was defined at cut-off of 1.5 [87
].Table 7Galactomannan testing in samples other than blood
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Any | To diagnose pulmonary IA | To apply GM test on BAL fluid | A | II | GM in BAL is a good tool to diagnose, optimal cut-off to positivity 0.5 to 1.0 | 86 , 88 ,
Comparison of an aspergillus real-time polymerase chain reaction assay with galactomannan testing of bronchoalvelolar lavage fluid for the diagnosis of invasive pulmonary aspergillosis in lung transplant recipients. Clin Infect Dis. 2011; 52: 1218-1226 411 ,
Diagnosing pulmonary aspergillosis in patients with hematological malignancies: a multicenter prospective evaluation of an Aspergillus PCR assay and a galactomannan elisa in bronchoalveolar lavage sample. Eur J Haematol. 2012; 89: 120-127 412 ,
Utility of bronchoalveolar lavage fluid galactomannan alone or in combination with PCR for the diagnosis of invasive aspergillosis in adult hematology patients: a systematic review and meta-analysis. Crit Rev Microbiol. 2015; 41: 124-134 413 , 414 |
| Any | To diagnose cerebral IA | To apply GM test on cerebrospinal fluid | B | II | No validated cut-off | 415 , 416 |
| Any | To detect GM in tissue | To apply GM test on lung biopsies | B | II | Using a cut-off 0.5 resulted in a sensitivity of 90 % and a specificity of 95%; specimens need to be sliced, precondition for doing so is that sufficient material is available; dilution in isotonic saline | 61 , 417 |
Abbreviations: BAL, bronchoalveolar lavage; GM, galactomannan; IA, invasive aspergillosis; QoE, Quality of evidence; SoR, Strength of recommendation.
A constituent of the cell wall of many species and genera of fungi, (1-3)-β-d-glucan (BDG), is released into body fluids in association with fungal infection. A limited role is given for the exclusive testing of the BDG in diagnosing IA (BII) (Table 8); however, the combination with GM or PCR improves specific detection [
90
].Table 8β-d-glucan assays
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Mixed population: adult ICU, haematological disorders, SOT | To diagnose IFD | Diagnostic assay | C | II | Five different assays Overall sensitivity of 77% and specificity of 85% Specificity limits its value in this setting | 90 , 418 |
| Screening assays | C | II | Two or more consecutive samples: sensitivity: 65%; specificity: 93% Studies included once to thrice weekly. Varies with assay and cut-off: Wako assay sensitivity: 40%–97%, specificity: 51%–99% | 90 , 418 | ||
| Adult haematological malignancy and HSCT | To diagnose IFD | Diagnostic assay | C | II | Overall sensitivity: 50%–70%, specificity: 91%–99% | 193 , 194 , 195 , 419 ,
β-glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: a systematic review and meta-analysis of cohort studies from the third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis. 2012; 54: 633-643 420 , 421 , 422 ,
Prospective comparison of the diagnostic potential of real-time PCR, double-sandwich enzyme-linked immunosorbent assay for galactomannan, and a (1→3)- β-d-glucan test in weekly screening for invasive aspergillosis in patients with hematological disorders. J Clin Microbiol. 2004; 42: 2733-2741 423 , 424 |
| ICU—mixed adult immunocompromised patients (haematology, SOT, cancer, immunosuppressive therapy, liver failure, HIV) | To diagnose IA | Diagnostic assay | C | II | Overall sensitivity: 78%–85%, specificity: 36%–75%, NPV: 85%–92% Specificity increased at higher cut-off values | 425 , 426 |
| ICU—mixed adult population: SOT, liver failure, immunosuppressed | Screening assays | C | III | Sensitivity: 91%, specificity: 58%, PPV: 25%, NPV: 98%. Positive mean of 5.6 days before positive mould culture High false-positive rate in early ICU admission | 427
Prospective study in critically ill non-neutropenic patients: diagnostic potential of (1,3)- β-d-glucan assay and circulating galactomannan for the diagnosis of invasive fungal disease. Eur J Clin Microbiol Infect Dis. 2012; 31: 721-731 | |
| Adult haematological malignancy and HSCT | To diagnose IA | Diagnostic assay | C | II | Overall sensitivity: 57%–76%, specificity: 95%–97% | 418 , 419 ,
β-glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: a systematic review and meta-analysis of cohort studies from the third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis. 2012; 54: 633-643 425 |
| Screening assays | C | II | Overall sensitivity: 46%, specificity: 97% Confirmation with GM increases specificity Data suggest BDG is unsuitable for ruling out diagnosis of IA |
Abbreviations: BDG, β-d-glucan test; GM, galactomannan; HSCT, haematopoietic stem cell transplantation; IA, invasive aspergillosis; ICU, intensive care unit; IFD, invasive fungal disease; NPV, negative predictive value; PPV, positive predictive value; QoE, Quality of evidence; SoR, Strength of recommendation; SOT, solid organ transplantation.
