Efficacy of Unilamellar Liposomal Amphotericin B in Treatment of Pulmonary Aspergillosis in Persistently Granulocytopenic Rabbits: The Potential Role of Bronchoalveolar D-Mannitol and Serum Galactomannan as Markers of Infection

Francis, Peter; Lee, James W.; Hoffman, A. G. D.; Peter, Joanne; Francesconi, Andrea; Bacher, John; Shelhamer, James H.; Pizzo, Philip A.; Walsh, Thomas J.

doi:10.1093/infdis/169.2.356

Cited by 178 publications

(131 citation statements)

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“…to rabbits. Previous studies of experimental invasive pulmonary aspergillosis with rabbit models have demonstrated patterns of circulating galactomannan that are similar to those of humans for both detection and correlation with therapeutic response (1,4,8,10,16).…”

Section: Discussionmentioning

confidence: 91%

“…Healthy female New Zealand White rabbits (Hazleton, Research Products, Inc., Denver, Pa.) weighing 2.8 to 3.3 kg were used in an experiment (n ϭ 6). Rabbits were selected in these experiments because of the similarity between their patterns of expression of circulating galactomannan in experimental pulmonary aspergillosis and those found in humans with invasive aspergillosis (4,8,10,18). As in noninfected humans, rabbits have a normal mean GMI level well below the threshold of a positive value of 0.5.…”

Section: Methodsmentioning

confidence: 99%

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Detection of Galactomannan Antigenemia in Patients Receiving Piperacillin-Tazobactam and Correlations between In Vitro, In Vivo, and Clinical Properties of the Drug-Antigen Interaction

et al. 2004

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Recent case reports describe patients receiving piperacillin-tazobactam who were found to have circulating galactomannan detected by the double sandwich enzyme-linked immunosorbent assay (ELISA) system, leading to the false presumption of invasive aspergillosis. Since this property of piperacillin-tazobactam and galactomannan ELISA is not well understood, we investigated the in vitro, in vivo, and clinical properties of this interaction. Among the 12 reconstituted antibiotics representing four classes of antibacterial compounds that are commonly used in immunocompromised patients, piperacillin-tazobactam expressed a distinctively high level of galactomannan antigen in vitro (P ‫؍‬ 0.001). After intravenous infusion of piperacillin-tazobactam into rabbits, the serum galactomannan index (GMI) in vivo changed significantly (P ‫؍‬ 0.0007) from a preinfusion mean baseline value of 0.27 to a mean GMI of 0.83 by 30 min to slowly decline to a mean GMI of 0.44 24 h later. Repeated administration of piperacillin-tazobactam over 7 days resulted in accumulation of circulating galactomannan to a mean peak GMI of 1.31 and a nadir of 0.53. Further studies revealed that the antigen reached a steady state by the third day of administration of piperacillin-tazobactam. Twenty-six hospitalized patients with no evidence of invasive aspergillosis who were receiving antibiotics and ten healthy blood bank donors were studied for expression of circulating galactomannan. Patients (n ‫؍‬ 13) receiving piperacillin-tazobactam had significantly greater mean serum GMI values (0.74 ؎ 0.14) compared to patients (n ‫؍‬ 13) receiving other antibiotics (0.14 ؎ 0.08) and compared to healthy blood bank donors (0.14 ؎ 0.06) (P < 0.001). Five (38.5%) of thirteen patients receiving piperacillin-tazobactam had serum GMI values > 0.5 compared to none of thirteen subjects receiving other antibiotics (P ‫؍‬ 0.039) and to none of ten healthy blood bank donors (P ‫؍‬ 0.046). These data demonstrate that among antibiotics that are commonly used in immunocompromised patients, only piperacillin-tazobactam contains significant amounts of galactomannan antigen in vitro, that in animals receiving piperacillin-tazobactam circulating galactomannan antigen accumulates in vivo to significantly increased and sustained levels, and that some but not all patients receiving this antibiotic will demonstrate circulating galactomannan above the threshold considered positive for invasive aspergillosis by the recently licensed double sandwich ELISA.The recent development and introduction of the double sandwich enzyme-linked immunosorbent assay (ELISA) for the detection of galactomannan antigenemia is an important advance in the nonculture diagnosis of invasive aspergillosis (3, 5-8, 14, 15). Depending on the patient population, several studies have demonstrated a sensitivity ranging from 50 to 95% and a specificity ranging from 87 to 99% for the diagnosis of invasive aspergillosis. However, recent clinical reports describing results of circulating galactomannan antigenemia in ...

