ECIL guidelines for the diagnosis of Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients

Abstract

The Fifth European Conference on Infections in Leukaemia (ECIL-5) convened a meeting to establish evidence-based recommendations for using tests to diagnose Pneumocystis jirovecii pneumonia (PCP) in adult patients with haematological malignancies. Immunofluorescence assays are recommended as the most sensitive microscopic method (recommendation A-II: ). Real-time PCR is recommended for the routine diagnosis of PCP ( A-II: ). Bronchoalveolar lavage (BAL) fluid is recommended as the best specimen as it yields good negative predictive value ( A-II: ). Non-invasive specimens can be suitable alternatives ( B-II: ), acknowledging that PCP cannot be ruled out in case of a negative PCR result ( A-II: ). Detecting β-d-glucan in serum can contribute to the diagnosis but not the follow-up of PCP ( A-II: ). A negative serum β-d-glucan result can exclude PCP in a patient at risk ( A-II: ), whereas a positive test result may indicate other fungal infections. Genotyping using multilocus sequence markers can be used to investigate suspected outbreaks ( A-II: ). The routine detection of dihydropteroate synthase mutations in cases of treatment failure is not recommended ( B-II: ) since these mutations do not affect response to high-dose co-trimoxazole. The clinical utility of these diagnostic tests for the early management of PCP should be further assessed in prospective, randomized interventional studies.

Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with <b><i>Pneumocystis jirovecii</i></b> Pneumonia

“…There is no need to delay treatment initiation for diagnostic assessment since cysts persist for several days in respiratory material, even under PCP-specific treatment [41, 42]. …”

“…2). The sensitivity of microscopy is lower in non-HIV-infected compared to HIV-infected patients due to a lower fungal load [42, 44]. …”

“…However, it is rather easy to establish the test on a coagulation automate and do single-sample testing [50]. Diagnostic guidelines commonly recommend combining different methods, e.g., microscopy (immunofluorescence and conventional staining) and qPCR [42]. When analyzed in parallel with qPCR fungal load, a correlation between both markers is observable, suggesting that circulating (1,3)-β-D-glucan levels reflect the fungal load in the lungs [51].…”

“…The TMP/SMX dosage needs to be adjusted to renal function (Table 4). TMP/SMX is usually also effective in patients who have PCP despite TMP/SMX prophylaxis [42]. …”

Molecular Demonstration of a Pneumocystis Outbreak in Stem Cell Transplant Patients: Evidence for Transmission in the Daycare Center

“…Person-to-person transmission has been documented during outbreaks, especially in solid organ transplant wards (Yiannakis and Boswell, 2016). To avoid such transmission, recent guidelines for managing PCP in hematology patients published by the European Conference on Infections in Leukemia group (Alanio et al, 2016c; Maertens et al, 2016; Maschmeyer et al, 2016) state that “it seems reasonable that severely immunocompromised patients should avoid contact with patients with documented PCP.” However, because data is lacking in this population, this is a C-III recommendation (e.g., there is poor evidence to support it). Similarly, the 2007 guidelines for isolation precautions from the US Centers for Disease Control and Prevention advises that PCP-infected patients should not be placed in the same room as immunocompromised patients, and other standard precautions should be taken (Siegel et al, 2007).…”