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Arendrup MC, Hare RK, Jørgensen KM, Bollmann UE, Bech TB, Hansen CC, Heick TM, Jørgensen LN. Environmental Hot Spots and Resistance-Associated Application Practices for Azole-Resistant Aspergillus fumigatus, Denmark, 2020-2023. Emerg Infect Dis 2024; 30:1531-1541. [PMID: 38935978 PMCID: PMC11286046 DOI: 10.3201/eid3008.240096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
Azole-resistant Aspergillus fumigatus (ARAf) fungi have been found inconsistently in the environment in Denmark since 2010. During 2018-2020, nationwide surveillance of clinical A. fumigatus fungi reported environmental TR34/L98H or TR46/Y121F/T289A resistance mutations in 3.6% of isolates, prompting environmental sampling for ARAf and azole fungicides and investigation for selection of ARAf in field and microcosmos experiments. ARAf was ubiquitous (20% of 366 samples; 16% TR34/L98H- and 4% TR46/Y121F/T289A-related mechanisms), constituting 4.2% of 4,538 A. fumigatus isolates. The highest proportions were in flower- and compost-related samples but were not correlated with azole-fungicide application concentrations. Genotyping showed clustering of tandem repeat-related ARAf and overlaps with clinical isolates in Denmark. A. fumigatus fungi grew poorly in the field experiment with no postapplication change in ARAf proportions. However, in microcosmos experiments, a sustained complete (tebuconazole) or partial (prothioconazole) inhibition against wild-type A. fumigatus but not ARAf indicated that, under some conditions, azole fungicides may favor growth of ARAf in soil.
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Arendrup MC, Guinea J, Meletiadis J. Twenty Years in EUCAST Anti-Fungal Susceptibility Testing: Progress & Remaining Challenges. Mycopathologia 2024; 189:64. [PMID: 38990395 DOI: 10.1007/s11046-024-00861-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/15/2024] [Indexed: 07/12/2024]
Abstract
Since its inception in 2002, the EUCAST Antifungal Susceptibility Testing Subcommittee (AFST) has developed and refined susceptibility testing methods for yeast, moulds and dermatophytes, and established epidemiological cut-off values and breakpoints for antifungals. For yeast, three challenges have been addressed. Interpretation of trailing growth in fluconazole susceptibility testing, which has been proven without impact on efficacy if below the 50% endpoint. Variability in rezafungin MIC testing due to laboratory conditions, which has been solved by the addition of Tween 20 to the growth medium in E.Def 7.4. And third, interpretation of MICs for rare yeast with no breakpoints, where recommendations have been established for MIC-based clinical advice. For moulds, refinements include the validation of spectrophotometer reading for A. fumigatus to facilitate objective MIC determination, and for dermatophytes the establishment of a microdilution method with automated reading and a selective medium to minimise the risk of contaminations. Recent initiatives involve development and validation of agar-based screening assays for detection of potential azole and echinocandin resistance in A. fumigatus and Aspergillus species, respectively, and of terbinafine resistance in Trichophyton species. Moreover, the development of a EUCAST guidance document for molecular resistance testing represents an advancement, particularly for identifying target gene alterations associated with resistance. In summary, EUCAST AFST continues to play a pivotal role in standardizing AFST and facilitating accurate interpretation of susceptibility data for clinical decision-making. Adoption of EUCAST breakpoints for commercial test methods, however, requires thorough validation to ensure concordance with EUCAST reference testing species-specific MIC distributions.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Building 45/112, Artillerivej 5, 2300, Copenhagen, Denmark.
- Department Clinical Microbiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.
| | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007, Madrid, Spain
- Faculty of Health Sciences-HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Emirdağ S, Ulusoy NG, Aksel M. Design, Synthesis and Biological Evaluation of Novel Gypsogenin Derivatives as Potential Anticancer and Antimicrobial Agents. Chem Biodivers 2024; 21:e202400471. [PMID: 38594210 DOI: 10.1002/cbdv.202400471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/11/2024]
Abstract
Natural compounds are important sources for the treatment of chronic disorders such as cancer and microbial infectious disorders. In this research, Gypsogenin and its derivatives (2 a-2 f) have been tested against different cancer cell lines (MCF-7, HeLa, Jurkat and K562 cell lines) and further analyzed for cell proliferation, cell death type, and for act of the mechanism. Cell proliferation was determined by the MTT method and cell death types were analyzed with HO/PI staining. Fibroblast Growth Factor 1 (FGF-1), Interleukin 1 (IL-1), Interleukin 6 (IL-6), and Tumor Necrosis Factor Alpha (TNF-α), key players in breast cancer development and progression, were determined by Elisa kits. Results showed that compound 2 e inhibited the MCF-7 cell line proliferation with an IC50 value of 0.66±0.17 μM with 93.38 % apoptosis rate. Compound 2 e also decreased FGF-1, IL-1, IL-6, and TNF-α levels. Molecular docking studies performed in the binding site of FGFR-1 indicated that compound 2 e formed key hydrogen bonding with Arg627 and Asn568. Besides, compounds 2 a-2 f were evaluated for their antimicrobial activities against gram-negative and gram-positive bacteria and C. albicans via the microdilution method. Overall, compound 2 e stands out as a potential anticancer agent for future studies.
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Affiliation(s)
- Safiye Emirdağ
- Faculty of Science Dean's Department of Chemistry, Ege University, 35040, İzmir, Turkey
| | - Nafia Gökçe Ulusoy
- Faculty of Science Dean's Department of Chemistry, Ege University, 35040, İzmir, Turkey
| | - Mehran Aksel
- Department of Biophysics, Faculty of Medicine, Aydın Adnan Menderes University, 09010, Aydin, Turkey
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de Souza CS, Lopes VRDC, Barcellos G, Alexandrino-Junior F, Neves PCDC, Patricio BFDC, Rocha HVA, Ano Bom APD, Figueiredo ABC. Unleashing Fungicidal Forces: Exploring the Synergistic Power of Amphotericin B-Loaded Nanoparticles and Monoclonal Antibodies. J Fungi (Basel) 2024; 10:344. [PMID: 38786699 PMCID: PMC11122123 DOI: 10.3390/jof10050344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Fungal infections cause 1.7 million deaths annually, which can be attributed not only to fungus-specific factors, such as antifungal resistance and biofilm formation, but also to drug-related challenges. In this study, the potential of Amphotericin (AmB) loaded polymeric nanoparticles (AmB-NPs) combined with murine monoclonal antibodies (mAbs) (i.e., CC5 and DD11) was investigated as a strategy to overcome these challenges. To achieve this goal, AmB-NPs were prepared by nanoprecipitation using different polymers (polycaprolactone (PCL) and poly(D,L-lactide) (PLA)), followed by comprehensive characterization of their physicochemical properties and in vitro biological performance. The results revealed that AmB-loaded NPs exhibited no cytotoxicity toward mammalian cells (baby hamster kidney cells-BHK and human monocyte cells-THP-1). Conversely, both AmB-NPs demonstrated a cytotoxic effect against C. albicans, C. neoformans, and H. capsulatum throughout the entire evaluated range (from 10 µg/mL to 0.1 µg/mL), with a significant MIC of up to 0.031 µg/mL. Moreover, the combination of AmB-NPs with mAbs markedly intensified antifungal activity, resulting in a synergistic effect that was two to four times greater than that of AmB-NPs alone. These findings suggest that the combination of AmB-NPs with mAbs could be a promising new treatment for fungal infections that is potentially more effective and less toxic than current antifungal treatments.
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Affiliation(s)
- Carla Soares de Souza
- Laboratório de Tecnologia Imunológica (LATIM), Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (C.S.d.S.); (P.C.d.C.N.)
| | - Victor Ropke da Cruz Lopes
- Laboratório de Tecnologia Imunológica (LATIM), Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (C.S.d.S.); (P.C.d.C.N.)
| | - Gabriel Barcellos
- Programa de Pós-Graduação em Pesquisa Translacional em Fármacos e Medicamentos, Farmanguinhos, Fundação Oswaldro Cruz (Fiocruz), Rio de Janeiro 21040-900, Brazil (H.V.A.R.)
| | - Francisco Alexandrino-Junior
- Laboratório de Micro e Nanotecnologia, Farmanguinhos, Fundação Oswaldro Cruz (Fiocruz), Rio de Janeiro 21040-361, Brazil
| | - Patrícia Cristina da Costa Neves
- Laboratório de Tecnologia Imunológica (LATIM), Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (C.S.d.S.); (P.C.d.C.N.)
| | - Beatriz Ferreira de Carvalho Patricio
- Laboratório de Inovação Farmacêutica e Tecnológica, Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro (Unirio), Rio de Janeiro 22290-250, Brazil;
| | - Helvécio Vinícius Antunes Rocha
- Programa de Pós-Graduação em Pesquisa Translacional em Fármacos e Medicamentos, Farmanguinhos, Fundação Oswaldro Cruz (Fiocruz), Rio de Janeiro 21040-900, Brazil (H.V.A.R.)
- Laboratório de Micro e Nanotecnologia, Farmanguinhos, Fundação Oswaldro Cruz (Fiocruz), Rio de Janeiro 21040-361, Brazil
| | - Ana Paula Dinis Ano Bom
- Laboratório de Tecnologia Imunológica (LATIM), Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (C.S.d.S.); (P.C.d.C.N.)
| | - Alexandre Bezerra Conde Figueiredo
- Laboratório de Tecnologia Imunológica (LATIM), Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (C.S.d.S.); (P.C.d.C.N.)