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Section: Discussionmentioning

confidence: 91%

Section: Methodsmentioning

confidence: 99%

Detection of Galactomannan Antigenemia in Patients Receiving Piperacillin-Tazobactam and Correlations between In Vitro, In Vivo, and Clinical Properties of the Drug-Antigen Interaction

et al. 2004

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“…Invasive pulmonary aspergillosis was established as described elsewhere (11). Briefly, Aspergillus fumigatus (A. fumigatus isolate NIH 4215, ATCC MYA-1163) obtained from a fatal case of IPA was used in all experiments.…”

Section: Methodsmentioning

confidence: 99%

“…These curves were then used to define cutoff, sensitivity, and specificity values that optimized the test performance of each assay. Both methods were studied using a well-established persistently neutropenic rabbit model of IPA (11,28,42). We further investigated the impact of different antifungal modalities, including ravuconazole, micafungin, and deoxycholate amphotericin B, on the sensitivity and specificity of each assay.…”

mentioning

confidence: 99%

Characterization and Comparison of Galactomannan Enzyme Immunoassay and Quantitative Real-Time PCR Assay for Detection of Aspergillus fumigatus in Bronchoalveolar Lavage Fluid from Experimental Invasive Pulmonary Aspergillosis

et al. 2006

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Bronchoalveolar lavage (BAL) is widely used for evaluation of patients with suspected invasive pulmonary aspergillosis (IPA). However, the diagnostic yield of BAL for detection of IPA by culture and direct examination is limited. Earlier diagnosis may be facilitated by assays that can detect Aspergillus galactomannan antigen or DNA in BAL fluid. We therefore characterized and compared the diagnostic yields of a galactomannan enzyme immunoassay (GM EIA), quantitative real-time PCR (qPCR), and quantitative cultures in experiments using BAL fluid from neutropenic rabbits with experimentally induced IPA defined as microbiologically and histologically evident invasion. The qPCR assay targeted the rRNA gene complex of Aspergillus fumigatus. The GM EIA and qPCR assay were characterized by receiver operator curve analysis. With an optimal cutoff of 0.75, the GM EIA had a sensitivity and specificity of 100% in untreated controls. A decline in sensitivity (92%) was observed when antifungal therapy (AFT) was administered. The optimal cutoff for qPCR was a crossover of 36 cycles, with sensitivity and specificity of 80% and 100%, respectively. The sensitivity of qPCR also decreased with AFT to 50%. Quantitative culture of BAL had a sensitivity of 46% and a specificity of 100%. The sensitivity of quantitative culture decreased with AFT to 16%. The GM EIA and qPCR assay had greater sensitivity than culture in detection of A. fumigatus in BAL fluid in experimentally induced IPA (P ؎ 0.04). Use of the GM EIA and qPCR assay in conjunction with culture-based diagnostic methods applied to BAL fluid could facilitate accurate diagnosis and more-timely initiation of specific therapy.Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in immunocompromised patients (7-9, 13, 14, 18, 27). Mortality rates of this severe infection range from 30% to 90% in neutropenic patients (9,10,15,20). Accurate diagnosis of IPA routinely relies upon bronchoalveolar lavage (BAL) as a standard of care in assessing immunocompromised patients (1, 12). However, current culture-based methods for evaluation of BAL fluid may have low sensitivity (3,19,32,33). Other methods, such as tissue biopsy, are often not optimal due to the fragile condition of the patient with respect to sustaining an invasive procedure. Early diagnosis of IPA remains difficult. Improved prognosis for IPA requires early diagnosis (40). The development of nonculture and noninvasive methods may facilitate an early diagnosis of IPA (5,22,25).The sandwich enzyme immunoassay (EIA) based on the detection of the Aspergillus antigen galactomannan (GM) (3,4,21,38) and real-time PCR methods (25, 34) for the detection of Aspergillus-specific DNA are encouraging alternatives to biopsy and culture. However, the sensitivity and optimal interpretive cutoff values of the GM EIA in studies using BAL fluid are not well defined (4,34,38). Although quantitative real-time PCR (qPCR) assays have been developed for the detection of IPA (16,26,34,35), their diagnostic sensitivity...

