Korean J Transplant.  2023 Sep;37(3):155-164. 10.4285/kjt.23.0043.

Culture-independent diagnostic approaches for invasive aspergillosis in solid organ transplant recipients

• Yoo IY
• Park YJ

• KMID: 2546473
• DOI: http://doi.org/10.4285/kjt.23.0043

Abstract

Prompt and accurate diagnosis of invasive aspergillosis (IA) is crucial for immunocompromised patients, including those who have received a solid organ transplant (SOT). Despite their low sensitivity, microscopic detection and conventional culture are considered the 'gold standard' methods. In conjunction with conventional culture, culture-independent assays such as serum galactomannan testing and Aspergillus polymerase chain reaction (PCR) have been incorporated into the diagnostic process for IA. The recently revised consensus definitions from the European Organization for Research and Treatment of Cancer and the Mycosis Study Group have adjusted the threshold for positive galactomannan testing based on the sample type, and have excluded 1,3-β-D-glucan testing as a mycological criterion. Following extensive standardization efforts, positive Aspergillus PCR tests using serum, plasma, or bronchoalveolar lavage fluid have been added. However, there are limited studies evaluating the clinical utility of these culture-independent assays for the early diagnosis of IA in SOT recipients. Therefore, further research is required to determine whether these assays could aid in the early diagnosis of IA in SOT recipients, particularly in relation to the organ transplanted. In this review, we examine the culture-independent diagnostic methods for IA in SOT recipients, as well as the clinical utility of these assays.

Keyword

Invasive aspergillosis; Galactomannan; Polymerase chain reaction; Transplant

Reference

1. Silveira FP, Husain S. 2007; Fungal infections in solid organ transplantation. Med Mycol. 45:305–20. DOI: 10.1080/13693780701200372. PMID: 17510855.

2. Grossi P, Farina C, Fiocchi R, Dalla Gasperina D. 2000; Prevalence and outcome of invasive fungal infections in 1,963 thoracic organ transplant recipients: a multicenter retrospective study. Italian Study Group of Fungal Infections in Thoracic Organ Transplant Recipients. Transplantation. 70:112–6.

3. Husain S, Tollemar J, Dominguez EA, Baumgarten K, Humar A, Paterson DL, et al. 2003; Changes in the spectrum and risk factors for invasive candidiasis in liver transplant recipients: prospective, multicenter, case-controlled study. Transplantation. 75:2023–9. DOI: 10.1097/01.TP.0000065178.93741.72. PMID: 12829905.

4. Minari A, Husni R, Avery RK, Longworth DL, DeCamp M, Bertin M, et al. 2002; The incidence of invasive aspergillosis among solid organ transplant recipients and implications for prophylaxis in lung transplants. Transpl Infect Dis. 4:195–200. DOI: 10.1034/j.1399-3062.2002.t01-2-02002.x. PMID: 12535262.

5. Husain S, Camargo JF. 2019; Invasive Aspergillosis in solid-organ transplant recipients: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 33:e13544. DOI: 10.1111/ctr.13544. PMID: 30900296.

6. López-Medrano F, Fernández-Ruiz M, Silva JT, Carver PL, van Delden C, Merino E, et al. 2016; Clinical presentation and determinants of mortality of invasive pulmonary aspergillosis in kidney transplant recipients: a multinational cohort study. Am J Transplant. 16:3220–34. DOI: 10.1111/ajt.13837. PMID: 27105907.

7. López-Medrano F, Fernández-Ruiz M, Silva JT, Carver PL, van Delden C, Merino E, et al. 2018; Multinational case-control study of risk factors for the development of late invasive pulmonary aspergillosis following kidney transplantation. Clin Microbiol Infect. 24:192–8. DOI: 10.1016/j.cmi.2017.06.016. PMID: 28652112.

8. Hosseini-Moghaddam SM, Ouédraogo A, Naylor KL, Bota SE, Husain S, Nash DM, et al. 2020; Incidence and outcomes of invasive fungal infection among solid organ transplant recipients: a population-based cohort study. Transpl Infect Dis. 22:e13250. DOI: 10.1111/tid.13250. PMID: 31981389.

