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PCR diagnosis of candidemia
Journal of Critical Care (2013) 28, 524
PCR diagnosis of candidemia
We read with interest the article by Bloos et al. [1]. It offers an estimate of increased direct costs attributable to candidemia in severe sepsis patients. Part of the article focuses on the evaluation of PCR-based diagnosis of invasive candidiasis. The author identified 11 patients with positive pan fungal PCR. They implicitly considered these patients as suffering from an invasive fungal infection and concluded that PCR allowed for a reduction in time to antifungal therapy. The ICU mortality of the PCR positive patients, 27.7% was close to the mortality of the non candida group, 31.2% and markedly lower than the mortality of candidemic patients, 53.1%. It is stated that no PCR positive patient had a candida positive blood culture. We assume some patients were diagnosed with candidemia between May 2009 and June 2010, the time period when PCR was performed. Thus, none of them were PCR positive. This raises a concern on the usefulness of this PCR as the pathological significance of candidemia is non controversial [2]. That lack of detailed data on the number of candida positive blood culture between May 2009 and June 2010 precludes any detailed analysis; however, the false negative rate of PCR in this sample appears to be 100%. Are the positive PCR results more trustworthy or are they only false positive?. If the later, PCR only resulted in increasing the inappropriate use of antifungal agents.
0883-9441/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
In another patient setting, leukemia and stemm cell transplant, a recent European recommendation [3] does not even cite PCR as a diagnosis tool for candidemia. We agree with the authors that a randomized trial should be performed, however, it should initially evaluate the diagnostic performance of fungal PCR in the ICU setting, rather than the interest of PCR driven therapy. Serge Alfandari MD Pierre-Yves Delannoy MD Hugues Georges MD Service de Réanimation et Maladies Infectieuses CH Dron, 59208 Tourcoing, France E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2013.01.002
References [1] Bloos F, Bayer O, Sachse S, et al. Attributable costs of patients with candidemia and potential implications of polymerase chain reactionbased pathogen detection on antifungal therapy in patients with sepsis. J Crit Care 2013;28:2-8. [2] Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:503-35. [3] Marchetti O, Lamoth F, Mikulska M, et al. ECIL recommendations for the use of biological markers for the diagnosis of invasive fungal diseases in leukemic patients and hematopoietic SCT recipients. Bone Marrow Transplant 2012;47:846-54.
PCR diagnosis of candidemia
We read with interest the article by Bloos et al. [1]. It offers an estimate of increased direct costs attributable to candidemia in severe sepsis patients. Part of the article focuses on the evaluation of PCR-based diagnosis of invasive candidiasis. The author identified 11 patients with positive pan fungal PCR. They implicitly considered these patients as suffering from an invasive fungal infection and concluded that PCR allowed for a reduction in time to antifungal therapy. The ICU mortality of the PCR positive patients, 27.7% was close to the mortality of the non candida group, 31.2% and markedly lower than the mortality of candidemic patients, 53.1%. It is stated that no PCR positive patient had a candida positive blood culture. We assume some patients were diagnosed with candidemia between May 2009 and June 2010, the time period when PCR was performed. Thus, none of them were PCR positive. This raises a concern on the usefulness of this PCR as the pathological significance of candidemia is non controversial [2]. That lack of detailed data on the number of candida positive blood culture between May 2009 and June 2010 precludes any detailed analysis; however, the false negative rate of PCR in this sample appears to be 100%. Are the positive PCR results more trustworthy or are they only false positive?. If the later, PCR only resulted in increasing the inappropriate use of antifungal agents.
0883-9441/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
In another patient setting, leukemia and stemm cell transplant, a recent European recommendation [3] does not even cite PCR as a diagnosis tool for candidemia. We agree with the authors that a randomized trial should be performed, however, it should initially evaluate the diagnostic performance of fungal PCR in the ICU setting, rather than the interest of PCR driven therapy. Serge Alfandari MD Pierre-Yves Delannoy MD Hugues Georges MD Service de Réanimation et Maladies Infectieuses CH Dron, 59208 Tourcoing, France E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2013.01.002
References [1] Bloos F, Bayer O, Sachse S, et al. Attributable costs of patients with candidemia and potential implications of polymerase chain reactionbased pathogen detection on antifungal therapy in patients with sepsis. J Crit Care 2013;28:2-8. [2] Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:503-35. [3] Marchetti O, Lamoth F, Mikulska M, et al. ECIL recommendations for the use of biological markers for the diagnosis of invasive fungal diseases in leukemic patients and hematopoietic SCT recipients. Bone Marrow Transplant 2012;47:846-54.