A Diagnostic Stewardship Intervention to Improve Utilization of 1,3 ß-D-Glucan Testing at a Single Academic Center: Five-Year Experience.

Background: (1,3)- ß-D-glucan (BDG) testing is one of the noninvasive tests to aid diagnosis of invasive fungal infections (IFIs). The study results have been heterogenous, and diagnostic performance varies depending on the risks for IFI. Thus, it is important to select appropriate patients for BDG testing to prevent false-positive results. An algorithmic diagnostic stewardship intervention was instituted at a single academic medical center to improve BDG test utilization. Methods: The BDG test order in the electronic health record was replaced with the BDG test request order, which required approval to process the actual test order. The approval criteria were (1) immunocompromised or intensive care unit patient and (2) on empiric antifungal therapy, or inability to undergo invasive diagnostic procedures. A retrospective observational study was conducted to evaluate the efficacy of the intervention by comparing the number of BDG tests performed between 1 year pre- and post-intervention. Safety was assessed by chart review of the patients for whom BDG test requests were deemed inappropriate and rejected. Results: The number of BDG tests performed per year decreased by 85% from 156 in the pre-intervention period to 24 in the post-intervention period. The average monthly number of BDG tests performed was significantly lower between those periods (P = .002). There was no delay in IFI diagnosis or IFI-related deaths in the patients whose BDG test requests were rejected. The sustained effectiveness of the intervention was observed for 5 years. Conclusions: Institution of the diagnostic stewardship intervention successfully and safely improved BDG test utilization.

An evaluation of Rezafungin: the latest treatment option for adults with candidemia and invasive candidiasis.

INTRODUCTION: Invasive fungal infections, especially candidemia and invasive candidiasis, continue to cause substantial morbidity and mortality. In addition, the emergence of drug-resistant Candida species, notably C. glabrata and C. auris, along with limitations in available treatments, highlights the urgent need for novel, effective antifungal agents. AREAS COVERED: This review discusses the results of in vitro studies evaluating the spectrum and highlights the pharmacokinetic/pharmacodynamic properties. It also includes discussions on two key clinical studies that assess safety, tolerability, and efficacy. EXPERT OPINION: Rezafungin has demonstrated comparable efficacy to other echinocandins in two clinical studies and exhibits in vitro activity against a broad range of Candida species and Aspergillus spp. It has a favorable safety profile with minimal side effects, and no drug interactions or effects on QT intervals. In contrast to other echinocandins, it demonstrates dose-dependent killing, a prolonged half-life, and low clearance make it suitable for once-weekly dosing, which is supported by clinical trials confirming its efficacy. Rezafungin offers a promising option for the outpatient management of difficult to treat fungal infections. It has become a valuable addition to the antifungal arsenal, with the potential to reduce hospital length of stay and hospitalization costs and combat drug-resistant Candida species.

Evaluation of the Performance of the Dynamiker Fungus (1-3)-ß-D-Glucan and Fungitell Assay for Diagnosis of Candidemia: Need for New Cut-off Development and Test Validation.

(1-3)-Beta-D Glucan (BDG) detection has shown to be a highly effective tool to diagnose invasive fungal infections. Therefore, this study aimed to compare clinical characteristics of the Fungitell (FA) and Dynamiker Fungus (1-3)-ß-D-Glucan assay (DFA) for the diagnosis of candidemia. Using DFA and FA, the BDG levels of 57 serum samples from case and control groups were determined. The kappa coefficient (κ) and Spearman's rank correlation (rs) were used to examine the consistency of assays on a quantitative and qualitative level, respectively. The sensitivity, specificity, and accuracy were 94.6 %, 65.0 %, and 87.7% for DFA, and 94.6 %, 75.0 %, and 89.4 % for FA, respectively. The performance of the DFA for the diagnosis of candidemia was highly consistent with that of the FA, both quantitatively (rs: 0.9) and qualitatively (kappa = 0.78). Collectively, the DFA assay performed excellently in comparison to the FA for the diagnosis of candidemia.

Aminated yeast ß-D-glucan for macrophage-targeted delivery of CpG oligodeoxynucleotides and synergistically enhanced cancer immunotherapy.

