A Systematic Review of Diagnostic Accuracy: Serological and Molecular Tests Compared to Culture for Invasive Fungal Infections

Dhuha A. Athouf; Hawraa A. Mohammed; Fatima Assad Baker

doi:10.47134/ijm.v3i1.6038

Authors

Dhuha A. Athouf University of Thi-Qar https://orcid.org/0009-0006-2667-4398
Hawraa A. Mohammed University of Al-Shatrah
Fatima Assad Baker University of Thi-Qar

DOI:

https://doi.org/10.47134/ijm.v3i1.6038

Keywords:

Immunocompromised Individuals, Invasive Fungal Infections, Molecular Testing, Serological Testing, Culture

Abstract

Invasive fungal infections (IFIs) remain a major clinical challenge, particularly among immunocompromised patients, due to their high morbidity, mortality, and diagnostic complexity. Despite being the gold standard, traditional fungal culture has low sensitivity and takes a long time to produce results. Recently, serological and molecular diagnostic approaches have emerged as potential alternatives to earlier and more precise IFI detection. The goal of this systematic review was to evaluate the effectiveness of various non-culture approaches and their potential impact on diagnostic precision. To detect invasive fungal infections (IFIs), this systematic review compared the diagnostic accuracy of commonly used genetic and serological approaches to fungal culture. A thorough literature search yielded eligible studies testing assays including β-D-glucan, galactomannan, cryptococcal antigen, and PCR-based approaches. A random-effects model was employed to calculate pooled sensitivity and specificity. While several serological techniques demonstrated good specificity and consistency across numerous fungal species, molecular assays were often more sensitive than culture, particularly for early detection. Despite variations in research quality and inconsistency in diagnostic thresholds, the data show that combining serological and molecular approaches significantly improves diagnosis accuracy and may reduce delays associated with culture-based identification. This systematic review demonstrates that for the diagnosis of invasive fungal infections, both molecular and serological diagnostic procedures outperform culture-based approaches. Molecular assays are important for early diagnosis due to their high sensitivity and rapid turnaround time. Serological tests are highly specific and reliable when performed correctly.

References

Abassi, M., Boulware, D. R., & Rhein, J. (2015). Cryptococcal meningitis: Diagnosis and management update. Current Tropical Medicine Reports, 2(2), 90–99. https://doi.org/10.1007/s40475-015-0046-y.

Abdallah, W., Myint, T., LaRue, R., Minderman, M., Gunn, S., Wheat, L. J., & Hage, C. A. (2021). Diagnosis of histoplasmosis using the MVista Histoplasma galactomannan antigen qualitative lateral flow–based immunoassay: A multicenter study. Open Forum Infectious Diseases, 8(9), Article ofab454. https://doi.org/10.1093/ofid/ofab454.

Alanio, A., & Bretagne, S. (2014). Difficulties with molecular diagnostic tests for mould and yeast infections: Where do we stand?. Clinical Microbiology and Infection, 20(s6), 36–41. https://doi.org/10.1111/1469-0691.12613.

Albert, E., Alcaraz, M. J., Giménez, E., Clari, M. Á., Torres, I., Colomina, J., ... & Navarro, D. (2024). Comparative performance of the Platelia Aspergillus Antigen and Aspergillus Galactomannan antigen Virclia Monotest immunoassays in serum and lower respiratory tract specimens: A “real-life” experience. Microbiology Spectrum, 12(8), Article e03910-23. https://doi.org/10.1128/spectrum.03910-23.

Arvanitis, M., Anagnostou, T., Fuchs, B. B., Caliendo, A. M., & Mylonakis, E. (2014). Molecular and nonmolecular diagnostic methods for invasive fungal infections. Clinical Microbiology Reviews, 27(3), 490–526. https://doi.org/10.1128/CMR.00091-13.

Avni, T., Leibovici, L., & Paul, M. (2011). PCR diagnosis of invasive candidiasis: Systematic review and meta-analysis. Journal of Clinical Microbiology, 49(2), 665–670. https://doi.org/10.1128/JCM.01603-10.

