Title

Author(s)

Retrospective analysis of (1 [arrow] 3)-b-D-glucan assay in the

diagnosis of invasive fungal infection

Lai, Koon-chi, Christopherher;

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Issued Date

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2011

http://hdl.handle.net/10722/144850

The author retains all proprietary rights, (such as patent rights)

and the right to use in future works.

Retrospective analysis of (1 3)--D-Glucan assay in the

diagnosis of invasive fungal infection

By

Dr LAI Koon Chi Christopher

This work is submitted to

Faculty of Medicine of The University of Hong Kong
In partial fulfilment of the requirements for
The Postgraduate Diploma in Infectious Diseases, PDipID (HK)

Date: 18 November 2010

Supervisor: Dr P L Ho

Declaration

I, Lai Koon Chi Christopher, declare that this dissertation represents my own work and that it
has not been submitted to this or other institution in application for a degree, diploma or any
other qualifications.
I, Lai Koon Chi Christopher, also declare that I have read and understand the guideline on
What is plagiarism? published by The University of Hong Kong (available at
http://www.hku.hk/plagiarism/) and that all parts of this work complies with the guideline.

Candidate: Lai Koon Chi Christopher

Signature:

Date:

18 November 2010

Acknowledgement

I would like to thank my supervisor, Dr PL Ho who had given me invaluable advices to allow
me to materialize my study idea. I would also like to thank my work supervisor Dr. Dominic
Tsang who allowed me to assess the data from the hospital laboratory database which makes
my study project feasible.

I declare there is no conflict of interests

Abstract (word count: 318)

Background: The incidence of invasive fungal infections (IFI) is increasing steadily.

Intensive care unit (ICU) admission is recognized as being a risk factor for development of
IFI and carries a high mortality. (1 3)--D-Glucan (BDG) is a cell wall component of many
fungi and is useful in the diagnosis of IFI.
Objective: To assess the performance of (BDG) in the diagnosis of IFI in the setting of an
adult ICU in Hong Kong.
Method: This is a retrospective observational analysis on 142 patients who was admitted to
the adult ICU of a regional hospital in Hong Kong and had BDG assay collected between
2007 and 2008. Case definitions for invasive fungal infections were based on to the European
Organization for Research and Treatment of Cancer (EORTC) criteria.
Results: When using the conventional cut-off value of 80pg/mL, the sensitivity of BDG in
detecting IFI was 85.7% (95% CI 59.8% 100%), and the positive predictive value was 8.5%
(95% CI: 2.0% - 14.9%). The overall positive rate of all patients tested for BDG was 50.0%.
When a cut-off value of 60pg/mL was used, the sensitivity of BDG was 87.5% (95% CI:
64.6% - 100%), the positive predictive value was 8.6% (95% CI: 2.5% - 14.8%). We cannot
determine the specificity and negative predictive value as we did not have any controls as
true negatives. BDG was able to detect C. albicans and C. tropicalis fungemia, as well as
Pneumocystis jiroveci pneumonia (PCP). One patient with C. parapsilosis fungemia had
indeterminate BDG result and is again consistent with other studies.
Conclusion: We found that BDG assay have a role in the assistance of diagnosis of invasive
fungal infection in adult ICU. However, one must interpret the result with caution. The main
value of BDG could be its negative predictive value. Further prospective studies with

recruitment of negative controls can give a clearer picture of the true performance of the
BDG assay.

