Undiagnosed invasive candidiasis: incorporating non-culture diagnostics into rational prophylactic and preemptive antifungal strategies.
The insensitivity of blood cultures for diagnosing invasive candidiasis fuels prophylactic and preemptive antifungal treatment. Assays like serum β-D-glucan or mannan/anti-mannan detection can identify blood culture-negative invasive candidiasis, but their roles in guiding antifungal therapy are undefined. We propose that non-culture tests can be incorporated into rational management strategies, based on clinical setting. As an example, β-D-glucan sensitivity/specificity for blood culture-negative, deep-seated candidiasis is approximately 60/75%. In intensive care units with <1 or 3% invasive candidiasis rates, positive/negative predictive values are <2/>99% and 6/98%, respectively. With pre-test likelihoods of 10 and 33%, positive/negative predictive values are 20/94% and 54/79%, respectively. Based on these data, negative and positive β-D-glucan results likely will be most useful for discontinuing prophylaxis among low-risk to moderate-risk patients (pre-test likelihoods ∼3-10%), and triggering preemptive therapy among moderate-risk to high-risk patients (pre-test likelihoods ∼10-25%), respectively. In extremely high-risk patients, universal prophylaxis is likely to be the best strategy.
VA Pittsburgh Healthcare System, Division of Infectious Diseases, University of Pittsburgh, Scaife 867, 3550 Terrace St, Pittsburgh, PA 15261, USA.
Cornelius J
CJ
Clancy
Minh Hong
MH
Nguyen
D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D058365:Candidiasis, Invasive / Q000175:diagnosis* / Q000188:drug therapy / Q000517:prevention & control; D006801:Humans; D016533:Mycological Typing Techniques; D012680:Sensitivity and Specificity
D000935:Antifungal Agents
Candida; Fungitell; anti-mannan antibody; candidemia; candidiasis; deep-seated candidiasis; intra-abdominal candidiasis; mannan; β-D-glucan