The impact of anti-mould prophylaxis on Aspergillus PCR blood testing for the diagnosis of invasive aspergillosis.

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.

Interlaboratory evaluation of Mucorales PCR assays for testing serum specimens: A study by the fungal PCR Initiative and the Modimucor study group.

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.

Predictors of large and small for gestational age birthweight in offspring of women with gestational diabetes mellitus.

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.

Sources of Differences in On-Orbital Total Solar Irradiance Measurements and Description of a Proposed Laboratory Intercomparison.

There is a 5 W/m(2) (about 0.35 %) difference between current on-orbit Total Solar Irradiance (TSI) measurements. On 18-20 July 2005, a workshop was held at the National Institute of Standards and Technology (NIST) in Gaithersburg, Maryland that focused on understanding possible reasons for this difference, through an examination of the instrument designs, calibration approaches, and appropriate measurement equations. The instruments studied in that workshop included the Active Cavity Radiometer Irradiance Monitor III (ACRIM III) on the Active Cavity Radiometer Irradiance Monitor SATellite (ACRIMSAT), the Total Irradiance Monitor (TIM) on the Solar Radiation and Climate Experiment (SORCE), the Variability of solar IRradiance and Gravity Oscillations (VIRGO) on the Solar and Heliospheric Observatory (SOHO), and the Earth Radiation Budget Experiment (ERBE) on the Earth Radiation Budget Satellite (ERBS). Presentations for each instrument included descriptions of its design, its measurement equation and uncertainty budget, and the methods used to assess on-orbit degradation. The workshop also included a session on satellite- and ground-based instrument comparisons and a session on laboratory-based comparisons and the application of new laboratory comparison techniques. The workshop has led to investigations of the effects of diffraction and of aperture area measurements on the differences between instruments. In addition, a laboratory-based instrument comparison is proposed that uses optical power measurements (with lasers that underfill the apertures of the TSI instruments), irradiance measurements (with lasers that overfill the apertures of the TSI instrument), and a cryogenic electrical substitution radiometer as a standard for comparing the instruments. A summary of the workshop and an overview of the proposed research efforts are presented here.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline.

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.

Antifungal susceptibility of Candida species using the Clinical and Laboratory Standards Institute disk diffusion and broth microdilution methods.

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.

'Spiking' as a rapid method for differentiation of Candida albicans from other yeast species.

This paper describes a simple and rapid method for the differentiation of Candida albicans from other yeast species in primary cultures based on colonial morphology following incubation in carbon dioxide. The technique has superior sensitivity to the traditional germ-tube method and requires no additional laboratory tests. In a busy laboratory, this can result in significant savings in cost and time, as well as improvements in patient care.

Detection of meningitis antigens in buffer and body fluids by ultrasound-enhanced particle agglutination.

The standard test card agglutination of antibody-coated latex by Neisseria meningitidis. Streptococcus group B, Haemophilus influenzae type b and Streptococcus pneumoniae antigens has been compared with a technique involving local concentration of the coated latex in an ultrasonic standing wave. The detection of positive control antigen was enhanced, compared with the test-card procedure, over a 16 to 64 fold range on exposure to ultrasound. Sample filtration eliminated non-specific agglutination on ultrasonic exposure of latex in control serum, urine or concentrated urine. Tests of meningitis patient body fluids showed increased detection of antigen with ultrasound for CSF (11/14 > 7/14) serum (8/13 > 3/13) and concentrated urine (8/17 > 2/17) compared to test card assays. The ultrasound detection of antigen in serum or concentrated urine was comparable to that achieved with CSF on test cards. Serum dilution experiments showed that ultrasound could detect antigen in serum over a 1000 fold concentration range.

Use of IgM enriched intravenous immunoglobulin (Pentaglobin) in bone marrow transplantation.

