Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice

In patients with severe immune compromise, such as those with neutropenia, hematologic malignancy or recipients of hematologic stem cell or solid organ transplants presenting with unexplained lung infiltrates suspected of invasive fungal disease, the ATS recommends the use of serum GM testing. (S, H)

In patients suspected of invasive fungal diseases, including those with a negative serum GM, but strong risk factors for invasive aspergillosis, or positive serum GM but confounding factors for false positive GM results (ex. those patients undergoing chemotherapy or at risk for mucositis where cross-reactive epitopes from other fungi or bacteria can penetrate the intestinal mucosa causing positivity of the test), the ATS recommends bronchoalveolar lavage (BAL) testing with GM. (S, H)

In patients with severe immune compromise, such as those with hematologic malignancy or recipients of hematologic stem cell or solid organ transplants, who are suspected of having IPA, the ATS recommends the use of blood or serum Aspergillus PCR testing. (S, H)

In patients with severe immune compromise, such as those with hematologic malignancy or recipients of hematologic stem cell or solid organ transplants, who are suspected of having IPA, the ATS recommends the inclusion of Aspergillus PCR on BAL testing as part of the evaluation. (S, H)

In patients with severe immune compromise, such as those with hematologic malignancy or recipients of hematologic stem cell or solid organ transplants, who are strongly suspected of having IPA but in whom PCR testing for Aspergillus is negative, the ATS suggests consideration of biopsy and/or additional testing with or without additional PCR or galactomannan testing. (C, L)

In critically ill patients in whom there is clinical concern for invasive candidiasis, the ATS suggests against reliance solely on results of serum BDG testing for diagnostic and treatment decisions. (C, L)

The ATS recommends the use of Histoplasma antigen in urine or serum for rapid diagnosis of suspected disseminated and acute pulmonary histoplasmosis where timely diagnosis and treatment are paramount to outcome. (S, H)

The ATS suggests the use of Histoplasma serologies in immunocompetent patients with suspected pulmonary histoplasmosis. (C, M)

In patients with appropriate geographic exposure and illness compatible with infection or pneumonia due to blastomycosis, the ATS suggests using more than one diagnostic test, including direct visualization and culture of sputum BAL or other biopsy material, urine antigen testing, and serum antibody testing. (C, M)

In patients with suspected blastomycosis, the ATS suggests that serum antibody testing specifically directed against the anti-BAD-1 antigen for blastomycosis be used along with clinical and epidemiological data to establish the diagnosis. (C, L)

In patients with suspected blastomycosis, particularly in immunocompromised patients, the ATS suggests that urinary antigen testing for blastomycosis be used along with clinical and epidemiological data to establish the diagnosis. (C, M)

In patients with appropriate geographic exposure and illness compatible with infection or pneumonia due to coccidioidomycosis, the ATS suggests using more than one diagnostic test, including direct visualization and culture of sputum BAL or other biopsy material, urine and serum antigen testing, and serology (serum antibody testing). (C, M)

In patients with suspected coccidioidomycosis, particularly in immunocompromised patients, the ATS suggests performing urinary and serum antigen testing to aid in establishing the diagnosis. (C, M)

In patients with suspected community acquired pneumonia (CAP) from the endemic area for coccidioidomycosis, the ATS suggests initial serological testing with close clinical follow up and serial testing. (C, M)