Tobias Lahmer. Sebastian Rasch. Christopher Schnappauf. Analena Beitz. Roland M. Schmid. Wolfgang Huber

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1 DOI /s x Comparison of Serum Galactomannan and 1,3-Beta-D- Glucan Determination for Early Detection of Invasive Pulmonary Aspergillosis in Critically Ill Patients with Hematological Malignancies and Septic Shock Tobias Lahmer. Sebastian Rasch. Christopher Schnappauf. Analena Beitz. Roland M. Schmid. Wolfgang Huber Received: 5 March 2016 / Accepted: 17 April 2016 Springer Science+Business Media Dordrecht 2016 Abstract Introduction Invasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in critically ill patients with hematological malignancies. New diagnosis strategies include the noninvasive biomarkers 1,3-beta-D-glucan (BDG) and serum galactomannan (GM). Methods For early detection of IPA, we compared BDG Fungitell assay with GM Platelia assay. Results Twenty-two out of 30 patients (74 %) had elevated BDG levels (mean 306 pg/ml) beyond the cutoff of 80 pg/ml. GM levels were elevated in only 3 patients (10 %) over the ODI cutoff of[0.5. Following the BDG/GM and microbiological findings, 10 (34 %) cases were classified as probable IPA and 12 (40 %) as possible IPA. Eight (26 %) were classified as no IPA. An overall sensitivity of 90 % (95 % CI %) and specificity of 85 % (95 % CI %) was found for the BDG Fungitell assay in IPA. In contrast, an overall sensitivity of 30 % (95 % CI %) and specificity of 98 % (95 % CI %) was found for the GM Platelia assay. A false-negative rate of 70 % for probable IPA and 85 % for probable/possible IPA was detected for GM. The T. Lahmer (&) S. Rasch C. Schnappauf A. Beitz R. M. Schmid W. Huber II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, Munich, Germany TobiasLahmer@me.com false-negative rate for BDG was 0 % in cases of probable IPA and 45 % in cases of possible cases. Conclusion BDG is a sensitive marker for patients surveillance at risk of IPA. In patients with hematological malignancies and septic shock, early diagnosis of IPA might be significantly improved by BDG compared to GM, also considering that BDG has the advantage of detecting fungal diseases other than IPA. Keywords 1,3-Beta-D-Glucan Critically ill Hematological malignancies Invasive aspergillosis Septic shock Introduction Invasive pulmonary aspergillosis (IPA) remains a significant cause of morbidity and mortality in patients with hematological malignancies [1]. Especially in critically ill patients with hematological malignancies, the incidence of IPA is continuously increasing, due to both pathologic and therapeutic reasons [1, 2]. Early identification of IPA is challenging, because of the patients complexity; moreover, accompanying signs and symptoms are nonspecific in most cases and may not be present until the disease is advanced or disseminated [1, 3]. The traditional approach to diagnosis of IPA requires the direct detection of the involved microorganism by microscope analysis, followed by culture

2 and identification of clinical isolates [4, 5]. Even though this approach is still considered as a gold standard, it is affected by a poor sensitivity and long times-to-results [5]. Furthermore, delayed initiation of antifungal treatment increases mortality [3]. To overcome such limitations, different strategies have been proposed, based on either risk stratification such as host and clinical factors or use of non-cultural microbiological assays to detect specific markers of infection [5, 6]. Detection of circulating galactomannan (GM) with a sandwich enzyme-linked immunosorbent assay (ELISA, Platelia Aspergillus) has been widely used [7, 8]. Another method is the determination of 1,3- beta-d-glucan (BDG) serum levels as a noninvasive test for detection of circulating fungal cell wall components that allow systematic screening and prompt identification of fungal infections (with the exception of cryptococcosis and zygomycosis) [7, 8]. The BDG search is one of the microbiological criteria for definition of IFD, according to the Joint Committee of the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC-MSG) [6]. In line with this, the 3rd European Conference on Infections