Molecular epidemiology, risk factor analysis and Comparison of diagnostic methods for Rapid Diagnosis of Fungal Pneumonia in Critically ill Cirrhotics
Pratibha Kale1, Vikas Khillan1, L G Mitra2, S K Sarin3.

1)Department of Microbiology, 2)Department of Critical Care Medicine, 3)Department of Hepatology, Institute of Liver and Biliary Sciences,  New Delhi.
Objectives:
Liver cirrhosis is associated with dysregulation of the immune system and increased susceptibility to fungal infections. We aimed to study the major risk factors andmolecular epidemiology of fungal pneumonia in critically ill cirrhotic patients. Also compared the rapid diagnostic methods and biomarkers for fungal pneumonia. 
Methods:
Single-center, prospective cohort study of 50critically ill cirrhotic patients with fungal pneumonia between January-September 2017.Demographics, comorbidities, and laboratory variables were recorded. Comparative analysis of culture, real time PCR and biomarkers; Bronchoalveolar lavage and serum galactomannan, serum procalcitoninwere measured by ELISA and chemiluminescence assay on day 1, day 3 and day 7. The final outcome considered were mortality within one month after diagnosis or discharge of the patient with stable parameters. Genotyping was done with amplified fragment length polymorphism of clinical and air sampling Aspergillus isolates.
Results:Aspergillusflavus was the most common species (34/50,68%). The risk factors identified were, neutropenia (p 0.03), steroids prior to ICU admission (p 0.02), prolonged hospitalizations >21 days (p 0.05). Culture positivity was 80%. Culture was not inferior to real time PCR for diagnosis of fungal pneumonia. BAL Galactomannan was early and better prognostic marker with median rise above >1 index value on day 1. Combination of molecular test and galactomannan could detect invasive aspergillosis in 90% cases. The median PCT level was higher from day 1in the fungal pneumonianon-survivor group (3.29 vs. 0.8ng/ml) withhigher 30-day mortality (72%). There was an association was found between PCT concentration associated bacterial infection(48%),antibiotic(74%) and antifungal therapy and renal failure. Patients with higher PCT at admission had higher mortality.Genotyping revealed; in two clusters, clinical isolates recovered from patients matched those recovered from air. 
Conclusion:
Fungal pneumonia is a serious complication in cirrhotics with neutropenia, prolonged hospitalization and steroids as major risk factors. Aspergillus species predominate in consanguity with Asian epidemiology. Culture methods are reliable for diagnosis and combination of molecular test with BAL galactomannan is useful for rapid diagnosis. Serum procalcitonin is raised in patients with fungal pneumonia. Higher procalcitonin values are associated with higher mortality and poor outcome in critically ill patients.In our study the baseline PCT at admission to ICU was higher in non- survivor group, levels on D3 and D7 were persistantly higher. High serum procalcitonin level is an independent prognostic biomarker of mortality risk, and it’s a promising biomarker of prognosis in critically ill patients with fungal pneumonia to step up therapeutic measures. The observation of genetic relatedness of clinical and environmental sample might open new perspectives in the development of infection control measures to prevent invasive aspergillosis in high-risk patients.

6 / Molecular epidemiology, risk factor analysis and Comparison of diagnostic methods for Rapid Diagnosis of Fungal Pneumonia in Critically ill Cirrhotics