Table 2.
Comparison of available diagnostic techniques for mycological diagnosis in Italy
| Overall (n = 49) | GDP | ||||||
|---|---|---|---|---|---|---|---|
| < 30,000 € (n = 19) | > 30,000 € (n = 30) | ||||||
| n | % | n | % | n | % | ||
| Microscopy | 46 | 93.9 | 17 | 89.5 | 29 | 96.7 | |
| Stains | |||||||
| China/India ink | 34 | 69.4 | 14 | 73.7 | 20 | 66.7 | |
| Silver stain | 24 | 49.0 | 8 | 42.1 | 16 | 53.3 | |
| Giemsa stain | 24 | 49.0 | 7 | 36.8 | 17 | 56.7 | |
| Potassium hydroxide | 15 | 30.6 | 6 | 31.6 | 9 | 30.0 | |
| Calcofluor white | 12 | 24.5 | 4 | 21.1 | 8 | 26.7 | |
| Direct microscopy frequency when IFD suspected | |||||||
| Never | 1 | 2.0 | 1 | 5.3 | 0 | 0.0 | |
| Rarely | 6 | 12.2 | 4 | 21.1 | 2 | 6.7 | |
| Sometimes | 12 | 24.5 | 6 | 31.6 | 6 | 20.0 | |
| Often | 9 | 18.4 | 1 | 5.3 | 8 | 26.7 | |
| Always | 21 | 42.9 | 7 | 36.8 | 14 | 46.7 | |
| Access to fluorescent dye | 19 | 38.8 | 8 | 42.1 | 11 | 36.7 | |
| Direct examination in body fluids for suspected cryptococcosis | 39 | 79.6 | 15 | 78.9 | 24 | 80.0 | |
| India ink | 34 | 69.4 | 14 | 73.7 | 20 | 66.7 | |
| Other dyes | 5 | 10.2 | 1 | 5.3 | 4 | 13.3 | |
| Direct microscopy for suspected mucormycosis | 26 | 53.1 | 12 | 63.2 | 14 | 46.7 | |
| Silver stain for suspected pneumocystosis | 21 | 42.9 | 8 | 42.1 | 13 | 43.3 | |
| Culture and fungal identification | 49 | 100.0 | 19 | 100.0 | 30 | 100.0 | |
| Blood cultures for suspected fungemia | 49 | 100.0 | 19 | 100.0 | 30 | 100.0 | |
| Fungal culture media | |||||||
| Sabouraud dextrose agar | 27 | 55.1 | 10 | 52.6 | 17 | 56.7 | |
| Sabouraud dextrose agar + chloramphenicol | 26 | 53.1 | 11 | 57.9 | 15 | 50.0 | |
| Sabouraud dextrose agar + gentamicin | 22 | 44.9 | 10 | 52.6 | 12 | 40.0 | |
| Chromogen | 21 | 42.9 | 7 | 36.8 | 14 | 46.7 | |
| Selective agar (chloramphenicol + cycloheximide) | 17 | 34.7 | 6 | 31.6 | 11 | 36.7 | |
| Potato dextrose agar | 13 | 26.5 | 6 | 31.6 | 7 | 23.3 | |
| Agar Niger | 10 | 20.4 | 6 | 31.6 | 4 | 13.3 | |
| Lactrimel agar | 4 | 8.2 | 2 | 10.5 | 2 | 6.7 | |
| Available tests for specific identification | 46 | 93.9 | 18 | 94.7 | 28 | 93.3 | |
| MALDI–TOF–MS | 40 | 81.6 | 14 | 73.7 | 26 | 86.7 | |
| Automated identification (i.e., VITEK®) | 33 | 67.3 | 14 | 73.7 | 19 | 63.3 | |
