Diagnostic-driven antifungal therapy in neutropenic patients using the D-index and serial serum galactomannan testing

• Published in: The Brazilian journal of infectious diseases 2016-07, Vol.20 (4), p.354-359
• Main Authors: Garnica, Marcia, Sinhorelo, Aline, Madeira, Laura, Portugal, Rodrigo, Nucci, Marcio
• Format: Article
• Language: English
• Subjects: Adult; Aged; Algorithms; Antifungal agents; Antifungal Agents - therapeutic use; Aspergillosis - diagnosis; Aspergillosis - drug therapy; Aspergillosis - immunology; Care and treatment; Computational biology; Development and progression; Dosage and administration; Female; Fungal disease; Fusariosis - diagnosis; Fusariosis - drug therapy; Fusariosis - immunology; Humans; INFECTIOUS DISEASES; Innovations; Leukemia; Leukemia, Myeloid, Acute - immunology; Leukemia, Myeloid, Acute - microbiology; Male; Mannans - blood; Mannans - immunology; Middle Aged; Myelodysplastic Syndromes - immunology; Myelodysplastic Syndromes - microbiology; Neutropenia; Neutropenia - immunology; Neutropenia - microbiology; Original; Prospective Studies; Risk Assessment; Risk stratification; Sensitivity and Specificity; Tomography, X-Ray Computed; Young Adult
• ISSN: 1413-8670; 1678-4391; 1678-4391
• DOI: 10.1016/j.bjid.2016.04.007

Invasive mold disease is an important complication of patients with hematologic malignancies, and is associated with high mortality. A diagnostic-driven approach has been an alternative to the classical empiric antifungal therapy. In the present study we tested an algorithm that incorporated risk stratification using the D-index, serial serum galactomannan and computed tomographic-scan to guide the decision to start antifungal therapy in neutropenic patients. Between May 2010 and August 2012, patients with acute leukemia in induction remission were prospectively monitored from day 1 of chemotherapy until discharge or death with the D-index and galactomannan. Patients were stratified in low, intermediate and high risk according to the D-index and an extensive workup for invasive mold disease was performed in case of positive galactomannan (≥0.5), persistent fever, or the appearance of clinical manifestations suggestive of invasive mold disease. Among 29 patients, 6 (21%), 11 (38%), and 12 (41%) were classified as high, intermediate, and low risk, respectively. Workup for invasive mold disease was undertaken in 67%, 73% and 58% (p=0.77) of patients in each risk category, respectively, and antifungal therapy was given to 67%, 54.5%, and 17% (p=0.07). Proven or probable invasive mold disease was diagnosed in 67%, 45.5%, and in none (p=0.007) of high, intermediate, and low risk patients, respectively. All patients survived. A risk stratification using D-index was a useful instrument to be incorporated in invasive mold disease diagnostic approach, resulting in a more comprehensive antifungal treatment strategy, and to guide an earlier start of treatment in afebrile patients under very high risk.