TIMM 2013 Role of non-culture biomarkers for detection of fungal infections

TIMM 2013 Role of non-culture biomarkers for detection of fungal infections Tom Rogers Clinical Microbiology, Trinity College Dublin Tom Rogers, TCD & St James s Hospital Dublin, Ireland

FACTORS INFLUENCING DIAGNOSTIC STRATEGY Possible changing epidemiological landscape Patient population, and disease categories Facilities for protective environment Antifungal prophylaxis used Availability of trained laboratory staff Costs

Pie charts showing the evolving epidemiology of invasive fungal infections by their prevalence in autopsies of patients with leukemia at M. D Anderson Leventakos K et al. Clin Infect Dis. 2010;50:405-415 2010 by the Infectious Diseases Society of America

Austrian National Registry of 186 cases of invasive mould infections (Perkhofer et al IJAA2010; 36 : 531) Aspergillus spp 67% (note high incidence of A terreus Innsbruck) Zygomycetes 28% Other moulds 4%

Studies of incidence of invasive aspergillosis HLA matched allo SCT* 2-3% Unrelated donor allo SCT* 4-5% Autologous SCT* <1% Acute leukaemia chemo** 5% Sources: *Morgan et al 2005; ** Pagano et al, 2007

Epidemiology of Invasive Aspergillosis in Acute Leukaemia and after HSCT Unrelated/AML chemo/mds Mis-matched Allo 4-5% Autologous 0.5% Matched allo 2.3% 3.2% 0%

Patients at SJH Monitored in the Study Rogers TR et al British J Haematol 2013 161: 517-524

Patients at SJH monitored prospectively study Study Rogers TR et al British J Haematol 2013 161: 517-524

Non-culture methods: what is your practice? Galactomannan twice weekly surveillance of serum from leukaemic patients?

Non-culture methods: what is your practice? Or BDGlucan performed similarly in leukaemic patients?

Non-culture methods: what is your practice? Or a blood/serum PCR assay for surveillance of Candida or Aspergillus infection in leukaemic patients?

Non-culture methods: what is your practice? Any of these biomarkers on BAL samples?

Biomarkers applied to bronchoalveolar lavage samples

Forest plot of sensitivities and specificities from studies of BAL-GM to diagnose Invasive Aspergillosis (Meta-analysis conducted by Zou et al PLoS One 2012; 7: e43347)

Histogram by index value in 99 bronchoalveolar lavage samples from case and control patients. Maertens J et al. Clin Infect Dis. 2009;49:1688-1693 2009 by the Infectious Diseases Society of America

Sensitivity and specificity of PCR for the detection of proven or probable IPA. The reference standard (RStype) was classified as the 2002 or 2008 EORTC/MSG criteria (3, 11) or as nonadherent to both definitions. Avni T et al. J. Clin. Microbiol. 2012;50:3652-3658

Comparison of Performance of BAL PCR vs GM* Sensitivity Specificity DOR P Value PCR vs GM (ODI > 0.5) 0.088 PCR 86.4% 96.2% 163 GM 82% 96.6% 129 PCR vs GM (ODI > 1.0) 0.01 PCR 92.6% 97.7% 516 GM 85.1% 99.7% 1,731 Avni et al., J. Clin. Microbiol. 2012, 50(11): 3652

Forest plot of diagnostic odds ratios (DORs) of β-glucan (BG) assays for the diagnosis of invasive fungal infections (IFIs; European Organization for Research and Treatment of Cancer and Mycoses Study Group criteria) using the cutoffs recommended by the manufacturer (Fungitell cutoff, 60 80 pg/ml; Fungitec-G cutoff, 20 pg/ml; Wako and Maruha cutoff, 11 pg/ml). Lamoth F et al. Clin Infect Dis. 2012;54:633-643 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

We know a lot about the performance of Galactomannan, BDG, and PCR on blood/serum and BAL samples What s new?

SOP Human serum and Haemorrhagic BAL Infection (2013), in press. DOI:10.1007/s15010-013-0472-5

Animal Infection Studies & Publications

Clinical Results & Publications

LFD detection - Human serum 103 adult haematology patients: 8 proven cases of IA, 14 probable cases, 22 possible cases, and 59 controls Proven/probable versus no IA populations: Specificity of LFD (98.0%) similar to PCR (96.6%) and superior to GM-EIA (91.5%) Sensitivity of LFD (81.8%) inferior to PCR (95.5%) but better than GM-EIA (77.3%) Journal of Clinical Microbiology (2013) 51: 510-516

LFD detection - human BAL Journal of Infection (2012) 65: 588-591 LFD with BAL provides 100% NPV

Haynes, Latge, Rogers J Clin Microbiol 1992

Figure 5. MAb476-based Lateral flow immunochromatographic assay device (LFD) detects Galf antigen in simulated and human urine samples. Dufresne SF, Datta K, Li X, Dadachova E, et al. (2012) Detection of Urinary Excreted Fungal Galactomannan-like Antigens for Diagnosis of Invasive Aspergillosis. PLoS ONE 7(8): e42736. doi:10.1371/journal.pone.0042736 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0042736