in Leukaemia (ECIL-3) for onco-hematological patients and the Surviving Sepsis Campaign for Intensive Care Unit (ICU) patients recommend the GM as well as the BDG test, in the diagnosis of invasive mycoses. However, data on the performance of BDG in ICU patients are scarce for the diagnosis of IPA [8 10]. Moreover, only few studies have performed direct comparisons of the two assays for the diagnosis of IPA in the same patients. Therefore, we undertook this study to examine the performance of the BDG assay for early diagnosis of IPA in critically ill patients with hematological malignancies and septic shock and compared it to serum GM. Materials and Methods This observational study was conducted at the medical ICU of the University Hospital Technische Universität München, Germany. This observational study without any specific intervention was reviewed and approved by the ethics committee of our university hospital, and all data were processed anonymously. Need for informed consent was waived for this analysis. We analyzed the medical records of all patients (18 years and older) with respiratory failure and septic shock who were treated at the ICU between December 2014 and December Out of these 144 patients we identified 30 (11 %) patients with hematological malignancies who were included in this study. Both tests were performed initially after admission to the ICU. As a standard procedure every patient with suspected IPA receives computed tomography of the chest. For validation reasons Galactomannan was also performed in BAL. Definitions and Microbiological Testings Septic shock was defined following the International Guidelines for Management of Severe Sepsis and Septic Shock from For definition of fungal disease, we used the criteria proposed by the European Organization for Research and Treatment of Cancer/ Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Standard Fungal Testing Fungals were detected by direct examination and culture. Fungal culture was performed using a Schaedler broth (Becton Dickinson) and Sabouraud dextrose agar slant (Becton Dickinson). Galactomannan Antigen Detection GM antigen was detected using a sandwich immunocapture ELISA (Platelia Aspergillus; Bio-Rad, Marnes-la-Coquette, France), according to the manufacturer s recommendations. Positive and negative controls were included in each assay. A result was considered positive with index values of [0.5 in duplicate tests. 1,3-Beta-D-Glucan BDG was detected with the Fungitell test kit, as recommended by the manufacturer (Associates of Cape Cod). BDG levels of C80 pg/ml were considered positive results.

3 Statistics We used IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL, USA) for all statistical analyses in this study. To present descriptive statistics, we calculated mean ± SD for normally distributed continuous data and absolute and relative frequencies for categorical data (Fishers exact test). The diagnostic performance of GM and BDG test was evaluated as sensitivity and specificity, calculated using the mean parameters, with 95 % confidence intervals (CI). Results Patients Characteristics The demographic and clinical characteristics of the patients are presented in Table 1. 1,3-Beta-D-Glucan and Galactomannan Results, Microbiological Findings The results of 1,3-beta-D-glucan (BDG) and galactomannan levels as well as the microbiological findings are presented in Table 2. The BDG cutoff for invasive fungal diseases was set beyond 80 pg/ml as recommended by the manufacturer. Twenty-two out of 30 patients (74 %) had elevated BDG levels with a mean BDG level of 306 pg/ml ( pg/ml). Following the EORTC/MSG Consensus Group, one case could be classified as proven invasive aspergillosis, however, by autopsy, 9 (30 %) cases as probable IPA and 12 (40 %) cases as possible IPA. Eight (26 %) patients had no elevated BDG, GM or microbiological findings and were classified as no IPA. The BDG level was highest in proven IPA (1000 pg/ml). Mean BDG levels were in cases of probable IPA 284 pg/ml ( pg/ml) and 190 pg/ml ( pg/ml) in cases of possible IPA. An overall sensitivity of 90 % (95 % CI %) and specificity of 85 % (95 % CI %) was found for the BDG Fungitell assay in