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Antifungal susceptibility testing results of New Zealand yeast isolates, 2001-2015: Impact of recent CLSI breakpoints and epidemiological cut-off values for Candida and other yeast species. J Glob Antimicrob Resist 2018; 14:72-77. [PMID: 29486358 DOI: 10.1016/j.jgar.2018.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES We reviewed the antifungal susceptibility testing results of local yeast isolates (2001-2015) to record the impact of recently updated interpretive criteria and epidemiological cut-off values (ECVs) for yeast species. METHODS Susceptibility testing was performed using Sensititre® YeastOne®. The results were interpreted following CLSI criteria or YeastOne-derived ECVs. RESULTS A total of 2345 isolates were tested; 62.0% were from sterile body sites or tissue. Application of new CLSI interpretative criteria for fluconazole increased the proportion of non-susceptible isolates of Candida parapsilosis, Candida tropicalis and Candida glabrata (P≤0.03 for all species). For voriconazole, the greatest increase was for C. tropicalis (P<0.0001). Application of new CLSI interpretive criteria for caspofungin increased the proportion of non-susceptible isolates for C. glabrata and Pichia kudriavzevii (P<0.0001 for both). The new amphotericin ECV (≤2mg/L) did not reveal any non-wild-type (non-WT) isolates in the five species covered. YeastOne itraconazole ECVs detected 2%, 5% and 6% non-WT isolates for P. kudriavzevii, C. tropicalis and C. glabrata, respectively. No itraconazole non-WT isolates of Clavispora lusitaniae were detected. CONCLUSIONS Whilst most results are similar to other large surveys of fungal susceptibility, the new CLSI interpretive criteria significantly altered the proportion of non-susceptible isolates to fluconazole, voriconazole and caspofungin for several Candida spp. Application of CLSI and YeastOne-derived ECVs revealed the presence of a low proportion of non-WT isolates for many species. The results serve as a baseline to monitor the susceptibility of Candida and other yeast species in New Zealand over time.
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Sardana K, Kaur R, Arora P, Goyal R, Ghunawat S. Is Antifungal Resistance a Cause for Treatment Failure in Dermatophytosis: A Study Focused on Tinea Corporis and Cruris from a Tertiary Centre? Indian Dermatol Online J 2018; 9:90-95. [PMID: 29644192 PMCID: PMC5885633 DOI: 10.4103/idoj.idoj_137_17] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Dermatophytoses are one of the most common skin diseases that have been largely simple to treat. However, in recent years, these infections have become recalcitrant to treatment which can possibly be due to antifungal resistance. Aim: To analyze the resistance pattern of patients with recalcitrant dermatophytoses. Materials and Methods: A cross-sectional evaluation was undertaken of 40 consecutive patients with recalcitrant tinea corporis/cruris/both who had taken systemic antifungal treatment and did not respond completely to therapy or had recurrent lesion within 1 month of stopping the therapy. Terbinafine, fluconazole, itraconazole, ketoconazole, amphotericin B, and voriconazole were the antifungals tested using broth microdilution assay for antifungal susceptibility testing of dermatophytes, and MIC50, 90 values were recorded. Results: KOH mount was positive in 18 (45%) patients, culture was positive in 28 (70%) patients. Trichophyton mentagrophytes (35%) and T. rubrum (27.5%) were the predominant isolates. Overall, activity of terbinafine and itraconazole were significantly higher than the other drugs tested. For terbinafine, both T. mentagrophytes and T. rubrum were inhibited at MIC90 of 0.125 μg/ml. Itraconazole-inhibited T. mentagrophytes and T. rubrum at MIC90 of 0.0625 and 0.25 μg/ml, respectively. All isolates had reduced susceptibility to fluconazole. Conclusion: While MIC seen were higher than western data, in-vitro resistance (>1 μg/ml) to antifungals was not seen and probably may not be a cause of treatment failure. Possibly, treatment failure lies in the intricate host fungal interaction and virulence of species which help it to evade host immune response.
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Affiliation(s)
- Kabir Sardana
- Department of Dermatology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
| | - Ravinder Kaur
- Department of Microbiology, Lady Hardinge Medical College, New Delhi, India
| | - Pooja Arora
- Department of Dermatology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
| | - Ritu Goyal
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
| | - Sneha Ghunawat
- Department of Dermatology, Maulana Azad Medical College, New Delhi, India
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Abstract
Cutaneous fungal infections affect more than one-fourth of world's population. The pathogenesis and severity of fungal infection depend on various immunological and nonimmunological factors. The rampant use of antifungal therapy in immunocompromised individuals marked the onset of antifungal drug resistance. Fungal resistance can be microbiological or clinical. Microbiological resistance depends on various fungal factors which have established due to genetic alteration in the fungi. Clinical resistance is due to host- or drug-related factors. All these factors may cause fungal resistance individually or in tandem. In addition to standardized susceptibility testing and appropriate drug dosing, one of the ways to avoid resistance is the use of combinational antifungal therapy. Combination therapy also offers advantages in increased synergistic action with enhanced spectrum activity. Newer insights into mechanisms of drug resistance will help in the development of appropriate antifungal therapy.
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Affiliation(s)
- Varadraj Pai
- Department of Dermatology, Goa Medical College, Bambolim, Goa, India
| | - Ajantha Ganavalli
- Department of Microbiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Sinha S, Sardana K. Antifungal Efficacy of Amphotericin B against Dermatophytes and its Relevance in Recalcitrant Dermatophytoses: A Commentary. Indian Dermatol Online J 2018; 9:120-122. [PMID: 29644200 PMCID: PMC5885619 DOI: 10.4103/idoj.idoj_103_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Surabhi Sinha
- Department of Dermatology, STD and Leprosy, Dr. Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, STD and Leprosy, Dr. Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
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Mahajan S, Pandey S. Authors' reply. Indian J Dermatol Venereol Leprol 2018; 84:63-64. [DOI: 10.4103/ijdvl.ijdvl_871_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Osaigbovo II, Lofor PV, Oladele RO. Fluconazole Resistance among Oral Candida Isolates from People Living with HIV/AIDS in a Nigerian Tertiary Hospital. J Fungi (Basel) 2017; 3:jof3040069. [PMID: 29371583 PMCID: PMC5753171 DOI: 10.3390/jof3040069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 11/29/2017] [Accepted: 12/07/2017] [Indexed: 12/19/2022] Open
Abstract
Oropharyngeal candidiasis, a common fungal infection in people living with HIV/AIDS (PLWHA), arises from Candida species colonizing the oral cavity. Fluconazole is the preferred treatment and is often used empirically. Few studies have investigated the prevalence of fluconazole resistance in Nigeria. This study aimed at determining the burden of fluconazole resistance among Candida species in the oral cavities of PLWHA. We sampled the oral cavities of 350 HIV-infected adults and an equal number of HIV-negative controls. Candida isolates were identified using germ tube tests, CHROMagar Candida (CHROMagar, Paris, France), and API Candida yeast identification system (BioMérieux, Marcy-l’Étoile, France). Fluconazole susceptibility was determined using the Clinical and Laboratory Standards Institute disc diffusion method. Data were analysed using SPSS version 21 (IBM, New York, NY, USA). The significance level was set at p ≤ 0.05. The isolation rates for Candida amongst HIV-infected subjects and controls were 20.6% and 3.4%, respectively (p < 0.001). In PLWHA, Candida albicans was most frequently isolated (81.3%) and fluconazole resistance was present in 18 (24%) of the 75 Candida isolates. Resistance to fluconazole was present in half of the non-albicans Candida isolates. Fluconazole resistance is prevalent among oral Candida isolates in PLWHA in the study area with a significantly higher rate among non-albicans Candida spp.
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Affiliation(s)
- Iriagbonse I Osaigbovo
- Department of Medical Microbiology, School of Medicine, University of Benin, Benin City PMB 1154, Nigeria.
- Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City PMB 1111, Nigeria.
| | - Patrick V Lofor
- Department of Medical Microbiology, School of Medicine, University of Benin, Benin City PMB 1154, Nigeria.
- Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City PMB 1111, Nigeria.
| | - Rita O Oladele
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M139PL, UK.