9. De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, et al. 2008; 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. 46:1813–21. DOI: 10.1086/588660. PMID: 18462102. PMCID: PMC2671227.

10. Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. 2020; Revision and update of the consensus definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin Infect Dis. 71:1367–76. DOI: 10.1093/cid/ciz1008. PMID: 31802125. PMCID: PMC7486838.

11. Cahill BC, Hibbs JR, Savik K, Juni BA, Dosland BM, Edin-Stibbe C, et al. 1997; Aspergillus airway colonization and invasive disease after lung transplantation. Chest. 112:1160–4. DOI: 10.1378/chest.112.5.1160. PMID: 9367451.

12. Riwes MM, Wingard JR. 2012; Diagnostic methods for invasive fungal diseases in patients with hematologic malignancies. Expert Rev Hematol. 5:661–9. DOI: 10.1586/ehm.12.53. PMID: 23216596. PMCID: PMC3563387.

13. Arvanitis M, Anagnostou T, Fuchs BB, Caliendo AM, Mylonakis E. 2014; Molecular and nonmolecular diagnostic methods for invasive fungal infections. Clin Microbiol Rev. 27:490–526. DOI: 10.1128/CMR.00091-13. PMID: 24982319. PMCID: PMC4135902.

14. Tissot F, Lamoth F, Hauser PM, Orasch C, Fluckiger U, Siegemund M, et al. 2013; β-glucan antigenemia anticipates diagnosis of blood culture-negative intraabdominal candidiasis. Am J Respir Crit Care Med. 188:1100–9. DOI: 10.1164/rccm.201211-2069OC. PMID: 23782027.

15. Marty FM, Koo S. 2009; Role of (1→3)-beta-D-glucan in the diagnosis of invasive aspergillosis. Med Mycol. 47 Suppl 1:S233–40. DOI: 10.1080/13693780802308454. PMID: 18720216.

16. Lamoth F, Akan H, Andes D, Cruciani M, Marchetti O, Ostrosky-Zeichner L, et al. 2021; Assessment of the role of 1,3-β-d-glucan testing for the diagnosis of invasive fungal infections in adults. Clin Infect Dis. 72(Suppl 2):S102–8. DOI: 10.1093/cid/ciaa1943. PMID: 33709130.

17. Akamatsu N, Sugawara Y, Kaneko J, Tamura S, Makuuchi M. 2007; Preemptive treatment of fungal infection based on plasma (1→3)beta-D-glucan levels after liver transplantation. Infection. 35:346–51. DOI: 10.1007/s15010-007-6240-7. PMID: 17885729.

18. Alexander BD, Smith PB, Davis RD, Perfect JR, Reller LB. 2010; The (1,3){beta}-D-glucan test as an aid to early diagnosis of invasive fungal infections following lung transplantation. J Clin Microbiol. 48:4083–8. DOI: 10.1128/JCM.01183-10. PMID: 20720025. PMCID: PMC3020816.

19. Levesque E, El Anbassi S, Sitterle E, Foulet F, Merle JC, Botterel F. 2015; Contribution of (1,3)-beta-D-glucan to diagnosis of invasive candidiasis after liver transplantation. J Clin Microbiol. 53:771–6. DOI: 10.1128/JCM.03018-14. PMID: 25520448. PMCID: PMC4390652.

20. Mutschlechner W, Risslegger B, Willinger B, Hoenigl M, Bucher B, Eschertzhuber S, et al. 2015; Bronchoalveolar lavage fluid (1,3)β-D-glucan for the diagnosis of invasive fungal infections in solid organ transplantation: a prospective multicenter study. Transplantation. 99:e140–4. DOI: 10.1097/TP.0000000000000635. PMID: 25710608.

