Koehler et al reported the EQUAL (European QUALity) score for mucormycosis management in a hematology patient. The score is intended to measure adherence to current guidelines. The authors are from multiple institutions in Europe.
Patient selection: hematology patient at risk for mucormycosis
Parameters:
(1) anti-fungal prophylaxis for neutropenia > 10 days or allogenic hematopoietic stem cell (HSC) transplant
(2) chest CT after 72-96 hours of persistent fever
(3) CT/MR staging of head, neck and abdomen if inverse halo seen
(4) BAL (broncho-alveolar lavage) performed for inverse halo: direct microscopy using optical brighteners
(5) BAL performed for inverse halo: cultures
(6) BAL performed for inverse halo: fungal PCR
(7) biopsy performed if microbiology test result negative: culture
(8) biopsy performed if microbiology test result negative: histopathology
(9) biopsy performed if microbiology test result negative: molecular testing
(10) isolate in culture identified to species level with susceptibility testing
(11) surgical debridement
(12) antifungal therapy (liposomal amphotericin B >= 5 mg/kg/d; isovuconazole with therapeutic drug monitoring; posaconazole with therapeutic drug monitoring)
(13) control of risk factors (neutropenia, hyperglycemia, ketoacidosis, corticosteroids)
(14) CT scans during follow-up
|
Parameter |
Finding |
Points |
|
mold active prophylaxis |
no |
0 |
|
|
yes |
3 |
|
chest CT |
no |
0 |
|
|
yes |
3 |
|
CT/MR staging |
no |
0 |
|
|
yes |
2 |
|
direct microscopy on BAL |
no |
0 |
|
|
yes |
1 |
|
culture on BAL |
no |
0 |
|
|
yes |
1 |
|
fungal PCR on BAL |
no |
0 |
|
|
yes |
1 |
|
culture on biopsy |
no |
0 |
|
|
yes |
2 |
|
histopathology on biopsy |
no |
0 |
|
|
yes |
2 |
|
molecular testing on biopsy |
no |
0 |
|
|
yes |
1 |
|
isolate speciated with susceptibility testing |
no |
0 |
|
|
yes |
2 |
|
surgical debridement |
no |
0 |
|
|
yes |
2 |
|
surgical margins negative |
no |
0 |
|
|
yes |
1 |
|
therapy |
amphotericin B |
3 |
|
|
isavuconazole with TDM |
2 |
|
|
posaconazole with TDM |
2 |
|
|
none of these |
0 |
|
control of risk factors |
no |
0 |
|
|
yes |
2 |
|
CT on follow-up day 7 |
no |
0 |
|
|
yes |
2 |
|
CT on follow-up day 14 |
no |
0 |
|
|
yes |
2 |
|
CT on follow-up weekly until improved |
no |
0 |
|
|
yes |
2 |
subscore for diagnosis =
= SUM(scores for items 1 to 10)
subscore for treatment =
= SUM(scores for items 11 to 13)
subscore for follow-up =
= SUM(points for item 14)
total score =
= SUM(points for subscores)
Interpretation:
• minimum score: 0
• maximum subscore for diagnosis: 18
• maximum subscore for treatment: 8
• maximum subscore for follow-up: 6
• maximum total score: 32
• The higher the score the greater the adherence to mucormycosis guidelines.
Specialty: Infectious Diseases