CpG oligodeoxynucleotides (CpG ODNs) activate immune system and show strong potential in cancer immunotherapy. However, therapeutic efficacy of CpG ODNs is hampered due to rapid nuclease degradation and insufficient cellular uptake. Delivery of CpG ODNs into antigen presenting cells (APCs) is vital to enhance their therapeutic efficacy. Herein, we developed a super-convenient yet efficient strategy for macrophage-targeted delivery of CpG ODNs and synergistically enhanced cancer immunotherapy. Aminated yeast ß-D-glucan (NH2-Glu) was simply synthesized through functionalization of ß-D-glucan with DETA, which exhibited a dendrimer-like shape with size of about 80 nm. NH2-Glu complexed negatively-charged CpG ODNs. The as-prepared NH2-Glu/CpG complexes were positively charged, uniformly dispersed and exhibited good stability against nuclease degradation. Due to the specific recognition with dectin-1 expressed on macrophages, NH2-Glu/CpG complexes targeted macrophage and exhibited significantly enhanced cellular uptake due to dectin-1-mediated endocytosis. NH2-Glu/CpG complexes showed potent immunostimulatory activity. Contributed by the inherent immunostimulatory and antitumor activity, yeast ß-D-glucan functioned synergistically with CpG ODNs in inducing antitumor immunity. NH2-Glu/CpG complexes remarkably inhibited tumor growth without causing toxic effect. In summary, this work provides a facile yet efficient macrophage-targeted CpG ODNs delivery system for cancer immunotherapy.

Recent Advances in the Preparation, Structure, and Biological Activities of ß-Glucan from Ganoderma Species: A Review.

Ganoderma has served as a valuable food supplement and medicinal ingredient with outstanding active compounds that are essential for human protection against chronic diseases. Modern pharmacology studies have proven that Ganoderma ß-d-glucan exhibits versatile biological activities, such as immunomodulatory, antitumor, antioxidant, and antiviral properties, as well as gut microbiota regulation. As a promising polysaccharide, ß-d-glucan is widely used in the prevention and treatment of various diseases. In recent years, the extraction, purification, structural characterization, and pharmacological activities of polysaccharides from the fruiting bodies, mycelia, spores, and fermentation broth of Ganoderma species have received wide attention from scholars globally. Unfortunately, comprehensive studies on the preparation, structure and bioactivity, toxicology, and utilization of ß-d-glucans from Ganoderma species still need to be further explored, which may result in limitations in future sustainable industrial applications of ß-d-glucans. Thus, this review summarizes the research progress in recent years on the physicochemical properties, structural characteristics, and bioactivity mechanisms of Ganoderma ß-d-glucan, as well as its toxicological assessment and applications. This review is intended to provide a theoretical basis and reference for the development and application of ß-d-glucan in the fields of pharmaceuticals, functional foods, and cosmetics.

Pneumocystis jirovecii pneumonia in intensive care units: a multicenter study by ESGCIP and EFISG.

BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic, life-threatening disease commonly affecting immunocompromised patients. The distribution of predisposing diseases or conditions in critically ill patients admitted to intensive care unit (ICU) and subjected to diagnostic work-up for PJP has seldom been explored. MATERIALS AND METHODS: The primary objective of the study was to describe the characteristics of ICU patients subjected to diagnostic workup for PJP. The secondary objectives were: (i) to assess demographic and clinical variables associated with PJP; (ii) to assess the performance of Pneumocystis PCR on respiratory specimens and serum BDG for the diagnosis of PJP; (iii) to describe 30-day and 90-day mortality in the study population. RESULTS: Overall, 600 patients were included in the study, of whom 115 had presumptive/proven PJP (19.2%). Only 8.8% of ICU patients subjected to diagnostic workup for PJP had HIV infection, whereas hematological malignancy, solid tumor, inflammatory diseases, and solid organ transplants were present in 23.2%, 16.2%, 15.5%, and 10.0% of tested patients, respectively. In multivariable analysis, AIDS (odds ratio [OR] 3.31; 95% confidence interval [CI] 1.13-9.64, p = 0.029), non-Hodgkin lymphoma (OR 3.71; 95% CI 1.23-11.18, p = 0.020), vasculitis (OR 5.95; 95% CI 1.07-33.22, p = 0.042), metastatic solid tumor (OR 4.31; 95% CI 1.76-10.53, p = 0.001), and bilateral ground glass on CT scan (OR 2.19; 95% CI 1.01-4.78, p = 0.048) were associated with PJP, whereas an inverse association was observed for increasing lymphocyte cell count (OR 0.64; 95% CI 0.42-1.00, p = 0.049). For the diagnosis of PJP, higher positive predictive value (PPV) was observed when both respiratory Pneumocystis PCR and serum BDG were positive compared to individual assay positivity (72% for the combination vs. 63% for PCR and 39% for BDG). Cumulative 30-day mortality and 90-day mortality in patients with presumptive/proven PJP were 52% and 67%, respectively. CONCLUSION: PJP in critically ill patients admitted to ICU is nowadays most encountered in non-HIV patients. Serum BDG when used in combination with respiratory Pneumocystis PCR could help improve the certainty of PJP diagnosis.