Background

The incidence of invasive fungal infections (IFI) is increasing steadily over the past two
decades. The emergence of human immunodeficiency virus infection, the increase in severely
ill patients are clear contributing factors, and the advancement in transplant medicine
resulting in an increased number of patients receiving solid-organ or hematopoietic stem cell
transplantation are contributing factors. The presence of immunosuppresion not only
predisposes the patient to opportunistic fungal infections, but it may also prevent the patient
from displaying typical signs and symptoms of an infectious process (1)

The diagnosis of IFI is usually made by cultures or histopathological examination from blood
or other sterile sites. Obtaining suitable specimens usually involves invasive procedures for
obtaining tissue biopsies; although a histopathological diagnosis is conclusive, the procedure
is invasive and not always feasible in critically ill patients (2). Fungal cultures obtained from
sterile sites or clinically or radiologically abnormal sites are also useful, however, it is slow
as cultures require several days to become positive. To further complicate the issue, it has
been documented that blood cultures are positive in only about 50% of invasive candidiasis
and in less than 10% of invasive aspergillosis (3)

IFI are of increasing relevance for severely ill and immunocompromised patients. The
attributable mortality is up to 50% (6, 7). Early diagnosis and treatment are therefore
mandatory and is associated with a better prognosis (8). Mortality rates increased from 15%
when antifungal therapy was administered early to 41% when there is a delay of more than 2
days (9)

Intensive care unit (ICU) admission is recognized as being a risk factor in its own right for
development of fungal infection (10, 11). Infection by Candida spp. being the most common
cause, contributing 70 87% of all IFI (4, 5) and approximately 10.4% of all infections in
ICU, with the majority being nosocomial (12, 13).

Current strategies for the management of patients with suspected fungal infection include
empirical or prophylactic use of antifungal agents; clearly this is not the most desirable
approach and cannot be generally recommended (1, 8)

What is (1 3)--D-Glucan (BDG)

Glucans are a cell-wall component of many saprophytic and pathogenic fungi as well as
certain bacteria (10). Important exceptions are zygomycetes and cryptococcus species. BDG
are released or actively secreted from the cell wall as exopolymers (14-16). They can be
detected in serum in amounts as low as 1 pg/ml by commercial assays. The detection is based
on the detection of BDG by the innate immune system of horseshoe crabs (17) BDG activates
factor G of the horseshoe crab coagulation cascade, leading to the production of a
chromogenic substance.

Fungitell has been approved by the United States Food and Drug Administration (US FDA)
in 2005 as an adjunct for the diagnosis of IFIs based on its evaluation on hematological
patients (18). The recommended cut-off value for positivity was greater than 80pg/mL.
Many studies have addressed the performance of BDG in the diagnosis of IFI. Most of which
involved patients suffering from hematological malignancies, and few involved patients
admitted to intensive care units. BDG Assay provides a satisfactorily sensitive and specificity,

and were not influenced by the use of prophylactic or empirical antifungals. Many
recommended it use as a non-invasive adjunct for the diagnosis of IFI (2, 3). The major factor
of concerning about the use of BDG was its extremely low PPV (10% - 12%) (19).

The use of BDG in the diagnosis of IFI was introduced in a regional hospital in 2006 in Hong
Kong. It is now a common investigation used by clinicians to aid the diagnosis of IFI in the
ICU setting. Its performance has however, not been evaluated.

Study Objectives

The objective of our study is to assess the performance of (1 3)--D-Glucan (BDG) in the
diagnosis of invasive fungal infections (IFI) in adult intensive care unit in a regional hospital
in Hong Kong. The sensitivity and the positive predictive value will be addressed.

Methodology

This is a retrospective, observational study. All patients admitted to ICU of Queen Elizabeth
Hospital (QEH) with serum collected for BDG assay between 1st Jan 2007 and 31st Dec 2008
is included. Only one serum result per patient was analyzed. For patients with multiple
specimens and with concordant results, the first result was counted. For those with discordant
results, the first positive or indeterminate result was counted. For example, if a patient had
two negative results, one indeterminate result, and one positive BDG result within a hospital
admission, only the positive result will be analyzed.

Case notes of the patients were retrieved for the demographic data and for any evidence of
invasive fungal infections. We used the definitions of Proven invasive fungal infections,
Probable invasive fungal infections, and Possible invasive fungal infections according to
the European Organization for Research and Treatment of Cancer (EORTC) criteria (20).
Microbiological culture results from normally sterile sites as well as non-sterile sites were
retrieved. All histological or cytopathological results from obtained by sterile procedure from
normally sterile and clinically or radiologically abnormal sites were also reviewed. All
respiratory specimens for cytological examination for Pneumocystis jiroveci were also
reviewed.