In a study of 63 allogeneic and autologous bone marrow transplants, patients were randomized to receive the IgM and IgA enriched intravenous immunoglobulin (IVIG) preparation (Pentaglobin). Pentaglobin has been postulated to have anti-endotoxin properties and one of the aims of the study was to measure endotoxin levels in these patients together with the clinical sequelae of infection. The anti-endotoxin effects of Pentaglobin were found to reside in the IgM fraction. Those patients who received Pentaglobin were significantly protected from dying from infection in the first 100 days after the transplant, although it was not actually possible to document bacterial infections as the cause of death in the control patients. Peak endotoxin levels were significantly reduced (p = 0.02) in those patients receiving Pentaglobin. Liver damage as assessed by liver enzyme abnormalities correlated significantly with the presence of endotoxaemia greater than 25 pg/ml and up to 70% of pyrexial episodes were associated with endotoxaemia. Our results suggest that Pentaglobin is useful in reducing hepatic toxicity and this may be related to a reduction in endotoxaemia.

Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization.

The authors assessed the prevalence and demography of depressive symptoms, their association with specific chronic diseases, and their influence on health service use in a large sample of elderly men seen in a primary care setting. Twenty-four percent of respondents reported clinically significant depressive symptoms; the prevalence of major depressive disorders was estimated at 10%, but only 1% reported receiving mental health treatment by a specialist. Self-reported marital separation or divorce and physical disability affecting employment were strongly associated with high depression scores, whereas the normative stresses of aging (widowhood, retirement, social isolation) were not. Only chronic lung disease was differentially associated with high depression scores, and this effect was weak. The authors discuss the implications of these findings for the design of comprehensive health services for the elderly with chronic disease.

The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages.

OBJECTIVES: (1)To assess the diagnostic utility of quantitative cultures of non-bronchoscopic lung lavage (NBL) in ventilator-associated pneumonia and evaluate the role of the Bacterial Index; (2) To assess the predictive value of NBL surveillance quantitative cultures in ventilated patients; (3) To evaluate the Clinical Pulmonary Infection Score (CPIS) system in ventilated patients. DESIGN: A prospective comparison of NBL with bronchoscopic bronchoalveolar lavage and protected specimen brush. SETTING: Three intensive care units in academic tertiary care centres. PATIENTS: 145 adults ventilated for 72 h, with and without clinical signs of pneumonia. INTERVENTIONS: Sampling of lower airway secretions by NBL, bronchoalveolar lavage and protected specimen brush. MAIN OUTCOME MEASURES: Diagnostic reliability of quantitative cultures, Bacterial Index and CPIS. RESULTS: 34 episodes of clinical ventilator-associated pneumonia were documented in 32 patients. 9 episodes were confirmed by concordant blood/pleural culture or post-mortem lung examination. Qualitative concordance of the predominant pathogen between sequential NBL: bronchoalveolar lavage and protected specimen brush was 83 %. Sensitivity and specificity of non-directed bronchial lavage at a threshold of 10(4) CFU/ml were 68 % and 70 % respectively (p = 0. 003) and were comparable with the bronchoscopic methods. However, the low positive predictive value of NBL indicates that quantitation in the absence of clinical signs is unlikely to be useful. Bacterial Index did not improve discriminatory power of quantitation compared with bacterial load of predominant organism. Mean CPIS for confirmed pneumonia cases was 8.4 +/- 1.01, significantly higher than for non-pneumonia observations (p = < 0.0001). CONCLUSION: NBL is a simple, safe, cheap, readily-available method of diagnosing ventilator-associated pneumonia with comparable diagnostic accuracy to bronchoscopic techniques. Quantitation of respiratory tract cultures can exclude pneumonia in patients with equivocal clinical signs. The diagnostic threshold should vary depending on the length of ventilation, likelihood of pneumonia and antibiotic administration. The Bacterial Index is a flawed mathematical device that has no contributory role in pneumonia diagnosis. The CPIS has some diagnostic role in selected cohorts of ventilated patients.

A novel simple method for quantifying bacteria from endotracheal aspirates.