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Molecular Tools for the Detection and Deduction of Azole Antifungal Drug Resistance Phenotypes in Aspergillus Species. Clin Microbiol Rev 2017; 30:1065-1091. [PMID: 28903985 DOI: 10.1128/cmr.00095-16] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The incidence of azole resistance in Aspergillus species has increased over the past years, most importantly for Aspergillus fumigatus. This is partially attributable to the global spread of only a few resistance alleles through the environment. Secondary resistance is a significant clinical concern, as invasive aspergillosis with drug-susceptible strains is already difficult to treat, and exclusion of azole-based antifungals from prophylaxis or first-line treatment of invasive aspergillosis in high-risk patients would dramatically limit drug choices, thus increasing mortality rates for immunocompromised patients. Management options for invasive aspergillosis caused by azole-resistant A. fumigatus strains were recently reevaluated by an international expert panel, which concluded that drug resistance testing of cultured isolates is highly indicated when antifungal therapy is intended. In geographical regions with a high environmental prevalence of azole-resistant strains, initial therapy should be guided by such analyses. More environmental and clinical screening studies are therefore needed to generate the local epidemiologic data if such measures are to be implemented on a sound basis. Here we propose a first workflow for evaluating isolates from screening studies, and we compile the MIC values correlating with individual amino acid substitutions in the products of cyp51 genes for interpretation of DNA sequencing data, especially in the absence of cultured isolates.
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Turnidge JD, Martinez MN. Proposed method for estimating clinical cut-off (CO CL) values: An attempt to address challenges encountered when setting clinical breakpoints for veterinary antimicrobial agents. Vet J 2017; 228:33-37. [PMID: 29153105 DOI: 10.1016/j.tvjl.2017.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 06/14/2017] [Accepted: 10/11/2017] [Indexed: 11/16/2022]
Affiliation(s)
- John D Turnidge
- Department of Molecular and Cellular Biology, University of Adelaide, Women's and Children's Hospital, North Adelaide, South Australia 5006, Australia
| | - Marilyn N Martinez
- US Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation and Research, Rockville, MD 20855, USA.
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Job KM, Olson J, Stockmann C, Constance JE, Enioutina EY, Rower JE, Linakis MW, Balch AH, Yu T, Liu X, Thorell EA, Sherwin CMT. Pharmacodynamic studies of voriconazole: informing the clinical management of invasive fungal infections. Expert Rev Anti Infect Ther 2017; 14:731-46. [PMID: 27355512 DOI: 10.1080/14787210.2016.1207526] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Voriconazole is a broad-spectrum antifungal agent commonly used to treat invasive fungal infections (IFI), including aspergillosis, candidiasis, Scedosporium infection, and Fusarium infection. IFI often occur in immunocompromised patients, leading to increased morbidity and mortality. AREAS COVERED The objective of this review is to summarize the pharmacodynamic properties of voriconazole and to provide considerations for potential optimal dosing strategies. Studies have demonstrated superior clinical response when an AUC/MIC >25 or Cmin/MIC >1 is attained in adult patients, correlating to a trough concentration range as narrow as 2-4.5 mg/L; however, these targets are poorly established in the pediatric population. Topics in this discussion include voriconazole use in multiple age groups, predisposing patient factors for IFI, and considerations for clinicians managing IFI. Expert commentary: The relationship between voriconazole dosing and exposure is not well defined due to the large inter- and intra-subject variability. Development of comprehensive decision support tools for individualizing dosing, particularly in children who require higher dosing, will help to increase the probability of achieving therapeutic efficacy and decrease sub-therapeutic dosing and adverse events.
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Affiliation(s)
- Kathleen M Job
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Jared Olson
- b Pharmacy, Primary Children's Hospital, Intermountain Healthcare , University of Utah , Salt Lake City , UT , USA
| | - Chris Stockmann
- c Division of Pediatric Infectious Diseases, Department of Pediatrics , University of Utah , Salt Lake City , UT , USA
| | - Jonathan E Constance
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Elena Y Enioutina
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA.,d Division of Microbiology and Immunology, Department of Pathology , University of Utah , Salt Lake City , UT , USA
| | - Joseph E Rower
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Matthew W Linakis
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Alfred H Balch
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Tian Yu
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Xiaoxi Liu
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Emily A Thorell
- c Division of Pediatric Infectious Diseases, Department of Pediatrics , University of Utah , Salt Lake City , UT , USA
| | - Catherine M T Sherwin
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA.,e Department of Pharmacology and Toxicology, College of Pharmacy , University of Utah , Salt Lake City , UT , USA
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60
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Ostrosky-Zeichner L, Andes D. The Role of In Vitro Susceptibility Testing in the Management of Candida and Aspergillus. J Infect Dis 2017; 216:S452-S457. [PMID: 28911047 DOI: 10.1093/infdis/jix239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Antifungal susceptibility testing has evolved from a research technique to a standardized and well-validated tool for the clinical management of fungal infections and for epidemiological studies. Genetic mutations and phenotypic resistance in vitro have been shown to correlate with clinical outcomes and treatment failures, and this in turn has led to the creation of clinical breakpoints and, more recently, epidemiological cutoff values for clinically relevant fungal pathogens. Resistance mechanisms for Candida and Aspergillus species have been extensively described and their corresponding genetic mutations can now be readily detected. Epidemiological studies have been able to detect the emergence of regional clonal and nonclonal resistance in several countries. The clinical microbiology laboratory is expected to transition from culture and traditional susceptibility testing to molecular methods for detection, identification, and resistance profiling over the next 5-10 years.
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Affiliation(s)
- Luis Ostrosky-Zeichner
- Division of Infectious Diseases, McGovern Medical School, University of Texas Health Science Center at Houston
| | - David Andes
- Division of Infectious Diseases, University of Wisconsin, Madison
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61
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Perlin DS, Wiederhold NP. Culture-Independent Molecular Methods for Detection of Antifungal Resistance Mechanisms and Fungal Identification. J Infect Dis 2017; 216:S458-S465. [PMID: 28911041 DOI: 10.1093/infdis/jix121] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Resistance to azoles and echinocandins has emerged as a significant factor affecting the clinical management of patients with invasive fungal infections. Immunosuppressed patients at high risk for invasive fungal infections often have prolonged or repeated exposure to antifungals resulting in either the well-documented selection of naturally occurring, less susceptible fungal species, or the in situ development of specific resistance mechanisms. Nucleic acid-based molecular diagnostics are particularly well suited for the rapid detection of low-abundance fungal pathogens and identification of the infecting pathogen to the genus and species levels, as well as assessment of resistance mechanisms. A wide range of molecular probing technologies involving real-time polymerase chain reaction (PCR) assays that facilitate direct analysis of a single infecting genome in a sterile blood specimen are available and have recently been commercialized (eg, Roche LightCycler SeptiFast and T2 Biosystems T2Candida). One of the exciting applications of molecular technology is the direct detection of specific resistance mechanisms that evolve during therapy. In principle, the detection of resistance mechanisms that have been independently validated to cause resistance provides a culture-independent biomarker for potential therapeutic failure. The emergence of real-time PCR assays utilizing allele-specific molecular detection technology that is highly sensitive, robust, and high-throughput has the potential to improve patient care by providing faster detection of drug-resistant infecting strains and to help inform therapeutic management.
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Affiliation(s)
- David S Perlin
- Public Health Research Institute, Rutgers Biomedical and Health Sciences, Newark, New Jersey
| | - Nathan P Wiederhold
- Fungus Testing Laboratory, University of Texas Health Science Center, San Antonio
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Wattal C, Chakrabarti A, Oberoi JK, Donnelly JP, Barnes RA, Sherwal BL, Goel N, Saxena S, Varghese GM, Soman R, Loomba P, Tarai B, Singhal S, Mehta N, Ramasubramanian V, Choudhary D, Mehta Y, Ghosh S, Muralidhar S, Kaur R. Issues in antifungal stewardship: an opportunity that should not be lost. J Antimicrob Chemother 2017; 72:969-974. [PMID: 27999053 DOI: 10.1093/jac/dkw506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Many countries have observed an increase in the incidence of invasive fungal infections (IFIs) over the past two decades with emergence of new risk factors and isolation of new fungal pathogens. Early diagnosis and appropriate antifungal treatment remain the cornerstones of successful outcomes. However, due to non-specific clinical presentations and limited availability of rapid diagnostic tests, in more than half of cases antifungal treatment is inappropriate. As a result, the emergence of antifungal resistance both in yeasts and mycelial fungi is becoming increasingly common. The Delhi Chapter of the Indian Association of Medical Microbiologists (IAMM-DC) organized a 1 day workshop in collaboration with BSAC on 10 December 2015 in New Delhi to design a road map towards the development of a robust antifungal stewardship programme in the context of conditions in India. The workshop aimed at developing a road map for optimizing better outcomes in patients with IFIs while minimizing unintended consequences of antifungal use, ultimately leading to reduced healthcare costs and prevention development of resistance to antifungals. The workshop was a conclave of all stakeholders, eminent experts from India and the UK, including clinical microbiologists, critical care specialists and infectious disease physicians. Various issues in managing IFIs were discussed, including epidemiology, diagnostic and therapeutic algorithms in different healthcare settings. At the end of the deliberations, a consensus opinion and key messages were formulated, outlining a step-by-step approach to tackling the growing incidence of IFIs and antifungal resistance, particularly in the Indian scenario.