| Biochemical tests (conventional mycology) | 28 | 57.1 | 13 | 68.4 | 15 | 50.0 | |
| DNA sequencing | 26 | 53.1 | 8 | 42.1 | 18 | 60.0 | |
| Mounting medium | 4 | 8.2 | 0 | 0.0 | 4 | 13.3 | |
| Antifungal susceptibility tests? | 45 | 91.8 | 16 | 84.2 | 29 | 96.7 | |
| For yeasts and moulds | 32 | 65.3 | 13 | 68.4 | 19 | 63.3 | |
| For yeasts | 13 | 26.5 | 3 | 15.8 | 10 | 33.3 | |
| Available antifungal susceptibility test technologies | |||||||
| Broth microdilution, using EUCAST standards | 23 | 46.9 | 9 | 47.4 | 14 | 46.7 | |
| VITEK® | 18 | 36.7 | 8 | 42.1 | 10 | 33.3 | |
| E-test® | 18 | 36.7 | 5 | 26.3 | 13 | 43.3 | |
| Broth microdilution, using CLSI standards | 18 | 36.7 | 3 | 15.8 | 15 | 50.0* | |
| Maximum identification capability | |||||||
| Yeasts | 49 | 100.0 | 19 | 100.0 | 30 | 100.0 | |
| Genus/species | 20 | 40.8 | 11 | 57.9 | 9 | 30.0 | |
| Genus/species/complex | 19 | 38.8 | 4 | 21.1 | 15 | 50.0 | |
| Genus/species/complex/cryptic species | 8 | 16.3 | 4 | 21.1 | 4 | 13.3 | |
| Genus | 2 | 4.1 | 0 | 0.0 | 2 | 6.7 | |
| Moulds | 49 | 100.0 | 19 | 100.0 | 30 | 100.0 | |
| Genus/species | 41 | 83.7 | 17 | 89.5 | 24 | 80.0 | |
| Genus | 8 | 16.3 | 2 | 10.5 | 6 | 20.0 | |
| Serology | 41 | 83.7 | 16 | 84.2 | 25 | 83.3 | |
| Aspergillus spp. | 39 | 79.6 | 16 | 84.2 | 23 | 76.7 | |
| Onsite | 31 | 63.3 | 12 | 63.2 | 19 | 63.3 | |
| Outsourced | 8 | 16.3 | 4 | 21.1 | 4 | 13.3 | |
| Candida spp. | 28 | 57.1 | 13 | 68.4 | 15 | 50.0 | |
| Onsite | 20 | 40.8 | 9 | 47.4 | 11 | 36.7 | |
| Outsourced | 8 | 16.3 | 4 | 21.1 | 4 | 13.3 | |
| Histoplasma spp. | 25 | 51.0 | 8 | 42.1 | 17 | 56.7 | |
| Onsite | 14 | 28.6 | 4 | 21.1 | 10 | 33.3 | |
| Outsourced | 11 | 22.4 | 4 | 21.1 | 7 | 23.3 | |
| Antigen detection | 49 | 100.0 | 19 | 100.0 | 30 | 100.0 | |
| Aspergillus overall | 42 | 85.7 | 17 | 89.5 | 25 | 83.3 | |
| Aspergillus galactomannan ELISA | 47 | 95.9 | 19 | 100.0 | 28 | 93.3 | |
| Onsite | 39 | 79.6 | 16 | 84.2 | 23 | 76.7 | |
| Outsourced | 8 | 16.3 | 3 | 15.8 | 5 | 16.7 | |
| Aspergillus galactomannan LFA | 18 | 36.7 | 8 | 42.1 | 10 | 33.3 | |
| Onsite | 14 | 28.6 | 6 | 31.6 | 8 | 26.7 | |
| Outsourced | 4 | 8.2 | 2 | 10.5 | 2 | 6.7 | |
| Aspergillus LFD | 13 | 26.5 | 6 | 31.6 | 7 | 23.3 | |
| Onsite | 10 | 20.4 | 4 | 21.1 | 6 | 20.0 | |