Baker, J., Kosmidis, C., Rozaliyani, A., Wahyuningsih, R., & Denning, D. W. (2020). Chronic pulmonary histoplasmosis—A scoping literature review. Open Forum Infectious Diseases, 7(5), Article ofaa119. https://doi.org/10.1093/ofid/ofaa119.

Bao, J. R., Master, R. N., Jones, R. S., Clark, R. B., Moore, E. C., & Shier, K. L. (2021). Recovery and its dynamics of filamentous fungi from clinical specimen cultures: An extensive study. Microbiology Spectrum, 9(1), Article e00016-21. https://doi.org/10.1128/Spectrum.00016-21.

Bongomin, F., Gago, S., Oladele, R. O., & Denning, D. W. (2017). Global and multi-national prevalence of fungal diseases—Estimate precision. Journal of Fungi, 3(4), Article 57. https://doi.org/10.3390/jof3040057.

Boulware, D. R., Rolfes, M. A., Rajasingham, R., von Hohenberg, M., Qin, Z., Taseera, K., ... & Meya, D. B. (2014). Multisite validation of cryptococcal antigen lateral flow assay and quantification by laser thermal contrast. Emerging Infectious Diseases, 20(1), 45–53. https://doi.org/10.3201/eid2001.130906.

Bregón-Villahoz, M., et al. (2025). Diagnostic potential of a recombinant Candida albicans Hyr1 protein (Preprint). Research Square. https://doi.org/10.21203/rs.3.rs-7120136/v1.

Brown, L., Cruciani, M., Morton, C. O., Alanio, A., Barnes, R. A., Donnelly, J. P., ... & White, P. L. (2025). The molecular diagnosis of invasive fungal diseases with a focus on PCR. Diagnostics, 15(15), Article 1909. https://doi.org/10.3390/diagnostics15151909.

Bryant, S., Almahmoud, I., Pierre, I., Bardet, J., Touati, S., Maubon, D., ... & Caspar, Y. (2020). Evaluation of microbiological performance and the potential clinical impact of the ePlex® blood culture identification panels for the rapid diagnosis of bacteremia and fungemia. Frontiers in Cellular and Infection Microbiology, 10, Article 594951. https://doi.org/10.3389/fcimb.2020.594951.

Černáková, L., Roudbary, M., Brás, S., Tafaj, S., & Rodrigues, C. F. (2021). Candida auris: A quick review on identification, current treatments, and challenges. International Journal of Molecular Sciences, 22(9), Article 4470. https://doi.org/10.3390/ijms22094470.

Clancy, C. J., & Nguyen, M. H. (2013). Finding the “missing 50%” of invasive candidiasis: How nonculture diagnostics will improve understanding of disease spectrum and transform patient care. Clinical Infectious Diseases, 56(9), 1284–1292. https://doi.org/10.1093/cid/cit006.

Cornely, O. A., Alastruey-Izquierdo, A., Arenz, D., Chen, S. C., Dannaoui, E., Hochhegger, B., ... & Chakrabarti, A. (2019). Global guideline for the diagnosis and management of mucormycosis: An initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. The Lancet Infectious Diseases, 19(12), e405–e421. https://doi.org/10.1016/S1473-3099(19)30312-3.

Dannaoui, E. (2022). Recent developments in the diagnosis of mucormycosis. Journal of Fungi, 8(5), Article 457. https://doi.org/10.3390/jof8050457.

De Carolis, E., Marchionni, F., Torelli, R., Angela, M. G., Pagano, L., Murri, R., ... & Posteraro, B. (2020). Comparative performance evaluation of Wako β-glucan test and Fungitell assay for the diagnosis of invasive fungal diseases. PLoS One, 15(7), Article e0236095. https://doi.org/10.1371/journal.pone.0236095.

De Pauw, B., Walsh, T. J., Donnelly, J. P., Stevens, D. A., Edwards, J. E., Calandra, T., ... & Bennett, J. E. (2008). Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clinical Infectious Diseases, 46(12), 1813–1821. https://doi.org/10.1086/588660.