IPA. In detail, a sensitivity of 98 % (95 % CI %) and specificity of 86 % (95 % CI %) for proven, a sensitivity of 92 % (95 % CI %) and specificity of 86 % (95 % CI %) for probable IPA and a sensitivity of 88 % (95 % CI Table 1 Basic parameters and risk/host factors All patients (n = 30) Age (years) 59; 25 78; 12 Male gender n; (%) 16; (56) APACHE II score 25; 18 30; 3 SOFA score 15; 10 18; 2 Reason for ICU admission All septic shock Underlying disease n; (%) Acute myeloid leukemia 6; (20) Non-Hodgkin s lymphoma 14; (46) Multiple myeloma 8; (26) Myelodysplastic syndrome 2; (8) Stem cell transplant recipients (n) Allogenic stem cell transplantation 10 Autologous stem cell transplantation. 4 Neutropenia n; (%) 15; (50) Risk factors n; (%) Mechanical ventilation 30; (100) Parenteral nutrition 14; (45) Renal replacement therapy 10; (30) Medical devices a 3 ± 2 Norepinephrine Therapy n; (%) 30; (100) ICU stay (days) 17; 5 54; 12 Mortality rate n; (%) 24; (80) Data are presented as mean ± SD APACHE Acute Physiology and Chronic Health Evaluation, SOFA Sequential Organ Failure Assessment score a Medical devices (arterial and central venous lines, urinary catheter, endotracheal tube, surgical drains) left in place for [2 days were considered %) and specificity of 82 % (95 % CI %) for possible IPA were found. Elevated galactomannan (GM) beyond the optical density index (ODI) cutoff of [0.5 could be detected in 3 (10 %) out of 30 patients. An overall sensitivity of 30 % (95 % CI %) and specificity of 98 % (95 % CI %) was found for the GM Platelia assay. A false-negative rate of 70 % for probable IPA and 85 % for probable/possible IPA was detected for GM. The false-negative rate for BDG was 0 % in cases of probable IPA and 45 % in cases of possible cases. Standard laboratory parameters, antibiotic and antimycotic use are presented in Table 2. BAL GM for validation reasons was in all cases with susptected IPA beyond the cut-off of[0.5.

4 Table 2 1,3-Beta-D-glucan and galactomannan levels, microbiological findings, standard infection parameters and possible influencing factors All patients (n = 30) Patients with elevated BGD levels n; (%) 22; (74) Patients with elevated GM levels n; (%) 3; (10) 1,3-Beta-D-glucan levels (pg/ml) in IPA Mean 306; ; 274 Proven 1000 Probable 284; ; 87 Possible 190; ; 63 Galactomannan levels (ODI) in IPA Probable 3.37; ; 0.47 Invasive pulmonary aspergillosis following EORTC/MSG Consensus Group n; (%) Proven 1; (3) Probable 9; (30) Possible 12; (40) No IPA 8; (26) BDG Sensitivity (%) 90 % (95 % CI %) Specificity (%) 85 % (95 % CI %) Galactomannan Sensitivity (%) 30 % (95 % CI %) Specificity (%) 98 % (95 % CI %) Microbiological findings Fungal findings in BAL n; (%) Aspergillus spp. A. fumigatus 8; (27) A. terreus 1; (3) A. niger 1; (3) Candida spp. C. albicans 2; (6) C. dubliniensis 1; (3) Leukocytes G/l 7.97; ; C-reactive protein mg/dl 23.5; ; 13.5 Procalcitonin ng/ml 16.1; ; 29.1 Used antibiotics n; (%) Meropenem 14; (46) Table 2 continued Discussion All patients (n = 30) Piperacillin/tazobactam 10; (30) Ceftazidime 6; (20) Linezolid 12; (40) Vancomycin 8; (27) Used antifungals before ICU stay n; (%) Voriconazole 15; (50) Caspofungin 9; (30) Liposomal amphotericin B 3; (10) Data are presented as mean ± SD IPA invasive pulmonary aspergillosis In our observational study, we compared serum galactomannan (GM) and 1,3-beta-D-glucan (BDG) determination for early detection of invasive pulmonary aspergillosis (IPA) in critically ill patients with hematological malignancies and septic shock. Our results presented a highly reliable diagnostic value for the BDG Fungitell assay with an overall sensitivity of 90 % (95 % CI %) and specificity of 85 % (95 % CI %). By comparison, the GM Platelia assay presented an overall sensitivity of 30 % (95 % CI %) and specificity of 98 % (95 % CI %). The diagnostic performance of the BDG assay for invasive fungal infections has been evaluated in several meta-analyses, and this assay is considered a useful diagnostic tool if it is used for diagnosis among immunocompromised patients, with knowledge of the limitations of the assay [11 13]. For the diagnosis of IPA, BDG and GM assays seem to be in the same performance range, considering the wide dispersion of the reported sensitivity and specificity values in studies [13 16]. The reported sensitivity values for the GM assay have been variable, with a range of %, and specificity values have ranged from 38 to 98 % [17 20]. Similarly, variable results have been reported for the BDG assay, with sensitivity values ranging from 80 to 90 % and specificity values ranging from 36 to 92 %, according to the cutoff value used [21, 22]. The measurement of BDG levels is based on the Limulus test. BDG activates factor G, a cascade, and