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Affiliation(s)
- Chand Wattal
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | | | - Jaswinder Kaur Oberoi
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | | | - Rosemary A Barnes
- Department of Medical Microbiology & Infectious Diseases, Division of Infection & Immunity, School of Medicine, Cardiff University, UK
| | - B L Sherwal
- Rajendra Institute of Medical Sciences, Ranchi, India
| | - Neeraj Goel
- Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | - Sonal Saxena
- Department of Medical Microbiology, Lady Hardinge Medical College, New Delhi, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | | | - Poonam Loomba
- G. B. Pant Institute of Post Graduate Medical Education & Research, New Delhi, India
| | | | | | - Naimish Mehta
- Surgical Gastroenterology & Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - V Ramasubramanian
- Infectious Diseases & Tropical Medicine, Apollo Hospitals, Infectious Diseases, Sri Ramachandra Medical College & Research Institute, Infectious Diseases, MGR Medical University, Chennai, India
| | | | - Yatin Mehta
- Medanta (The Medicity), Medanta Institute of Critical Care and Anesthesiology, Gurgaon, Haryana, India
| | - Supradip Ghosh
- Department of Critical Care Medicine, Fortis-Escorts Hospital, Faridabad, Haryana, India
| | - Sumathi Muralidhar
- Apex Regional STD Teaching Training & Research Centre, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi, India
| | - Ravinder Kaur
- Department of Medical Microbiology, Lady Hardinge Medical College, New Delhi, India
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63
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Methodological Issues in Antifungal Susceptibility Testing of Malassezia pachydermatis. J Fungi (Basel) 2017; 3:jof3030037. [PMID: 29371554 PMCID: PMC5715951 DOI: 10.3390/jof3030037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/21/2017] [Accepted: 06/29/2017] [Indexed: 12/22/2022] Open
Abstract
Reference methods for antifungal susceptibility testing of yeasts have been developed by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antibiotic Susceptibility Testing (EUCAST). These methods are intended to test the main pathogenic yeasts that cause invasive infections, namely Candida spp. and Cryptococcusneoformans, while testing other yeast species introduces several additional problems in standardization not addressed by these reference procedures. As a consequence, a number of procedures have been employed in the literature to test the antifungal susceptibility of Malassezia pachydermatis. This has resulted in conflicting results. The aim of the present study is to review the procedures and the technical parameters (growth media, inoculum preparation, temperature and length of incubation, method of reading) employed for susceptibility testing of M. pachydermatis, and when possible, to propose recommendations for or against their use. Such information may be useful for the future development of a reference assay.
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64
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Yeasts. Microbiol Spectr 2017; 4. [PMID: 27726781 DOI: 10.1128/microbiolspec.dmih2-0030-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Yeasts are unicellular organisms that reproduce mostly by budding and less often by fission. Most medically important yeasts originate from Ascomycota or Basidiomycota. Here, we review taxonomy, epidemiology, disease spectrum, antifungal drug susceptibility patterns of medically important yeast, laboratory diagnosis, and diagnostic strategies.
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65
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Borman AM, Fraser M, Palmer MD, Szekely A, Houldsworth M, Patterson Z, Johnson EM. MIC Distributions and Evaluation of Fungicidal Activity for Amphotericin B, Itraconazole, Voriconazole, Posaconazole and Caspofungin and 20 Species of Pathogenic Filamentous Fungi Determined Using the CLSI Broth Microdilution Method. J Fungi (Basel) 2017; 3:E27. [PMID: 29371545 PMCID: PMC5715917 DOI: 10.3390/jof3020027] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 01/21/2023] Open
Abstract
For filamentous fungi (moulds), species-specific interpretive breakpoints and epidemiological cut-off values (ECVs) have only been proposed for a limited number of fungal species-antifungal agent combinations, with the result that clinical breakpoints are lacking for most emerging mould pathogens. In the current study, we have compiled minimum inhibitory concentration (MIC) data for 4869 clinical mould isolates and present full MIC distributions for amphotericin B, itraconazole, voriconazole, posaconazole, and caspofungin with these isolates which comprise 20 species/genera. In addition, we present the results of an assessment of the fungicidal activity of these same five antifungal agents against a panel of 123 mould isolates comprising 16 of the same species.
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Affiliation(s)
- Andrew M Borman
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Mark Fraser
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Michael D Palmer
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Adrien Szekely
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Marian Houldsworth
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Zoe Patterson
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
| | - Elizabeth M Johnson
- Public Health England United Kingdom, Mycology Reference Laboratory, Myrtle Road, Bristol BS2 8EL, UK.
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66
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Ersoy SC, Heithoff DM, Barnes L, Tripp GK, House JK, Marth JD, Smith JW, Mahan MJ. Correcting a Fundamental Flaw in the Paradigm for Antimicrobial Susceptibility Testing. EBioMedicine 2017; 20:173-181. [PMID: 28579300 PMCID: PMC5478264 DOI: 10.1016/j.ebiom.2017.05.026] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/20/2017] [Accepted: 05/23/2017] [Indexed: 12/25/2022] Open
Abstract
The emergence and prevalence of antibiotic-resistant bacteria are an increasing cause of death worldwide, resulting in a global ‘call to action’ to avoid receding into an era lacking effective antibiotics. Despite the urgency, the healthcare industry still relies on a single in vitro bioassay to determine antibiotic efficacy. This assay fails to incorporate environmental factors normally present during host-pathogen interactions in vivo that significantly impact antibiotic efficacy. Here we report that standard antimicrobial susceptibility testing (AST) failed to detect antibiotics that are in fact effective in vivo; and frequently identified antibiotics that were instead ineffective as further confirmed in mouse models of infection and sepsis. Notably, AST performed in media mimicking host environments succeeded in identifying specific antibiotics that were effective in bacterial clearance and host survival, even though these same antibiotics failed in results using standard test media. Similarly, our revised media further identified antibiotics that were ineffective in vivo despite passing the AST standard for clinical use. Supplementation of AST medium with sodium bicarbonate, an abundant in vivo molecule that stimulates global changes in bacterial structure and gene expression, was found to be an important factor improving the predictive value of AST in the assignment of appropriate therapy. These findings have the potential to improve the means by which antibiotics are developed, tested, and prescribed. Standard antimicrobial susceptibility testing (AST) is fundamentally flawed because it is based largely on in vitro efficacy. AST performed under conditions that mimic natural infections improves the assignment of appropriate antibiotic therapy. In vivo altered susceptibility (IVAS) provides a new paradigm for drug discovery and therapeutic intervention.
Drug testing often excludes potent antibiotics for the treatment of bacterial infections, while frequently identifying antibiotics that are ineffective. However, drug testing under conditions that mimic natural infections succeeded in identifying effective antibiotics, even though these same antibiotics failed standard tests. This work suggests that standard drug-testing may be hindering patient treatment and slowing the process of discovery of new, effective, and safe antibiotics because it disqualifies effective compounds. These findings call for an overhaul of standardized drug testing which hasn't changed in > 50 years.
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Affiliation(s)
- Selvi C Ersoy
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA
| | - Douglas M Heithoff
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA; Center for Nanomedicine, University of California, Santa Barbara, CA 93106, USA
| | - Lucien Barnes
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA
| | - Geneva K Tripp
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA
| | - John K House
- University of Sydney, Faculty of Veterinary Science, Camden, New South Wales, Australia
| | - Jamey D Marth
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA; Center for Nanomedicine, University of California, Santa Barbara, CA 93106, USA; Sanford Burnham Prebys Medical Discovery Institute, Cancer Research Center, La Jolla, CA 92037, USA
| | - Jeffrey W Smith
- Sanford Burnham Prebys Medical Discovery Institute, Cancer Research Center, La Jolla, CA 92037, USA
| | - Michael J Mahan
- Dept. of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA 93106, USA; Center for Nanomedicine, University of California, Santa Barbara, CA 93106, USA.