21. Levesque E, Rizk F, Noorah Z, Ait-Ammar N, Cordonnier-Jourdin C, El Anbassi S, et al. 2017; Detection of (1,3)-β-d-glucan for the diagnosis of invasive fungal infection in liver transplant recipients. Int J Mol Sci. 18:862. DOI: 10.3390/ijms18040862. PMID: 28422065. PMCID: PMC5412443.

22. McCarthy MW, Petraitiene R, Walsh TJ. 2017; Translational development and application of (1→3)-β-d-glucan for diagnosis and therapeutic monitoring of invasive mycoses. Int J Mol Sci. 18:1124. DOI: 10.3390/ijms18061124. PMID: 28538702. PMCID: PMC5485948.

23. Shi XY, Liu Y, Gu XM, Hao SY, Wang YH, Yan D, et al. 2016; Diagnostic value of (1→3)-β-D-glucan in bronchoalveolar lavage fluid for invasive fungal disease: a meta-analysis. Respir Med. 117:48–53. DOI: 10.1016/j.rmed.2016.05.017. PMID: 27492513.

24. Albert O, Toubas D, Strady C, Cousson J, Delmas C, Vernet V, et al. 2011; Reactivity of (1→3)-β-d-glucan assay in bacterial bloodstream infections. Eur J Clin Microbiol Infect Dis. 30:1453–60. DOI: 10.1007/s10096-011-1244-8. PMID: 21479838.

25. Latgé JP, Kobayashi H, Debeaupuis JP, Diaquin M, Sarfati J, Wieruszeski JM, et al. 1994; Chemical and immunological characterization of the extracellular galactomannan of Aspergillus fumigatus. Infect Immun. 62:5424–33. DOI: 10.1128/iai.62.12.5424-5433.1994. PMID: 7960122. PMCID: PMC303284.

26. Ascioglu S, Rex JH, de Pauw B, Bennett JE, Bille J, Crokaert F, et al. 2002; Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis. 34:7–14. DOI: 10.1086/323335. PMID: 11731939.

27. Mercier T, Castagnola E, Marr KA, Wheat LJ, Verweij PE, Maertens JA. 2021; Defining galactomannan positivity in the updated EORTC/MSGERC consensus definitions of invasive fungal diseases. Clin Infect Dis. 72(Suppl 2):S89–94. DOI: 10.1093/cid/ciaa1786. PMID: 33709125.

28. Kudoh A, Okawa Y, Shibata N. 2015; Significant structural change in both O- and N-linked carbohydrate moieties of the antigenic galactomannan from Aspergillus fumigatus grown under different culture conditions. Glycobiology. 25:74–87. DOI: 10.1093/glycob/cwu091. PMID: 25187160.

29. Tefsen B, Ram AF, van Die I, Routier FH. 2012; Galactofuranose in eukaryotes: aspects of biosynthesis and functional impact. Glycobiology. 22:456–69. DOI: 10.1093/glycob/cwr144. PMID: 21940757.

30. Sulahian A, Touratier S, Ribaud P. 2003; False positive test for Aspergillus antigenemia related to concomitant administration of piperacillin and tazobactam. N Engl J Med. 349:2366–7. DOI: 10.1056/NEJM200312113492424. PMID: 14668472.

31. Swanink CM, Meis JF, Rijs AJ, Donnelly JP, Verweij PE. 1997; Specificity of a sandwich enzyme-linked immunosorbent assay for detecting Aspergillus galactomannan. J Clin Microbiol. 35:257–60. DOI: 10.1128/jcm.35.1.257-260.1997. PMID: 8968919. PMCID: PMC229550.

32. Petraitiene R, Petraitis V, Witt JR 3rd, Durkin MM, Bacher JD, Wheat LJ, et al. 2011; Galactomannan antigenemia after infusion of gluconate-containing Plasma-Lyte. J Clin Microbiol. 49:4330–2. DOI: 10.1128/JCM.05031-11. PMID: 21976760. PMCID: PMC3232943.

