The current state of laboratory mycology in Asia/Pacific: a survey from the European Confederation of Medical Mycology (ECMM) and International Society for Human and Animal Mycology (ISHAM)

Publication summary

Invasive fungal infections (IFIs) and antifungal resistance present a significant risk to people living in areas where pathogenic fungi are endemic and are a particular threat to people living with HIV, uncontrolled diabetes, and/or cancer. The availability of diagnostic tests to quickly and accurately identify fungal infections is crucial to ensuring that people receive appropriate healthcare and to prevent antimicrobial resistance (AMR). This study surveyed 235 centers across 40 countries and territories in the Asia-Pacific region from June 2021 to April 2022 to understand connections between the availability of fungal diagnostic and treatment capacity and Gross Domestic Product (GDP) per capita, acknowledging that national economic factors play a significant role in access to fungal disease diagnosis.

Who this is for

• Microbiologists and mycologists working in the Asia-Pacific region
• Healthcare and public health policymakers in the Asia-Pacific region

Key findings

Centers were categorized by their countries’ per capita GDP, with 89 centers in the lowest GDP bracket (<$3,000 USD), 102 centers associated with mid-range GDP ($3,000 to $20,000 USD), and 44 centers in countries with high GDP (>$20,000 USD). The authors note that the availability of diagnostic tests or antifungals does not mean that those resources are affordable to everyone who might need them.

Most centers treated hematological disease (197 centers) and/or solid tumors (183 centers), and 179 centers provided neonatal intensive care.

Invasive fungal infection incidence. Over half of centers (118) identified their IFI incidence as very low or low, while 39 said IFI incidence was high or very high. Most (33) of the centers that identified their IFI incidence as high were in countries with endemic mycoses. Five of the 11 centers characterized by a high incidence of mucormycosis were in India. Fungi identified as particularly important pathogens included Candida species (218 centers), Aspergillus species (177), Cryptococcus species (104), and Mucorales (93). Centers located in low-GDP countries were more likely to identify Fusarium species and Mucorales as important pathogenic fungi.

Availability of fungal diagnostic and susceptibility tests

Microscopic techniques. Most centers (231) had some microscopic diagnostic techniques available, including China/India ink (204 centers), potassium hydroxide preparation (194), Giemsa staining (160), silver staining (113), and/or calcofluor white staining (103), although 36 centers reported never using microscopy to diagnose suspected IFI.  Giemsa and potassium hydroxide staining were more frequently available in low-GDP countries, possibly because of their low costs. The authors note that availability of microscopy across the Asia-Pacific region has improved substantially in recent years.

Culture-based tests. Most centers (229) had culture-based diagnostic tests available, including Sabouraud dextrose agar (197 centers), Sabouraud dextrose with chloramphenicol (162), potato dextrose agar (131), and lactrimel agar (17), with lactrimel agar significantly more accessible in high-GDP countries.

Pathogen-specific tests. Many centers (207) offered pathogen-specific fungal tests, including phenotypic mycology (154 centers), automated identification systems (152), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry or MALDI-TOF (101), and DNA sequencing (85), with MALDI-TOF and DNA sequencing significantly more available in high-GDP countries.

Antibody detection tests. Some centers (149) were able to offer fungal antibody detection testing for Aspergillus (139 centers), Candida (92), and Histoplasma (63). Low-GDP countries were more likely to offer Histoplasma antibody testing, but had lower access to serology for Aspergillus antibody detection. 

Antigen detection tests. Many centers (186) had antigen detection tests available, including those for Aspergillus (165 centers), enzyme-linked immunosorbent assay or ELISA (148), Cryptococcus lateral flow assay (115), Cryptococcus latex agglutination (113), and beta-d-glucan assay (103). ELISA was less likely to be available in low-GDP countries.

Polymerase chain reaction (PCR) and other molecular tests. Many centers (155) offered PCR and other molecular tests for Aspergillus (103 centers), Candida (104), and Pneumocystis (103) detection.

Antifungal susceptibility tests. Many centers (197) had antifungal susceptibility testing available, including VITEK (117 centers), broth microdilution using Clinical and Laboratory Standards Institute (CLSI) standards (114), Etest (87), and broth microdilution using European Committee on Antimicrobial Susceptibility Testing (EUCAST) standards (37).

Antifungal access

Antifungal availability varied across centers and economies. Most centers (219) had access to triazoles, with fluconazole (217 centers) and voriconazole (184) most frequently available. Liposomal amphotericin B was available in 135 centers, while the deoxycholate (non-liposomal) formulation, which is associated with a higher risk of toxicity, was available in 144 centers. Echninocandins were available in 170 centers. Centers in high-GDP countries had the most diverse antifungal options available, yet low-GDP countries had a greater availability of all antifungals except for micafungin when compared with mid-range-GDP countries. Centers in low-GDP countries also had relatively low access to therapeutic drug monitoring.