5 the activity of this reaction can be measured with the use of colorimetric or turbidimetric methods, in which optical density is converted to beta-d-glucan concentrations; the results are interpreted as negative (range \60 pg/ml), indeterminate (60 79 pg/ml), or positive ([80 pg/ml) [21, 32]. In our study, 74 % of the patients had significantly elevated 1,3-beta-D-glucan (mean 306 pg/ml) levels beyond the cutoff of[80 pg/ml. The results described above indicate that BDG has a good clinical performance. The overall sensitivity of 90 % and specificity of 85 % described in our study is in line and even higher than as those described by the recent meta-analysis studies with a sensitivity of 87.9 and specificity of 80.5 % [22 28]. Moreover, sensitivity and specificity is even higher in proven and probable than in possible IPA. Following the EORTC/MSG guidelines and the microbiological findings in this study, ten patients (34 %) had probable IPA (one patient proven IPA by autopsy) and twelve patients (40 %) had possible IPA. Correlated with the BDG findings, the false-negative rate for BDG was 0 % in cases of probable IPA and 45 % in cases of possible cases. In contrast, only three patients (10 %) had positive GM levels, which means that 19 patients or 86 % were tested as false negative for IPA in the cohort of probable/possible IPA. Thus, in line with our findings, we found a falsenegative rate of 70 % for probable and 85 % for possible IPA using GM. However, early detection is vital and effective therapy is the cornerstone in reducing mortality, especially in critically ill patients with IPA. One reason for the high false-negative rate of GM might be that antibodies against Aspergillus are frequently undetectable in immunocompromised patients [19, 20]. Galactomannan may be released by several Aspergillus spp. and is not specific for the most common species. Circulation of GM in serum is transient, even more in antimycotic pretreated patients as reported in our study [19, 20, 23, 24]. Therefore, repeated testing should be carried out. In contrast in one comparative study, the diagnostic marker BDG (Fungitell; Associates of Cape Cod Inc.) was shown to have a higher sensitivity than that of GM in detecting IPA and other mold infections in hematological malignancy patients [29]. In a second study using a different BDG test (Waco Pure Ltd, Osaka, Japan), monitoring BDG antigenemia proved to be a useful noninvasive method for early diagnosis of IPA in patients with acute leukemia [30 32]. Beyond this, BDG has the potential to identify other fungal infections caused by Candida spp., Aspergillus spp., Fusarium spp., Acremonium spp. and Pneumocystis jiroveci [33]. However, BDG concentrations are usually low or absent in patients with cryptococcal infections, and BDG is usually absent in patients with zygomycosis since these fungi do not produce BDG. Further limitations of the BDG test are due to interference with BDG released from plastic tubes, water or dust, hemodialysis with cellulose membranes, intravenous immunoglobulin, usage of albumin, gauze packing of serosal surfaces, and intravenous application of antibiotics such as piperacillin/tazobactam [33]. Previous studies, aimed at comparing BDG and GM assays, provide contrasting results, especially in ICU patients. In this respect, our data demonstrate a significant increase in sensitivity when using BDG alone or combining BDG and GM determination with respect to the use of GM alone. As far as ICU patients, the literature provides once again heterogeneous results, probably because of substantial differences in study design and investigated