For all fungal cultures to be significant, we defined the difference between the collection date
of BDG and the positive microbiological specimens to be less than or equal to 7 days. This
criterion is set as the hospital length of stay of ICU patients is usually prolonged and the tests
can be performed far apart. We want to improve the specificity of our analysis by maximizing
the relatedness of the results.

10

How the BDG and blood culture are performed

The assay for BDG in serum was performed by Fungitell (Associates of Cape Cod, Inc.)
Patients serum was assayed according to the manufacturers instructions. The samples were
thawed and brought to room temperature. In the assay, the clotting enzyme cleaves pnitroaniline (pNA) from the chromogenic substrate peptide. The free pNA is measured in a
kinetic microplate assay. The samples were analyzed at 405 and 490 nm on a Moleculare
Devices SpectraMax 340 spectrometer maintained at 37oC

All blood was cultured for bacteria and yeast with the Bactec 9240 continuous monitoring
system (BD Diagnostic Systems, Sparks, MD) until 31st Mar 2008 when the system was
replaced by BacT/ALERT (Biomerieux) blood culture system. All blood culture specimens
were cultured for 5 days before issuing negative results. If fungal culture was specifically
requested, the incubation will be prolonged to 28 days before a negative result is issued.

Data analysis

Independent t-test was used to assess for difference for continuous data between groups. Chisquare test was used to assess difference in discrete data between groups. Specificity,
sensitivity, negative predictive value and positive predictive value were calculated to evaluate
the performance of BDG test in detecting proven positive cases. SPSS ver. 15.0 and
Microsoft Excel 2003 were used for statistical analysis. A probability level of 0.05 or smaller
was used to indicate statistical significance.

11

Results

During the study period, a total of 144 cases were recruited into our study and were assessed.
Two cases were excluded due to incomplete case records. A total of 192 BDG tests were
performed. The number of BDG taken per case ranged from one to five. The overall positive
BDG rate for the cohort was 50.0% (71/142), negative BDG rate 43.0% (61/142). The
percentage of indeterminate BDG result was 7.0% (10/142). The mean age was 61.7 (range
26-88). The female to male ratio was 1: 1.96. There were 7 patients and 20 patients with
underlying hematological malignancies and other malignancies respectively. The most
common causes for admission to ICU were as follows: severe pneumonia (27.5%);
complicated acute abdomen including perforation and gangrenous internal organs (19.0%);
trauma (6.3%); carcinoma of lung (5.6%); acute renal failure (5.6%); autoimmune disorders
(4.9%); cardiovascular diseases including infective endocarditis, rupture aortic aneurysm, and
acute pulmonary oedema (4.9%), and; hematological malignancies (4.9%). There were no
significant differences between the positive group and the combined indeterminate and
negative group. (Table 1)

For the 71 patients tested positive for BDG, six had confirmed IFI and one had probable IFI
(Table 2a). Five (7.0%) confirmed IFI had positive blood cultures for fungal organisms (Four
C.albicans, one C.tropicalis). One confirmed IFI case was diagnosed Pneumocystis jiroveci
pneumonia by cytological examination from tracheal aspirate. The probable IFI case was due
to pulmonary aspergillosis. The diagnosis was based on persistent fever despite prolonged
broad spectrum antibiotics, isolation of aspergillus spp. from sputum, and typical thoracic
computer tomography imaging findings. The remaining 65 patients tested BDG positive had
no evidence of IFI. One patient with C.albicans fungaemia was not counted as a true positive

12

case as the blood culture collection date was more than one week earlier than that of the BDG,
and between which, two negative blood cultures was obtained.