| Outsourced | 3 | 6.1 | 2 | 10.5 | 1 | 3.3 | |
| 1–3-Beta-d-glucan | 42 | 85.7 | 14 | 73.7 | 28 | 93.3 | |
| Onsite | 27 | 55.1 | 10 | 52.6 | 17 | 56.7 | |
| Outsourced | 15 | 30.6 | 4 | 21.1 | 11 | 36.7 | |
| Cryptococcus overall | 38 | 77.6 | 13 | 68.4 | 25 | 83.3 | |
| Cryptococcus LAT | 38 | 77.6 | 15 | 78.9 | 23 | 76.7 | |
| Onsite | 34 | 69.4 | 12 | 63.2 | 22 | 73.3 | |
| Outsourced | 4 | 8.2 | 3 | 15.8 | 1 | 3.3 | |
| Cryptococcus LFA | 20 | 40.8 | 9 | 47.4 | 11 | 36.7 | |
| Onsite | 15 | 30.6 | 5 | 26.3 | 10 | 33.3 | |
| Outsourced | 5 | 10.2 | 4 | 21.1 | 1 | 3.3 | |
| Candida antigen | 22 | 44.9 | 11 | 57.9 | 11 | 36.7 | |
| Onsite | 15 | 30.6 | 7 | 36.8 | 8 | 26.7 | |
| Outsourced | 7 | 14.3 | 4 | 21.1 | 3 | 10.0 | |
| Histoplasma | 18 | 36.7 | 7 | 36.8 | 11 | 36.7 | |
| Onsite | 8 | 16.3 | 2 | 10.5 | 6 | 20.0 | |
| Outsourced | 10 | 20.4 | 5 | 26.3 | 5 | 16.7 | |
| Molecular tests | 41 | 83.7 | 16 | 84.2 | 25 | 83.3 | |
| Pneumocystis PCR | 35 | 71.4 | 14 | 73.7 | 21 | 70.0 | |
| Onsite | 29 | 59.2 | 11 | 57.9 | 18 | 60.0 | |
| Outsourced | 6 | 12.2 | 3 | 15.8 | 3 | 10.0 | |
| Aspergillus PCR | 32 | 65.3 | 12 | 63.2 | 20 | 66.7 | |
| Onsite | 23 | 46.9 | 8 | 42.1 | 15 | 50.0 | |
| Outsourced | 9 | 18.4 | 4 | 21.1 | 5 | 16.7 | |
| Candida PCR | 25 | 51.0 | 9 | 47.4 | 16 | 53.3 | |
| Onsite | 15 | 30.6 | 4 | 21.1 | 11 | 36.7 | |
| Outsourced | 10 | 20.4 | 5 | 26.3 | 5 | 16.7 | |
| PCR for other fungi | 19 | 38.8 | 8 | 42.1 | 11 | 36.7 | |
| Onsite | 9 | 18.4 | 3 | 15.8 | 6 | 20.0 | |
| Outsourced | 10 | 20.4 | 5 | 26.3 | 5 | 16.7 | |
| Mucorales PCR | 18 | 36.7 | 9 | 47.4 | 9 | 30.0 | |
| Onsite | 9 | 18.4 | 3 | 15.8 | 6 | 20.0 | |
| Outsourced | 9 | 18.4 | 6 | 31.6 | 3 | 10.0 | |
*This difference was considered as statistically significance, p = 0.032
CLSI Clinical and Laboratory Standards Institute, DNA deoxyribonucleic acid, ELISA enzyme-linked immunosorbent assay, E test® epsilometer test, EUCAST European Committee on Antimicrobial Susceptibility Testing, € euros, GDP gross domestic product, IFD invasive fungal disease, LAT latex agglutination test, LFA lateral flow assay, LFD lateral flow device, MALDI—TOF, matrix-assisted laser desorption/ionization—time-of-flight mass spectrometer, PCR polymerase chain reaction, spp. species