The diagnosis of mucormycosis by PCR in patients at risk: a systematic review and meta-analysis

Lottie Brown; Lena Tschiderer; Alexandre Alanio; Rosemary A Barnes; Sharon C-A Chen; Massimo Cogliati; Mario Cruciani; J Peter Donnelly; Ferry Hagen; Catriona Halliday; Lena Klingspor; Katrien Lagrou; Willem Melchers; Laurence Millon; Florent Morio; Elena Salvador; Giacomo Stroffolini; Markus Ruhnke; Stephanie Toepfer; Karin van Dijk; Andrew M Borman; María José Buitrago; Rebecca Gorton; Jürgen Löffller; Riina Rautemaa-Richardson; Boualem Sendid; Peter Willeit; P Lewis White; Michaela Lackner

doi:10.1016/j.eclinm.2025.103115

The diagnosis of mucormycosis by PCR in patients at risk: a systematic review and meta-analysis

EClinicalMedicine. 2025 Feb 22:81:103115. doi: 10.1016/j.eclinm.2025.103115. eCollection 2025 Mar.

Authors

Lottie Brown^{1

2}, Lena Tschiderer³, Alexandre Alanio^{4

5}, Rosemary A Barnes^{6

7}, Sharon C-A Chen⁸, Massimo Cogliati⁹, Mario Cruciani¹⁰, J Peter Donnelly¹¹, Ferry Hagen^{12

13

14}, Catriona Halliday¹⁵, Lena Klingspor¹⁶, Katrien Lagrou^{17

18}, Willem Melchers¹⁹, Laurence Millon^{20

21}, Florent Morio²², Elena Salvador²³, Giacomo Stroffolini²³, Markus Ruhnke²⁴, Stephanie Toepfer⁷, Karin van Dijk²⁵, Andrew M Borman^{26

27}, María José Buitrago²⁸, Rebecca Gorton²⁹, Jürgen Löffller³⁰, Riina Rautemaa-Richardson^{31

32}, Boualem Sendid³³, Peter Willeit^{3

34

35}, P Lewis White³⁶, Michaela Lackner⁷

Affiliations

¹ St George's Hospital, St George's NHS Foundation Trust, London, UK.
² Institute of Infection and Immunity, City St George's University of London, London, UK.
³ Institute of Clinical Epidemiology, Public Health, Health Economics, Medical Statistics and Informatics, Medical University of Innsbruck, Innsbruck, Austria.
⁴ Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, F-75015, France.
⁵ Laboratoire de Parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Paris, F-75010, France.
⁶ School of Medicine, Cardiff University, Cardiff, UK.
⁷ Institute for Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
⁸ Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clincial Pathology and Medical Research, New South Wales Pathology, Westmead Hospital and The University of Sydney, Sydney, Australia.
⁹ Medical Mycology Laboratory, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy.
¹⁰ Fungal PCR Initiative, A Working Group of the International Society of Human and Animal Mycology, Verona, Italy.
¹¹ EAPCRI Foundation, De Hoefkamp 1096, Nijmegen, 6545MD, the Netherlands.
¹² Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands.
¹³ Institute for Biodiversity and Ecosystems Dynamics, University of Amsterdam, Amsterdam, the Netherlands.
¹⁴ Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands.
¹⁵ Clinical Mycology Reference Laboratory, Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research - New South Wales Health Pathology, Westmead Hospital, Westmead, NSW, Australia.
¹⁶ Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
¹⁷ Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Microbiology, KU Leuven, Leuven, Belgium.
¹⁸ Department of Laboratory Medicine, National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium.
¹⁹ Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands.
²⁰ Chrono-environnement UMR6249, CNRS, Franche-Comté University, Besançon, F-25000, France.
²¹ Parasitology-Mycology Department, Besançon University Hospital, Besançon, France.
²² CHU de Nantes, Cibles et Médicaments des Infections et de l'Immunité, Nantes Université, IICiMed, UR1155, Nantes, 44000, France.
²³ Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, 5, Verona, 37024, Italy.
²⁴ Helios Klinikum Aue, Klinik fürHämatologie/Onkologie & Palliativmedizin, Aue, Germany.
²⁵ Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands.
²⁶ UKHSA Mycology Reference Laboratory, Southmead Hospital, Bristol, UK.
²⁷ MRC Centre for Medical Mycology, University of Exeter, UK.
²⁸ Mycology Reference Laboratory, National Centre for Microbiology and CIBERINFEC, ISCIII -CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
²⁹ Department of Infection Sciences, Health Services Laboratories, London, UK.
³⁰ Medizinische Klinik II, Labor WÜ4i, Universitätsklinikum Würzburg, Germany.
³¹ Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK.
³² Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, UK.
³³ INSERM U1285, CNRS UMR 8576, Université de Lille, CHU Lille, Institut de Microbiologie, Service de Parasitologie-Mycologie, Lille, F-59000, France.
³⁴ Ignaz Semmelweis Institute, Interuniversity Institute for Infection Research, Vienna, Austria.
³⁵ Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
³⁶ Public Health Wales Mycology Reference Laboratory and Cardiff University Centre for Trials Research, UHW, Cardiff, UK.