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Boyer J, Hoenigl M, Kriegl L. Therapeutic drug monitoring of antifungal therapies: do we really need it and what are the best practices? Expert Rev Clin Pharmacol 2024; 17:309-321. [PMID: 38379525 DOI: 10.1080/17512433.2024.2317293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Despite advancements, invasive fungal infections (IFI) still carry high mortality rates, often exceeding 30%. The challenges in diagnosis, coupled with limited effective antifungal options, make managing IFIs complex. Antifungal drugs are essential for IFI management, but their efficacy can be diminished by drug-drug interactions and pharmacokinetic variability. Therapeutic Drug Monitoring (TDM), especially in the context of triazole use, has emerged as a valuable strategy to optimize antifungal therapy. AREAS COVERED This review provides current evidence regarding the potential benefits of TDM in IFI management. It discusses how TDM can enhance treatment response, safety, and address altered pharmacokinetics in specific patient populations. EXPERT OPINION TDM plays a crucial role in achieving optimal therapeutic outcomes in IFI management, particularly for certain antifungal agents. Preclinical studies consistently show a link between therapeutic drug levels and antifungal efficacy. However, clinical research in mycology faces challenges due to patient heterogeneity and the diversity of fungal infections. TDM's potential advantages in guiding Echinocandin therapy for critically ill patients warrant further investigation. Additionally, for drugs like Posaconazole, assessing whether serum levels or alternative markers like saliva offer the best measure of efficacy is an intriguing question.
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Affiliation(s)
- Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
- Translational Mycology Working Group, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria
| | - Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Arendrup MC, Arikan-Akdagli S, Jørgensen KM, Barac A, Steinmann J, Toscano C, Arsenijevic VA, Sartor A, Lass-Flörl C, Hamprecht A, Matos T, Rogers BRS, Quiles I, Buil J, Özenci V, Krause R, Bassetti M, Loughlin L, Denis B, Grancini A, White PL, Lagrou K, Willinger B, Rautemaa-Richardson R, Hamal P, Ener B, Unalan-Altintop T, Evren E, Hilmioglu-Polat S, Oz Y, Ozyurt OK, Aydin F, Růžička F, Meijer EFJ, Gangneux JP, Lockhart DEA, Khanna N, Logan C, Scharmann U, Desoubeaux G, Roilides E, Talento AF, van Dijk K, Koehler P, Salmanton-García J, Cornely OA, Hoenigl M. European candidaemia is characterised by notable differential epidemiology and susceptibility pattern: Results from the ECMM Candida III study. J Infect 2023; 87:428-437. [PMID: 37549695 DOI: 10.1016/j.jinf.2023.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 08/03/2023] [Indexed: 08/09/2023]
Abstract
The objectives of this study were to assess Candida spp. distribution and antifungal resistance of candidaemia across Europe. Isolates were collected as part of the third ECMM Candida European multicentre observational study, conducted from 01 to 07-07-2018 to 31-03-2022. Each centre (maximum number/country determined by population size) included ∼10 consecutive cases. Isolates were referred to central laboratories and identified by morphology and MALDI-TOF, supplemented by ITS-sequencing when needed. EUCAST MICs were determined for five antifungals. fks sequencing was performed for echinocandin resistant isolates. The 399 isolates from 41 centres in 17 countries included C. albicans (47.1%), C. glabrata (22.3%), C. parapsilosis (15.0%), C. tropicalis (6.3%), C. dubliniensis and C. krusei (2.3% each) and other species (4.8%). Austria had the highest C. albicans proportion (77%), Czech Republic, France and UK the highest C. glabrata proportions (25-33%) while Italy and Turkey had the highest C. parapsilosis proportions (24-26%). All isolates were amphotericin B susceptible. Fluconazole resistance was found in 4% C. tropicalis, 12% C. glabrata (from six countries across Europe), 17% C. parapsilosis (from Greece, Italy, and Turkey) and 20% other Candida spp. Four isolates were anidulafungin and micafungin resistant/non-wild-type and five resistant to micafungin only. Three/3 and 2/5 of these were sequenced and harboured fks-alterations including a novel L657W in C. parapsilosis. The epidemiology varied among centres and countries. Acquired echinocandin resistance was rare but included differential susceptibility to anidulafungin and micafungin, and resistant C. parapsilosis. Fluconazole and voriconazole cross-resistance was common in C. glabrata and C. parapsilosis but with different geographical prevalence.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Sevtap Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey
| | | | - Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jörg Steinmann
- Institute for Clincal Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Cristina Toscano
- Microbiology Laboratory, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Valentina Arsic Arsenijevic
- Faculty of Medicine University of Belgrade, Institute of Microbiology and Immunology, Medical Mycology Reference Laboratory (MMRL), Belgrade, Serbia
| | - Assunta Sartor
- SC Microbiology, Department of Laboratory Medicine, Friuli Centrale University Health Authority, Udin, Italy
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Axel Hamprecht
- University of Cologne, University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Cologne, Germany; University of Oldenburg, Institute for Medical Microbiology and Virology, Oldenburg, Germany
| | - Tadeja Matos
- Institute of Microbiology and Immunology, Medical Faculty, University of Ljubljana, Slovenia
| | - Benedict R S Rogers
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Inmaculada Quiles
- Department of Microbiology, La Paz University Hospital, Madrid, Spain
| | - Jochem Buil
- Canisius Wilhelmina Hospital (CWZ), Medical Microbiology and Infectious Diseases, Nijmegen, the Netherlands; Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands; Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
| | - Volkan Özenci
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Robert Krause
- Biotech Med, Graz, Austria; Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Matteo Bassetti
- Infectious Diseases Unit, IRCCS San Martino Polyclinic Hospital, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Laura Loughlin
- Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Blandine Denis
- Department of Infectious Diseases, Hôpital Saint-Louis, Fernand Widal, Lariboisière, AP-HP, Paris, France
| | - Anna Grancini
- U.O.S Microbiology - Analysis Laboratory, IRCCS Foundation, Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Lewis White
- Public Health Wales Microbiology Cardiff and Cardiff University School of Medicine, United Kingdom
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Laboratory Medicine and National Reference Center for Mycosis University Hospitals Leuven, Leuven, Belgium
| | - Birgit Willinger
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Petr Hamal
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Beyza Ener
- Department of Medical Microbiology, Bursa Uludağ University Medical School, Bursa, Turkey
| | - Tugce Unalan-Altintop
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey
| | - Ebru Evren
- Department of Medical Microbiology, Ankara University Medical School, Ankara, Turkey
| | | | - Yasemin Oz
- Department of Medical Microbiology, Eskisehir Osmangazi University Medical School, Eskisehir, Turkey
| | - Ozlem Koyuncu Ozyurt
- Department of Medical Microbiology, Akdeniz University Medical School, Antalya, Turkey
| | - Faruk Aydin
- KTÜ Tıp Fakültesi Tıbbi Mikrobiyoloji AbD, Trabzon, Turkey
| | - Filip Růžička
- Masaryk University, Faculty of Medicine and St. Anne's Faculty Hospital, Department of Microbiology, Brno, Czech Republic
| | - Eelco F J Meijer
- Canisius Wilhelmina Hospital (CWZ), Medical Microbiology and Infectious Diseases, Nijmegen, the Netherlands; Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands; Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
| | - Jean Pierre Gangneux
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, F-35000 Rennes, France
| | - Deborah E A Lockhart
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, United Kingdom; Institute of Medical Sciences, School of Medicine Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Clare Logan
- Clinical Infection Unit, St Georges University NHS Hospital Foundation Trust, Blackshaw Road, London, United Kingdom; Institute of Infection & Immunity, St Georges University London, Cranmer Terrace, London, United Kingdom
| | - Ulrike Scharmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Guillaume Desoubeaux
- Department of Parasitology-Mycology-Tropical medicine, CHRU Tours, Tours, France
| | - Emmanuel Roilides
- Hippokration General Hospital, Infectious Diseases Department, Medical School, Aristotle University of Thessaloniki, Greece
| | | | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Institute of Translational Research, Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Jon Salmanton-García
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Institute of Translational Research, Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Institute of Translational Research, Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Martin Hoenigl
- Biotech Med, Graz, Austria; Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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Gomez-Lopez A, Sanchez Galiano S, Ortega Madueño S, Carballo Gonzalez C. Observed isavuconazole exposure: 5-year experience of azole TDM from a Spanish reference laboratory. Med Mycol 2023; 61:myad086. [PMID: 37580172 DOI: 10.1093/mmy/myad086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/28/2023] [Accepted: 08/12/2023] [Indexed: 08/16/2023] Open
Abstract
We aimed to assess patient exposure to isavuconazole (ISZ) from samples received in our laboratory for therapeutic antifungal monitoring. We used liquid chromatography coupled with ultraviolet (UV) absorbance detection adapted from a multiplex-validated method with photodiode array (PDA) detection to monitor the analytes. The latter device allows the characterization of the azoles UV spectra. The method was validated according to international guidelines for efficient ISZ monitoring. The assay exhibited linearity between 0.25 and 16 mg/l for ISZ. Accuracy and intra- and inter-day precision were within acceptable ranges, and the method was successfully applied to quantify azoles and major metabolites from clinical samples collected from treated patients. We focus on ISZ blood concentrations and compared them to those of voriconazole, posaconazole, and itraconazole for a period of 5 years (2017-2021). Median ISZ concentration was 2.92 mg/l (interquartile range 1.82-5.33 mg/l) with 89% of measurements classified as adequate exposure (> 1 mg/l). Additionally, 71% of samples reach concentration values > 2 mg/l. Different ISZ exposure between adults to children were found. In conclusion, ISZ achieves excellent blood concentrations compared to other azole drugs, they are almost identical to those previously described, they exceed the MICs of most fungi for which its use was recommended and they differ depending on the patient's age. The method we describe for antifungal monitoring is simple, robust, and efficient. It simultaneously analyzes azoles and metabolites, and can be used for tailored interventions, achieve exposures associated with therapeutic success, decrease treatment-related toxicity, and help prevent resistance emergence due to continuous azole sub-optimal concentrations.
