First-ever Study of Mycology Lab Practices in Asia
Asia has the biggest burden of fungal disease in the world, possibly because of factors such as a largely tropical environment, inadequately trained healthcare professionals, misuse or abuse of steroids and broad-spectrum antibiotics, and compromised healthcare practices due to over-capacity patient loads in public sector hospitals. Alarmingly, the true burden of fungal infections in the region may even be underestimated because of the absence of diagnostic mycology laboratories in many of the developing countries in Asia.
As part of their aim to improve patient care by advancing the diagnosis and management of fungal infections, the Asia Fungal Working Group (AFWG) performed a gap analysis of mycology laboratories in 7 Asian countries through an online survey conducted during 2016. This type of survey to provide a status report on medical mycology services is the first in Asia, and a summary of its results is provided below.
Method
A 36-item online survey of mycology laboratories in China, India, Indonesia, the Philippines, Singapore, Taiwan and Thailand was conducted to assess the status, competence, and services available. Country representatives from the AFWG contacted as many laboratories performing mycology diagnosis as possible in their respective countries, requesting that the laboratory heads complete the online survey.
Results
In total, 241 laboratories responded, including 71 in China, 104 in India, 11 in Indonesia, 26 in the Philippines, 4 in Singapore, 18 in Taiwan, and 7 in Thailand.
Overall, 129/241 (53.5%) surveyed mycology laboratories operate as separate designated mycology laboratories, and the remaining perform fungal diagnosis within a bacteriology/microbiology lab. Of the surveyed laboratories, 103/241 (42.7%) were accredited by national or international agencies (Table). In Singapore, all 4 surveyed laboratories were accredited, and the lowest accreditation rate was observed in Indonesia. The Table summarizes the other findings on laboratory characteristics.
Table. Country comparison of laboratory characteristics
|
Determinant |
Overall N=241 |
China N=71 |
India N=104 |
Indonesia N=11 |
Philippines N=26 |
Singapore N=4 |
Taiwan N=18 |
Thailand N=7 |
|
Formal staff training:
|
||||||||
|
Regular |
31.1% |
32.4% |
34.6% |
9.1% |
11.5% |
75.0% |
50.0% |
0% |
|
Occasional |
31.5% |
32.4% |
29.8% |
27.3% |
34.6% |
25.0% |
27.8% |
57.1% |
|
No regular laboratory-clinician interaction |
10.8% |
8.5% |
2.9% |
18.2% |
19.2% |
0% |
44.4% |
28.6% |
|
Mycology laboratory is accredited |
42.7% |
36.6% |
40.4% |
18.2% |
46.2% |
100% |
77.8% |
42.9% |
|
Participates in EQAS program |
56.1% (88/157) |
33.3% (11/33) |
68.8% (55/80) |
0% (0/5) |
37.5% (6/16) |
100% |
71.4% (10/14) |
40.0% (2/5) |
|
Availability of bio-safety hood in mycology laboratory |
79.7% |
53.5% |
94.2% |
63.6% |
88.5% |
100% |
88.9% |
85.7% |
EQAS, External Quality Assurance Scheme
% out of N, unless indicated
Microscopy and culture methods are available in nearly all laboratories, although few perform DNA sequencing (37/219; 16.9%) or use matrix-assisted laser desorption/ionization time-of-flight mass spectroscopy (MALDI-TOF MS) (27/219; 12.3%) for isolate identification. The vast majority (230/241, 95.4%) of laboratories participating in the survey perform direct microscopy of samples.
Of 241 laboratories, antifungal susceptibility testing is performed in 58.9%, mainly for yeasts. Antifungal susceptibility testing of mycelial fungi is performed in some laboratories in India (22/74), China (13/31), Indonesia (2/5) and the Philippines (1/11), but none of the laboratories in Singapore, Taiwan, or Thailand. Almost all (134/139, 96.4%) the laboratories performing antifungal susceptibility testing follow the Clinical and Laboratory Standards Institute (CLSI) protocol and 15/139 (10.8%) laboratories evaluate their results also using European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints.
Of all surveyed laboratories, 77/241 (32%) perform serological/antigen testing. Only 6.6% (5/76) of laboratories that conduct serological/antigen testing perform Histoplasma antigen assays. Candida antigen testing is available in 18.2% (37/203) of laboratories. β-D-glucan testing is available in 24 of 35 laboratories: 18 in China, 4 in India and 1 in Thailand. Galactomannan antigen testing is available in 22.8% (55/241) of surveyed laboratories. There is almost no access to advanced diagnostic tests, like galactomannan, β-D-glucan, and polymerase chain reaction (PCR), in the surveyed laboratories in Indonesia, the Philippines and Thailand.
Twenty-one laboratories (21/241, 8.7%) perform therapeutic drug monitoring (TDM) for azoles: 12/71 in China; 6/104 in India; 2/18 in Taiwan; and 1/7 in Thailand.
Discussion
Results show that aside from few laboratories included in the survey, most laboratories in the 7 Asian countries lack continuing medical mycology education and training. Only a little over half of the Asian laboratories in the study (none in Indonesia) participate in an External Quality Assurance Scheme (EQAS) program; more than half of the surveyed laboratories are not accredited. The AFWG is undertaking to initiate EQAS programs for mycology laboratories in each country.
The survey also suggests that MALDI-TOF MS and DNA sequencing facilities are not widely available, which could possibly be a hurdle to proper identification of Candida auris – a recent global threat. With the rise of antifungal resistance in Asian countries, having only about 40% of laboratories conducting antifungal susceptibility testing (only 38.2% of which use the standard microbroth dilution technique) is also an issue to address.
The study authors point out that the present survey identifies an urgent need to increase investment in mycology laboratories, especially to fund the incorporation of MALDI-TOF MS and non–culture-based biomarker tests like galactomannan, β-D-glucan and fungal PCR. A concerted effort from government, academia, and other stakeholders is required to support the development of new quality mycology laboratories and the improvement of existing laboratories with regular staff training, accreditation, and inclusion of essential advanced rapid biomarker tests and equipment. These advances could possibly help improve invasive fungal disease outcomes in Asia.
Reference
Chindamporn A, Chakrabarti A, Li R, et al. Survey of laboratory practices for diagnosis of fungal infection in seven Asian countries: An Asia Fungal Working Group (AFWG) initiative. Med Mycol 2017 Sep 20 [Epub ahead of print].