A convenient dipstrip method (Bacteruritest; Mast Diagnostics) for bacterial quantification was evaluated with 42 endotracheal aspirates. For 31 specimens, the dipstrip method yielded counts within a 10-fold range of surface plate counts. Two specimens yielded counts by the dipstrip within a 100-fold range of plate counts. Six specimens yielded confluent growth at the greatest dilution tested by the dipstrip method, and counts > 10(10) cfu/ml in the surface plate method. Three specimens yielded no detectable growth by the dipstrip and surface plate counts < 10(2) cfu/ml. Dipstrips provide a cheap, convenient method for the routine quantification of the bacterial load in endotracheal aspirates.

Immunotherapy and immunoprophylaxis in bone marrow transplantation.

Immunotherapy can be defined as treatment directed at augmenting host immune defence mechanisms. Non-antimicrobial therapies and immunoprophylaxis in bone marrow transplantation (BMT) can be subdivided into three broad categories: passive immunotherapy with intravenous immunoglobulin (IVIG); cytokine therapy; and anti-endotoxin-directed treatments. Most studies using IVIG in BMT are prophylactic and suffer from variability in study design, type of IVIG and dosing regimens. Various effects on viral and bacterial infections and graft-versus-host disease (GVHD) have been reported but few if any have shown benefit in terms of improved patient survival. Moreover the immunomodulatory effect of immunoglobulin G preparations is frequently overlooked. With the exception of cytomegalovirus (CMV) pneumonitis, there is little evidence of benefit in the treatment of established infections and the relative benefits of hyperimmune preparations are poorly established. The development of haemopoietic growth factors has led to the widespread use of cytokines in BMT. The benefits of these agents both in the prevention of fever and infection and as adjuvants to standard antimicrobial therapy in established infection (e.g. invasive mycoses) are rapidly becoming apparent. Both human recombinant granulocyte-macrophage colony-stimulating factor (rhGM-CSF) and granulocyte colony-stimulating factor (rhG-CSF) have been shown to accelerate granulocyte recovery following BMT and reduce fever days, antibiotic usage and hospitalization. RhGM-CSF appears superior in these respects. The roles of interleukin 1 (IL1), IL3, IL6 and interferons are also under evaluation. As with the much publicised studies using anti-endotoxin antibodies as therapy in sepsis, there is little evidence of benefit in the few studies performed in BMT patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Control of an outbreak of nosocomial aspergillosis by laminar air-flow isolation.

In the course of construction of a new bone marrow transplantation (BMT) unit, six of nineteen children undergoing BMT in the adjacent ward area died of invasive pulmonary aspergillosis (IPA). Ward air samples confirmed that heavy fungal spore contamination had occurred. The introduction of laminar air flow (LAF) isolation terminated the outbreak and no subsequent cases of IPA have been documented in patients nursed entirely in LAF. LAF has not reduced the rates of other complications associated with BMT.

Fungal infection in the intensive care unit.

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.

Management and outcome of bloodstream infections due to Candida species in England and Wales.

This two-year prospective hospital population-based study of candidaemia is the first to be conducted in the UK. It was carried out on behalf on the British Society for Medical Mycology (BSMM) as part of the European Confederation of Medical Mycology (ECMM) epidemiological survey of candidaemia. Six hospitals in England and Wales acted as sentinel hospitals. Main outcome measures were hospital population-based incidence and 30-day mortality. There were 18.7 episodes of candidaemia per 100,000 finished consultant episodes or 3.0/100,000 bed days and 45.4% cases occurred in intensive care unit (ICU) patients. Candida albicans was isolated in 64.7% of confirmed cases. The majority of isolates were sensitive to standard antifungal agents, including fluconazole. The overall 30-day mortality was 26.4% and removal of the central venous catheter was associated with a significant reduction in mortality. In conclusion, the incidence of candidaemia in England and Wales is similar to that of the USA, the majority of isolates remain sensitive to commonly used antifungal agents and mortality associated with this infection appears to be falling.

Hazards of inadequate fluconazole dosage to treat deep-seated or systemic Candida albicans infection.