Figure 4. MAb476 detects a urinary excreted Galf antigen in a GP model of pulmonary IA. Dufresne SF, Datta K, Li X, Dadachova E, et al. (2012) Detection of Urinary Excreted Fungal Galactomannan-like Antigens for Diagnosis of Invasive Aspergillosis. PLoS ONE 7(8): e42736. doi:10.1371/journal.pone.0042736 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0042736

DR CLIFF is a 2-year old beagle that can sniff out cases of C difficile at University of Amsterdam Hospitals

Scheme for use of an electronic nose Exhaled breath Odours Sensors Sensor signal Breathprint

Electronic nose technology for detection of invasive pulmonary aspergillosis (IA) (de Heer K, et al J Clinical Microbiology 2013, in press) Conducted a proof of principle study in neutropenic patients at risk of invasive aspergillosis 46 had 16 diagnostic workups 6 cases of proven/probable IA vs 5 controls (no IA) Cross validated accuracy was 90% Using ROC analysis: AUC was 0.93 Authors concluded this was a rapid, inexpensive, approach

We know a lot about the performance of the Galactomannan test and PCR on blood/serum and BAL samples What about combining the established biomarkers as part of prospective monitoring of high-risk patients?

Diagnostic Performance of each assay in the allosct patient cohort in SJH Single Positive Assay Sensitivity Specificity Positive Predictive Value Negative Predictive Value ITS 0.79 0.45 0.28 0.89 28S 0.86 0.58 0.35 0.94 Confirmed Positive GM 0.57 0.89 0.57 0.89 ITS 0.43 0.79 0.35 0.84 28S 0.00 0.85 0.00 0.76 GM + ITS 0.71 0.87 0.59 0.92 GM + 28S 0.50 0.92 0.64 0.87 Nearer to 1 is optimal

Diagnostic Performance of each assay in the allosct patient cohort in SJH Single Positive Assay Sensitivity Specificity Positive Predictive Value Negative Predictive Value ITS 0.79 0.45 0.28 0.89 28S 0.86 0.58 0.35 0.94 Confirmed Positive GM 0.57 0.89 0.57 0.89 ITS 0.43 0.79 0.35 0.84 28S 0.00 0.85 0.00 0.76 GM + ITS 0.71 0.87 0.59 0.92 GM + 28S 0.50 0.92 0.64 0.87 Nearer to 1 is optimal Rogers TR et al British J Haematol 2013 161: 517-524

LFD detection - Human serum LFD and PCR in combination provides 100% specificity and 100% PPV Journal of Clinical Microbiology (2013) 51: 510-516

EORTC/ MSG criteria Host factors Neutropenia, allogeneic stem cell transplant, steroids, T cell immunosuppressants Clinical features CT changes, tracheobronchitis; sinonasal infection Mycology Cytological/ mould in sputum, BAL, sinus aspirate; Antigen detection

EORTC/MEOESG category Host factors Clinical features Not classified Mycology

The 90-day cumulative survival of 125 patients with invasive aspergillosis was 53% for European Organization for Research and Treatment of Cancer-Mycosis Study Group-defined invasive aspergillosis (proven or probable; controls) versus 68% for probable invasive aspergillosis without prespecified radiologic criteria (cases) (P =.08). Nucci M et al. Clin Infect Dis. 2010;51:1273-1280 2010 by the Infectious Diseases Society of America

Rogers TR et al 2011 British J Haematol 153: 681-697

Randomised controlled trial of a biomarker diagnostic strategy (GM/PCR) vs a standard diagnostic (culture and histology) strategy in patients at high risk of invasive aspergillosis CO Morrissey et al (multicentre Australian study) Lancet Infectious Diseases April 30 th 2013

Figure 1: Diagnostic and treatment algorithm for the biomarker based diagnostic strategy

Figure 2: Trial profile

Main results There was a lower number of empirical treatment episodes in biomarker group (p<0.002) There was a higher incidence of probable IA in biomarker group (p<0.0001) This specifically applied to pts receiving fluconazole or itraconazole prophylaxis If biomarkers had been applied to standard group there was no difference in incidence of IFD

Results cont d No patients in biomarker group with serially negative GM and PCR had a diagnosis of IA No difference in all-cause mortality or death attributable to invasive aspergillosis No difference in hepatoxicity or nephrotoxicity between 2 groups

Discussion points: Biomarker strategy improves management of high risk leukaemic patients More clear differentiation between those with and those without Inv. aspergillosis Suggest PCR should be included in updated EORTC/MSG diagnostic criteria Propose biomarker strategy for pts not receiving mould active antifungal prophylaxis

Figure 3: proposed options for integrated antifungal strategies in pts at high risk of IFD (Morrissey et al 2013)