For the 61 patients tested negative for BDG, One (1.64%) had a positive blood culture for
C.albicans and we regard the case as a true IFI case and the BDG result of this patient was a
false negative result. The reading was 47.24pg/mL. The remaining 60 patients had no
evidence of IFI. For the 10 patients tested indeterminate for BDG, there was one case that we
regarded as a true IFI whom the blood culture was positive for C.parapsilosis. The remaining
9 patients tested indeterminate had no evidence of IFI. There were no cases of probable or
possible IFI for those tested indeterminate or negative.

The performance of BDG for IFI diagnosis:

We evaluated the sensitivity and positive predictive value using several cut-off criteria (Table
2b): When we use the FDA recommended cutoff point of 80 pg/mL, and disregard the
indeterminate results, the sensitivity is 85.7% (95% CI: 59.8% - 100%), the positive
predictive value is 8.5% (95% CI: 2.0% - 14.9%). When we try to lower the cut-off value for
positivity to 60 pg/mL to improve the sensitivity of the test, we counted those tested
indeterminate as positives, the sensitivity of BDG is 87.5% (95% CI: 64.6% - 100%), the
positive predictive value is 8.6% (95%CI: 2.5% - 14.8%).

We also looked at the performance of BDG regarding IFI caused by specific organisms; For
C.albicans, 75% (3/4) showed positive results with the value of >500pg/mL, 369.8pg/mL,
and 158pg/mL respectively. One IFI due to C. tropicalis was identified in our cohort with a
value of >500 pg/mL. The one invasive C.parapsilosis infection in our cohort has an

13

indeterminate result (between 60 - 79 pg/mL). The only pneumocystis jiroveci infected

patient had a strong positive reading of >500pg/mL.

When we analyzed those patients who had a positive non-fungal blood culture results within
seven days of the BDG. Four patients had positive blood culture results; one with
Corynebacterium resistens, one with two strains of Escherichia coli, and 2 patients with
Streptococcus pneumoniae. The positive BDG rate for these cases is 75%. The negative case
is a case with Strepococcus pneumoniae bacteremia. All of these cases do not meet the
criteria for confirmed IFI by EORTC and are thus considered to be false positives.

We also examined the positive rate in patients admitted from medical department and
surgical departments (including cardiothoracic surgery, general surgery, gynecology, and
neurosurgery). The positive rate is not statistically different for medical 57.5% (46/80), and
surgical departments 40.7% (24/59).

We also tried to look into the performance of BDG in patients suffering from hematological
malignancies, however, only seven patients were identified and hence the sample size is too
small for any meaningful analysis.

Episode Mortality:

We tried to look at if there is a relationship between BDG positivity and episode mortality.
We found that for those tested BDG positive, the mortality rate was 54.9%, while the
mortality rate of those tested negative and indeterminate was 39.4%. However, this is not
statistically significant. (Table 3) The mortality was also not significantly different in cases

14

admitted from medical department 51.3% (41/80) and surgical departments 42.4% (25/59).
(Table 3 and Table 4)

15

Discussion

The aim of our study is to evaluate the performance of BDG in Hong Kong. ICU patients
were recruited as they are well known to be at risk of IFI but data for use of BDG in this
group of patients has been lacking.

In our study, the sensitivity of BDG for the diagnosis of IFI was 85.7% (95% CI: 59.8% 100%). This is comparable to other published data where the sensitivity ranged from 77.8%
to 93.3% (3, 22, and 23). Different cutoffs values (60 pg/mL and 120pg/mL) have been used
in other studies with mixed results (18, 24). When we lowered the cut-off value to 60 pg/mL
by including the indeterminate results as positives, the sensitivity of the BDG was improved
to 87.5% (95% CI: 64.6% - 100%).
However, the positive predictive value had been dismally low no matter which cut-off value
we used; 8.5% (95% CI: 2.0% - 14.9%), and 8.6% (95%CI: 2.5% - 14.8%) for a cut-off of
80mg/mL and 60mg/mL respectively.

We cannot determine the specificity and negative predictive value for the BDG as we did not
include any negative controls in our study. Published data suggested that the test had
excellent negative predictive value of >95% (10, 23, 28). At a cut-off of 60pg/ml, the
negative predictive value of twice weekly sampling was 100%. Based on its excellent
negative predictive value, it seems to be most useful for excluding IFIs (10, 24).

