Utility of a commercially available multiplex real-time PCR assay to detect bacterial and fungal pathogens in febrile neutropenia

Abstract

Infection is the main treatment-related cause of mortality in cancer patients. Rapid and accurate diagnosis to facilitate specific therapy of febrile neutropenia is therefore urgently warranted. Here, we evaluated a commercial PCR-based kit to detect the DNA of 20 different pathogens (SeptiFast) in the setting of febrile neutropenia after chemotherapy. Seven hundred eighty-four serum samples of 119 febrile neutropenic episodes (FNEs) in 70 patients with hematological malignancies were analyzed and compared with clinical, microbiological, and biochemical findings. In the antibiotic-naïve setting, bacteremia was diagnosed in 34 FNEs and 11 of them yielded the same result in the PCR. Seventy-three FNEs were negative in both systems, leading to an overall agreement in 84 of 119 FNEs (71%). During antibiotic therapy, positivity in blood culture occurred only in 3% of cases, but the PCR yielded a positive result in 15% of cases. In six cases the PCR during antibiotic treatment detected a new pathogen repetitively; this was accompanied by a significant rise in procalcitonin levels, suggestive of a true detection of infection. All patients with probable invasive fungal infection (IFI; n = 3) according to the standards of the European Organization for Research and Treatment of Cancer had a positive PCR result for Aspergillus fumigatus; in contrast there was only one positive result for Aspergillus fumigatus in an episode without signs and symptoms of IFI. Our results demonstrate that the SeptiFast kit cannot replace blood cultures in the diagnostic workup of FNEs. However, it might be helpful in situations where blood cultures remain negative (e.g., during antimicrobial therapy or in IFI).

FIG. 1.

PCT levels in the group of patients with repetitively positive PCR results in follow-up (n = 6; median, 1.64 ng/ml; IQR, 0.49 to 2.48 ng/ml) compared to the group with only one positive PCR sample (n = 22; median, 0.24 ng/ml; IQR, 0.19 to 0.69 ng/ml) or with negative PCR/blood culture results throughout the FNE (n = 50; median, 0.29 ng/ml; IQR, 0.17 to 0.88 ng/ml; P = 0.001, Kruskal-Wallis test). Horizontal lines within bars represent medians; bars represent IQRs; whiskers represent confidence intervals; circles and asterisks represent outliers.

FIG. 2.

Time course of examples with a positive result for fungal DNA. The left axis depicts the temperature in degrees Celsius; the right axis depicts PCT levels (ng/ml) and galactomannan optical density indices. (A) Episode with PCR positive for Candida albicans. (B) Episode with PCR positive for Aspergillus. This episode was classified as probable IFI with typical radiological features of fungal pneumonia and repetitively positive Aspergillus antigen.