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Affiliation(s)
- Alicia Gomez-Lopez
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo Km 2 Madrid, Spain
| | - Susana Sanchez Galiano
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
| | - Sheila Ortega Madueño
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
| | - Cristina Carballo Gonzalez
- Mycology Reference and Research Laboratory (National Centre for Microbiology CNM-ISCIII), Instituto de Salud Carlos III Carretera Majadahonda-Pozuelo Km 2 28220 Madrid, Spain
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Peláez-García de la Rasilla T, Mato-López Á, Pablos-Puertas CE, González-Huerta AJ, Gómez-López A, Mellado E, Amich J. Potential Implication of Azole Persistence in the Treatment Failure of Two Haematological Patients Infected with Aspergillus fumigatus. J Fungi (Basel) 2023; 9:805. [PMID: 37623576 PMCID: PMC10455522 DOI: 10.3390/jof9080805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
Invasive aspergillosis (IA) is a major cause of morbidity and mortality in patients receiving allogeneic haematopoieticcell transplantation. The deep immunosuppression and a variety of potential additional complications developed in these patients result in IA reaching mortality rates of around 50-60%. This mortality is even higher when the patients are infected with azole-resistant isolates, demonstrating that, despite the complexity of management, adequate azole treatment can have a beneficial effect. It is therefore paramount to understand the reasons why antifungal treatment of IA infections caused by azole-susceptible isolates is often unsuccessful. In this respect, there are already various factors known to be important for treatment efficacy, for instance the drug concentrations achieved in the blood, which are thus often monitored. We hypothesize that antifungal persistence may be another important factor to consider. In this study we present two case reports of haematological patients who developed proven IA and suffered treatment failure, despite having been infected with susceptible isolates, receiving correct antifungal treatment and reaching therapeutic levels of the azole. Microbiological analysis of the recovered infective isolates showed that the patients were infected with multiple strains, several of which were persisters to voriconazole and/or isavuconazole. Therefore, we propose that azole persistence may have contributed to therapeutic failure in these patients and that this phenomenon should be considered in future studies.
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Affiliation(s)
- Teresa Peláez-García de la Rasilla
- Microbiology Department, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Asturias, Spain
- Institute for Health Research in the Principality of Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Asturias, Spain
| | - Álvaro Mato-López
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología LRIM), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain
| | - Clara E. Pablos-Puertas
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología LRIM), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain
| | - Ana Julia González-Huerta
- Hematology-Stem Cell Transplantation Unit, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Asturias, Spain
| | - Alicia Gómez-López
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología LRIM), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología LRIM), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jorge Amich
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología LRIM), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain
- Manchester Fungal Infection Group (MFIG), Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M139NT, UK
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9
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Kanaujia R, Singh S, Rudramurthy SM. Aspergillosis: an Update on Clinical Spectrum, Diagnostic Schemes, and Management. CURRENT FUNGAL INFECTION REPORTS 2023; 17:1-12. [PMID: 37360858 PMCID: PMC10157594 DOI: 10.1007/s12281-023-00461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review gives an overview of the diseases caused by Aspergillus, including a description of the species involved and the infected clinical systems. We provide insight into the various diagnostic methods available for diagnosing aspergillosis, particularly invasive aspergillosis (IA), including the role of radiology, bronchoscopy, culture, and non-culture-based microbiological methods. We also discuss the available diagnostic algorithms for the different disease conditions. This review also summarizes the main aspects of managing infections due to Aspergillus spp., such as antifungal resistance, choice of antifungals, therapeutic drug monitoring, and new antifungal alternatives. Recent Findings The risk factors for this infection continue to evolve with the development of many biological agents that target the immune system and the increase of viral illnesses such as coronavirus disease. Due to the limitations of present mycological test methods, establishing a fast diagnosis is frequently difficult, and reports of developing antifungal resistance further complicate the management of aspergillosis. Many commercial assays, like AsperGenius®, MycAssay Aspergillus®, and MycoGENIE®, have the advantage of better species-level identification and concomitant resistance-associated mutations. Fosmanogepix, ibrexafungerp, rezafungin, and olorofim are newer antifungal agents in the pipeline exhibiting remarkable activity against Aspergillus spp. Summary The fungus Aspergillus is found ubiquitously around the world and can cause various infections, from harmless saprophytic colonization to severe IA. Understanding the diagnostic criteria to be used in different patient groups and the local epidemiological data and antifungal susceptibility profile is critical for optimal patient management.
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Affiliation(s)
- Rimjhim Kanaujia
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
| | - Shreya Singh
- Department of Microbiology, Dr B R Ambedkar State Institute of Medical Sciences (AIMS), Mohali, Punjab India
| | - Shivaprakash M. Rudramurthy
- Mycology Division, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
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10
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Wang YS, Hsu JF, Lee WJ, Wang SH, Chu SM, Huang HR, Yang PH, Fu RH, Tsai MH. Invasive Candida parapsilosis Bloodstream Infections in Children: The Antifungal Susceptibility, Clinical Characteristics and Impacts on Outcomes. Microorganisms 2023; 11:1149. [PMID: 37317123 DOI: 10.3390/microorganisms11051149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 06/16/2023] Open
Abstract
Background: Candida parapsilosis is the most common non-albicans candida species that causes invasive candidiasis, but little is known about its impacts on the outcomes of pediatric patients. We aimed to characterize the clinical characteristics, risk factors and outcomes of C. parapsilosis bloodstream infections (BSIs) in children. Methods: All pediatric patients with Candida parapsilosis BSIs between 2005 and 2020 from a medical center in Taiwan were enrolled and analyzed. The antifungal susceptibility, clinical manifestations, management and outcomes were investigated. Cases of Candida parapsilosis BSIs were compared between patients with C. albicans BSIs and other Candida spp. BSIs. Results: During the study period, 95 episodes (26.0% of total cases) of Candida parapsilosis BSIs were identified and analyzed. No significant difference was found between pediatric patients with C. parapsilosis BSIs and those with C. albicans BSIs in terms of patients' demographics, most chronic comorbidities or risk factors. Pediatric patients with C. parapsilosis BSIs were significantly more likely to have previous azole exposure and be on total parenteral nutrition than those with C. albicans BSIs (17.9 vs. 7.6% and 76.8 vs. 63.7%, p = 0.015 and 0.029, respectively). The duration of C. parapsilosis candidemia was relatively longer, and therefore patients often required a longer duration of antifungal treatment when compared with those of C. albicans candidemia, although the candidemia-attributable mortality rates were comparable. Of the C. parapsilosis isolates, 93.7% were susceptible to all antifungal agents, and delayed appropriate antifungal treatment was an independent factor in treatment failure. Conclusions: Pediatric patients with C. parapsilosis BSIs were more likely to have previous azole exposure and be on total parenteral nutrition, and the clinical significances included a longer duration of candidemia and patients often required a longer duration of antifungal treatment.
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Affiliation(s)
- Yao-Sheng Wang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Jen-Fu Hsu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Wei-Ju Lee
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Shao-Hung Wang
- Department of Microbiology Immunology and Biopharmaceuticals, National Chiayi University, Chiayi 613, Taiwan
| | - Shih-Ming Chu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Hsuan-Rong Huang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Peng-Hong Yang
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Ren-Huei Fu
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 244, Taiwan
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan 244, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
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11
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Stemler J, Többen C, Lass-Flörl C, Steinmann J, Ackermann K, Rath PM, Simon M, Cornely OA, Koehler P. Diagnosis and Treatment of Invasive Aspergillosis Caused by Non- fumigatus Aspergillus spp. J Fungi (Basel) 2023; 9:jof9040500. [PMID: 37108955 PMCID: PMC10141595 DOI: 10.3390/jof9040500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
With increasing frequency, clinical and laboratory-based mycologists are consulted on invasive fungal diseases caused by rare fungal species. This review aims to give an overview of the management of invasive aspergillosis (IA) caused by non-fumigatus Aspergillus spp.-namely A. flavus, A. terreus, A. niger and A. nidulans-including diagnostic and therapeutic differences and similarities to A. fumigatus. A. flavus is the second most common Aspergillus spp. isolated in patients with IA and the predominant species in subtropical regions. Treatment is complicated by its intrinsic resistance against amphotericin B (AmB) and high minimum inhibitory concentrations (MIC) for voriconazole. A. nidulans has been frequently isolated in patients with long-term immunosuppression, mostly in patients with primary immunodeficiencies such as chronic granulomatous disease. It has been reported to disseminate more often than other Aspergillus spp. Innate resistance against AmB has been suggested but not yet proven, while MICs seem to be elevated. A. niger is more frequently reported in less severe infections such as otomycosis. Triazoles exhibit varying MICs and are therefore not strictly recommended as first-line treatment for IA caused by A. niger, while patient outcome seems to be more favorable when compared to IA due to other Aspergillus species. A. terreus-related infections have been reported increasingly as the cause of acute and chronic aspergillosis. A recent prospective international multicenter surveillance study showed Spain, Austria, and Israel to be the countries with the highest density of A. terreus species complex isolates collected. This species complex seems to cause dissemination more often and is intrinsically resistant to AmB. Non-fumigatus aspergillosis is difficult to manage due to complex patient histories, varying infection sites and potential intrinsic resistances to antifungals. Future investigational efforts should aim at amplifying the knowledge on specific diagnostic measures and their on-site availability, as well as defining optimal treatment strategies and outcomes of non-fumigatus aspergillosis.