Denning, D. W. (2021). Diagnosing pulmonary aspergillosis is much easier than it used to be: A new diagnostic landscape. The International Journal of Tuberculosis and Lung Disease, 25(7), 525–536. https://doi.org/10.5588/ijtld.21.0053.

Donnelly, J. P., Chen, S. C., Kauffman, C. A., Steinbach, W. J., Baddley, J. W., Verweij, P. E., ... & Pappas, P. G. (2020). Revision and update of the consensus definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clinical Infectious Diseases, 71(6), 1367–1376. https://doi.org/10.1093/cid/ciz1008.

Dos Santos, A. P., Amorim, B. C., da Silva, D. G., de Rodrigues, D. K. B., da Costa Marques, A. P., Gasparoto, A. L. D. B., ... & Venturini, J. (2024). Performance of the IMMY® sona Aspergillus lateral flow assay for the detection of galactomannan in tracheal aspirate samples from Brazilian patients with COVID‐19‐associated pulmonary aspergillosis: Cross‐sectional and systematic review of literature. Mycoses, 67(8), Article e13789. https://doi.org/10.1111/myc.13789.

Driemeyer, C., Falci, D. R., Hoenigl, M., Cornely, O. A., Chakrabarti, A., Gangneux, J. P., ... & Pasqualotto, A. C. (2022). The current state of clinical mycology in Eastern and South-Eastern Europe. Medical Mycology, 60(4), Article myac017. https://doi.org/10.1093/mmy/myac017.

Enoch, D. A., Yang, H., Aliyu, S. H., & Micallef, C. (2016). The changing epidemiology of invasive fungal infections. In Human Fungal Pathogen Identification (pp. 17–65). Springer. https://doi.org/10.1007/978-1-4939-6515-1_2.

Fang, W., Wu, J., Cheng, M., Zhu, X., Du, M., Chen, C., ... & Pan, W. (2023). Diagnosis of invasive fungal infections: Challenges and recent developments. Journal of Biomedical Science, 30(1), Article 42. https://doi.org/10.1186/s12929-023-00926-2.

Hamam, J., Navellou, J. C., Bellanger, A. P., Bretagne, S., Winiszewski, H., Scherer, E., ... & Collaborative RESSIF Group. (2021). New clinical algorithm including fungal biomarkers to better diagnose probable invasive pulmonary aspergillosis in ICU. Annals of Intensive Care, 11(1), Article 41. https://doi.org/10.1186/s13613-021-00827-x.

Hay, R., Denning, D. W., Bonifaz, A., Queiroz-Telles, F., Beer, K., Bustamante, B., ... & Zijlstra, E. E. (2019). The diagnosis of fungal neglected tropical diseases (fungal NTDs) and the role of investigation and laboratory tests: An expert consensus report. Tropical Medicine and Infectious Disease, 4(4), Article 122. https://doi.org/10.3390/tropicalmed4040122.

Hoenigl, M., Salmanton-García, J., Walsh, T. J., Nucci, M., Neoh, C. F., Jenks, J. D., ... & Cornely, O. A. (2021). Global guideline for the diagnosis and management of rare mould infections: An initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology and the American Society for Microbiology. The Lancet Infectious Diseases, 21(8), e246–e257. https://doi.org/10.1016/S1473-3099(20)30784-2.

Honarvar, B., Lankarani, K. B., Taghavi, M., Vahedi, G., & Mortaz, E. (2018). Biomarker-guided antifungal stewardship policies for patients with invasive candidiasis. Current Medical Mycology, 4(4), 37–44. https://doi.org/10.18502/cmm.4.4.385.

Huang, Y. S., Wang, F. D., Chen, Y. C., Huang, Y. T., Hsieh, M. H., Hii, M., ... & Liu, W. L. (2021). High rates of misidentification of uncommon Candida species causing bloodstream infections using conventional phenotypic methods. Journal of the Formosan Medical Association, 120(5), 1179–1187. https://doi.org/10.1016/j.jfma.2020.10.026.