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Gómez-Sequeda N, Torres R, Ortiz C. Synthesis, characterization, and in vitro activity against Candida spp. of fluconazole encapsulated on cationic and conventional nanoparticles of poly(lactic-co-glycolic acid). Nanotechnol Sci Appl 2017; 10:95-104. [PMID: 28572725 PMCID: PMC5441665 DOI: 10.2147/nsa.s96018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
In this study, nanoparticles (NPs) of poly(lactic-co-glycolic acid) (PLGA) loaded with fluconazole (FLZ) and FLZ-NPs coated with the cationic polymer polyethylenimine (PEI) (FLZ-NP-PEI) were synthetized in order to improve antimycotic activity against four strains of Candida spp. of clinical relevance. FLZ-NPs and FLZ-NP-PEI were synthesized by double emulsion solvent-diffusion (DES-D) and characterized. Minimum inhibitory concentration (MIC50) and minimum fungicide concentration (MFC) were determined in vitro by culturing Candida strains in the presence of these nanocompounds. FLZ-NPs were spherical in shape with hydrodynamic sizes of ~222 nm and surface charge of -11.6 mV. The surface charges of these NPs were successfully modified using PEI (FLZ-NP-PEI) with mean hydrodynamic sizes of 281 nm and surface charge of 23.5 mV. The efficiency of encapsulation (~53%) and a quick release of FLZ (≥90% after 3 h) were obtained. Cytotoxicity assay showed a good cell viability for FLZ-NPs (≥86%), and PEI-modified NPs presented a decrease in cell viability (~38%). FLZ-NPs showed an increasing antifungal activity of FLZ for sensitive (Candida parapsilosis ATCC22019 and Candida albicans ATCC10231, MIC50 =0.5 and 0.1 µg/mL, respectively) and resistant strains (Candida glabrata EMLM14 and Candida krusei ATCC6258, MIC50 =0.1 and 0.5 µg/mL, respectively). FLZ-NP-PEI showed fungicidal activity even against C. glabrata and C. krusei (MFC =4 and 8 µg/mL, respectively). MIC50 values showed best results for FLZ-NPs and FLZ-NP-PEI. Nevertheless, only FLZ-NP-PEI displayed fungicidal activity against the studied strains.
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Affiliation(s)
| | | | - Claudia Ortiz
- School of Microbiology, Faculty of Health, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
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Al-Hatmi AMS, Curfs-Breuker I, de Hoog GS, Meis JF, Verweij PE. Antifungal Susceptibility Testing of Fusarium: A Practical Approach. J Fungi (Basel) 2017; 3:jof3020019. [PMID: 29371537 PMCID: PMC5715922 DOI: 10.3390/jof3020019] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/14/2017] [Accepted: 04/19/2017] [Indexed: 12/12/2022] Open
Abstract
In vitro susceptibility testing of Fusarium is becoming increasingly important because of frequency and diversity of infections and because resistance profiles are species-specific. Reference methods for antifungal susceptibility testing (AFST) are those of Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility (EUCAST), but breakpoints (BPs) have not yet been established. One of the problems is that phylogenetic distances between Fusarium species are much smaller than between species of, e.g., Candida. Epidemiological cutoff values (ECVs) for some Fusarium species have been determined in order to differentiate wild-type from non-wild-type isolates. In clinical routine, commercially available assays such as Etest, Sensititre or others provide essential agreement with reference methods. Our objective is to summarize antifungal susceptibility testing of Fusarium genus in the clinical laboratory: how to do it, when to do it, and how to interpret it.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, PO Box 85167, 3508 AD Utrecht, The Netherlands.
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Ministry of Health, Directorate General of Health Services, PO Box 393, 100 Muscat, Oman.
| | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, PO Box 85167, 3508 AD Utrecht, The Netherlands.
- Basic Pathology Department, Federal University of Paraná State, Curitiba, 81540-970 Paraná, Brazil.
- Biological Sciences Department, Faculty of Science, King Abdulaziz University, PO Box 80203 Jeddah, Saudi Arabia.
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, 6500GS Nijmegen, The Netherlands.
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Mourad A, Perfect JR. What Can the Clinical Mycology Laboratory Do for Clinicians Today and Tomorrow? CURRENT CLINICAL MICROBIOLOGY REPORTS 2017. [DOI: 10.1007/s40588-017-0061-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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70
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Martirosov DM, Bidell MR, Pai MP, Scheetz MH, Rosenkranz SL, Lodise TP. Relationship between vancomycin exposure and outcomes among patients with MRSA bloodstream infections with vancomycin Etest® MIC values of 1.5mg/L: A pilot study. Diagn Microbiol Infect Dis 2017; 88:259-263. [PMID: 28449844 DOI: 10.1016/j.diagmicrobio.2017.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/09/2017] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
Abstract
Data suggest that vancomycin is less effective for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) with vancomycin Etest® MIC (MICEtest) ≥1.5 mg/L. No published studies have evaluated the relationship between vancomycin exposure and outcomes among patients with MRSA BSIs vancomycin MICEtest ≥1.5 mg/L. This study was a retrospective cohort of 71 hospitalized, adult, non-dialysis patients with MRSA BSIs treated with vancomycin. All but three patients had a vancomycin MICEtest of 1.5 mg/L. Achievement of CART-derived AUC24-48h of at least 550 mg*h/L (AUC24-48h/MIC of 366 mg*h/L) was associated with a lower incidence of treatment failure. In multivariate analyses, the risk ratio was 0.45 for the CART-derived AUC24-48h threshold, indicating that achievement of the CART-derived AUC24-48h threshold of 550 was associated with a 2-fold decrease in treatment failure. These findings suggest a potential association between vancomycin exposure and outcomes in patients with MRSA BSIs with MICEtest ≥1.5 mg/L. As this study was retrospective, these findings provide the basis for a future large-scale, multi-center prospective study.
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Affiliation(s)
- D M Martirosov
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M R Bidell
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M P Pai
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M H Scheetz
- Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL 60515, USA
| | - S L Rosenkranz
- Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - T P Lodise
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA.
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71
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Oldenburg CE, Lietman TM. The Challenge of Controlling Infectious Keratitis. Am J Ophthalmol 2017; 176:xv-xvi. [PMID: 28168969 DOI: 10.1016/j.ajo.2017.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 01/16/2017] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
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Clinical and Microbiological Characteristics of Breakthrough Candidemia in Allogeneic Hematopoietic Stem Cell Transplant Recipients in a Japanese Hospital. Antimicrob Agents Chemother 2017; 61:AAC.01791-16. [PMID: 28115352 DOI: 10.1128/aac.01791-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/14/2017] [Indexed: 12/29/2022] Open
Abstract
Few data on breakthrough candidemia (BC), defined as candidemia that develops on administration of antifungal agents (AFAs), in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients are available. The medical and microbiological records of recipients of an allo-HSCT obtained between December 2008 and December 2014 were reviewed. Of 768 allo-HSCT cases, 26 developed BC. Among the 26 causative strains, 22 strains were stored and identified by sequencing. The following species were isolated: Candida parapsilosis (9 strains), C. glabrata (4 strains), C. guilliermondii (3 strains), and other Candida species (6 strains). The AFAs being used when BC developed were micafungin (17 cases), liposomal amphotericin B (5 cases), itraconazole (2 cases), and voriconazole (2 cases). All 17 cases who developed BC during micafungin administration were administered 150 mg/day of micafungin. The susceptibilities of the causative Candida species to the administered AFAs when breakthrough occurred ranged from susceptible to resistant. Especially, 85% of the Candida species that caused BC during micafungin administration were susceptible to micafungin. Additionally, 75% of the strains were wild type for susceptibility to the administered AFAs when breakthrough occurred. Systemic steroid administration and a longer severe neutropenic phase (≥5 days) were independent risk factors for BC (P = 0.016 and P = 0.015, respectively). BC developed in allo-HSCT recipients even when they received a sufficient dose of AFA, including micafungin, to which the causative Candida species were susceptible and/or had wild-type susceptibility in vitro Systemic steroid administration and a longer severe neutropenic phase were host-based factors associated with BC.
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73
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Fernández-Ruiz M, Guinea J, Lora-Pablos D, Zaragoza Ó, Puig-Asensio M, Almirante B, Cuenca-Estrella M, Aguado JM. Impact of fluconazole susceptibility on the outcome of patients with candidaemia: data from a population-based surveillance. Clin Microbiol Infect 2017; 23:672.e1-672.e11. [PMID: 28143788 DOI: 10.1016/j.cmi.2017.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/05/2017] [Accepted: 01/21/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The clinical correlation of fluconazole antifungal susceptibility testing (AST) for Candida isolates and its integration with pharmacokinetics/pharmacodynamics (PK/PD) parameters is unclear. We analysed the impact of fluconazole minimum inhibitory concentration (MIC) values, 24-hour area under the concentration-time curve (AUC24) and AUC24/MIC ratio on the outcome of candidemic patients. METHODS We included 257 episodes of candidaemia treated with fluconazole monotherapy for ≥72 hours from a population-based surveillance conducted in 29 hospitals (CANDIPOP Project). AST was centrally performed by European Committee on Antimicrobial Susceptibility Testing (EUCAST) and Clinical and Laboratory Standards Institute (CLSI) microdilution methods. Primary outcome was clinical failure (30-day mortality and/or persistent candidaemia for ≥72 hours from initiation of therapy). Secondary outcomes included early (3-7 days) and late (3-30 days) mortality. RESULTS Rates of clinical failure, early and late mortality among evaluable episodes were 32.3% (80/248), 3.1% (8/257) and 23.4% (59/248). There was no relationship between fluconazole MIC values or PK/PD parameters and clinical failure. Although MIC values ≥2 mg/L by EUCAST (positive predictive value 32.1%, negative predictive value 68.7%) and ≥0.5 mg/L by CLSI (positive predictive value 34.8%, negative predictive value 74.4%) appeared to be optimal for predicting clinical failure, no significant associations remained after multivariate adjustment (odds ratio 1.67; 95% confidence interval 0.48-5.79; p 0.423). Lack of association was consistent for alternative thresholds (including proposed clinical breakpoints). The only association found for secondary outcomes was between an AUC24/MIC ratio >400 h by CLSI and early mortality (odds ratio 0.18; 95% confidence interval 0.04-0.98; p 0.026). CONCLUSIONS High fluconazole MIC values did not negatively impact outcome of patients with candidaemia treated with fluconazole. No effect of PK/PD targets on the risk of clinical failure was found.