We report three cases of deep-seated and systemic Candida albicans infection in which inadequate dosages of fluconazole were used, leading to breakthrough fungaemia, candidal osteomyelitis and endocarditis. The need to modify fluconazole dosage in patients receiving continuous venovenous haemofiltration is discussed.

Infective endocarditis: an epidemiological review of 128 episodes.

OBJECTIVES: The objective was to determine the current epidemiology of infective endocarditis. PATIENTS AND METHODS: All microbiologically positive episodes of infective endocarditis treated at The University Hospital of Wales over a 9-year period from March 1987 to March 1996 was reviewed. Patients originated from the catchment area of The University Hospital of Wales or were referred from other hospitals in Wales. Data extraction was from records held in the Microbiology Department and, whenever possible, from patients' casenotes. The epidemiological parameters were: (1) age and sex of patients; (2) distribution of affected sites; (3) frequency of predisposing risk factors (cardiac and extracardiac); (4) incidence of early prosthetic valve endocarditis; and (5) mortality rates. RESULTS: There were 128 microbiologically positive episodes of endocarditis in 125 patients. The mean age of the population was 53.1 years and the aortic valve was the most frequently involved site of infection (51.6%). A presumed source of infection was identified in 20% if episodes. The commonest predisposing cardiac risk factor in native valve episodes was bicuspid aortic valve (16.7%) but there was no identifiable cardiac risk factor in a much larger proportion (37.7%) of native valve episodes. There was a low incidence (0.6%) of culture positive early prosthetic valve episodes and low mortality rates for both native and prosthetic valve endocarditis (12.3% and 24.5%) in this study. Viridans streptococci were the predominant organisms. In prosthetic valve episodes with onset after the 60th postoperative day but within one postoperative year the identity of the isolate suggested, in most cases, perioperative valve contamination. CONCLUSIONS: The epidemiology of infective endocarditis has undergone significant change. Inability to detect clinically common predisposing lesions, and the frequent absence of any identifiable predisposing cardiac risk factor mean that initial diagnosis is often difficult and demands a high index of suspicion. There was a low incidence of culture positive early prosthetic valve episodes and there were low mortality rates for both native and prosthetic valve endocarditis; these figures suggest improvements in cardiac care. The microbiological evidence indicates that the duration of the postoperative time period used for classifying prosthetic valve endocarditis into 'early' and 'late' episodes should be extended from 60 days to 1 year.

Detection of meningococcal antigen by latex agglutination.

Meningococcal meningitis and septicemia are serious infections with significant morbidity and mortality. A sensitive affordable test is required to provide evidence of meningococcal disease at the earliest opportunity to improve local management and give early warning of potential outbreaks of disease. Culture of organisms is considered the gold standard for diagnosis but is slow (24 h or more) and increasingly influenced by prior antibiotic treatment. Recently, the development of polymerase chain reaction (PCR) has improved diagnosis but this sensitive assay is costly, is not available at most primary care institutions and is not feasible for developing countries. Conventional latex agglutination (LA) enables rapid detection of bacterial antigen in cerebrospinal fluid (CSF) (1,2) and can also be used to test specimens of blood (3,4) or urine (5) and for serogroup determinations on primary cultures (6,7). We discuss here test-card agglutination and also describe a new technique based upon LA in an ultrasonic standing wave that retains the speed of direct antigen testing while significantly increasing sensitivity.

The recurrent self-harm patient.

A semistructured interview was used to collect information on a consecutive series of 163 self-harm patients (suicide attempters); 65.8% of the patients had a history of previous self-harm (repeaters). Male repeaters were more likely than men with no self-harm history (first cases) to have left school before ninth grade, to have alcohol abuse problems, and to have family stress. Female repeaters were younger than first cases and reported more difficulties with sexual adjustment and loneliness. Repeaters were more likely to have contacted distress centers and to have had previous mental health contact, including psychiatric hospitalization. A 6-month follow-up indicated four suicides in the repeaters' group and none in the first cases' group. Repeaters appear to be much more dependent than first cases on professional care and to present a high short-term risk for suicide.