Jenks, J. D., White, P. L., Kidd, S. E., Goshia, T., Fraley, S. I., Hoenigl, M., & Thompson III, G. R. (2023). An update on current and novel molecular diagnostics for the diagnosis of invasive fungal infections. Expert Review of Molecular Diagnostics, 23(12), 1135–1152. https://doi.org/10.1080/14737159.2023.2282333.

Kidd, S. E., Chen, S. C. A. , Meyer, W., & Halliday, C. L. (2020). A new age in molecular diagnostics for invasive fungal disease: Are we ready?. Frontiers in Microbiology, 10, Article 2903. https://doi.org/10.3389/fmicb.2019.02903.

Kullberg, B. J., & Arendrup, M. C. (2015). Invasive candidiasis. New England Journal of Medicine, 373(15), 1445–1456. https://doi.org/10.1056/NEJMra1411811.

Lass-Flörl, C., Samardzic, E., & Knoll, M. (2021). Serology anno 2021—Fungal infections: From invasive to chronic. Clinical Microbiology and Infection, 27(9), 1230–1241. https://doi.org/10.1016/j.cmi.2021.02.012.

Liang, M., Xu, J., Luo, Y., & Qu, J. (2024). Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: A review. Annals of Medicine, 56(1), Article 2396570. https://doi.org/10.1080/07853890.2024.2396570.

Lin, H. H., Tseng, K. H., Tien, N., Lin, Y. T., Yu, J., Hsueh, P. R., & Cho, D. Y. (2022). Evaluation of the Rapid Sepsityper protocol and specific MBT-Sepsityper module for the identification of bacteremia and fungemia using Bruker Biotyper MALDI-TOF MS. Journal of Microbiology, Immunology and Infection, 55(6), 1330–1333. https://doi.org/10.1016/j.jmii.2021.09.014.

Liu, Y., Fahle, G. A., & Kovacs, J. A. (2018). Inability to culture Pneumocystis jirovecii. mBio, 9(3), Article e00939-18. https://doi.org/10.1128/mBio.00939-18.

Lu, Y., Hatch, J., Holmberg, K., Hurlock, A., Drobysheva, D., Spaulding, U., ... & Bourzac, K. (2019). 651. Multi-center evaluation of the BioFire® FilmArray® Blood Culture Identification 2 Panel for the detection of microorganisms and resistance markers in positive blood cultures. Open Forum Infectious Diseases, 6(Supplement_2), S299–S300. https://doi.org/10.1093/ofid/ofz360.719.

Malcolm, T. R., & Chin-Hong, P. V. (2013). Endemic mycoses in immunocompromised hosts. Current Infectious Disease Reports, 15(6), 536–543. https://doi.org/10.1007/s11908-013-0387-3.

Mauri, C., Consonni, A., Briozzo, E., Giubbi, C., Meroni, E., Tonolo, S., & Luzzaro, F. (2024). The Molecular Mouse system: A new useful tool for guiding antimicrobial therapy in critically ill septic patients. Antibiotics, 13(6), Article 517. https://doi.org/10.3390/antibiotics13060517.

McCarty, T. P., & Pappas, P. G. (2016). Invasive candidiasis. Infectious Disease Clinics of North America, 30(1), 103–124. https://doi.org/10.1016/j.idc.2015.10.011.

Mellinghoff, S. C., Bassetti, M., Dörfel, D., Hagel, S., Lehners, N., Plis, A., ... & Cornely, O. A. (2018). Isavuconazole shortens the QTc interval. Mycoses, 61(4), 256–260. https://doi.org/10.1111/myc.12733.

Mendonça, A., Santos, H., Franco-Duarte, R., & Sampaio, P. (2022). Fungal infections diagnosis–Past, present and future. Research in Microbiology, 173(3), Article 103915. https://doi.org/10.1016/j.resmic.2021.103915.

Mikulska, M., Calandra, T., Sanguinetti, M., Poulain, D., Viscoli, C., & Third European Conference on Infections in Leukemia Group. (2010). The use of mannan antigen and anti-mannan antibodies in the diagnosis of invasive candidiasis: Recommendations from the Third European Conference on Infections in Leukemia. Critical Care, 14(6), Article R222. https://doi.org/10.1186/cc9365.

