a) Outline the risk factors for developing an invasive fungal infection in a critically ill patient. (60% marks)
b) Discuss the role and limitations of galactomannan and beta-Glucan antigen testing in diagnosing suspected invasive aspergillus infection. (20% marks)
c) List four situations where an azole would NOT be appropriate first line empiric treatment. (20% marks)
Although reasonably well answered, many answers lacked structure, with various facets of information listed in a random order. Those answers that categorised well scored better. This is not to say that answers that were not categorised were penalised, but to state that those answers that used a sensible categorisation contained
more relevant information. Candidates should consider this when answering the questions in the paper, and whilst we appreciate that time management is critical in the paper, practicing answering written questions prior to the written exam in this manner will lead to improved answers in the exam itself. This reflects clinical practice
where you be required to outline the generic and specific problems of a patient has to a colleague.
In a website that is often highly critical of the college examiners, one occasionally finds praise for their efforts, and this is one of those rare times. Not only did somebody create a clever question with some real clinical relevance, but they also composed a comment to the candidates which contained actual valuable information about what, and why, was expected. Quite right, an answer without structure should not be penalised for the lack of structure if the content is the same, but as the comment points out, often the use of structure improves the content of the answer by reminding you about points you would have otherwise forgotten.
Anyway, fungus: for 60% of the marks, this would have needed to have a lot of meat. The list presented below is a melange of carefully curated findings from a meta-analysis by Muskett et al (2011) combined with what appears to be a list of random thoughts from Zabalza et al (2013).
"Discuss the role and limitations of galactomannan and beta-Glucan antigen testing" for 20% of the marks would have been necessarily very brief. As most adults can only hand-write about twenty words per minute, and a 2-mark question should only be allocated two minutes, the candidates would have needed to discuss the role and limitations in forty words or less. What follows is an exactyly-eighty-word answer constructed using the excellent papers by Hites et al (for galactomannan) and Marty et al (for beta-glucan).
There are actually probably more than just four such situations:
Schuster, Mindy G., et al. "Empirical Fluconazole versus Placebo for Intensive Care Unit PatientsA Randomized Trial." Annals of internal medicine 149.2 (2008): 83-90.
Fisher, Matthew C., et al. "Tackling the emerging threat of antifungal resistance to human health." Nature Reviews Microbiology 20.9 (2022): 557-571.
Van Rhijn, Norman, et al. "CYP51 paralogue structure is associated with intrinsic azole resistance in fungi." MBio 12.5 (2021): e01945-21.
Felton, Timothy, Peter F. Troke, and William W. Hope. "Tissue penetration of antifungal agents." Clinical microbiology reviews 27.1 (2014): 68-88.
Blot, Stijn I., et al. "A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients." American journal of respiratory and critical care medicine 186.1 (2012): 56-64.
Muskett, Hannah, et al. "Risk factors for invasive fungal disease in critically ill adult patients: a systematic review." Critical care 15.6 (2011): 1-15.
Shoham, Shmuel, and Shilpa Marwaha. "Invasive fungal infections in the ICU." Journal of intensive care medicine 25.2 (2010): 78-92.
Zabalza, Amaya, et al. "Voriconazole and its clinical potential in the prophylaxis of systemic fungal infection in patients with hematologic malignancies: a perspective review." Therapeutic Advances in Hematology 4.3 (2013): 217-230.
Hites, Maya, Eduardo Wilfrido Goicoechea Turcott, and Fabio Silvio Taccone. "The role of galactomannan testing to diagnose invasive pulmonary aspergillosis in critically ill patients." Annals of translational medicine 4.18 (2016).
Marty, Francisco M., and Sophia Koo. "Role of (1→ 3)-β-D-glucan in the diagnosis of invasive aspergillosis." Medical mycology 47.Supplement_1 (2009): S233-S240.