populations; also, intrinsic limitations, such as standard microbiological analysis, still remain the gold standard for IPA classification [34, 35]. In accordance with the literature, our data strengthen the relevance of BDG as a predictive factor of clinical outcome, particularly in our study demonstrating high APACHE II and SOFA scores, as well a high mortality rate. Alternatives such as the Aspergillus Lateral Flow Device test and Aspergillus PCR, both targeting Aspergillus infections, may also be helpful tools in the near future. According to the observed good agreement between BDG kinetics and IPA detection, we propose BDG as a useful tool that, together with clinical parameters, may be used for early detection of IPA. Conclusion Overall, BDG is a very promising marker for early detection of patients at risk of IPA, in different clinical

6 settings. In patients with hematological malignancies and septic shock, the diagnostic performance significantly enhances when BDG is run in parallel with GM; moreover, the association of the two parameters has also the advantage of detecting early and reliable IPA. Authors Contribution TL, SR, CS, AB, RMS and WH were involved in the study design. TL, CS, SR, AB and WH collected data. TL, CS, SR, AB, RMS and WH analyzed data. TL, CS, SR, AB, RMS and WH wrote the paper. Compliance with Ethical Standards Conflict of interest None of the authors have any potential financial no non-financial conflicts of interest related to this manuscript. None of the authors have got any funding or financial support regarding this manuscript. The manuscript has not been submitted or accepted elsewhere. All authors fulfill the criteria given in the Authorship paragraph. No writing assistance other than copy editing was provided in the preparation of the manuscript. References 1. Steinbach WJ, Marr KA, Anaissie EJ, et al. Clinical epidemiology of 960 patients with invasive aspergillosis from the PATH Alliance registry. J Infect. 2012;65(5): Ninin E, Milpied N, Moreau P, et al. Longitudinal study of bacterial, viral, and fungal infections in adult recipients of bone marrow transplants. Clin Infect Dis. 2001;33(1): Upton A, Kirby KA, Carpenter P, et al. Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors associated with mortality. Clin Infect Dis. 2007;44(4): Pagano L, Caira M, Nosari A, et al. Fungal infections in recipients of hematopoietic stem cell transplants: results of the SEIFEM B-2004 study Sorveglianza Epidemiologica Infezioni Fungine Nelle Emopatie Maligne. Clin Infect Dis. 2007;45(9): Cornely OA, Gachot B, Akan H, EORTC Infectious Diseases Group, et al. Epidemiology and outcome of fungemia in a cancer Cohort of the Infectious Diseases Group (IDG) of the European Organization for Research and Treatment of Cancer (EORTC 65031). Clin Infect Dis. 2015;61(3): De Pauw B, Walsh TJ, Donnelly JP, European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group, National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/ MSG) Consensus Group, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008;46(12): Maertens J, Verhaegen J, Demuynck H, et al. Autopsy-controlled prospective evaluation of serial screening for circulating galactomannan by a sandwich enzyme-linked immunosorbent assay for hematological patients at risk for invasive aspergillosis. J Clin Microbiol. 1999;37(10): Marchetti O, Lamoth F, Mikulska M, et al. ECIL recommendations for the use of biological markers for the diagnosis of invasive fungal diseases in leukemic patients and hematopoietic SCT recipients. Bone Marrow Transplant. 2012;47: Dellinger RP, Levy MM, Rhodes A, Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, Intensive Care Med. 2013;39(2): Roosen J, Frans E, Wilmer A, et al. Comparison of premortem clinical diagnoses in critically ill patients and subsequent autopsy findings. Mayo Clin Proc. 2000;75: Meersseman W, Lagrou K, Maertens J, et al. Invasive aspergillosis in the intensive care unit. Clin Infect Dis. 2007;45: Hope WW, Walsh TJ, Denning DW. Laboratory diagnosis of invasive aspergillosis. Lancet Infect Dis. 2005;5: Digby J, Kalbfleisch J, Glenn A, et al. Serum glucan levels are not specific for presence of fungal infections in Intensive Care Unit patients. Clin Diagn Lab Immunol. 