Pneumocystis pneumonia diagnosed by repeated measurements of ß-D-glucan levels.

ß-D-glucan is extensively employed as a supplementary diagnostic tool for Pneumocystis pneumonia (PCP) and typically yields positive results in most cases. We present a case of a 73-year-old woman with a history of rheumatoid arthritis, who was receiving biological agents and was admitted due to pneumonia. Initially, the ß-D-glucan test was negative. However, as the disease progressed, it eventually turned positive, leading to the diagnosis of PCP. The patient was treated with corticosteroids and trimethoprim-sulfamethoxazole, resulting in pneumonia resolution. Our findings suggest that repeated assessment of ß-D-glucan levels holds diagnostic value in patients without human immunodeficiency virus infection.

Oat ß-D-glucan ameliorates type II diabetes through TLR4/PI3K/AKT mediated metabolic axis.

Diabetes is one of the major global public health problems. Our previous results found that oat ß-D-glucan exhibited ameliorative effects on diabetic mice, but the underlying mechanism is unclear. The present study indicates that oat ß-D-glucan increased glycogen content, decreased glycogen synthase (GS) phosphorylation and increased hepatic glycogen synthase kinase 3ß (GSK3ß) phosphorylation for glycogen synthesis via PI3K/AKT/GSK3-mediated GS activation. Moreover, oat ß-D-glucan inhibited gluconeogenesis through the PI3K/AKT/Foxo1-mediated phosphoenolpyruvate carboxykinase (PEPCK) decrease. In addition, oat ß-D-glucan enhanced glucose catabolism through elevated protein levels of COQ9, UQCRC2, COXIV and ATP5F complexes involved in oxidative phosphorylation, as well as that of TFAM, a key regulator of mitochondrial gene expression. Importantly, our results showed that oat ß-D-glucan maintained hepatic glucose balance via TLR4-mediated intracellular signal. After TLR4 blocking with anti-TLR4 antibody, oat ß-D-glucan had almost no effect on high glucose-induced HepG2 cells. These data revealed that oat ß-D-glucan maintains glucose balance by regulating the TLR4/PI3K/AKT signal pathway.

Developments in Fungal Serology.

Purpose of Review: The true incidence of fungal disease is hampered by conventionally poor diagnostic tests, limited access to advanced diagnostics, and limited surveillance. The availability of serological testing has been available for over two decades and generally underpins the modern diagnosis of the most common forms of fungal disease. This review will focus on technical developments of serological tests for the diagnosis of fungal disease, describing advances in clinical performance when available. Recent Findings: Despite their longevity, technical, clinical, and performance limitations remain, and tests specific for fungal pathogens outside the main pathogens are lacking. The availability of LFA and automated systems, capable of running multiple different tests, represents significant developments, but clinical performance data is variable and limited. Summary: Fungal serology has significantly advanced the diagnosis of the main fungal infections, with LFA availability increasing accessibility to testing. Combination testing has the potential to overcome performance limitations.

Dectin-1 signaling coordinates innate and adaptive immunity for potent host defense against viral infection.

Background: Most commercial foot-and-mouth disease (FMD) vaccines have various disadvantages, such as low antibody titers, short-lived effects, compromised host defense, and questionable safety. Objectives: To address these shortcomings, we present a novel FMD vaccine containing Dectin-1 agonist, ß-D-glucan, as an immunomodulatory adjuvant. The proposed vaccine was developed to effectively coordinate innate and adaptive immunity for potent host defense against viral infection. Methods: We demonstrated ß-D-glucan mediated innate and adaptive immune responses in mice and pigs in vitro and in vivo. The expressions of pattern recognition receptors, cytokines, transcription factors, and co-stimulatory molecules were promoted via FMD vaccine containing ß-D-glucan. Results: ß-D-glucan elicited a robust cellular immune response and early, mid-, and long-term immunity. Moreover, it exhibited potent host defense by modulating host's innate and adaptive immunity. Conclusion: Our study provides a promising approach to overcoming the limitations of conventional FMD vaccines. Based on the proposed vaccine's safety and efficacy, it represents a breakthrough among next-generation FMD vaccines.

A case of Neurospora sitophila causing PD peritonitis.