Performance of BDG in different fungal pathogens

16

In our study, BDG was able to detect C. albicans and C. tropicalis fungemia. This is
consistent with published data. BDG positive results have been obtained for candidemia of
other Candida species including C. glabrata, C. krusei, C.guilliermondii and C. lusitaniae.

In our patient with C. parapsilosis fungemia, the BDG result was indeterminate. This is again
consistent with other studies (22). The low BDG levels have already been reported in patients
infected with this C .parapsilosis, for which the caspofungin MICs are generally elevated (3)

There has been proven value of the BDG assay in the diagnosis of a wide range of
opportunistic IFI other than candidiasis including aspergillosis, geotrichosis, and
pneumocystosis. It was also reported to be useful for the diagnosis of histoplasmosis (23) and
fusariosis (3). In our cohort, there is one case of Pneumocystis jiroveci pneumonia (PCP) and
the BDG value is >500pg/mL. This is consistent with other reports: In a Japanese cohort, 16
PCP patients diagnosed by specific immunofluorsecence staining of respiratory specimens,
15 are BDG positive with a median value greater than 500.(25, 26). In another cohort, all 20
patients diagnosed to have PCP are tested positive for BDG (22). High levels of BDG in the
context of PCP have also been reported. (28, 29) This suggests that the test could be useful in
diagnosing PCP, especially for patients in whom bronchoscopy is problematic because of
respiratory status. (22, 27) A recent study indicates that BDG levels decreased during
treatment with cotrimoxazole (30). This could imply the possible role of BDG in monitoring
the treatment response of pneumocystosis.

We had one case of probable IFI due to pulmonary aspergillosis. However, we did not have
any confirmed case of invasive aspergillosis, nor did we evaluate the performance of

17

galactomannan together with BDG. Stratified invasive fungal infections screening and
diagnostic strategies using both galactomannan and BDG has been suggested and should be
explored. (31)

BDG performance in ICU patients with bacterial sepsis

In our study, 75% of patients with a positive blood culture for bacteria had a false positive
BDG result. It is consistent with other studies. High rate of false positivity have been reported
in patients who have bacterial infections and ranged from 54% to 68% (10, 23). In addition,
serum glucan levels were elevated in infected patients in the presence or even in the absence
of positive blood cultures. This suggests that the assay can readily detect a localized, as well
as a systemic, infection through the release of cell wall glucans. (10).

Since introduction, the lack of specificity and the low positive predictive value limited the
use of the test. One study reported false positive results in 26% of patients who had
neutropenic fever in whom an invasive fungal infection was not observed. Another recent
report suggested false positive results can be observed in as high as 44% of patients from
hematology wards or ICUs who were at risk for invasive fungal infection. (22, 33) Egan and
colleagues reported positive results in 44% of hospital controls without an identifiable
mycosis (46). Others reported that 15% of immunocompetent noninfected children had
positive BDG test (47) compared with the reported rates of 7% in health adults (48) and 8%
in adults without fungal infections (3)

Apart from bacteraemia, other reasons for the high false positive rate can be explained by the
following factors:

18

Patients undergoing hemodialysis are known to have false positive BDG results. False
positive BDG results had been observed in patients who used cellulose hemodialysis
membranes, but this was not observed in regenerated cellulose (cellulose triacetate)
membranes (34, 35, 36). Patients Receiving certain blood products such as albumin and
immunoglobulins (37,38) or patients undergoing treatment with glucan-containing anticancer drugs such as lentinan and sizofiran (39) are other well known causes.

