Development of Novel Real-Time PCR Assays for Detection and[1]

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JOURNALOFCLINICALMICROBIOLOGY,Mar.2007,p.906–914Vol.45,No.3

0095-1137/07/$08.00ϩ0doi:10.1128/JCM.01344-06

Copyright©2007,AmericanSocietyforMicrobiology.AllRightsReserved.

DevelopmentofNovelReal-TimePCRAssaysforDetectionand

DifferentiationofElevenMedicallyImportantAspergillusand

CandidaSpeciesinClinicalSpecimensᰔ

ClaudiaSchabereiter-Gurtner,*BrigitteSelitsch,ManfredL.Rotter,

AlexanderM.Hirschl,andBirgitWillinger

DepartmentofClinicalMicrobiology,InstituteofHygieneandMedicalMicrobiology,MedicalUniversityofVienna,Vienna,Austria

Received30June2006/Returnedformodification8August2006/Accepted13January2007

Inthepresentstudy,novelreal-timePCRassaystargetingthefungalITS2regionweredevelopedforthe

detectionanddifferentiationofmedicallyimportantAspergillusspecies(Aspergillusfumigatus,Aspergillus

flavus,Aspergillusnidulans,Aspergillusniger,andAspergillusterreus)andCandidaspecies(Candidaalbicans,

Candidadubliniensis,Candidaglabrata,Candidakrusei,Candidaparapsilosis,andCandidatropicalis)using

aLightCyclerinstrument.Thecombinationofagroup-specificandauniversalprimerwithfiveAspergillus

orsixCandidaspecies-specificbiprobesinonereactionmixturefacilitatedrapidscreeningandspecies

differentiationbythecharacteristicpeakmeltingtemperaturesofthebiprobes.Bothassayscanbe

performedeitherassingleassaysorsimultaneouslyinthesameLightCyclerrun.Theanalyticalsensitivity

usingpureculturesandEDTA-anticoagulatedblood,cerebrospinalfluid(CSF),andtissuesamplesspiked

withA.fumigatusandC.albicanscellsuspensionswasshowntobeatleast1CFUperPCR,corresponding

to5to10CFU/mlbloodand10CFU/200␮lCSFor0.02gtissue.Toassesstheclinicalapplicability,26

respiratorysamples,4tissuesamplesfromthemaxillarysinus,and1bloodsamplewereretrospectively

testedandreal-timePCRresultswerecomparedwithresultsfromculture,histology,oragalactomannan

enzyme-linkedimmunosorbentassay(ELISA).Twentysamples(64.5%)werebothculturepositiveand

positivebyreal-timePCR.Sixsamples(19.4%)showednogrowthoffungibutwerepositivebyreal-time

PCR.However,allofthetissuesampleswerepositivebybothPCRandhistology.Thebloodsample

showednogrowthofAspergillus,butaspergillosiswasconfirmedbypositivegalactomannanELISA,

histology,andPCRresults.Theremainingsamples(16.1%)werecultureandPCRnegative;also,noother

signsindicatingfungalinfectionwereobserved.OurdatasuggestthattheAspergillusandCandidaassays

maybeappropriateforuseinclinicallaboratoriesassimpleandrapidscreeningtestsforthemost

frequentlyencounteredAspergillusandCandidaspeciesandmightbecomeanimportanttoolintheearly

diagnosisoffungalinfectionsinthefuture.

Invasivefungalinfectionsareincreasinglyrecognizedasa

primarycauseofmorbidityandmortality,especiallyinimmu-

nocompromisedpatients.Thefrequencyofnosocomialcandi-

demiahasincreased10-foldduringthepasttwodecades(3).

Candidaalbicans,formerlythemostimportantspecies,isstill

theonewhichmostoftencausesdisease.However,otherspe-

ciesthanC.albicans,inparticular,Candidaglabrata,butalso

Candidatropicalis,Candidakrusei,andCandidaparapsilosis,

havegainedgreatersignificanceandmustnotbeoverlooked

(15,31).Theprevalenceofcandidiasisandtheincreasein

Candidabeingresistanttopolyeneandazoledrugshavemade

rapidspeciesdifferentiationmandatory(29,31).Therehas

beenalessstriking,thoughalsosubstantial,increaseinthe

incidenceofinvasiveaspergillosis(IA)(27).Invasiveaspergil-

losisismainlycausedbyAspergillusfumigatus,followedby

AspergillusflavusandAspergillusterreus.Otherspecies,suchas

Aspergillusnidulans,Aspergillusniger,andAspergillusustus,are

rarelyfoundindiagnosingIA.

Thedefiniteandrapiddiagnosisofinvasivefungalinfectionsisdifficultduetothelackofsensitivetestmethods.Therefore,

effortstoimprovediagnosisareongoingandneedtobefurther

intensified.Althoughprovingthepresenceofinfectionbyhis-

tologyandcultureremainsthecornerstoneofdiagnosis,non-

culture-basedmethodsarebeingdevelopedtoallowearlyde-

tection.Amongthemostpromisingapproachesarethedetection

offungalantigensandPCR(2,4,42).Theresultsofsome

studiessuggestthatacombinationoftheAspergillusgalacto-

mannanenzyme-linkedimmunosorbentassay(GM-ELISA)

andreal-timePCRmayprovideimproveddiagnosisofinvasive

aspergillosis(5,7,20,35).

Nevertheless,notonlythedetectionoffungi,butalsotheir

identification,whichcanbeobtainedonlybyPCRorculture,

isimportantfortheoptimalchoiceofantifungalsandduration

oftherapy.AvarietyofPCRassaysbasedonthedetectionof

fungalDNAinsterilehumanbodyfluidsortissuesamplesto

allowearlydiagnosisoffungalinfectionsandtoimprovethe

survivalrateofpatientssufferingfrominvasiveinfectionshas

beendescribed.However,incontrasttotheGM-ELISA,none

ofthedevelopedPCRassayshavebeenstandardized,resulting

indivergingresults.Ingeneral,theintroductionofreal-time

PCRtechnologyinthedetectionoffungalinfectionshasin-