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Affiliation(s)
- Jannik Stemler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Christina Többen
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, European Diamond Excellence Center for Medical Mycology (ECMM), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Jörg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Katharina Ackermann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
| | - Peter-Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Michaela Simon
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
| | - Oliver Andreas Cornely
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, 50935 Cologne, Germany
| | - Philipp Koehler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
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12
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Destere A, Marquet P, Labriffe M, Drici MD, Woillard JB. A Hybrid Algorithm Combining Population Pharmacokinetic and Machine Learning for Isavuconazole Exposure Prediction. Pharm Res 2023; 40:951-959. [PMID: 36991227 DOI: 10.1007/s11095-023-03507-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Maximum a posteriori Bayesian estimation (MAP-BE) based on a limited sampling strategy and a population pharmacokinetic (POPPK) model is used to estimate individual pharmacokinetic parameters. Recently, we proposed a methodology that combined population pharmacokinetic and machine learning (ML) to decrease the bias and imprecision in individual iohexol clearance prediction. The aim of this study was to confirm the previous results by developing a hybrid algorithm combining POPPK, MAP-BE and ML that accurately predicts isavuconazole clearance. METHODS A total of 1727 isavuconazole rich PK profiles were simulated using a POPPK model from the literature, and MAP-BE was used to estimate the clearance based on: (i) the full PK profiles (refCL); and (ii) C24h only (C24h-CL). Xgboost was trained to correct the error between refCL and C24h-CL in the training dataset (75%). C24h-CL as well as ML-corrected C24h-CL were evaluated in a testing dataset (25%) and then in a set of PK profiles simulated using another published POPPK model. RESULTS A strong decrease in mean predictive error (MPE%), imprecision (RMSE%) and the number of profiles outside ± 20% MPE% (n-out20%) was observed with the hybrid algorithm (decreased in MPE% by 95.8% and 85.6%; RMSE% by 69.5% and 69.0%; n-out20% by 97.4% and 100% in the training and testing sets, respectively. In the external validation set, the hybrid algorithm decreased MPE% by 96%, RMSE% by 68% and n-out20% by 100%. CONCLUSION The hybrid model proposed significantly improved isavuconazole AUC estimation over MAP-BE based on the sole C24h and may improve dose adjustment.
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Affiliation(s)
- Alexandre Destere
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, 87000, Limoges, France
- Department of Pharmacology and Pharmacovigilance Center, Côte d'Azur University Medical Center, Nice, France
| | - Pierre Marquet
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, 87000, Limoges, France
- Department of Pharmacology Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Marc Labriffe
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, 87000, Limoges, France
- Department of Pharmacology Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center, Côte d'Azur University Medical Center, Nice, France
| | - Jean-Baptiste Woillard
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, 87000, Limoges, France.
- Department of Pharmacology Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France.
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13
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Scott J, Valero C, Mato-López Á, Donaldson IJ, Roldán A, Chown H, Van Rhijn N, Lobo-Vega R, Gago S, Furukawa T, Morogovsky A, Ben Ami R, Bowyer P, Osherov N, Fontaine T, Goldman GH, Mellado E, Bromley M, Amich J. Aspergillus fumigatus Can Display Persistence to the Fungicidal Drug Voriconazole. Microbiol Spectr 2023; 11:e0477022. [PMID: 36912663 PMCID: PMC10100717 DOI: 10.1128/spectrum.04770-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/12/2023] [Indexed: 03/14/2023] Open
Abstract
Aspergillus fumigatus is a filamentous fungus that can infect the lungs of patients with immunosuppression and/or underlying lung diseases. The mortality associated with chronic and invasive aspergillosis infections remain very high, despite availability of antifungal treatments. In the last decade, there has been a worrisome emergence and spread of resistance to the first-line antifungals, the azoles. The mortality caused by resistant isolates is even higher, and patient management is complicated as the therapeutic options are reduced. Nevertheless, treatment failure is also common in patients infected with azole-susceptible isolates, which can be due to several non-mutually exclusive reasons, such as poor drug absorption. In addition, the phenomena of tolerance or persistence, where susceptible pathogens can survive the action of an antimicrobial for extended periods, have been associated with treatment failure in bacterial infections, and their occurrence in fungal infections already proposed. Here, we demonstrate that some isolates of A. fumigatus display persistence to voriconazole. A subpopulation of the persister isolates can survive for extended periods and even grow at low rates in the presence of supra-MIC of voriconazole and seemingly other azoles. Persistence cannot be eradicated with adjuvant drugs or antifungal combinations and seemed to reduce the efficacy of treatment for certain individuals in a Galleria mellonella model of infection. Furthermore, persistence implies a distinct transcriptional profile, demonstrating that it is an active response. We propose that azole persistence might be a relevant and underestimated factor that could influence the outcome of infection in human aspergillosis. IMPORTANCE The phenomena of antibacterial tolerance and persistence, where pathogenic microbes can survive for extended periods in the presence of cidal drug concentrations, have received significant attention in the last decade. Several mechanisms of action have been elucidated, and their relevance for treatment failure in bacterial infections demonstrated. In contrast, our knowledge of antifungal tolerance and, in particular, persistence is still very limited. In this study, we have characterized the response of the prominent fungal pathogen Aspergillus fumigatus to the first-line therapy antifungal voriconazole. We comprehensively show that some isolates display persistence to this fungicidal antifungal and propose various potential mechanisms of action. In addition, using an alternative model of infection, we provide initial evidence to suggest that persistence may cause treatment failure in some individuals. Therefore, we propose that azole persistence is an important factor to consider and further investigate in A. fumigatus.
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Affiliation(s)
- Jennifer Scott
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Clara Valero
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Álvaro Mato-López
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología [LRIM]), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Ian J. Donaldson
- Bioinformatics Core Facility, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alejandra Roldán
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología [LRIM]), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Harry Chown
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Norman Van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Rebeca Lobo-Vega
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología [LRIM]), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Sara Gago
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Takanori Furukawa
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alma Morogovsky
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben Ami
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paul Bowyer
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Nir Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thierry Fontaine
- Institut Pasteur, Université de Paris, INRAE, USC2019, Unité Biologie et Pathogénicité Fongiques, Paris, France
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Emilia Mellado
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología [LRIM]), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
- CiberInfec ISCIII, CIBER en Enfermedades Infecciosas, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Michael Bromley
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Jorge Amich
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Mycology Reference Laboratory (Laboratorio de Referencia e Investigación en Micología [LRIM]), National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
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14
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Chen X, Lei W, Meng H, Jiang Y, Zhang S, Chen H, Du M, Xue X. Succinylation modification provides new insights for the treatment of immunocompromised individuals with drug-resistant Aspergillus fumigatus infection. Front Immunol 2023; 14:1161642. [PMID: 37138872 PMCID: PMC10150703 DOI: 10.3389/fimmu.2023.1161642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 05/05/2023] Open
Abstract
Invasive Aspergillus fumigatus infection poses a serious threat to global human health, especially to immunocompromised individuals. Currently, triazole drugs are the most commonly used antifungals for aspergillosis. However, owing to the emergence of drug-resistant strains, the effect of triazole drugs is greatly restricted, resulting in a mortality rate as high as 80%. Succinylation, a novel post-translational modification, is attracting increasing interest, although its biological function in triazole resistance remains unclear. In this study, we initiated the screening of lysine succinylation in A. fumigatus. We discovered that some of the succinylation sites differed significantly among strains with unequal itraconazole (ITR) resistance. Bioinformatics analysis showed that the succinylated proteins are involved in a broad range of cellular functions with diverse subcellular localizations, the most notable of which is cell metabolism. Further antifungal sensitivity tests confirmed the synergistic fungicidal effects of dessuccinylase inhibitor nicotinamide (NAM) on ITR-resistant A. fumigatus. In vivo experiments revealed that treatment with NAM alone or in combination with ITR significantly increased the survival of neutropenic mice infected with A. fumigatus. In vitro experiments showed that NAM enhanced the killing effect of THP-1 macrophages on A. fumigatus conidia. Our results suggest that lysine succinylation plays an indispensable role in ITR resistance of A. fumigatus. Dessuccinylase inhibitor NAM alone or in combination with ITR exerted good effects against A. fumigatus infection in terms of synergistic fungicidal effect and enhancing macrophage killing effect. These results provide mechanistic insights that will aid in the treatment of ITR-resistant fungal infections.
