Capítulo 2: Un sistema integrado de procedimientos como propuesta para la gestión del Polo
2.3 Procedimientos del proceso Planificación
The advances made in Europe and Australia have gone a long way in providing a standard for PCR diagnosis of aspergillosis and allowed clinical evaluation in
haematological populations. This has resulted in widespread agreement that PCR is a useful tool in diagnosis and should contribute to consensus definitions 3. Lack of an FDA recommended assay has limited clinical usage in many countries. Recent
guidelines are couched with caution although they still make a strong recommendation for use of Aspergillus PCR ‘in conjunction with other diagnostic tests and the clinical context’ 46. Understanding the clinical context remains the key factor and increasing understanding and awareness of this should bring about more widespread acceptance of aspergillus PCR.
Conflicts of Interest
RAB is a founding member of the EAPCRI, received an educational grant and scientific fellowship award from Gilead Sciences and Pfizer, is a member of the advisory board and speaker bureau for Gilead Sciences, MSD, Astellas, and Pfizer, and was sponsored by Gilead Sciences and Pfizer to attend international meetings.
PLW is a founding member of the EAPCRI, received project funding from Bruker, Myconostica, Luminex, and Renishaw diagnostics, was sponsored by Myconostica, MSD, Launch Diagnostics, Bruker and Gilead Sciences to attend international meetings, on a speaker’s bureau for Gilead Sciences, and provided consultancy for
RenishawDiagnostics Limited and Gilead Sciences.
TRR is a member of the advisory board for Gilead Sciences and Basilea. He has also received lecturing fees and travel grants from Pfizer Healthcare Ireland, MSD Ireland and Gilead Sciences.
JL is a founding member of the EAPCRI, received an educational grant and scientific fellowship award from Pfizer, and was sponsored by Astellas to attend international meetings.
JPD is a founding member of the EAPCRI, has received grants from Astellas, Gliead, MSD and Pfizer, provided consultancy for Gilead, Pfizer and Viamet and received honoraria for lectures from Gilead, MSD, Pfizer and Basilea.
COM and MC: No Conflicts declared.
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Table 1. Underlying clinical conditions and the associated risk of invasive aspergillosis Condition (Age limits) Approximate
incidence of
Acute myeloid leukaemia and myelodysplastic
Solid organ transplantation (NS)
Kidney/pancreas 0-4 Low 49
liver 1-7 Low/moderate 49
Heart/lung 1-15 Moderate/High 49
Small bowel 0-10 Limited data 59
Critical Illness (NS) 0.3-6 Low 50
Key:
YO: years old
NS: not specified
Table 2. Clinical signs, symptoms and conditions associated with invasive aspergillosis [adapted from Prentice et al 51]
* Also a indicator of mucormycosis
Clinical signs, symptoms and conditions associated with Invasive aspergillosis Any non-resolving fever despite antibiotics during prolonged, severe neutropenia or immunosuppression
Symptoms and signs of new, resistant or progressive lower respiratory tract infection, e.g. pleuritic pain, pleural rub
Prolonged, severe lymphopenia in chronic graft versus host disease (GVHD) and immunosuppression
Symptoms and signs of progressive upper respiratory tract infection Periorbital swelling
Maxillary swelling and tenderness Palatal necrosis or perforation*
Focal neurological or meningeal irritation symptoms and signs with fever Unexplained mental changes with fever
Papular or nodular skin lesions
Intra-ocular signs of systemic fungal infection
Table 3. Technical considerations when extracting nucleic acid from blood based samples
Relative Lowe Higher Lowe Higher Highe Highest
Cost d st st r
Key:
a Very low: basic training to run specific instrument; Low: experience of molecular based methods; Medium: specific training in respect to WB processing and basic training to run specific instrument; High: specific training in respect to WB processing in
combination with experience of molecular based methods.
b Basic: General laboratory equipment (safety cabinets, pipettes, microfuges, heating blocks etc); Advanced/specific: Automated nucleic acid extraction platform required.
c General applicability to refers to the suitability of the method in a generic molecular diagnostics laboratory
d Costs include the requirement to purchase automated nucleic acid equipment but exclude labour costs.
Table 4. The theoretical effect of non-compliance with the EAPCRI recommendations when PCR testing whole blood, serum and plasma. The clinical performance for non-compliant methods has been adjusted using the differences between non-compliant and non-compliant protocols noted in the original analytical studies of WB and serum.4, 5 For plasma testing it has been assumed that non-compliance would have the same effect on performance as it did on serum testing. The sensitivity and specificity represent pooled data derived from three recent EAPCRI compliant studies 12, 52, 53.
Performance Parameter (Population = 1000)
Sample type/Compliance of NA extraction protoco WB –
DOR 13.93 1.64 30 9.21 10.65
KEY:
NA: Nucleic Acid
WB: Whole blood
IA: Invasive aspergillosis
PPV: Positive predictive value
NPV: Negative predictive value
LR: Likelihood ratio
DOR: Diagnostic odds ratio
Figure 1. Screening strategy for high risk patients not receiving mould active prophylaxis and fever-driven strategy incorporating Aspergillus PCR and antigen testing
Figure 1 Screening strategy for high risk patients not receiving mould active prophylaxis and fever-driven strategy incorporating Aspergillus PCR and antigen testing
a Current antigen tests available: Galactomannan, Beta D glucan, (lateral flow device) b See table 2
Figure 2 Diagnostic strategy incorporating Aspergillus PCR and antigen testing
Figure 3 The EAPCRI method for extracting cell associated Aspergillus DNA from EDTA whole blood
Figure 4 The EAPCRI method for extracting cell associated Aspergillus DNA from serum/plasma