Nguyen, M. H., Wissel, M. C., Shields, R. K., Salomoni, M. A., Hao, B., Press, E. G., ... & Clancy, C. J. (2012). Performance of Candida real-time polymerase chain reaction, β-D-glucan assay, and blood cultures in the diagnosis of invasive candidiasis. Clinical Infectious Diseases, 54(9), 1240–1248. https://doi.org/10.1093/cid/cis149.

Pagano, L., & Mayor, S. (2018). Invasive fungal infections in high-risk patients: Report from TIMM-8 2017. Future Science OA, 4(5), Article FSO296. https://doi.org/10.4155/fsoa-2018-0013.

Pappas, P. G., Kauffman, C. A., Andes, D. R., Clancy, C. J., Marr, K. A., Ostrosky-Zeichner, L., ... & Sobel, J. D. (2016). Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 62(4), e1–e50. https://doi.org/10.1093/cid/civ1194.

Patterson, T. F., & Donnelly, J. P. (2019). New concepts in diagnostics for invasive mycoses: Non-culture-based methodologies. Journal of Fungi, 5(1), Article 9. https://doi.org/10.3390/jof5010009.

Pemán, J., & Ruiz-Gaitán, A. (2025). Diagnosing invasive fungal infections in the laboratory today: It's all good news?. Revista Iberoamericana de Micología, 42(1), 15–22. https://doi.org/10.1016/j.riam.2024.10.001.

Pham, D., Sivalingam, V., Tang, H. M., Montgomery, J. M., Chen, S. C. A., & Halliday, C. L. (2024). Molecular diagnostics for invasive fungal diseases: Current and future approaches. Journal of Fungi, 10(7), Article 447. https://doi.org/10.3390/jof10070447.

Pini, P., Colombari, B., Marchi, E., Castagnoli, A., Venturelli, C., Sarti, M., & Blasi, E. (2019). Performance of Candida albicans germ tube antibodies (CAGTA) and its association with (1→3)-β-D-glucan (BDG) for diagnosis of invasive candidiasis (IC). Diagnostic Microbiology and Infectious Disease, 93(1), 39–43. https://doi.org/10.1016/j.diagmicrobio.2018.07.014.

Price, J. S., Fallon, M., Posso, R., Backx, M., & White, P. L. (2023). An evaluation of the OLM Pneum ID Real-Time Polymerase Chain Reaction to aid in the diagnosis of Pneumocystis pneumonia. Journal of Fungi, 9(11), Article 1106. https://doi.org/10.3390/jof9111106.

Rajasingham, R., Wake, R. M., Beyene, T., Katende, A., Letang, E., & Boulware, D. R. (2019). Cryptococcal meningitis diagnostics and screening in the era of point-of-care laboratory testing. Journal of Clinical Microbiology, 57(1), Article e01234-18. https://doi.org/10.1128/JCM.01234-18.

Robert, M. G., Romero, C., Dard, C., Garnaud, C., Cognet, O., Girard, T., ... & Maubon, D. (2020). Evaluation of ID fungi plates medium for identification of molds by MALDI Biotyper. Journal of Clinical Microbiology, 58(5), Article e01427-19. https://doi.org/10.1128/JCM.01427-19.

Roden, M. M., Zaoutis, T. E., Buchanan, W. L., Knudsen, T. A., Sarkisova, T. A., Schaufele, R. L., ... & Walsh, T. J. (2005). Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clinical Infectious Diseases, 41(5), 634–653. https://doi.org/10.1086/432571.

Salmanton-García, J., Au, W. Y., Hoenigl, M., Chai, L. Y. A., Badali, H., Basher, A., ... & Cornely, O. A. (2023). 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). International Journal of Antimicrobial Agents, 61(3), Article 106718. https://doi.org/10.1016/j.ijantimicag.2023.106718.

Salmanton-García, J., Hoenigl, M., Gangneux, J. P., Segal, E., Alastruey-Izquierdo, A., Akdagli, S. A., ... & Cornely, O. A. (2023). The current state of laboratory mycology and access to antifungal treatment in Europe: A European Confederation of Medical Mycology survey. The Lancet Microbe, 4(1), e47–e56. https://doi.org/10.1016/S2666-5247(22)00261-0.