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Affiliation(s)
- Xianzhen Chen
- Institute of Dermatology, Naval Medical University, Shanghai, China
- Department of Dermatology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wenzhi Lei
- Institute of Dermatology, Naval Medical University, Shanghai, China
| | - Hui Meng
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
| | - Yi Jiang
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
| | - Sanli Zhang
- Department of Nephrology, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Huyan Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
| | - Mingwei Du
- Department of Cardiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
| | - Xiaochun Xue
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
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15
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Arendrup MC, Arikan-Akdagli S, Castanheira M, Guinea J, Locke JB, Meletiadis J, Zaragoza O. Multicentre validation of a modified EUCAST MIC testing method and development of associated epidemiologic cut-off (ECOFF) values for rezafungin. J Antimicrob Chemother 2022; 78:185-195. [PMID: 36329639 DOI: 10.1093/jac/dkac373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Rezafungin EUCAST MIC testing has been associated with notable inter-laboratory variation, which prevented ECOFF setting for C. albicans. We assessed in vitro susceptibility and reproducibility for a modified EUCAST methodology and established associated wild-type upper limits (WT-ULs). METHODS MICs against 150 clinical Candida isolates (six species), molecularly characterized fks mutants (n = 13), and QC strains (n = 6) were determined at six laboratories according to E.Def 7.3 but using Tween 20 supplemented medium. WT-ULs were determined using the derivatization method, the ECOFFinder programme and visual inspection. Consensus WT-ULs were determined. RESULTS The laboratory- and species-specific MIC distributions were Gaussian with >99.5% MICs within four 2-fold dilutions except for C. parapsilosis (92.8%). The following consensus WT-UL were determined: C. albicans 0.008 mg/L; C. dubliniensis and C. glabrata 0.016 mg/L; C. krusei and C. tropicalis 0.03 mg/L; and C. parapsilosis 4 mg/L. Adopting these WT-UL, six clinical isolates were non-wild-type, five of which harboured Fks alterations. For 11/13 mutants, all 670 MICs were categorized as non-wild-type whereas MICs for C. glabrata Fks2 D666Y and C. tropicalis Fks1 R656R/G overlapped with the corresponding wild-type distributions. Repeat testing of six reference strains yielded 98.3%-100% of MICs within three 2-fold dilutions except for C. albicans CNM-CL-F8555 (96%) and C. parapsilosis ATCC 22019 (93.3%). CONCLUSIONS The modified EUCAST method significantly improved inter-laboratory variation, identified wild-type populations and allowed perfect separation of wild-type and fks mutants except for two isolates harbouring weak mutations. These consensus WT-UL have been accepted as ECOFFs and will be used for rezafungin breakpoint setting.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sevtap Arikan-Akdagli
- Unit of Mycology, Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey
| | | | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | | | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Oscar Zaragoza
- Mycology Reference Laboratory, National Centre for Microbiology, Health Institute Carlos III, Majadahonda, Madrid, Spain.,Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
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16
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Trevijano-Contador N, Torres-Cano A, Carballo-González C, Puig-Asensio M, Martín-Gómez MT, Jiménez-Martínez E, Romero D, Nuvials FX, Olmos-Arenas R, Moretó-Castellsagué MC, Fernández-Delgado L, Rodríguez-Sevilla G, Aguilar-Sánchez MM, Ayats-Ardite J, Ardanuy-Tisaire C, Sanchez-Romero I, Muñoz-Algarra M, Merino-Amador P, González-Romo F, Megías-Lobón G, García-Campos JA, Mantecón-Vallejo MÁ, Alcoceba E, Escribano P, Guinea J, Durán-Valle MT, Fraile-Torres AM, Roiz-Mesones MP, Lara-Plaza I, de Ayala AP, Simón-Sacristán M, Collazos-Blanco A, Nebreda-Mayoral T, March-Roselló G, Alcázar-Fuoli L, Zaragoza O. Global Emergence of Resistance to Fluconazole and Voriconazole in Candida parapsilosis in Tertiary Hospitals in Spain During the COVID-19 Pandemic. Open Forum Infect Dis 2022; 9:ofac605. [PMID: 36467290 PMCID: PMC9709632 DOI: 10.1093/ofid/ofac605] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 11/03/2022] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Candida parapsilosis is a frequent cause of candidemia worldwide. Its incidence is associated with the use of medical implants, such as central venous catheters or parenteral nutrition. This species has reduced susceptibility to echinocandins, and it is susceptible to polyenes and azoles. Multiple outbreaks caused by fluconazole-nonsusceptible strains have been reported recently. A similar trend has been observed among the C. parapsilosis isolates received in the last 2 years at the Spanish Mycology Reference Laboratory. METHODS Yeast were identified by molecular biology, and antifungal susceptibility testing was performed using the European Committee on Antimicrobial Susceptibility Testing protocol. The ERG11 gene was sequenced to identify resistance mechanisms, and strain typing was carried out by microsatellite analysis. RESULTS We examined the susceptibility profile of 1315 C. parapsilosis isolates available at our reference laboratory between 2000 and 2021, noticing an increase in the number of isolates with acquired resistance to fluconazole, and voriconazole has increased in at least 8 different Spanish hospitals in 2020-2021. From 121 recorded clones, 3 were identified as the most prevalent in Spain (clone 10 in Catalonia and clone 96 in Castilla-Leon and Madrid, whereas clone 67 was found in 2 geographically unrelated regions, Cantabria and the Balearic Islands). CONCLUSIONS Our data suggest that concurrently with the coronavirus disease 2019 pandemic, a selection of fluconazole-resistant C. parapsilosis isolates has occurred in Spain, and the expansion of specific clones has been noted across centers. Further research is needed to determine the factors that underlie the successful expansion of these clones and their potential genetic relatedness.
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Affiliation(s)
- Nuria Trevijano-Contador
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo, Madrid, Spain
| | - Alba Torres-Cano
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo, Madrid, Spain
| | - Cristina Carballo-González
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo, Madrid, Spain
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge-Institut d´Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid, Spain
| | - María Teresa Martín-Gómez
- Department of Microbiology, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Emilio Jiménez-Martínez
- Department of Infectious Diseases, Hospital Universitari de Bellvitge-Institut d´Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Daniel Romero
- Department of Microbiology, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Xavier Nuvials
- Intensive Care Unit, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Roberto Olmos-Arenas
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | | | | | | | | | - Josefina Ayats-Ardite
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | - Carmen Ardanuy-Tisaire
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
- Center for Biomedical Research Network in Respiratory Diseases (CIBERES-CB06/06/0037), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Sanchez-Romero
- Microbiology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - María Muñoz-Algarra
- Microbiology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Paloma Merino-Amador
- Microbiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
- Department of Medicine, Universidad Complutense School of Medicine, Madrid, Spain
| | - Fernando González-Romo
- Microbiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
- Department of Medicine, Universidad Complutense School of Medicine, Madrid, Spain
| | - Gregoria Megías-Lobón
- Department of Clinical Microbiology, Hospital Universitario de Burgos, Burgos, Castilla y León, Spain
| | - Jose Angel García-Campos
- Department of Clinical Microbiology, Hospital Universitario de Burgos, Burgos, Castilla y León, Spain
| | | | - Eva Alcoceba
- Clinical Microbiology Department, Hospital Universitari Son Espases, Mallorca, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jesús Guinea
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Center for Biomedical Research Network in Respiratory Diseases (CIBERES-CB06/06/0058), Madrid, Spain
| | | | | | - María Pía Roiz-Mesones
- Microbiology Department, Marqués de Valdecilla Universitary Hospital and Instituto de Investigación Valdecilla (IDIVAL), Santander, Cantabria,Spain
| | - Isabel Lara-Plaza
- Microbiology Department, Marqués de Valdecilla Universitary Hospital and Instituto de Investigación Valdecilla (IDIVAL), Santander, Cantabria,Spain
| | | | - María Simón-Sacristán
- Microbiology and Parasitology Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - Ana Collazos-Blanco
- Microbiology and Parasitology Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - Teresa Nebreda-Mayoral
- Microbiology and Immunology Unit, Universitary Clinic Hospital of Valladolid, Valladolid, Spain
| | - Gabriel March-Roselló
- Microbiology and Immunology Unit, Universitary Clinic Hospital of Valladolid, Valladolid, Spain
| | - Laura Alcázar-Fuoli
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
| | - Oscar Zaragoza
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III. Carretera Majadahonda-Pozuelo, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
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17
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Jørgensen KM, Astvad KMT, Hare RK, Arendrup MC. EUCAST Ibrexafungerp MICs and Wild-Type Upper Limits for Contemporary Danish Yeast Isolates. J Fungi (Basel) 2022; 8:jof8101106. [PMID: 36294671 PMCID: PMC9605171 DOI: 10.3390/jof8101106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022] Open
Abstract
Ibrexafungerp is a novel triterpenoid antifungal that inhibits glucan synthase and thus fungal cell wall synthesis. We examined the in vitro activity against contemporary clinical yeast, investigated inter-laboratory and intra-laboratory variability, suggested wild-type upper-limit values (WT-UL), and compared in vitro activity of ibrexafungerp to five licensed antifungals. Susceptibility to ibrexafungerp and comparators was investigated prospectively for 1965 isolates (11,790 MICs) and repetitively for three QC strains (1764 MICs) following the EUCAST E.Def 7.3.2 method. Elevated ibrexafungerp/echinocandin MICs prompted FKS sequencing. Published ibrexafungerp EUCAST MIC-distributions were retrieved and aggregated for WT-UL determinations following EUCAST principles. Ibrexafungerp MICs were ≤2 mg/L except against C. pararugosa, Cryptococcus and some rare yeasts. Modal MICs (mg/L) were 0.06/0.125/0.25/0.5/0.5/0.5/0.5/1/2 for C. albicans/C. dubliniensis/C. glabrata/C. krusei/C. parapsilosis/C. tropicalis/S. cerevisiae/C. guilliermondii/C. lusitaniae and aligned within ±1 dilution with published values. The MIC ranges for QC strains were: 0.06–0.25/0.5–1/0.125–0.5 for CNM-CL-F8555/ATCC6258/ATCC22019. The WT-UL (mg/L) were: 0.25/0.5/1/1/2 for C. albicans/C. glabrata/C. krusei/C. parapsilosis/C. tropicalis. Adopting these, non-wild-type rates were 0.3%/0.6%/0%/8%/3% for C. albicans/C. glabrata/C. krusei/C. parapsilosis/C. tropicalis and overall lower than for comparators except amphotericin B. Five/six non-wild-type C. albicans/C. glabrata were echinocandin and Fks non-wild-type (F641S, F659del or F659L). Eight C. parapsilosis and three C. tropicalis non-wild-type isolates were echinocandin and Fks wild-type. Partial inhibition near 50% in the supra-MIC range may explain variable MICs. Ibrexafungerp EUCAST MIC testing is robust, although the significance of paradoxical growth for some species requires further investigation. The spectrum is broad and will provide an oral option for the growing population with azole refractory infection.