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Affiliation(s)
- M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Universidad Complutense, Madrid, Spain.
| | - J Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario 'Gregorio Marañón', Universidad Complutense, Madrid, Spain
| | - D Lora-Pablos
- Unit of Clinical Research, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Ó Zaragoza
- Department of Mycology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - M Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari 'Vall d'Hebron', Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B Almirante
- Department of Infectious Diseases, Hospital Universitari 'Vall d'Hebron', Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Cuenca-Estrella
- Department of Mycology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Universidad Complutense, Madrid, Spain
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Rapid identification of Candida spp. frequently involved in invasive mycoses by using flow-through hybridization and Gene Chip (FHGC) technology. J Microbiol Methods 2017; 132:160-165. [DOI: 10.1016/j.mimet.2016.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 11/28/2016] [Accepted: 11/28/2016] [Indexed: 11/22/2022]
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Phillips S, MacDougall C, Holdford DA. Analysis of Empiric Antimicrobial Strategies for Cellulitis in the Era of Methicillin-Resistant Staphylococcus aureus. Ann Pharmacother 2016; 41:13-20. [PMID: 17200425 DOI: 10.1345/aph.1h452] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The rise in community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections potentially complicates the empiric management of cellulitis. The threshold at which drugs active against MRSA, such as clindamycin and trimethoprim/sulfamethoxazole (TMP/SMX), should be incorporated into empiric therapy is unknown. Objective: To evaluate the cost-effectiveness of using cephalexin, TMP/SMX, or clindamycin for outpatient empiric therapy of cellulitis, given various likelihoods of infection due to MRSA. Methods: A decision analysis of the empiric treatment of cellulitis was performed from the perspective of a third-party payer. The model included initial therapy with cephalexin, clindamycin, or TMP/SMX, followed by treatment with linezolid in cases of clinical failure. Probability and cost estimates were obtained from clinical trials, epidemiologic data, and publicly available cost data and were subjected to sensitivity analysis. Results: Under the base-case scenario (37% probability of infection by S. aureus and a 27% MRSA prevalence), cephalexin was the most cost-effective option. Clindamycin became a more cost-effective therapy at MRSA probabilities from 41–80% when the probability of staphylococcal infection was greater than 40%. TMP/SMX was cost-effective only at very high likelihoods of MRSA infection. Variables with the most influence in the model were probability of S. aureus being methicillin-resistant, cost of linezolid, probability of a cure with cephalexin for a non-MRSA infection, and probability of infection due to S. aureus. Conclusions: Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels. Cephalexin was the most cost-effective choice over most of the modeled range of probabilities, with clindamycin becoming more cost-effective at high likelihoods of MRSA infection. TMP/SMX is unlikely to be cost-effective for treatment of simple cellulitis. Further studies of the microbiology of cellulitis, the epidemiology of MRSA, and the clinical effectiveness of clindamycin and TMP/SMX in skin and soft tissue infections are needed.
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Affiliation(s)
- Suzanne Phillips
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
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Anti-Candida albicans natural products, sources of new antifungal drugs: A review. J Mycol Med 2016; 27:1-19. [PMID: 27842800 DOI: 10.1016/j.mycmed.2016.10.002] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 10/09/2016] [Accepted: 10/11/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Candida albicans is the most prevalent fungal pathogen in humans. Due to the development of drug resistance, there is today a need for new antifungal agents for the efficient management of C. albicans infections. Therefore, we reviewed antifungal activity, mechanisms of action, possible synergism with antifungal drugs of all natural substances experimented to be efficient against C. albicans for future. METHODS An extensive and systematic review of the literature was undertaken and all relevant abstracts and full-text articles analyzed and included in the review. REVIEW A total of 111 documents were published and highlighted 142 anti-C. albicans natural products. These products are mostly are reported in Asia (44.37%) and America (28.17%). According to in vitro model criteria, from the 142 natural substances, antifungal activity can be considered as important for 40 (28.20%) and moderate for 24 (16.90%). Sixteen products have their antifungal activity confirmed by in vivo gold standard experimentation. Microbial natural products, source of antifungals, have their antifungal mechanism well described in the literature: interaction with ergosterol (polyenes), inhibition 1,3-β-d-glucan synthase (Echinocandins), inhibition of the synthesis of cell wall components (chitin and mannoproteins), inhibition of sphingolipid synthesis (serine palmitoyltransferase, ceramide synthase, inositol phosphoceramide synthase) and inhibition of protein synthesis (sordarins). Natural products from plants mostly exert their antifungal effects by membrane-active mechanism. Some substances from arthropods are also explored to act on the fungal membrane. Interestingly, synergistic effects were found between different classes of natural products as well as between natural products and azoles. CONCLUSION Search for anti-C. albicans new drugs is promising since the list of natural substances, which disclose activity against this yeast is today long. Investigations must be pursued not only to found more new anti-Candida compounds from plants and organisms but also to carried out details on molecules from already known anti-Candida compounds and to more elucidate mechanisms of action.
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Pyrazinamide Resistance Assays and Two-Month Sputum Culture Status in Patients with Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2016; 60:6766-6773. [PMID: 27600032 DOI: 10.1128/aac.00632-16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/19/2016] [Indexed: 01/04/2023] Open
Abstract
Phenotypic drug susceptibility testing is the current "gold standard" for detecting Mycobacterium tuberculosis susceptibility to antituberculous drugs. Pyrazinamide is one antituberculous drug for which the correlation between in vitro resistance and clinical outcomes remains unclear. Here we performed latent class analysis (LCA) to develop a consensus gold standard definition of pyrazinamide resistance using three paired standard pyrazinamide resistance assays. We then compared this consensus measure to the 2-month culture results for patients with multidrug-resistant tuberculosis (MDR-TB) who were treated for 2 months with first-line antituberculous drugs before their resistance results were known. Among 121 patients with MDR-TB, 60 (49.6%) were resistant to pyrazinamide by the Wayne method (L. G. Wayne, Am Rev Respir Dis 109:147-151, 1974), 71 (58.7%) were resistant by the Bactec MGIT 960 method, and 68 (56.2%) were resistant by pncA sequencing. LCA grouped isolates with positive results by at least two assays into a category which we considered the "consensus gold standard" for pyrazinamide resistance. The sensitivity and specificity for this consensus gold standard were 82.4% and 92.5%, respectively, for the Wayne method; 95.6% and 88.7%, respectively, for the Bactec MGIT 960 method; and 92.6% and 90.6%, respectively, for pncA sequencing. After we adjusted for other factors associated with poor outcomes, including age, sex, alcohol use, and baseline ethambutol resistance, patients whose isolates were resistant by the LCA-derived consensus gold standard were more likely to be culture positive at 2 months with an odds ratio of 1.95 (95% confidence interval, 0.74 to 5.11), but this result was not statistically significant. These findings underscore the need for improved diagnostics for routine use in programmatic settings.
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Abstract
PURPOSE OF REVIEW We review and offer our clinical perspectives on the emergence of echinocandin-resistant Candida. RECENT FINDINGS Candida FKS gene mutations attenuate echinocandin activity, but overall mutation rates among clinical isolates remain low (Candida glabrata, ∼4%; other species, <1%). Rates are higher with prior echinocandin exposure, exceeding 50% among C. glabrata or Candida albicans isolates causing breakthrough invasive candidiasis. The median duration of prior echinocandin exposure among FKS mutant isolates is ∼100 days. The clinical usefulness of echinocandin susceptibility testing is limited by the low overall prevalence of resistance, and uncertainties surrounding testing methods and interpretation of minimum inhibitory concentrations (MICs). In single-center studies, caspofungin resistance (defined using institution-specific MIC breakpoints) was 32-53% sensitive and 75-95% specific for predicting treatment outcomes of C. glabrata invasive candidiasis; corresponding values for the presence of an FKS mutation were 35-41% and 90-98%. Results were similar using anidulafungin and micafungin MICs. Clinical data are scarce for non-C. glabrata species. SUMMARY Echinocandins remain preferred agents against invasive Candida infections. Susceptibility testing and FKS genotypic testing do not have roles in routine clinical practice, but may be useful in newly-diagnosed patients who are echinocandin-experienced or those who have not responded to echinocandin treatment.