The Aspergillus lateral flow device assay can be performed on serum and on BAL samples, but at the time of writing this assay is not commercially available [
91
] (Table 9).Table 9Lateral flow device antigen test for invasive aspergillosis
| Population | Intention | Intervention | SoR | QoE | Comment | Ref. |
|---|---|---|---|---|---|---|
| Haematological malignancy and solid organ transplant | To diagnose IA | LFD applied on BAL samples | B | II | Retrospective study. Sensitivity and specificity of BAL LFD tests for probable IPA were 100% and 81% (PPV 71%, NPV 100%), five patients with possible IPA had positive LFD, no proven IA | 428 |
| Haematopoietic stem cell transplantation | To diagnose IA | LFD applied on serum samples | B | II | Prospective screening in 101 patients undergoing allogeneic HSCT | 429 |
| Immunocompromised patients | To diagnose IA | LFD applied on BAL samples | B | II | Retrospective study. Sensitivities for LFD, GM, BDG and PCR were between 70% and 88%. Combined GM (cut-off >1.0 OD) with LFD increased the sensitivity to 94%, while combined GM (cut-off >1.0 OD) with PCR resulted in 100% sensitivity (specificity for probable/proven IPA 95%–98%). | 430
Performance of galactomannan, β-d-glucan, Aspergillus lateral-flow device, conventional culture, and PCR tests with bronchoalveolar lavage fluid for diagnosis of invasive pulmonary aspergillosis. J Clin Microbiol. 2014; 52: 2039-2045 |
Abbreviations: BAL, bronchoalveolar lavage; BDG, β-D-glucan test; GM, galactomannan; HSCT, haematopoietic stem cell transplantation; IA, invasive aspergillosis; IFD, invasive fungal diseases; LFD, lateral device flow; NPV, negative predictive value; PCR, polymerase chain reaction; PPV, positive predictive value; QoE, Quality of evidence; SoR, Strength of recommendation.
Aspergillus PCR has been applied mostly to blood and BAL fluid. For both sample types, a combination with other biomarkers increases the likelihood of IA [
92
, 93
]. The performance of serum PCR is not significantly different from that of whole blood [- Boch T.
- Spiess B.
- Cornely O.A.
- Vehreschild J.J.
- Rath P.M.
- Steinmann J.
- et al.
Diagnosis of invasive fungal infections in haematological patients by combined use of galactomannan, 1,3-β-d-glucan, aspergillus PCR, multifungal DNA-microarray, and aspergillus azole resistance PCRs in blood and bronchoalveolar lavage samples: results of a prospective multicentre study.
Clin Microbiol Infect. 2016; 22: 862-868
94
, 95
, 96
, 97
]. Prospective screening of high-risk haematological patients by a combination of GM and PCR improves the diagnostic accuracy and is associated with an earlier diagnosis [98
,