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Affiliation(s)
| | | | - Rasmus K. Hare
- Unit of Mycology, Statens Serum Institut, DK-2300 Copenhagen, Denmark
| | - Maiken C. Arendrup
- Unit of Mycology, Statens Serum Institut, DK-2300 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, DK-2100 Copenhagen, Denmark
- Correspondence: ; Tel.: +45-32683223
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18
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Abdolrasouli A, Rhodes JL. Phenotypic Variants of Azole-Resistant Aspergillus Fumigatus that Co-exist in Human Respiratory Samples are Genetically Highly Related. Mycopathologia 2022; 187:497-508. [PMID: 36098829 PMCID: PMC9469045 DOI: 10.1007/s11046-022-00665-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/26/2022] [Indexed: 11/28/2022]
Abstract
Respiratory specimens obtained from patients with chronic forms of aspergillosis contain phenotypic variants of azole-resistant Aspergillus fumigatus (ARAF) that co-exist in the airway. Here we aimed to study whether phenotypic variants of ARAF that co-exist in clinical specimens were genetically distinct. A panel of six phenotypic variants of ARAF cultured from two sputum samples collected from two patients with chronic aspergillosis were included. Preliminary identification of all isolates was obtained using MALDI–ToF mass spectrometry and confirmed by AsperGenius® real-time PCR assay. Antifungal susceptibility testing was determined using EUCAST E.Def 9.3 microbroth dilution. Genomic DNA libraries were constructed with the Illumina TruSeq Nano kit. Prepared whole-genome libraries were sequenced on an Illumina HiSeq 2500. Whole genome data were converted into presence/absence of a SNP with respect to the Af293 reference genome. Colonies of ARAF that co-existed in one respiratory sample demonstrated marked phenotypic diversity. Two cyp51A polymorphisms were found among azole-resistant isolates: TR34/L98H/T289A/I364V/G448S was consistently present in four variants with a pan-azole resistant phenotype and TR34/L98H was detected in two variants (itraconazole MIC > 16 mg/L). WGS typing showed that despite marked phenotypic variation, each sample contained a population of highly genetically related azole-resistant A. fumigatus variants. Our SNP analysis suggest that mechanisms additional to genetic-based variation are responsible for phenotypic diversity. Our data demonstrate that the phenotypic variants of ARAF that co-exist in clinical specimens are highly clonal and strongly suggest their origination from a single common ancestor.
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Affiliation(s)
- Alireza Abdolrasouli
- Department of Medical Microbiology, King's College Hospital, London, UK.,MRC Centre for Global Disease Analysis, Imperial College London, London, UK
| | - Johanna L Rhodes
- MRC Centre for Global Disease Analysis, Imperial College London, London, UK.
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19
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de Oliveira HC, Castelli RF, Reis FCG, Samby K, Nosanchuk JD, Alves LR, Rodrigues ML. Screening of the Pandemic Response Box Reveals an Association between Antifungal Effects of MMV1593537 and the Cell Wall of Cryptococcus neoformans, Cryptococcus deuterogattii, and Candida auris. Microbiol Spectr 2022; 10:e0060122. [PMID: 35471056 PMCID: PMC9241760 DOI: 10.1128/spectrum.00601-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/11/2022] [Indexed: 11/20/2022] Open
Abstract
There is an urgent unmet need for novel antifungals. In this study, we searched for novel antifungal activities in the Pandemic Response Box, a collection of 400 structurally diverse compounds in various phases of drug discovery. We identified five molecules which could control the growth of Cryptococcus neoformans, Cryptococcus deuterogattii, and the emerging global threat Candida auris. After eliminating compounds which demonstrated paradoxical antifungal effects or toxicity to mammalian macrophages, we selected compound MMV1593537 as a nontoxic, fungicidal molecule for further characterization of antifungal activity. Scanning electron microscopy revealed that MMV1593537 affected cellular division in all three pathogens. In Cryptococcus, MMV1593537 caused a reduction in capsular dimensions. Treatment with MMV1593537 resulted in increased detection of cell wall chitooligomers in these three species. Since chitooligomers are products of the enzymatic hydrolysis of chitin, we investigated whether surface chitinase activity was altered in response to MMV1593537 exposure. We observed peaks of enzyme activity in C. neoformans and C. deuterogattii in response to MMV1593537. We did not detect any surface chitinase activity in C. auris. Our results suggest that MMV1593537 is a promising, nontoxic fungicide whose mechanism of action, at least in Cryptococcus spp, requires chitinase-mediated hydrolysis of chitin. IMPORTANCE The development of novel antifungals is a matter of urgency. In this study, we evaluated antifungal activities in a collection of 400 molecules, using highly lethal fungal pathogens as targets. One of these molecules, namely, MMV1593537, was not toxic to host cells and controlled the growth of isolates of Cryptococcus neoformans, C. deuterogattii, C. gattii, Candida auris, C. albicans, C. parapsilosis, and C. krusei. We tested the mechanisms of antifungal action of MMV1593537 in the Cryptococcus and C. auris models and concluded that the compound affects the cell wall, a structure which is essential for fungal life. At least in Cryptococcus, this effect involved chitinase, an enzyme which is required for remodeling the cell wall. Our results suggest that MMV1593537 is a candidate for future antifungal development.
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Affiliation(s)
| | - Rafael F. Castelli
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil
- Programa de Pós-Graduação em Biologia Parasitária, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, Brazil
| | - Flavia C. G. Reis
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil
- Centro de Desenvolvimento Tecnológico em Saúde (CDTS), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Joshua D. Nosanchuk
- Department of Microbiology and Immunology and Division of Infectious Diseases, Albert Einstein College of Medicine of Yeshiva University, New York, New York, USA
| | - Lysangela R. Alves
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil
| | - Marcio L. Rodrigues
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil
- Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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20
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Stevenson EM, Gaze WH, Gow NAR, Hart A, Schmidt W, Usher J, Warris A, Wilkinson H, Murray AK. Antifungal Exposure and Resistance Development: Defining Minimal Selective Antifungal Concentrations and Testing Methodologies. FRONTIERS IN FUNGAL BIOLOGY 2022; 3:918717. [PMID: 37746188 PMCID: PMC10512330 DOI: 10.3389/ffunb.2022.918717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/16/2022] [Indexed: 09/26/2023]
Abstract
This scoping review aims to summarise the current understanding of selection for antifungal resistance (AFR) and to compare and contrast this with selection for antibacterial resistance, which has received more research attention. AFR is an emerging global threat to human health, associated with high mortality rates, absence of effective surveillance systems and with few alternative treatment options available. Clinical AFR is well documented, with additional settings increasingly being recognised to play a role in the evolution and spread of AFR. The environment, for example, harbours diverse fungal communities that are regularly exposed to antifungal micropollutants, potentially increasing AFR selection risk. The direct application of effect concentrations of azole fungicides to agricultural crops and the incomplete removal of pharmaceutical antifungals in wastewater treatment systems are of particular concern. Currently, environmental risk assessment (ERA) guidelines do not require assessment of antifungal agents in terms of their ability to drive AFR development, and there are no established experimental tools to determine antifungal selective concentrations. Without data to interpret the selective risk of antifungals, our ability to effectively inform safe environmental thresholds is severely limited. In this review, potential methods to generate antifungal selective concentration data are proposed, informed by approaches used to determine antibacterial minimal selective concentrations. Such data can be considered in the development of regulatory guidelines that aim to reduce selection for AFR.