Whether false positivity can be caused by intravenous antimicrobials are however, less well
documented. As learned from the galctomannan ELISA assay, cross-reactivity are observed
with piperacillin-tazobactam administration (41-43). The false positive results were not due
to detection of the antimicrobial itself but to the introduction of galactofuran in the
manufacturing process, which has a pharmacokinetic behavior different than that of the
antimicrobial itself (43). But in another published study, there was no obvious antimicrobial
class effect in terms of the BDG reactivity. No antimicrobial solution had detectable BDG at
the usual drug maximal plasma concentration, but this should be interpreted with caution (40)

Patients exposed to gauze or sponges containing BDG during surgery is another recognized
factor (21) Different BDG values were assessed based on the brand and type of gauze. Prewashed LAP sponge with X-ray detectable thread release a significantly higher level of BDG
compared to the non-washed product (2)
Environmental contamination has also been suggested as a cause of BDG reactivity (44)

Hence, serum glucan levels were not specific for fungal infections and the false positivity in
critically ill patients limits the usefulness of the BDG test.

19

Alternatives of BDG

Although the performance of BDG for the diagnosis of IFI had been disappointing, there
have not been an alternative that can satisfactorily replace its use. The amplification of gene
sequences unique to fungi by PCR assays has been developed to improve the diagnosis of
IFIs in high-risk patients and offers the potential for rapid diagnosis. However, because of the
absence of a standardized and validated commercial method, the routine use of PCR in the
diagnosis of IFI cannot yet be recommended. (8) Methods to detect antibodies against
Candida albicans germ tubes have been discussed, but studies to support their use are not
convincing.

20

Limitations of our study

In addition to the intrinsic limitation for the BDG test, there are several major limitations in
our study. The main limitation is the lack of negative controls. We were unable to calculate
the specificity and negative predictive values for our data. Being a retrospective study, many
important factors for false positivity as mentioned above cannot be accurately addressed. This
is particular true for the presence of hemodialysis, blood and blood products infusions, and
the use of particular type of gauze during surgeries. If these were identified, it may prove to
greatly enhance the knowledge on the use of the test and greatly improves the sensitivity.

We included only those confirmed IFI according to the EORTC. We did not include those
probable and possible IFI cases due to the difficulties in gathering all the necessary data
retrospectively which reduced the sensitivity of the test. This lack of true positive cases also
significantly limited the power of the study.

Published data suggested that blood cultures are positive in only about 50% of invasive
candidiasis and in less than 10% of invasive aspergillosis (3). This suboptimal sensitivity may
be due to the fact that glucan levels in patients with fungal infections are episodic. This may
be due to clearance of the carbohydrate by the renal system and/or uptake by the mononuclear phagocyte system (32). We do see non-confirmed cases showed clinical, radiological
improvement after appropriate anti-fungal therapy. Cases may have been true IFI cases
detected by BDG and regarded as false positive due to the inability to confirm the diagnosis
microbiologically, histologically, and cytopathologically.

21

Since exposing to gauze or sponges containing BDG during surgery (21) is a well know
cause of false positive BDG, we also examined the rate of positivity in patients admitted from
medical department and surgical departments. To our disappointment, the positive rate is not
statistically different for medical 57.5%, and surgical departments 40.7%. This could be due
to the fact that the gauze we used did not cause false positivity. Exact nature of gauze used
the time between operations and collection time of serum BDG could provide more
information

Patients admitted to the ICU are heterogeneous in both their admission diagnosis and
underlying co-morbidities. This could have a negative effect to the study outcome due to
unrecognized confounding factors. We however did not find any significant difference in the
age, sex, underlying malignancies, and admission diagnosis between the positive and
negative/indeterminate groups.

We expected the mortality to be greater for those BDG positive patients as it may represent
underlying undiagnosed infections. However, the mortality rate did not differ between those
tested positive (54.9%) and negative (39.4%).

Conclusion

BDG assay have a role in the assistance of diagnosis of invasive fungal infection in adult ICU.
It has been proven value in the diagnosis of a wide range of opportunistic IFI and was shown
to be able to detect candidiasis (except C. parapsilosis), and pneumocystosis in our current
study. However, one must be cautious on the interpretation of the test result as the sensitivity
is at best around 85% and has a positive predictive value of <10%. Many suggested the main

22

value of BDG assay could be its negative predictive value. Further prospective studies with
recruitment of controls as true negatives can give a clearer picture of the true performance of
the BDG assay.