33. Hope WW, Walsh TJ, Denning DW. 2005; Laboratory diagnosis of invasive aspergillosis. Lancet Infect Dis. 5:609–22. DOI: 10.1016/S1473-3099(05)70238-3. PMID: 16183515.

34. Mennink-Kersten MA, Verweij PE. 2006; Non-culture-based diagnostics for opportunistic fungi. Infect Dis Clin North Am. 20:711–27. DOI: 10.1016/j.idc.2006.06.009. PMID: 16984877.

35. Pfeiffer CD, Fine JP, Safdar N. 2006; Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis. 42:1417–27. DOI: 10.1086/503427. PMID: 16619154.

36. Zou M, Tang L, Zhao S, Zhao Z, Chen L, Chen P, et al. 2017; Correction: systematic review and meta-analysis of detecting galactomannan in bronchoalveolar lavage fluid for diagnosing invasive aspergillosis. PLoS One. 12:e0190459. DOI: 10.1371/journal.pone.0190459. PMID: 29281730. PMCID: PMC5744979.

37. Husain S, Kwak EJ, Obman A, Wagener MM, Kusne S, Stout JE, et al. 2004; Prospective assessment of Platelia Aspergillus galactomannan antigen for the diagnosis of invasive aspergillosis in lung transplant recipients. Am J Transplant. 4:796–802. DOI: 10.1111/j.1600-6143.2004.00415.x. PMID: 15084177.

38. Fortun J, Martin-Davila P, Alvarez ME, Sanchez-Sousa A, Quereda C, Navas E, et al. 2001; Aspergillus antigenemia sandwich-enzyme immunoassay test as a serodiagnostic method for invasive aspergillosis in liver transplant recipients. Transplantation. 71:145–9. DOI: 10.1097/00007890-200101150-00023. PMID: 11211181.

39. Kwak EJ, Husain S, Obman A, Meinke L, Stout J, Kusne S, et al. 2004; Efficacy of galactomannan antigen in the Platelia Aspergillus enzyme immunoassay for diagnosis of invasive aspergillosis in liver transplant recipients. J Clin Microbiol. 42:435–8. DOI: 10.1128/JCM.42.1.435-438.2004. PMID: 14715799. PMCID: PMC321718.

40. Clancy CJ, Jaber RA, Leather HL, Wingard JR, Staley B, Wheat LJ, et al. 2007; Bronchoalveolar lavage galactomannan in diagnosis of invasive pulmonary aspergillosis among solid-organ transplant recipients. J Clin Microbiol. 45:1759–65. DOI: 10.1128/JCM.00077-07. PMID: 17428933. PMCID: PMC1933052.

41. Husain S, Paterson DL, Studer SM, Crespo M, Pilewski J, Durkin M, et al. 2007; Aspergillus galactomannan antigen in the bronchoalveolar lavage fluid for the diagnosis of invasive aspergillosis in lung transplant recipients. Transplantation. 83:1330–6. DOI: 10.1097/01.tp.0000263992.41003.33. PMID: 17519782.

42. Lamoth F. 2016; Galactomannan and 1,3-β-d-glucan testing for the diagnosis of invasive aspergillosis. J Fungi (Basel). 2:22. DOI: 10.3390/jof2030022. PMID: 29376937. PMCID: PMC5753135.

43. Bennett JE, Friedman MM, Dupont B. 1987; Receptor-mediated clearance of Aspergillus galactomannan. J Infect Dis. 155:1005–10. DOI: 10.1093/infdis/155.5.1005. PMID: 3549914.

44. Verweij PE, Weemaes CM, Curfs JH, Bretagne S, Meis JF. 2000; Failure to detect circulating Aspergillus markers in a patient with chronic granulomatous disease and invasive aspergillosis. J Clin Microbiol. 38:3900–1. DOI: 10.1128/JCM.38.10.3900-3901.2000. PMID: 11015433. PMCID: PMC87506.

