State of Medical Mycology at German Academic Medical Centres: A Survey of the German‐Speaking Mycological Society (DMYKG) and the Paul‐Ehrlich‐Society for Chemotherapy (PEG)

Abstract

Background Little is known about the infrastructure to translate advances in the management of patients at risk to develop invasive opportunistic fungal diseases. To assess the current state of Medical Mycology support in Germany, we conducted a survey among all 36 academic medical centres. Methods The survey consisted of a 3‐pages questionnaire sent out in the first half of 2019. Information included details of infrastructure, education and teaching; consultation services and interdisciplinary conferences; research activities and participation in network groups; radiology, microbiology and pharmacology support; publication activity; and European Confederation for Medical Mycology (ECMM) Excellence Center designation, if assigned. Results Information was returned from 24 centres (67%). Thirteen institutions (54%) reported an independent infectious disease, and two a separate Medical Mycology department (8%); a Medical Mycology working group was reported for nine institutions (38%). An infectious disease consultation service was existent in 16 institutions (67%) and a multidisciplinary conference in 13 (54%). Fifteen institutions reported a separate study office with activities in infectious disease studies (63%). Laboratory capability for fungal identification and susceptibility testing was confirmed by all 24 institutions; testing of galactomannan by 23 (96%), cryptococcal antigen by 21 (88%), ß‐D‐Glucan by 9 (38%), and panfungal and Pneumocystis PCR by 21 and 22 (88% and 92%), respectively. Therapeutic drug monitoring of voriconazole was reported to be available in 15 (63%) institutions with a turnaround of ≤24 h during weekdays in 10 (42%). Two of the 24 University hospitals (8%) reported ECMM Diamond Excellence Status. Conclusions The results of this survey document the continuing need to improve the availability of specialised Medical Mycology support in German academic medical centres.

Performance of Multiplex PCR and β-1,3-D-Glucan Testing for the Diagnosis of Candidemia

“…Only five studies had more than twenty cases included (maximum = 47), which all applied in-house PCRs with very heterogenous sensitivities of 25%, 40%, 59%, 72%, and 89% [24,25,29,32,35]. The lack of standardization is the major reason current guidelines do not recommend the use of PCR (or only as an adjunct to other methods) for the diagnosis of candidemia [1,2,8,10,12,38]. Only one pilot study investigating the Bruker Fungiplex assay was recently published.…”

“…Late initiation of targeted therapy, which is a consequence of late diagnosis, is considered a major cause of the high mortality within patients suffering from Candida BSI [2,6]. This is due to an imperfect diagnostic gold standard, i.e., culture, which is associated with a sensitivity of as low as 50% for diagnosing invasive candidiasis [1,2,[7][8][9][10]. Even if cultivation is successful, this result often comes too late due to the slow fungal growth in blood culture (BC) with a time result of several days [7,11].…”

“…In contrast, the use of nonculture methods promises more rapid results. The use of combined antigen/antibody testing is well-established in Europe and recommended by current guidelines [1,8,10]. However, to date, none of the available assays has U.S. Food and Drug Administration (FDA) clearance [12].…”

“…β-1,3-D-glucan (BDG), a fungal cell wall polysaccharide, is the target of another type of serologic assay that is not based on specific antibodies but the activation of an enzyme cascade [13]. U.S. and European guidelines recommend testing for BDG in the setting of candidemia [1,8,10,12]. Considerably, serologic assays do not allow discrimination between different Candida species, which is a major drawback regarding therapy management.…”

“…However, despite the increasing impact and nearly universal availability of PCR tests, the value of this technique for the diagnosis of invasive candidiasis remains uncertain. Current guidelines recognize the potential of molecular diagnostics but are concerned with the lack of comparable data and assay standardization [1,8,10,12].…”