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Affiliation(s)
- Emily M. Stevenson
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
| | - William H. Gaze
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
| | - Neil A. R. Gow
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Alwyn Hart
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Wiebke Schmidt
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Jane Usher
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Adilia Warris
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Helen Wilkinson
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Aimee K. Murray
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
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21
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Enderle AG, Franco-Castillo I, Atrián-Blasco E, Martín-Rapún R, Lizarraga L, Culzoni MJ, Bollini M, de la Fuente JM, Silva F, Streb C, Mitchell SG. Hybrid Antimicrobial Films Containing a Polyoxometalate-Ionic Liquid. ACS APPLIED POLYMER MATERIALS 2022; 4:4144-4153. [PMID: 35720671 PMCID: PMC9194901 DOI: 10.1021/acsapm.2c00110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/02/2022] [Indexed: 05/30/2023]
Abstract
The increasing resistance of pathogenic microorganisms against common treatments requires innovative concepts to prevent infection and avoid long-term microbe viability on commonly used surfaces. Here, we report the preparation of a hybrid antimicrobial material based on the combination of microbiocidal polyoxometalate-ionic liquids (POM-ILs) and a biocompatible polymeric support, which enables the development of surface coatings that prevent microbial adhesion. The composite material is based on an antibacterial and antifungal room-temperature POM-IL composed of guanidinium cations (N,N,N',N'-tetramethyl-N″, N″-dioctylguanidinum) combined with lacunary Keggin-type polyoxotungstate anions, [α-SiW11O39]8-. Integration of the antimicrobial POM-IL into the biocompatible, flexible, and stable polymer poly(methyl methacrylate) (PMMA) results in processable films, which are suitable as surface coatings or packaging materials to limit the proliferation and spread of pathogenic microorganisms (e.g., on public transport and hospital surfaces, or in ready-to-eat-food packaging).
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Affiliation(s)
- Ana G. Enderle
- Institute
of Inorganic Chemistry I, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
- Centro
de Investigaciones en Bionanociencias (CIBION), CONICET, Godoy Cruz,
2390, C1425FQD Ciudad
de Buenos Aires, Argentina
- Laboratorio
de Desarrollo Analítico y Quimiometría (LADAQ), Universidad
Nacional del Litoral—CONICET, Ciudad
Universitaria, Paraje
El Pozo, CC242, S3000 Santa Fe, Argentina
| | - Isabel Franco-Castillo
- Instituto
de Nanociencia y Materiales de Aragón (INMA-CSIC), Consejo Superior de Investigaciones Científicas-Universidad
de Zaragoza, c/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- CIBER
de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Elena Atrián-Blasco
- Instituto
de Nanociencia y Materiales de Aragón (INMA-CSIC), Consejo Superior de Investigaciones Científicas-Universidad
de Zaragoza, c/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- CIBER
de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Rafael Martín-Rapún
- Instituto
de Nanociencia y Materiales de Aragón (INMA-CSIC), Consejo Superior de Investigaciones Científicas-Universidad
de Zaragoza, c/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- CIBER
de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Leonardo Lizarraga
- Centro
de Investigaciones en Bionanociencias (CIBION), CONICET, Godoy Cruz,
2390, C1425FQD Ciudad
de Buenos Aires, Argentina
| | - María J. Culzoni
- Laboratorio
de Desarrollo Analítico y Quimiometría (LADAQ), Universidad
Nacional del Litoral—CONICET, Ciudad
Universitaria, Paraje
El Pozo, CC242, S3000 Santa Fe, Argentina
| | - Mariela Bollini
- Centro
de Investigaciones en Bionanociencias (CIBION), CONICET, Godoy Cruz,
2390, C1425FQD Ciudad
de Buenos Aires, Argentina
| | - Jesús M. de la Fuente
- Instituto
de Nanociencia y Materiales de Aragón (INMA-CSIC), Consejo Superior de Investigaciones Científicas-Universidad
de Zaragoza, c/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- CIBER
de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Filomena Silva
- ARAID—Agencia
Aragonesa para la Investigación y el Desarrollo, Av. Ranillas, 1D, 2B, 50018 Zaragoza, Spain
- Facultad
de Veterinaria, Universidad de Zaragoza, Calle Miguel Servet 117, 50013 Zaragoza, Spain
| | - Carsten Streb
- Institute
of Inorganic Chemistry I, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Scott G. Mitchell
- Instituto
de Nanociencia y Materiales de Aragón (INMA-CSIC), Consejo Superior de Investigaciones Científicas-Universidad
de Zaragoza, c/Pedro Cerbuna 12, 50009 Zaragoza, Spain
- CIBER
de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, 28029 Madrid, Spain
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22
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de Oliveira HC, Castelli RF, Alves LR, Nosanchuk JD, Salama EA, Seleem M, Rodrigues ML. Identification of 4 compounds from the Pharmakon library with antifungal activity against Candida auris and species of Cryptococcus. Med Mycol 2022; 60:6586341. [PMID: 35575621 DOI: 10.1093/mmy/myac033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/11/2022] [Accepted: 05/12/2022] [Indexed: 11/14/2022] Open
Abstract
There is an urgent need to develop novel antifungals. In this study, we screened 1600 compounds for antifungal activity against Cryptococcus neoformans and Candida auris. We evaluated 4 promising compounds against 24 additional isolates of C. neoformans, C. auris, Cryptococcus deuterogattii, and Cryptococcus gattii. The 4 compounds, dequalinium chloride (DQC), bleomycin sulfate (BMS), pentamidine isethionate salt (PIS), and clioquinol (CLQ), varied in their efficacy against these pathogens but were generally more effective against cryptococci. The compounds exerted their antifungal effect via multiple mechanisms including interference with the capsule of cryptococci and induction of hyphal-like morphology in C. auris. Our results indicate that DQC, BMS, PIS, and CLQ represent potential prototypes for the future development of antifungals.
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Affiliation(s)
| | - Rafael F Castelli
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil.,Programa de Pós-Graduação em Biologia Parasitária, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, Brazil
| | - Lysangela R Alves
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil
| | - Joshua D Nosanchuk
- Departments of Medicine (Division of Infectious Diseases) and Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ehab A Salama
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
| | - Mohamed Seleem
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
| | - Marcio L Rodrigues
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba, Brazil.,Instituto de Microbiologia Paulo de Góes (IMPG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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23
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Brunet K, Verdon J, Ladram A, Arnault S, Rodier MH, Cateau E. Antifungal activity of [K 3]temporin-SHa against medically relevant yeasts and moulds. Can J Microbiol 2022; 68:427-434. [PMID: 35286812 DOI: 10.1139/cjm-2021-0250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Few antifungal agents are currently available for the treatment of fungal infections. Antimicrobial peptides (AMPs), which are natural molecules involved in the innate immune response of many organisms, represent a promising research method because of their broad killing activity. The aim of this study was to assess the activity of a frog AMP, [K3]temporin-SHa, against some species of yeasts and moulds, and to further explore its activity against Candida albicans. MIC determinations were performed according to EUCAST guidelines. Next, the activity of [K3]temporin-SHa against C. albicans was explored using time-killing curve experiments, membrane permeabilization assays, and electron microscopy. Finally, chequerboard assays were performed to evaluate the synergy between [K3]temporin-SHa and amphotericin B or fluconazole. [K3]temporin-SHa was found to be active in vitro against several yeasts with MIC between 5.5 and 45 µM. [K3]temporin-SHa displayed rapid fungicidal activity against C. albicans (inoculum was divided into two in less than an hour and no viable colonies were recovered after 5 h) with a mechanism that could be due to membrane permeabilization. [K3]temporin-SHa was synergistic with amphotericin B against C. albicans (FICI = 0.303). [K3]temporin-SHa could represent an additional tool to treat several Candida species and C. neoformans.
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Affiliation(s)
- Kévin Brunet
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, France.,Université de Poitiers, France
| | - Julien Verdon
- Université de Poitiers, France.,Laboratoire Écologie et Biologie des Interactions, UMR CNRS 7267, Université de Poitiers, France
| | - Ali Ladram
- CNRS, Institut de Biologie Paris-Seine, IBPS, BIOSIPE, Sorbonne Université, F-75252 Paris, France
| | - Simon Arnault
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, France
| | - Marie-Hélène Rodier
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, France.,Université de Poitiers, France.,Laboratoire Écologie et Biologie des Interactions, UMR CNRS 7267, Université de Poitiers, France
| | - Estelle Cateau
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, France.,Université de Poitiers, France.,Laboratoire Écologie et Biologie des Interactions, UMR CNRS 7267, Université de Poitiers, France
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24
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A Pragmatic Approach to Susceptibility Classification of Yeasts without EUCAST Clinical Breakpoints. J Fungi (Basel) 2022; 8:jof8020141. [PMID: 35205895 PMCID: PMC8877802 DOI: 10.3390/jof8020141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 11/17/2022] Open
Abstract
EUCAST has established clinical breakpoints for the six most common Candida species and Cryptococcus neoformans but not for less common yeasts because sufficient evidence is lacking. Consequently, the question “How to interpret the MIC?” for other yeasts often arises. We propose a pragmatic classification for amphotericin B, anidulafungin, fluconazole, and voriconazole MICs against 30 different rare yeasts. This classification takes advantage of MIC data for more than 4000 isolates generated in the EUCAST Development Laboratory for Fungi validated by alignment to published EUCAST MIC data. The classification relies on the following two important assumptions: first, that when isolates are genetically related, pathogenicity and intrinsic susceptibility patterns may be similar; and second, that even if species are not phylogenetically related, the rare yeasts will likely respond to therapy, provided the MIC is comparable to that against wild-type isolates of more prevalent susceptible species because rare yeasts are most likely “rare” due to a lower pathogenicity. In addition, the treatment recommendations available in the current guidelines based on the in vivo efficacy data and clinical experience are taken into consideration. Needless to say, it is of utmost importance (a) to ascertain that the species identification is correct (using MALDI-TOF or sequencing), and (b) to re-test the isolate once or twice to confirm that the MIC is representative for the isolate (because of the inherent variability in MIC determinations). We hope this pragmatic guidance is helpful until evidence-based EUCAST breakpoints can be formally established.