Sattler, J., Noster, J., Brunke, A., Plum, G., Wiegel, P., Kurzai, O., ... & Hamprecht, A. (2021). Comparison of two commercially available qPCR kits for the detection of Candida auris. Journal of Fungi, 7(2), Article 154. https://doi.org/10.3390/jof7020154.

Sedik, S., Wolfgruber, S., Hoenigl, M., & Kriegl, L. (2024). Diagnosing fungal infections in clinical practice: A narrative review. Expert Review of Anti-infective Therapy, 22(11), 935–949. https://doi.org/10.1080/14728214.2024.2381204.

Tabak, Y. P., Vankeepuram, L., Ye, G., Jeffers, K., Gupta, V., & Murray, P. R. (2018). Blood culture turnaround time in US acute care hospitals and implications for laboratory process optimization. Journal of Clinical Microbiology, 56(12), Article e01436-18. https://doi.org/10.1128/JCM.01436-18.

Terrero-Salcedo, D., & Powers-Fletcher, M. V. (2020). Updates in laboratory diagnostics for invasive fungal infections. Journal of Clinical Microbiology, 58(6), Article e00241-19. https://doi.org/10.1128/JCM.00241-19.

Vena, A., Bouza, E., Corisco, R., Machado, M., Valerio, M., Sánchez, C., ... & COMIC Study Group. (2020). Efficacy of a “checklist” intervention bundle on the clinical outcome of patients with Candida bloodstream infections: A quasi-experimental pre-post study. Infectious Diseases and Therapy, 9(1), 119–135. https://doi.org/10.1007/s40121-019-00277-x.

Vena, A., Muñoz, P., Mateos, M., Guinea, J., Galar, A., Pea, F., ... & Bouza, E. (2020). Therapeutic drug monitoring of antifungal drugs: Another tool to improve patient outcome?. Infectious Diseases and Therapy, 9(1), 137–149. https://doi.org/10.1007/s40121-019-00278-w.

Wang, H., Liu, N., Yin, M., Han, H., Yue, J., Zhang, F., ... & Wu, D. (2014). The epidemiology, antifungal use and risk factors of death in elderly patients with candidemia: A multicentre retrospective study. BMC Infectious Diseases, 14(1), Article 609. https://doi.org/10.1186/s12879-014-0609-0.

Wang, R. J., Miller, R. F., & Huang, L. (2017). Approach to fungal infections in HIV-infected individuals: Pneumocystis and beyond. Clinics in Chest Medicine, 38(3), 465–478. https://doi.org/10.1016/j.ccm.2017.04.008.

White, P. L., Price, J. S., Posso, R., Cutlan-Vaughan, M., Vale, L., & Backx, M. (2020). Evaluation of the performance of the IMMY sona Aspergillus galactomannan lateral flow assay when testing serum to aid in diagnosis of invasive aspergillosis. Journal of Clinical Microbiology, 58(6), Article e01452-19. https://doi.org/10.1128/JCM.01452-19.

Wickes, B. L., & Wiederhold, N. P. (2018). Molecular diagnostics in medical mycology. Nature Communications, 9(1), Article 5135. https://doi.org/10.1038/s41467-018-07556-5.

Yi, Q., Xiao, M., Fan, X., Zhang, G., Yang, Y., Zhang, J. J., ... & Xu, Y. C. (2021). Evaluation of Autof MS 1000 and Vitek MS MALDI-TOF MS system in identification of closely-related yeasts causing invasive fungal diseases. Frontiers in Cellular and Infection Microbiology, 11, Article 628828. https://doi.org/10.3389/fcimb.2021.628828.

Zou, M., Tang, L., Zhao, S., Zhao, Z., Chen, L., Chen, P., ... & Fan, X. (2012). Systematic review and meta-analysis of detecting galactomannan in bronchoalveolar lavage fluid for diagnosing invasive aspergillosis. PLoS One, 7(8), Article e43347. https://doi.org/10.1371/journal.pone.0043347.