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“…When the labeled probes align along the target in a sequence-specific manner, fluorescent energy is transferred from one dye to another to emit a signal in a different wavelength, hence the term FRET. We further validated the assay in a well-established animal model of IPA (6,17,24).…”

mentioning

confidence: 98%

Development and Validation of a Quantitative Real-Time PCR Assay Using Fluorescence Resonance Energy Transfer Technology for Detection of Aspergillus fumigatus in Experimental Invasive Pulmonary Aspergillosis

et al. 2003

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Invasive pulmonary aspergillosis (IPA) is a frequently fatal infection in immunocompromised patients that is difficult to diagnose. Present methods for detection ofInvasive pulmonary aspergillosis (IPA) is a major cause of infectious pneumonic morbidity and mortality of patients undergoing bone marrow transplantation, solid organ transplantation, and treatment for hematological malignancies (12, 16). Although there has been progress in attempts to expedite the diagnosis of IPA (5, 21), prompt diagnosis of this infection remains difficult. Unlike what occurs with many other serious infectious processes, A. fumigatus is virtually never isolated from blood cultures. Clinicians must therefore use other microbiological and radiological diagnostic approaches in cases of IPA. The detection of galactomannan antigen in serum by enzyme immunoassay is an important advance in the detection of invasive aspergillosis (13,21,22). However, more recent data demonstrate a lower sensitivity than has been previously reported (9). Definitive diagnosis involves the combination of positive cultures and the demonstration of histological tissue invasion. Bronchoalveolar lavage (BAL) is usually performed in lieu of biopsy in immunocompromised patients with pulmonary infiltrates suspicious for IPA. However, the lack of sensitivity of using BAL fluid to detect A. fumigatus in IPA cases has been well documented (19). Consequently, there is a critical need to improve the methodology of detection of A. fumigatus in BAL fluid.We therefore developed a rapid, quantitative, sensitive, and specific real-time PCR assay using fluorescence resonance energy transfer (FRET) technology to detect A. fumigatus. This technology uses two oligonucleotide probes, a donor and an acceptor, each of which is labeled with a different marker dye. These probes are designed to hybridize to adjacent regions of the target amplicon in a head-to-toe manner. When the labeled probes align along the target in a sequence-specific manner, fluorescent energy is transferred from one dye to another to emit a signal in a different wavelength, hence the term FRET. We further validated the assay in a well-established animal model of IPA (6,17,24).

show abstract

Efficacy of Unilamellar Liposomal Amphotericin B in Treatment of Pulmonary Aspergillosis in Persistently Granulocytopenic Rabbits: The Potential Role of Bronchoalveolar D-Mannitol and Serum Galactomannan as Markers of Infection

Cited by 178 publications

References 40 publications

Detection of Galactomannan Antigenemia in Patients Receiving Piperacillin-Tazobactam and Correlations between In Vitro, In Vivo, and Clinical Properties of the Drug-Antigen Interaction

Detection of Galactomannan Antigenemia in Patients Receiving Piperacillin-Tazobactam and Correlations between In Vitro, In Vivo, and Clinical Properties of the Drug-Antigen Interaction

Characterization and Comparison of Galactomannan Enzyme Immunoassay and Quantitative Real-Time PCR Assay for Detection of Aspergillus fumigatus in Bronchoalveolar Lavage Fluid from Experimental Invasive Pulmonary Aspergillosis

Development and Validation of a Quantitative Real-Time PCR Assay Using Fluorescence Resonance Energy Transfer Technology for Detection of Aspergillus fumigatus in Experimental Invasive Pulmonary Aspergillosis

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