Abstract

Background: This systematic review and meta-analysis aimed to examine the performance of polymerase chain reaction (PCR) assays for diagnosing mucormycosis.

Methods: A standardised search was conducted from conception to December 3rd 2024 using PubMed, Embase, Global Health, and Cochrane library. Original studies that used PCR-based methods on any human specimen to diagnose mucormycosis were analysed for eligibility. Using a bivariate meta-analysis, the diagnostic performance of PCR was examined against the European Organisation for Research and Treatment of Cancer-Mycoses Study Group Education and Research Consortium 2020 (EORTC-MSGERC) definitions of proven and probable invasive mould disease, which was modified to include all patients at risk of mucormycosis. The study protocol was registered on the PROSPERO database (CRD42023478667).

Findings: Of 4855 articles, a total of 30 met inclusion criteria, including 5920 PCR reactions on 5147 non-duplicate specimens from 819 cases of proven/probable mucormycosis and 4266 patients who did not meet the EORTC-MSGERC 2020 criteria. According to specimen type, sensitivity of PCR varied (p < 0.001) whereas specificity was similar (p = 0.662). Bronchoalveolar lavage fluid offered the highest sensitivity of 97.5% (95% CI 83.7-99.7%), specificity of 95.8% (95% CI 89.6-98.4%), positive likelihood ratio (LR+) of 23.5, and negative likelihood ratio (LR-) of 0.03. Tissue provided sensitivity of 86.4% (95% CI 78.9-91.5%), specificity of 90.6% (95% CI 78.1-96.3%), LR+ of 9.2, and LR- of 0.15. Blood provided reduced sensitivity of 81.6% (95% CI 70.1-89.4%), specificity of 95.5% (95% CI 87.4-98.5%), DOR of 95, LR+ of 18.3, and LR- of 0.19. Formalin-fixed paraffin-embedded specimens yielded the lowest sensitivity of 73.0% (95% CI 61.0-82.3%), highest specificity of 96.4% (CI 95% 87.5-99.0%), LR+ of 20.2, and LR- of 0.28. The covariates best explaining heterogeneity of the overall analysis were specimen type, study design (cohort versus case-control) and disease prevalence while patient population (COVID-19 versus other) and PCR (conventional versus quantitative) had less impact on heterogeneity.

Interpretation: This meta-analysis confirms the high performance of PCR for diagnosing mucormycosis and supports the instatement of PCR detection of free-DNA in blood, BALF and tissue into future updated definitions and diagnostic guidelines for mucormycosis.

Funding: None.

Keywords: Diagnosis; Fungal; Mucorales; Mucormycosis; PCR.