45. Meersseman W, Lagrou K, Maertens J, Wilmer A, Hermans G, Vanderschueren S, et al. 2008; Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing aspergillosis in intensive care unit patients. Am J Respir Crit Care Med. 177:27–34. DOI: 10.1164/rccm.200704-606OC. PMID: 17885264.

46. Musher B, Fredricks D, Leisenring W, Balajee SA, Smith C, Marr KA. 2004; Aspergillus galactomannan enzyme immunoassay and quantitative PCR for diagnosis of invasive aspergillosis with bronchoalveolar lavage fluid. J Clin Microbiol. 42:5517–22. DOI: 10.1128/JCM.42.12.5517-5522.2004. PMID: 15583275. PMCID: PMC535238.

47. Becker MJ, Lugtenburg EJ, Cornelissen JJ, Van Der Schee C, Hoogsteden HC, De Marie S. 2003; Galactomannan detection in computerized tomography-based broncho-alveolar lavage fluid and serum in haematological patients at risk for invasive pulmonary aspergillosis. Br J Haematol. 121:448–57. DOI: 10.1046/j.1365-2141.2003.04308.x. PMID: 12716367.

48. de Heer K, Gerritsen MG, Visser CE, Leeflang MM. 2019; Galactomannan detection in broncho-alveolar lavage fluid for invasive aspergillosis in immunocompromised patients. Cochrane Database Syst Rev. 5:CD012399. DOI: 10.1002/14651858.CD012399.pub2. PMID: 31107543. PMCID: PMC6526785.

49. Pasqualotto AC, Xavier MO, Sánchez LB, de Oliveira Costa CD, Schio SM, Camargo SM, et al. 2010; Diagnosis of invasive aspergillosis in lung transplant recipients by detection of galactomannan in the bronchoalveolar lavage fluid. Transplantation. 90:306–11. DOI: 10.1097/TP.0b013e3181e49bc1. PMID: 20548265.

50. Singh N. 2003; Fungal infections in the recipients of solid organ transplantation. Infect Dis Clin North Am. 17:113–34. DOI: 10.1016/S0891-5520(02)00067-3. PMID: 12751263.

51. Cruciani M, Mengoli C, Barnes R, Donnelly JP, Loeffler J, Jones BL, et al. 2019; Polymerase chain reaction blood tests for the diagnosis of invasive aspergillosis in immunocompromised people. Cochrane Database Syst Rev. 9:CD009551. DOI: 10.1002/14651858.CD009551.pub4. PMID: 31478559. PMCID: PMC6719256.

52. Mengoli C, Cruciani M, Barnes RA, Loeffler J, Donnelly JP. 2009; Use of PCR for diagnosis of invasive aspergillosis: systematic review and meta-analysis. Lancet Infect Dis. 9:89–96. DOI: 10.1016/S1473-3099(09)70019-2. PMID: 19179225.

53. Arvanitis M, Anagnostou T, Mylonakis E. 2015; Galactomannan and polymerase chain reaction-based screening for invasive aspergillosis among high-risk hematology patients: a diagnostic meta-analysis. Clin Infect Dis. 61:1263–72. DOI: 10.1093/cid/civ555. PMID: 26157047.

54. Hage CA, Carmona EM, Epelbaum O, Evans SE, Gabe LM, Haydour Q, et al. 2019; Microbiological laboratory testing in the diagnosis of fungal infections in pulmonary and critical care practice. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 200:535–50. DOI: 10.1164/rccm.201906-1185ST. PMID: 31469325. PMCID: PMC6727169.

55. Han Y, Wu X, Jiang G, Guo A, Jin Z, Ying Y, et al. 2023; Bronchoalveolar lavage fluid polymerase chain reaction for invasive pulmonary aspergillosis among high-risk patients: a diagnostic meta-analysis. BMC Pulm Med. 23:58. DOI: 10.1186/s12890-023-02343-5. PMID: 36750828. PMCID: PMC9906844.