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Aguilar-Zapata D, Petraitiene R, Petraitis V. Echinocandins: The Expanding Antifungal Armamentarium. Clin Infect Dis 2016; 61 Suppl 6:S604-11. [PMID: 26567277 DOI: 10.1093/cid/civ814] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The echinocandins are large lipopeptide molecules that, since their discovery approximately 41 years ago, have emerged as important additions to the expanding armamentarium against invasive fungal diseases. Echinocandins exert in vitro and in vivo fungicidal action against most Candida species and fungistatic action against Aspergillus species. However, the population of patients at risk for developing invasive fungal infections continues to increase. New therapeutic strategies using echinocandins are needed to improve clinical outcomes in patients with invasive fungal disease.
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Affiliation(s)
- Daniel Aguilar-Zapata
- Division of Infectious Diseases and Internal Medicine, Fundación Clínica Médica Sur, Mexico City, Mexico Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center of Cornell University, New York, New York
| | - Ruta Petraitiene
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center of Cornell University, New York, New York
| | - Vidmantas Petraitis
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center of Cornell University, New York, New York
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Impact of Time to Appropriate Therapy on Mortality in Patients with Vancomycin-Intermediate Staphylococcus aureus Infection. Antimicrob Agents Chemother 2016; 60:5546-53. [PMID: 27401565 DOI: 10.1128/aac.00925-16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/01/2016] [Indexed: 12/29/2022] Open
Abstract
Despite the increasing incidence of vancomycin-intermediate Staphylococcus aureus (VISA) infections, few studies have examined the impact of delay in receipt of appropriate antimicrobial therapy on outcomes in VISA patients. We examined the effects of timing of appropriate antimicrobial therapy in a cohort of patients with sterile-site methicillin-resistant S. aureus (MRSA) and VISA infections. In this single-center, retrospective cohort study, we identified all patients with MRSA or VISA sterile-site infections from June 2009 to February 2015. Clinical outcomes were compared according to MRSA/VISA classification, demographics, comorbidities, and antimicrobial treatment. Thirty-day all-cause mortality was modeled with Kaplan-Meier curves. Multivariate logistic regression analysis (MVLRA) was used to determine odds ratios for mortality. We identified 354 patients with MRSA (n = 267) or VISA (n = 87) sterile-site infection. Fifty-five patients (15.5%) were nonsurvivors. Factors associated with mortality in MVLRA included pneumonia, unknown source of infection, acute physiology and chronic health evaluation (APACHE) II score, solid-organ malignancy, and admission from skilled care facilities. Time to appropriate antimicrobial therapy was not significantly associated with outcome. Presence of a VISA infection compared to that of a non-VISA S. aureus infection did not result in excess mortality. Linezolid use was a risk for mortality in patients with APACHE II scores of ≥14. Our results suggest that empirical vancomycin use in patients with VISA infections does not result in excess mortality. Future studies should (i) include larger numbers of patients with VISA infections to confirm the findings presented here and (ii) determine the optimal antibiotic therapy for critically ill patients with MRSA and VISA infections.
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Jeong W, Haywood P, Shanmuganathan N, Lindsay J, Urbancic K, Ananda-Rajah MR, Chen SCA, Bajel A, Ritchie D, Grigg A, Seymour JF, Peleg AY, Kong DCM, Slavin MA. Safety, clinical effectiveness and trough plasma concentrations of intravenous posaconazole in patients with haematological malignancies and/or undergoing allogeneic haematopoietic stem cell transplantation: off-trial experience. J Antimicrob Chemother 2016; 71:3540-3547. [PMID: 27521358 DOI: 10.1093/jac/dkw322] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/22/2016] [Accepted: 07/08/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study describes the safety, clinical effectiveness and trough plasma concentration (Cmin) of intravenous (iv) posaconazole, provided as part of Merck Sharp and Dohme Australia's Named Patient Programme (NPP) in non-clinical trial settings. METHODS A multicentre, retrospective study on the NPP use of iv posaconazole between July 2014 and March 2015 across seven Australian hospitals. RESULTS Seventy courses of iv posaconazole were prescribed and evaluated in 61 patients receiving treatment for haematological malignancy. Sixty-one courses were prescribed for prophylaxis against invasive fungal disease (IFD), the majority of which (59) were initiated in patients with gastrointestinal disturbances and/or intolerance to previous antifungals. The median (IQR) duration for prophylaxis was 10 (6-15) days. No breakthrough IFD was observed during or at cessation of iv posaconazole. Nine courses of iv posaconazole were prescribed for treatment of IFD with a median (IQR) duration of 19 (7-30) days. Improvement in signs and symptoms of IFD was observed in five cases at cessation of, and six cases at 30 days post-iv posaconazole. Cmin was measured in 39 courses of iv posaconazole, with the initial level taken [median (IQR)] 4 (3-7) days after commencing iv posaconazole. The median (IQR) of initial Cmin was 1.16 (0.69-2.06) mg/L. No severe adverse events specifically attributed to iv posaconazole were documented, although six courses were curtailed due to potential toxicity. CONCLUSIONS This non-clinical trial experience suggests that iv posaconazole appeared to be safe and clinically effective for prophylaxis or treatment of IFD in patients receiving treatment for haematological malignancies.
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Affiliation(s)
- Wirawan Jeong
- Centre for Medicine Use and Safety, Monash University, VIC, Australia
| | - Peter Haywood
- Department of Clinical Haematology and Bone Marrow Transplant Service, Royal Melbourne Hospital, VIC, Australia
| | | | - Julian Lindsay
- Pharmacy Department, Royal North Shore Hospital, NSW, Australia
| | | | - Michelle R Ananda-Rajah
- General Medical Unit, Alfred Health and Central & Eastern Clinical School, Monash University, VIC, Australia
| | - Sharon C A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead Hospital, The University of Sydney, NSW, Australia
| | - Ashish Bajel
- Department of Clinical Haematology and Bone Marrow Transplant Service, Royal Melbourne Hospital, VIC, Australia
| | - David Ritchie
- Department of Clinical Haematology and Bone Marrow Transplant Service, Royal Melbourne Hospital and The University of Melbourne, VIC, Australia
| | - Andrew Grigg
- Department of Clinical Haematology, Austin Health and The University of Melbourne, VIC, Australia
| | - John F Seymour
- Department of Haematology, Peter MacCallum Cancer Centre and The University of Melbourne, VIC, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, VIC, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, VIC, Australia.,Pharmacy Department, Ballarat Health Services, VIC, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, VIC, Australia .,Victorian Infectious Diseases Service, Royal Melbourne Hospital, VIC, Australia
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Ceftazidime-avibactam or best available therapy in patients with ceftazidime-resistant Enterobacteriaceae and Pseudomonas aeruginosa complicated urinary tract infections or complicated intra-abdominal infections (REPRISE): a randomised, pathogen-directed, phase 3 study. THE LANCET. INFECTIOUS DISEASES 2016; 16:661-673. [DOI: 10.1016/s1473-3099(16)30004-4] [Citation(s) in RCA: 264] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 03/09/2016] [Accepted: 03/17/2016] [Indexed: 11/19/2022]
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83
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Gerstein AC, Rosenberg A, Hecht I, Berman J. diskImageR: quantification of resistance and tolerance to antimicrobial drugs using disk diffusion assays. MICROBIOLOGY-SGM 2016; 162:1059-1068. [PMID: 27126388 DOI: 10.1099/mic.0.000295] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Microbial pathogens represent an increasing threat to human health. Although many infections can be successfully treated and cleared, drug resistance is a widespread problem. The existence of subpopulations of 'tolerant' cells (where a fraction of the population is able to grow above the population resistance level) may increase the rate of treatment failure; yet, existing methods to measure subpopulation effects are cumbersome. Here we describe diskImageR, a computational pipeline that analyses photographs of disk diffusion assays to determine the degree of drug susceptibility [the radius of inhibition, (RAD)], and two aspects of subpopulation growth [the fraction of growth (FoG) within the zone of inhibition, (ZOI), and the rate of change in growth from no drug to inhibitory drug concentrations, (SLOPE)]. diskImageR was used to examine the response of the human fungal pathogen Candida albicans to the antifungal drug fluconazole across different strain backgrounds and growth conditions. Disk diffusion assays performed under Clinical and Laboratory Standards Institute (CLSI) conditions led to more susceptibility and less tolerance than assays performed using rich medium conditions. We also used diskImageR to quantify the effects of three drugs in combination with fluconazole, finding that all three combinations affected tolerance, with the effect of one drug (doxycycline) being very strain dependent. The three drugs had different effects on susceptibility, with doxycycline generally having no effect, chloroquine generally increasing susceptibility and pyrvinium pamoate generally reducing susceptibility. The ability to simultaneously quantitate different aspects of microbial drug responses will facilitate the study of mechanisms of subpopulation responses in the presence of antimicrobial drugs.