2003;10: Meersseman W, Lagrou K, Maertens J, et al. Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing aspergillosis in intensive care unit patients. Am J Respir Crit Care Med. 2008;177: Ostrosky-Zeichner L, Alexander B, Kett D, et al. Multicenter clinical evaluation of the (1? 3)-b-D-glucan assay as an aid to diagnosis of fungal Infections in humans. Clin Infect Dis. 2005;41: Koo S, Bryar JM, Page JH, et al. Diagnostic performance of the (1-3) D-glucan assay for invasive fungal disease. Clin Infect Dis. 2009;49: Karageorgopoulos DE, Vouloumanou EK, Ntziora F, et al. Beta-D-Glucan assay for the diagnosis of invasive fungal infections: a meta-analysis. Clin Infect Dis. 2011;52: Lamoth F, Cruciani M, Mengoli C, Third European Conference on Infections in Leukemia (ECIL-3), et al. 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: Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis. 2006;42: Leeflang MM, Debets-Ossenkopp YJ, Visser CE, et al. Galactomannan detection for invasive aspergillosis in immunocompromised patients. Cochrane Database Syst Rev. 2008;4:CD De Vlieger G, Lagrou K, Maertens J, et al. Beta-D-Glucan detection as a diagnostic test for invasive aspergillosis in immunocompromised critically ill patients with symptoms of respiratory infection: an autopsy-based study. J Clin Microbiol. 2011;49:

7 22. Kappe R, Schulze-Berge A, Sonntag HG. Evaluation of eight antibody tests and one antigen test for the diagnosis of invasive aspergillosis. Mycoses. 1996;39(1 2): Marr KA, Balajee SA, McLaughlin L, et al. Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. J Infect Dis. 2004;190(3): Onishi A, Sugiyama D, Kogata Y, et al. Diagnostic accuracy of serum 1,3-b-D-glucan for Pneumocystis jiroveci pneumonia, invasive candidiasis, and invasive aspergillosis: systematic review and meta-analysis. J Clin Microbiol. 2012;50: He S, Hang J-P, Zhang L, et al. A systematic review and metaanalysis of diagnostic accuracy of serum 1, 3-b-Dglucan for invasive fungal infection: focus on cutoff levels. J Microbiol Immunol Infect. 2015;48(4): Hachem RY, Kontoyiannis DP, Chemaly RF, et al. Utility of galactomannan enzyme immunoassay and (1,3) beta-d-glucan in diagnosis of invasive fungal infections: low sensitivity for Aspergillus fumigatus infection in hematologic malignancy patients. J Clin Microbiol. 2009;47(1): Senn L, Robinson JO, Schmidt S, et al. 1,3-Beta-D-glucan antigenemia for early diagnosis of invasive fungal infections in neutropenic patients with acute leukemia. Clin Infect Dis. 2008;46(6): Yoshida M, Obayashi T, Iwama A, et al. Detection of plasma (1? 3)-beta-D-glucan in patients with Fusarium, Trichosporon, Saccharomyces and Acremonium fungaemias. J Med Vet Mycol. 1997;35(5): Odabasi Z, Mattiuzzi G, Estey E, et al. Beta-D-glucan as a diagnostic adjunct for invasive fungal infections: validation, cutoff development, and performance in patients with acute myelogenous leukemia and myelodysplastic syndrome. Clin Infect Dis. 2004;39(2): Obayashi T, Yoshida M, Mori T, et al. Plasma (1? 3)-beta- D-glucan measurement in diagnosis of invasive deep mycosis and fungal febrile episodes. Lancet. 1995;345(8941): Pazos C, Ponton J, Del Palacio A. Contribution of (1? 3)- beta-d-glucan chromogenic assay to diagnosis and therapeutic monitoring of invasive aspergillosis in neutropenic adult patients: a comparison with serial screening for circulating galactomannan. J Clin Microbiol. 2005;43(1): Sulahian A, Porcher R, Bergeron A, et al. Use and limits of (1? 3)-b-D-glucan assay (fungitell), compared to galactomannan determination (platelia Aspergillus), for diagnosis of invasive aspergillosis. J Clin Microbiol. 2014;52: Persat F, Ranque S, Derouin F, et al. Contribution of the (1? 3)-b-D-glucan assay for diagnosis of invasive fungal infections. J Clin Microbiol. 2008;46: Sims CR, Jaijakul S, Mohr J, et al. Correlation of clinical outcomes with b-glucan levels in patients with invasive candidiasis. J Clin Microbiol. 2012;50: Jaijakul S, Vazquez JA, Swanson RN, Ostrosky-Zeichner L. (1,3)-b-D-glucan as a prognostic marker of treatment response in invasive candidiasis. Clin Infect Dis. 2012;55:521 6.