56. Botterel F, Farrugia C, Ichai P, Costa JM, Saliba F, Bretagne S. 2008; Real-time PCR on the first galactomannan-positive serum sample for diagnosing invasive aspergillosis in liver transplant recipients. Transpl Infect Dis. 10:333–8. DOI: 10.1111/j.1399-3062.2008.00323.x. PMID: 18627580.

57. Luong ML, Clancy CJ, Vadnerkar A, Kwak EJ, Silveira FP, Wissel MC, et al. 2011; 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. 52:1218–26. DOI: 10.1093/cid/cir185. PMID: 21507918.

58. Escamilla JE, January SE, Vazquez Guillamet R. 2023; Diagnosis and treatment of fungal infections in lung transplant recipients. Pathogens. 12:694. DOI: 10.3390/pathogens12050694. PMID: 37242364. PMCID: PMC10220796.

59. Barnes RA, White PL, Morton CO, Rogers TR, Cruciani M, Loeffler J, et al. 2018; Diagnosis of aspergillosis by PCR: clinical considerations and technical tips. Med Mycol. 56(Suppl 1):60–72. DOI: 10.1093/mmy/myx091. PMID: 29087518.

60. Rath PM, Steinmann J. 2018; Overview of commercially available PCR assays for the detection of Aspergillus spp. DNA in patient samples. Front Microbiol. 9:740. DOI: 10.3389/fmicb.2018.00740. PMID: 29740403. PMCID: PMC5928133.

61. Montesinos I, Argudin MA, Hites M, Ahajjam F, Dodemont M, Dagyaran C, et al. 2017; Culture-based methods and molecular tools for azole-resistant Aspergillus fumigatus detection in a Belgian university hospital. J Clin Microbiol. 55:2391–9. DOI: 10.1128/JCM.00520-17. PMID: 28515220. PMCID: PMC5527416.

62. Verweij PE, Chowdhary A, Melchers WJ, Meis JF. 2016; Azole resistance in Aspergillus fumigatus: can we retain the clinical use of mold-active antifungal azoles? Clin Infect Dis. 62:362–8. DOI: 10.1093/cid/civ885. PMID: 26486705. PMCID: PMC4706635.

63. Bosetti D, Neofytos D. 2023; Invasive aspergillosis and the impact of azole-resistance. Curr Fungal Infect Rep. 17:77–86. DOI: 10.1007/s12281-023-00459-z. PMID: 37360857. PMCID: PMC10024029.

64. Rybak JM, Fortwendel JR, Rogers PD. 2019; Emerging threat of triazole-resistant Aspergillus fumigatus. J Antimicrob Chemother. 74:835–42. DOI: 10.1093/jac/dky517. PMID: 30561652. PMCID: PMC6657284.

65. van der Linden JW, Arendrup MC, Warris A, Lagrou K, Pelloux H, Hauser PM, et al. 2015; Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus. Emerg Infect Dis. 21:1041–4. DOI: 10.3201/eid2106.140717. PMID: 25988348. PMCID: PMC4451897.

66. Wang Q, Kontoyiannis DP, Li R, Chen W, Bu D, Liu W. 2019; A novel broad allele-specific TaqMan real-time PCR method to detect triazole-resistant strains of Aspergillus fumigatus, even with a very low percentage of triazole-resistant cells mixed with triazole-susceptible cells. J Clin Microbiol. 57:e00604–19. DOI: 10.1128/JCM.00604-19. PMID: 31315952. PMCID: PMC6711921.

67. Douglas AP, Smibert OC, Bajel A, Halliday CL, Lavee O, McMullan B, et al. 2021; Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021. Intern Med J. 51 Suppl 7:143–76. DOI: 10.1111/imj.15591. PMID: 34937136.

68. Lamberink H, Wagemakers A, Sigaloff KC, van Houdt R, de Jonge NA, van Dijk K. 2022; The impact of the updated EORTC/MSG criteria on the classification of hematological patients with suspected invasive pulmonary aspergillosis. Clin Microbiol Infect. 28:1120–5. DOI: 10.1016/j.cmi.2022.02.026. PMID: 35248746.