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Affiliation(s)
- Aleeza C Gerstein
- Department of Microbiology & Immunology, Medical School, University of Minnesota, MN, USA.,Department of Genetics, Cell Biology & Development, College of Biological Sciences, University of Minnesota, MN, USA.,Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Rosenberg
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Hecht
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Judith Berman
- Department of Genetics, Cell Biology & Development, College of Biological Sciences, University of Minnesota, MN, USA.,Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.,Department of Microbiology & Immunology, Medical School, University of Minnesota, MN, USA
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85
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Albataineh MT, Sutton DA, Fothergill AW, Wiederhold NP. Update from the Laboratory: Clinical Identification and Susceptibility Testing of Fungi and Trends in Antifungal Resistance. Infect Dis Clin North Am 2015; 30:13-35. [PMID: 26739605 DOI: 10.1016/j.idc.2015.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite the availability of new diagnostic assays and broad-spectrum antifungal agents, invasive fungal infections remain a significant challenge to clinicians and are associated with marked morbidity and mortality. In addition, the number of etiologic agents of invasive mycoses has increased accompanied by an expansion in the immunocompromised patient populations, and the use of molecular tools for fungal identification and characterization has resulted in the discovery of several cryptic species. This article reviews various methods used to identify fungi and perform antifungal susceptibility testing in the clinical laboratory. Recent developments in antifungal resistance are also discussed.
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Affiliation(s)
- Mohammad T Albataineh
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Deanna A Sutton
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Annette W Fothergill
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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86
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Agudelo CA, Muñoz C, Ramírez A, Tobón AM, de Bedout Bact C, Cano LE, Restrepo A. Response to therapy in patients with cryptococcosis and AIDS: Association with in vitro susceptibility to fluconazole. Rev Iberoam Micol 2015; 32:214-20. [DOI: 10.1016/j.riam.2014.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 06/12/2014] [Accepted: 07/11/2014] [Indexed: 10/24/2022] Open
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87
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Nachimuthu N, Ostrosky-Zeichner L. Antifungal Susceptibility Testing: Evolution, Indications, and Role in Clinical Practice. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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88
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Application of Culture-Independent Rapid Diagnostic Tests in the Management of Invasive Candidiasis and Cryptococcosis. J Fungi (Basel) 2015; 1:217-251. [PMID: 29376910 PMCID: PMC5753112 DOI: 10.3390/jof1020217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 12/26/2022] Open
Abstract
The diagnosis of invasive candidiasis (IC) and cryptococcosis is often complicated by slow and insensitive culture-based methods. Such delay results in poor outcomes due to the lack of timely therapeutic interventions. Advances in serological, biochemical, molecular and proteomic approaches have made a favorable impact on this process, improving the timeliness and accuracy of diagnosis with resultant improvements in outcome. This paper will serve as an overview of recent developments in the diagnostic approaches to infections due to these important yeast-fungi.
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89
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Zavrel M, White TC. Medically important fungi respond to azole drugs: an update. Future Microbiol 2015; 10:1355-73. [DOI: 10.2217/fmb.15.47] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The increased numbers of patients with compromised immune systems in the last three decades have increased the chances of life-threatening fungal infections. Numerous antifungal drugs have been developed in the last 20 years to treat these infections. The largest group, the azoles, inhibits the synthesis of fungal sterols. The use of these fungistatic azoles has subsequently led to the emergence of acquired azole resistance. The most common mechanisms that result in azole resistance include the overexpression or mutation of the azole target enzyme, and overexpression of drug transporters that are responsible for azole efflux from cells. Additional, less-frequent mechanisms have also been identified. Understanding azole resistance mechanisms is crucial for current antifungal treatment and for the future development of new treatment strategies.
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Affiliation(s)
- Martin Zavrel
- University of Missouri-Kansas City, School of Biological Sciences, Division of Cell Biology & Biophysics, 5007 Rockhill Road, BSB 404, Kansas City, MO 64110, USA
| | - Theodore C White
- University of Missouri-Kansas City, School of Biological Sciences, Division of Cell Biology & Biophysics, 5007 Rockhill Road, BSB 404, Kansas City, MO 64110, USA
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Impact of borderline minimum inhibitory concentration on the outcome of invasive infections caused by Enterobacteriaceae treated with β-lactams: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2015; 34:1751-8. [DOI: 10.1007/s10096-015-2408-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/10/2015] [Indexed: 01/06/2023]
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91
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Pakshir K, Zomorodian K, Zakaei A, Motamedi M, Rahimi Ghiasi M, Karamitalab M. Molecular identification and in-vitro antifungal susceptibility testing of Candida species isolated from patients with onychomycosis. Curr Med Mycol 2015; 1:26-32. [PMID: 28681001 PMCID: PMC5490278 DOI: 10.18869/acadpub.cmm.1.4.26] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND PURPOSE Candida species are the most opportunistic fungi affecting the nails and resulting in onychomycosis. In this study, we identified and evaluated in-vitro susceptibility of the recovered isolates against fluconazole (FLC), voriconazole (VRC), and clotrimazole (CLT) using the Clinical and Laboratory Standards Institute (CLSI) M27-A3 document. MATERIALS AND METHODS From patients with either clinically or mycologically proven onychomycosis, 97 isolates comprising of seven Candida species were isolated, which were identified by both conventional and molecular techniques such as polymerase chain reaction-restriction fragment length polymorphism. In addition, Candida dubliniensis was confirmed by restriction endonuclease analysis. Antifungal susceptibility of each isolate against the three azoles applied in this study was determined using the CLSI microdilution reference method M27-A3. RESULTS Candida parapsilosis(C. parapsilosis) was the most frequently isolated species (n=44), followed by C. albicans (n=23), C.tropicalis (n=13), C.glabrata (n=7), C.krusei (n=6), C.guilliermondii (n=3), and C. dubliniensis (n=1). All the isolates were susceptible to CLT. VRC had lower minimum inhibitory concentration (MIC) values for the isolates compared to FLC. Geometric mean MIC values of VRC, FLC, and CLT for C. parapsilosis isolates were 0.07 μg/ml, 0.8 μg/ml, and 0.35 μg/ml, respectively. Collectively, all species exhibited greater susceptibility to VRC in comparison to C. albicans (P≤0.001). CONCLUSION This study showed that non-albicansCandida species were the most common etiologic agents of non-dermatophyte onychomycosis. The major antifungal agents used in clinics to empirically treat yeast onychomycosis are FLC and CLT. Our data suggested that CLT is a better choice for the treatment of Candida onychomycosis, especially in drug resistant cases.
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Affiliation(s)
- K Pakshir
- Basic Sciences in Infectious Diseases Research Center, Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - K Zomorodian
- Basic Sciences in Infectious Diseases Research Center, Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - A Zakaei
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M Motamedi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M Rahimi Ghiasi
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M Karamitalab
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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92
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Diekema DJ, Pfaller MA. Nosocomial Candidemia: An Ounce of Prevention Is Better Than a Pound of Cure. Infect Control Hosp Epidemiol 2015; 25:624-6. [PMID: 15357151 DOI: 10.1086/502451] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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93
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94
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Blyth DM, Mende K, Weintrob AC, Beckius ML, Zera WC, Bradley W, Lu D, Tribble DR, Murray CK. Resistance patterns and clinical significance of Candida colonization and infection in combat-related injured patients from iraq and afghanistan. Open Forum Infect Dis 2014; 1:ofu109. [PMID: 25734177 PMCID: PMC4324214 DOI: 10.1093/ofid/ofu109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/12/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and outcomes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. METHODS Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009-October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Susceptibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Standards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. RESULTS The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albicans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghanistan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. CONCLUSIONS Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate.
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Affiliation(s)
- Dana M. Blyth
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Katrin Mende
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - Amy C. Weintrob
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
- Infectious Disease, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Miriam L. Beckius
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Wendy C. Zera
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - William Bradley
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - Dan Lu
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
| | - Clinton K. Murray
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
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95
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The investigational agent E1210 is effective in treatment of experimental invasive candidiasis caused by resistant Candida albicans. Antimicrob Agents Chemother 2014; 59:690-2. [PMID: 25331706 DOI: 10.1128/aac.03944-14] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro and in vivo activity of the inositol acyltransferase inhibitor E1210 was evaluated against echinocandin-resistant Candida albicans. E1210 demonstrated potent in vitro activity, and in mice with invasive candidiasis caused by echinocandin-resistant C. albicans, oral doses of 10 and 40 mg E1210/kg of body weight twice daily significantly improved survival and reduced fungal burden compared to those of controls and mice treated with caspofungin (10 mg/kg/day). These results demonstrate the potential use of E1210 against resistant C. albicans infections.