We describe a rare case of fungal peritoneal dialysis (PD) peritonitis caused by the ascomycete fungus Neurospora sitophila (N. sitophila). The patient had little response to initial antibiotics and PD catheter removal was necessary for source control. The fungal biomarker ß-d-glucan (BDG) was positive prior to N. sitophila being cultured and remained positive for 6 months after discharge. Use of BDG early in the assessment of PD peritonitis may reduce time to definitive therapy in fungal peritonitis.

How to diagnose and treat a patient without human immunodeficiency virus infection having Pneumocystis jirovecii pneumonia?

BACKGROUND: Pneumocystis jirovecii pneumonia (PCP) incidence is increasing in patients without HIV infection. In contrast to PCP in patients infected with HIV, diagnosis is often delayed and illness is associated with increased mortality. OBJECTIVES: To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options for PCP in patients without HIV infection. SOURCES: Web-based literature review on PCP for trials, meta-analyses, and systematic reviews using PubMed. The restriction to the English language was applied. CONTENT: Common underlying conditions in patients without HIV infection having PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant, and previous corticosteroid exposure. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Patients without HIV infection who have PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms and radiological as well as mycological features. Results of immunofluorescence microscopy from bronchoalveolar lavage, PCR testing, and computed tomography imaging as well as the evaluation of clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS: Although the number of patients with immunosuppression due to causes different from HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of patients without HIV infection, rapid onset of symptoms, a more complex course, and a high mortality rate are recorded. Therefore, the time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provides clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.

Management of pulmonary aspergillosis in children: a systematic review.

Invasive pulmonary aspergillosis (IPA) is a severe condition in immunocompromised children, but the optimal management is still under debate. In order to better clarify this issue, a literature search was performed through MEDLINE/PubMed database to describe current risk factors and diagnostic, therapeutic and prophylactic tools for invasive pulmonary aspergillosis (IPA) in the paediatric age. Observational studies and clinical trials regarding diagnosis, treatment and prophylaxis were considered, and results were summarised. Five clinical trials and 25 observational studies (4453 patients) were included.Haematological malignancies, previous organ transplant and other primary or acquired immunodeficiency were identified as risk factors for IPA in children.Current diagnostic criteria distinguish between "proven", "probable" and "possible" disease. Consecutive galactomannan assays have good sensitivity and specificity, especially when performed on broncho-alveolar lavage. At the same time, ß-D-glucan should not be used since cut-off in children is unclear. PCR assays cannot currently be recommended for routine use.Voriconazole is the recommended first-line agent for IPA in children older than 2 years of age. Liposomal amphotericin B is preferred in younger patients or cases of intolerance to voriconazole. Its plasma concentrations should be monitored throughout the treatment. The optimal duration of therapy has yet to be determined. Posaconazole is the preferred prophylactic agent in children older than 13 years old, whereas oral voriconazole or itraconazole are the drugs of choice for those between 2-12 years. Further good-quality studies are warranted to improve clinical practice.

Current and Future Pathways in Aspergillus Diagnosis.

Aspergillus fumigatus has been designated by the World Health Organization as a critical priority fungal pathogen. Some commercially available diagnostics for many forms of aspergillosis rely on fungal metabolites. These encompass intracellular molecules, cell wall components, and extracellular secretomes. This review summarizes the shortcomings of antibody tests compared to tests of fungal products in body fluids and highlights the application of ß-d-glucan, galactomannan, and pentraxin 3 in bronchoalveolar lavage fluids. We also discuss the detection of nucleic acids and next-generation sequencing, along with newer studies on Aspergillus metallophores.

Yeast ß-D-glucan functionalized graphene oxide for macrophage-targeted delivery of CpG oligodeoxynucleotides and synergistically enhanced antitumor immunity.

Immunostimulatory CpG oligodeoxynucleotides (CpG ODNs) show strong potential in cancer immunotherapy. However, therapeutic efficacy of CpG ODNs is hindered due to rapid nuclease degradation and insufficient cellular uptake. Transfecting CpG ODNs into antigen presenting cells (APCs) is vital to enhance their therapeutic efficacy while reduce the potential side effects. Herein, a multifunctional CpG ODNs vector was fabricated through functionalization of graphene oxide (GO) with yeast ß-D-glucan, and its potential in cancer immunotherapy was further investigated. GO-ß-D-glucan protected CpG ODNs from nuclease digestion. ß-D-glucan endowed the delivery system with targeting ability for macrophage due to its recognition with dectin-1. Thus, GO-ß-D-glucan enhanced the delivery of CpG ODNs into RAW264.7 cells due to dectin-1-mediated endocytosis. More importantly, ß-D-glucan functioned synergistically with CpG ODNs in inducing antitumor immunity. GO-ß-D-glucan/CpG ODNs inhibited the tumor cells growth more effectively. This work provides a macrophage-targeted CpG ODNs delivery system for cancer immunotherapy. Graphic abstract.