23

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29

Tables and figures

Table 1: Patients' characteristics

Age

BDG result
Hypothesis
Positive
Negative/Equivocal
Testing
(n=71)
(n=71)
Mean
SD
Mean
SD
Independent t-test
61.3
14.3
62.1
14.9
NS

Count
%
Count
F
23
32.4%
25
Sex
M
48
67.6%
46
66
93.0%
69
Hematological No
Ca
Yes
5
7.0%
2
No
63
88.7%
59
Other Ca
Yes
8
11.3%
12
Severe pneumonia (HAP, CAP, PTB)
18
25.4%
21
Complicated acute abdomen (perforate organs,
17
23.9%
10
gangrene)
Carcinoma of lung
4
5.6%
4
Autoimmune disorders
3
4.2%
4
Cardiovascular (IE, Rupture AAA, APO)
4
5.6%
3
Hematological malignancies
5
7.0%
2
Trauma
(RTA,
Head
injury)
2
2.8%
7
Underlying
Condition
Acute pancreatitis
2
2.8%
4
Acute renal failure
6
8.5%
2
Sepsis, shock, MODS, ARDS
4
5.6%
1
Liver failure
1
1.4%
2
Severe gastrointestinal bleeding
2
2.8%
1
Carcinoma of esophagus
0
0.0%
2
CVA / ICH
0
0.0%
2
Others
3
4.2%
6
More than 20% of the cells in crosstab with expected count smaller than 5, Fisher's exact test was used

%
41.0%
75.4%
113.1%
3.3%
96.7%
19.7%
34.4%

Chi-square test

16.4%

NS

6.6%
6.6%
4.9%
3.3%
11.5%
6.6%
3.3%
1.6%
3.3%
1.6%
3.3%
3.3%
9.8%

NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS

NS
NS
NS
NS

30

Table 2a: The performance of BDG for IFI diagnosis By EORTC classification
IFI Status as classified by EORTC
BDG
result

Positive
Indeterminate
Negative

Proven IFI

Probable IFI

Possible IFI

5
1
1

1
0
0

0
0
0

No evidence of
IFI
65
9
60
Total

Total
71
10
61
142

Table 2b: Performance of BDG test for IFI diagnosis Sensitivity and PPV
i.

Include cases with BDG positive or negative results only

True result
Positive Negative Total
Positive
6
65
71
BDG
result
Negative
1
60
61
7
125
132
Total

Sensitivity
PPV

Value

95% CI

85.7%
8.5%

(59.8%, 100%)
(2.0%, 14.9%)

ii. Include all cases, cases with equivocal result are considered as positive
True result
Value
95% CI
Positive Negative Total
7
74
81
87.5% (64.6%, 100%)
BDG Positive/Indeterminate
Sensitivity
result
Negative
1
60
61
8.6%
(2.5%, 14.8%)
PPV
8
134
142
Total
All Proven IFI, probable IFI, and possible IFI are counted as true positives
NB Specificity and NPV cannot be calculated as we did not include true negative controls

31

Table 3: Episode mortality

BDG
results

Episode outcome
Alive
Dead
Total
Chi-square test
Count Row % Count Row % Count
Positive
32
45.1%
39
54.9%
71
NS
Negative/Equivocal
43
60.6%
28
39.4%
71
52.8%
67
47.2%
142
Overall 75

Request Medical
dept Surgical

39
48.8%
34
57.6%
52.5%
Overall 73
3 cases from RT department were excluded.

41
25
66

51.3%
42.4%
47.5%

80
59
139

Table 4: BDG results by department

BDG results
Positive
Negative/Equivocal Total
Count Row % Count
Row % Count
Medical
46
57.5%
34
42.5%
80
Request
dept
Surgical
24
40.7%
35
59.3%
59
50.4%
69
49.6%
139
Overall 70
3 cases from RT department were excluded.

NS

Chi-square test
*

32