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96
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Morace G, Perdoni F, Borghi E. Antifungal drug resistance in Candida species. J Glob Antimicrob Resist 2014; 2:254-259. [PMID: 27873684 DOI: 10.1016/j.jgar.2014.09.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 08/28/2014] [Accepted: 09/09/2014] [Indexed: 11/15/2022] Open
Abstract
Invasive Candida infections are well established infectious entities of immunocompromised or critically ill patients and are characterised by high morbidity and mortality. Owing to the common eukaryotic structure of fungi and humans, a limited number of antifungal drugs is available for therapeutic purposes. In this unsatisfactory scenario, the emergence of drug resistance represents an important health problem. Failure of antifungal treatment can be related to host factors, to the pharmacokinetic and pharmacodynamic parameters of the drug, or to morphological, reproductive modalities and biofilm production of the fungus itself. Innate or acquired antifungal resistance derives from the presence or onset of molecular mechanisms related to the toxic activity of the drug itself. The resulting resistance can thus be extended to different molecules of the same class according to a greater or lesser affinity of the molecules for the target. In addition, non-specific cellular mechanisms of extrusion of toxic substances, such as overexpression of efflux pumps, can play a role involving different antifungal classes. Here we briefly review the current antifungal susceptibility testing methods and their usefulness as predictors of antifungal resistance in Candida spp., focusing on assessment of the involved molecular mechanisms.
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Affiliation(s)
- Giulia Morace
- Department of Health Sciences, Università degli Studi di Milano, Blocco C, via A. di Rudinì 8, 20142 Milan, Italy.
| | - Federica Perdoni
- Department of Health Sciences, Università degli Studi di Milano, Blocco C, via A. di Rudinì 8, 20142 Milan, Italy
| | - Elisa Borghi
- Department of Health Sciences, Università degli Studi di Milano, Blocco C, via A. di Rudinì 8, 20142 Milan, Italy
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Perlin DS. Echinocandin resistance, susceptibility testing and prophylaxis: implications for patient management. Drugs 2014; 74:1573-85. [PMID: 25255923 PMCID: PMC4201113 DOI: 10.1007/s40265-014-0286-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This article addresses the emergence of echinocandin resistance among Candida species, mechanisms of resistance, factors that promote resistance and confounding issues surrounding standard susceptibility testing. Fungal infections remain a significant cause of global morbidity and mortality, especially among patients with underlying immunosupression. Antifungal therapy is a critical component of patient management for acute and chronic diseases. Yet, therapeutic choices are limited due to only a few drug classes available to treat systemic disease. Moreover, the problem is exacerbated by the emergence of antifungal resistance, which has resulted in difficult to manage multidrug resistant strains. Echinocandin drugs are now the preferred choice to treat a range of candidiasis. These drugs target and inhibit the fungal-specific enzyme glucan synthase, which is responsible for the biosynthesis of a key cell wall polymer. Therapeutic failures involving acquisition of resistance among susceptible organisms like Candida albicans is largely a rare event. However, in recent years, there is an alarming trend of increased resistance among strains of Candida glabrata, which in many cases are also resistant to azole drugs. Echinocandin resistance is always acquired during therapy and the mechanism of resistance is well established to involve amino acid changes in "hot-spot" regions of the Fks subunits carrying the catalytic portion of glucan synthase. These changes significantly decrease the sensitivity of the enzyme to drug resulting in higher MIC values. A range of drug responses, from complete to partial refractory response, is observed depending on the nature of the amino acid substitution, and clinical responses are recapitulated in pharmacodynamic models of infection. The cellular processes promoting the formation of resistant Fks strains involve complex stress response pathways, which yield a variety of adaptive compensatory genetic responses. Stress-adapted cells become drug tolerant and can form stable drug resistant FKS mutations with continued drug exposure. A major concern for resistance detection is that classical broth microdilution techniques show significant variability among clinical microbiology laboratories for certain echinocandin drugs and Candida species. The consequence is that susceptible strains are misclassified according to established clinical breakpoints, and this has led to confusion in the field. Clinical factors that appear to promote echinocandin resistance include the expanding use of antifungal agents for empiric therapy and prophylaxis. Furthermore, host reservoirs such as biofilms in the gastrointestinal tract or intra-abdominal infections can seed development of resistant organisms during therapy. A fundamental understanding of the primary molecular resistance mechanism, along with cellular and clinical factors that promote resistance emergence, is critical to develop better diagnostic tools and therapeutic strategies to overcome and prevent echinocandin resistance.
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Affiliation(s)
- David S Perlin
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, 07103, USA,
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98
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Posteraro B, Sanguinetti M. The future of fungal susceptibility testing. Future Microbiol 2014; 9:947-67. [DOI: 10.2217/fmb.14.55] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
ABSTRACT The antifungal treatment failures and the emergence of resistant fungal strains have stimulated the need for reproducible and clinically relevant antifungal susceptibility testing (AFST). While the standard reference methods are not intended for routine use, commercial methods are widely used for performing AFST. However, to accelerate AFST and to improve the detection of antifungal resistance, which is the most challenging goal of AFST, novel assays have been developed. Following brief drug exposures of fungal cells, the new antifungal susceptibility end points seem to provide a reliable means of identifying fungal isolates, which harbor mutations that have been associated with antifungal resistance. This article summarizes the recent progress in AFST that is destined to enhance its clinical utility in the near future.
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Affiliation(s)
- Brunella Posteraro
- Institute of Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | - Maurizio Sanguinetti
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
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Pili FMG, Erriu M, Piras A, Garau V. Application of the novel method in the diagnosis and treatment of median rhomboid glossitis Candida-associated. Eur J Dent 2014; 8:129-131. [PMID: 24966760 PMCID: PMC4054025 DOI: 10.4103/1305-7456.126268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this work is to demonstrate how current molecular techniques should be integrated in the diagnostic process and can have a crucial role in the management of oral fungal infections. A case of median rhomboid glossitis Candida-associated and its resolution will be described step by step. At the time of the first observation, the lesion on the surface of the tongue did not respond to the previous administration of topical antifungal agent, such a nystatin. Firstly, in order to identify the causative agent and confirm Candida albicans infection, a brushing of the lesion was performed and polymerase chain reaction analysis was carried out. In addition, deoxyribonucleic acid sequencing method, known as Pyrosequencing®, was used in the detection of point mutations commonly associated with fluconazole resistance and consequently, in the prediction of susceptibility to azole agents. According to molecular findings, the administration of fluconazole has therefore led to resolution of the case in 2 weeks. This case highlights how the use of molecular techniques, now-a-days, can assist the clinicians to quickly obtain the report with highly accurate and precise results and appropriately support them in the diagnosis and therapeutic process.
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Affiliation(s)
| | - Matteo Erriu
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
| | - Alessandra Piras
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
| | - Valentino Garau
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
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Cryptococcus neoformans meningoencephalitis in a patient with polyarteritis nodosa. Folia Microbiol (Praha) 2014; 59:515-21. [PMID: 24947767 DOI: 10.1007/s12223-014-0328-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 06/11/2014] [Indexed: 10/25/2022]
Abstract
Case of 59-year-old male with chronic obstructive pulmonary disease and a number of comorbidities, who has developed meningoencephalitis caused by Cryptococcus neoformans var. grubii with polyarteritis nodosa diagnosed during hospitalization, was presented. Before evidence of meningoencephalitis, the patient was being treated with ketoconazole and low doses of fluconazole (200 mg/day) for alleged candidiasis. The dosage was increased (800 mg/day) following laboratory diagnosis of C. neoformans based on positive latex agglutination test and biochemical identification of encapsulated yeast isolated from the blood and CSF. Later, the yeast identification was confirmed by sequencing analysis. Owing to inadequate clinical response, fluconazole therapy was switched to voriconazole (400 mg/day) and later to intravenous amphotericin B (1.0 mg/kg per day). Despite of a temporary stabilization and improvement, which correlated with decline of cryptococcal antigen titers (from 1:1024 to 1:8), after 6 weeks, the patient's underlying condition deteriorated due to severe pancolitis and serious nosocomial bacterial infections. The patient died of multiorgan failure several days later. Our case demonstrates a possible connection between the development of life-threatening cryptococcosis and an autoimmune vasculitis disease and emphasizes that the outcome of the management of cryptococcal meningoencephalitis is highly dependent on early diagnosis, adequate treatment, including dosage, and last but not least control of underlying disease and risk factors.
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