Evaluation of Vitreous Galactomannan and (1, 3) ß-D-Glucan Levels in the Diagnosis of Fungal Endophthalmitis in Southern India.

PURPOSE: To evaluate vitreous Galactomannan(GM) and 1,3 ß-D-Glucan (BDG) levels in the diagnosis of fungal endophthalmitis, with emphasis on culture-negative cases. METHODS: Vitreous from 31 clinically suspected fungal endophthalmitis patients and 11 controls were evaluated for GM and BDG using ELISA Kits. The Receiver Operating Characteristic (ROC) curves and diagnostic significance was calculated. RESULTS: The median vitreous GM in culture-positive (60.83pg/ml) and culture-negative (59.9pg/ml) samples were higher than the (51.2pg/ml) control group. The median vitreous BDG in culture-positive (1.47pg/ml) and culture-negative (1.52pg/ml) samples were also similar, and higher than the control group (1.18pg/ml). ROC analysis showed that at a cut-off of 51.35pg/ml, the sensitivity and specificity for GM were 0.88 and 0.73.Similarly, for BDG at a cut-off of 1.18pg/ml, the sensitivity and specificity were 0.94 and 0.82 respectively. CONCLUSION: Vitreous GM and BDG above the indicated threshold level could suggest a fungal infection, even when cultures are negative.

Functional Characterization of Extracellular Vesicles from Baker's Yeast Saccharomyces Cerevisiae as a Novel Vaccine Material for Immune Cell Maturation.

Extracellular vesicles (EVs) encapsulate various bioactive molecules, and much effort has been directed towards developing a novel EV-based therapy. Although recent studies reported the secretion of EVs from probiotics baker's yeast Saccharomyces cerevisiae (S. cerevisiae), their properties and functions remain obscure. The aim of this study was to clarify the usefulness of EVs from S. cerevisiae (S-EVs) as a novel vaccine material by defining their physicochemical properties and biological functions. The collected S-EVs contained ß-D-glucan and showed particle sizes and zeta potentials approximately 128.8 nm and -7.39 mV, respectively. S-EVs were positive for heat shock protein 70 kDa (HSP70). These S-EVs considerably enhanced the production of proinflammatory tumor necrosis factor-α and interleukin 6 from RAW264.7 cells (mouse macrophage-like cells) and DC2.4 cells (mouse dendritic cells). The expression of maturation markers CD40, CD80 and CD86 on the surface of these immune cells incubated with S-EVs was remarkably upregulated. Immune cells endocytosed S-EVs, and toll like receptor 2 on immune cells was involved in immune activation by S-EVs. These results indicate that extracellular vesicles derived from baker's yeast Saccharomyces cerevisiae are an attractive source as a novel vaccine material for immune cells maturation.

Cancer immunotherapeutic effect of carboxymethylated ß-d-glucan coupled with iron oxide nanoparticles via reprogramming tumor-associated macrophages.

The cancer immunotherapeutic effect of a carboxymethylated ß-d-glucan (CMPTR)/iron oxide nanoparticles (IONPs) system (CMPTR/IONPs) were investigated by using cell culture of bone marrow-derived macrophages (BMDMs) and B16F10 melanoma skin cancer-bearing mouse model. When compared with that of control group, CMPTR/IONPs-treated M2-like BMDMs exhibited upregulated M1 biomarkers expression, significantly inhibited the migration of B16F10 cancer cells (p < 0.05), and had the highest apoptotic percentage of B16F10 cancer cells (80.39 ± 8.73 %) in co-culture system. Intratumoral administration of CMPTR/IONPs significantly (p < 0.05) suppressed tumor growth (46.58 % based on tumor weight) in mice and enhanced the M1/M2 ratio from 0.40 ± 0.09 (control group) to 6.64 ± 1.61 in tumor associated macrophages (TAMs) which was higher than that of in CMPTR (1.27 ± 0.38), IONPs (1.38 ± 0.17). CMPTR/IONPs treatment also promoted apoptosis in cancer cells and increased the infiltration of CD4 and CD8 T-lymphocytes in tumor tissues. These results could be due to the combined effects of CMPTR and IONPs in the CMPTR/IONPs system, possibly mediated by the activation of NF-κB and IRF5 pathways for inducing M1 macrophages polarization and had potential cancer immunotherapeutic applications.