912 - Beyond the Usual Suspects in Invasive Mold Infections: Public Health Surveillance Identifies Clinical Diversity

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Presenting Author(s)

Karlyn Beer

Epidemiologist
CDC
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

HK

Hilary Kelly

Epidemiologist
Centers for Disease Control and Prevention
Atlanta, GA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
RB

Rebekah Blakney

Researcher
NIH
Washington, District of Columbia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
AR

Andrew Revis

Surveillance Officer
Foundation for Atlanta Veterans Education and Research/VA Health System, Georgia Emerging Infections Program
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
LP

Lewis Perry

Epidemiologist
Georgia Emerging Infections Program/Georgia VA Health System
Atlanta, GA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
MB

Meghan Bentz

Mycologist
CDC
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
EB

Elizabeth L. Berkow

Laboratory Team Lead
Centers for Disease Control and Prevention
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
SL

Shawn R. Lockhart

Senior Clinical Laboratory Advisor
Centers for Disease Control and Prevention
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Em

Eduard matkovic

Pathology Fellow
CDC
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
ST

Stepy Thomas

Epidemiologist
Emory University
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
NO

Nora Oliver

Infectious Disease Physician
Emory University School of Medicine, Atlanta VAMC, and Georgia Emerging Infections Program
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
AW

Andrew Webster

Physician
Emory University School of Medicine
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Stephanie M. Pouch

Associate Professor
Emory University School of Medicine
Atlanta, GA
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
MF

Monica M. Farley

Division Director/Professor of Medicine
Emory University School of Medicine, Division of Infectious Diseases
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
BJ

Brendan R. Jackson

Medical Epidemiologist
Centers for Disease Control and Prevention
Atlanta, Georgia
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Background: Invasive mold infections (IMI) such as aspergillosis and mucormycosis are often fatal among immunocompromised patients and cause high-profile outbreaks. Public health surveillance for IMI is challenging; most epidemiologic studies are limited to transplant and cancer patients at greatest risk of IMI. The established Mycoses Study Group (MSG) case definition is useful for clinical trials but lacks sensitivity. To address these challenges, we created IMI surveillance within the Georgia Emerging Infections Program. Here, we describe cases identified through this system, using both the MSG criteria and a novel, more sensitive surveillance case definition.

Methods: To identify potential IMI cases, we captured 2,363 positive fungal laboratory results, including cultures, histopathology, and galactomannan tests, within a 60-day window at three large Atlanta hospitals during April 2018–March 2019. We excluded yeast and dimorphic fungi, hair and nail specimens, and cystic fibrosis patients. Potential cases underwent chart review and were classified by 2 physicians as proven, probable, or non-case according to MSG criteria. Cases that partially met MSG probable criteria and included antifungal treatment were classified as surveillance cases; definitions were mutually exclusive (Fig 1).Figure 1: Case Classification Algorithm

Results: Of 120 potential IMI cases, 46 (38%) met an IMI case definition: 8 proven, 9 probable, and 29 surveillance cases (Fig 2). Of cases, 14 (30%) involved transplant or cancer in the previous year; 8 of these were proven or probable cases. IMI presented primarily as sinusitis among proven cases (50%), and pulmonary infections among probable (56%) and surveillance (45%) cases. Most surveillance cases were caused by Aspergillus spp. (72%) and accounted for all 5 cutaneous IMI (fig 3). Over 80% of cases vs. 10% of non-cases had antifungal treatment.Figure 2: Invasive mold infection case classifications

Figure 3: Attributes of IMI Cases and Non-cases from April 2018–March 2019 (N = 120)

Conclusion: Of IMI cases identified, nearly two thirds had evidence of infection but did not meet an MSG case definition. MSG captured over half of transplant and cancer-associated cases, but these were uncommon overall, revealing most IMI lack classical risk factors. A more sensitive surveillance case definition can capture a broader spectrum of IMI patients receiving antifungal treatment to help guide clinical and public health interventions.