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25
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Lara-Aguilar V, Rueda C, García-Barbazán I, Varona S, Monzón S, Jiménez P, Cuesta I, Zaballos Á, Zaragoza Ó. Adaptation of the emerging pathogenic yeast Candida auris to high caspofungin concentrations correlates with cell wall changes. Virulence 2021; 12:1400-1417. [PMID: 34180774 PMCID: PMC8244764 DOI: 10.1080/21505594.2021.1927609] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Candida auris has emerged as a fungal pathogen that causes nosocomial outbreaks worldwide. Diseases caused by this fungus are of concern, due to its reduced susceptibility to several antifungals. C. auris exhibits paradoxical growth (PG; defined as growth at high, but not intermediate antifungal concentrations) in the presence of caspofungin (CPF). We have characterized the cellular changes associated with adaptation to CPF. Using EUCAST AFST protocols, all C. auris isolates tested showed PG to CPF, although in some isolates it was more prominent. Most isolates also showed a trailing effect (TE) to micafungin and anidulafungin. We identified two FKS genes in C. auris that encode the echinocandins target, namely β-1,3-glucan synthase. FKS1 contained the consensus hot-spot (HS) 1 and HS2 sequences. FKS2 only contained the HS1 region which had a change (F635Y), that has been shown to confer resistance to echinocandins in C. glabrata. PG has been characterized in other species, mainly C. albicans, where high CPF concentrations induced an increase in chitin, cell volume and aggregation. In C. auris CPF only induced a slight accumulation of chitin, and none of the other phenomena. RNAseq experiments demonstrated that CPF induced the expression of genes encoding several GPI-anchored cell wall proteins, membrane proteins required for the stability of the cell wall, chitin synthase and mitogen-activated protein kinases (MAPKs) involved in cell integrity, such as BCK2, HOG1 and MKC1 (SLT2). Our work highlights some of the processes induced in C. auris to adapt to echinocandins.
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Affiliation(s)
- Violeta Lara-Aguilar
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Cristina Rueda
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Irene García-Barbazán
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Sarai Varona
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Sara Monzón
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Pilar Jiménez
- Genomics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Isabel Cuesta
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Ángel Zaballos
- Genomics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Óscar Zaragoza
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
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26
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Crone CG, Helweg-Larsen J, Steensen M, Arendrup MC, Helleberg M. Pulmonary mucormycosis in the aftermath of critical COVID-19 in an immunocompromised patient: Mind the diagnostic gap. J Mycol Med 2021; 32:101228. [PMID: 34826672 PMCID: PMC8600800 DOI: 10.1016/j.mycmed.2021.101228] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022]
Abstract
Mucormycosis has recently been recognized as a severe complication of COVID-19 with high fatality rates. We report a fatal case of COVID-19 associated mucormycosis (CAM) in a non-diabetic immunocompromised patient, who was first misdiagnosed and treated for COVID-19 associated aspergillosis (CAPA). The risk factors and initial clinical presentation of CAPA and CAM are similar, but CAM has a more aggressive course and CAPA and CAM are treated differently. Dedicated diagnostic workup is essential to ensure early treatment of CAM with surgical debridement and targeted antifungal therapy.
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Affiliation(s)
- Cornelia Geisler Crone
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | | | - Morten Steensen
- Department of Department of Intensive Care, 2100 Rigshospitalet, Copenhagen, Denmark
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen 2300, Denmark; Department of Clinical Microbiology, Rigshospitalet, Copenhagen 2100, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen 2100, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark; Department of Infectious Diseases, Rigshospitalet, Copenhagen 2100, Denmark
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27
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Figueiredo ABC, Fonseca FL, Kuczera D, Conte FDP, Arissawa M, Rodrigues ML. Monoclonal Antibodies against Cell Wall Chitooligomers as Accessory Tools for the Control of Cryptococcosis. Antimicrob Agents Chemother 2021; 65:e0118121. [PMID: 34570650 PMCID: PMC8597760 DOI: 10.1128/aac.01181-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Therapeutic strategies against systemic mycoses can involve antifungal resistance and significant toxicity. Thus, novel therapeutic approaches to fight fungal infections are urgent. Monoclonal antibodies (MAbs) are promising tools to fight systemic mycoses. In this study, MAbs of the IgM isotype were developed against chitin oligomers. Chitooligomers derive from chitin, an essential component of the fungal cell wall and a promising therapeutic target, as it is not synthesized by humans or animals. Surface plasmon resonance (SPR) assays and cell-binding tests showed that the MAbs recognizing chitooligomers have high affinity and specificity for the chitin derivatives. In vitro tests showed that the chitooligomer MAbs increased the fungicidal capacity of amphotericin B against Cryptococcus neoformans. The chitooligomer-binding MAbs interfered with two essential properties related to cryptococcal pathogenesis: biofilm formation and melanin production. In a murine model of C. neoformans infection, the combined administration of the chitooligomer-binding MAb and subinhibitory doses of amphotericin B promoted disease control. The data obtained in this study support the hypothesis that chitooligomer antibodies have great potential as accessory tools in the control of cryptococcosis.
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Affiliation(s)
| | - Fernanda L. Fonseca
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Diogo Kuczera
- Instituto Carlos Chagas, Fundação Oswaldo Cruz, Curitiba, Brazil
| | - Fernando de Paiva Conte
- Projeto Implantação Planta Piloto, Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Marcia Arissawa
- Vice Diretoria de Desenvolvimento Técnologico, Bio-Manguinhos, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Marcio L. Rodrigues
- Instituto Carlos Chagas, Fundação Oswaldo Cruz, Curitiba, Brazil
- Instituto de Microbiologia Paulo de Góes da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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28
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Shein AMS, Wannigama DL, Higgins PG, Hurst C, Abe S, Hongsing P, Chantaravisoot N, Saethang T, Luk-In S, Liao T, Nilgate S, Rirerm U, Kueakulpattana N, Laowansiri M, Srisakul S, Muhummudaree N, Techawiwattanaboon T, Gan L, Xu C, Kupwiwat R, Phattharapornjaroen P, Rojanathanes R, Leelahavanichkul A, Chatsuwan T. Novel colistin-EDTA combination for successful eradication of colistin-resistant Klebsiella pneumoniae catheter-related biofilm infections. Sci Rep 2021; 11:21676. [PMID: 34737361 PMCID: PMC8568960 DOI: 10.1038/s41598-021-01052-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/20/2021] [Indexed: 12/20/2022] Open
Abstract
Development of an effective therapy to overcome colistin resistance in Klebsiella pneumoniae, a common pathogen causing catheter-related biofilm infections in vascular catheters, has become a serious therapeutic challenge that must be addressed urgently. Although colistin and EDTA have successful roles for eradicating biofilms, no in vitro and in vivo studies have investigated their efficacy in catheter-related biofilm infections of colistin-resistant K. pneumoniae. In this study, colistin resistance was significantly reversed in both planktonic and mature biofilms of colistin-resistant K. pneumoniae by a combination of colistin (0.25-1 µg/ml) with EDTA (12 mg/ml). This novel colistin-EDTA combination was also demonstrated to have potent efficacy in eradicating colistin-resistant K. pneumoniae catheter-related biofilm infections, and eliminating the risk of recurrence in vivo. Furthermore, this study revealed significant therapeutic efficacy of colistin-EDTA combination in reducing bacterial load in internal organs, lowering serum creatinine, and protecting treated mice from mortality. Altered in vivo expression of different virulence genes indicate bacterial adaptive responses to survive in hostile environments under different treatments. According to these data discovered in this study, a novel colistin-EDTA combination provides favorable efficacy and safety for successful eradication of colistin-resistant K. pneumonia catheter-related biofilm infections.
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Affiliation(s)
- Aye Mya Sithu Shein
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Interdisciplinary Program of Medical Microbiology, Graduate School, Chulalongkorn University, Bangkok, Thailand
| | - Dhammika Leshan Wannigama
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - Paul G Higgins
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Cameron Hurst
- Statistics, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Shuichi Abe
- Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Parichart Hongsing
- Mae Fah Luang University Hospital, Chiang Rai, Thailand
- School of Integrative Medicine, Mae Fah Luang University, Chiang Rai, Thailand
| | - Naphat Chantaravisoot
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Systems Biology, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thammakorn Saethang
- Department of Computer Science, Faculty of Science, Kasetsart University, Bangkok, Thailand
| | - Sirirat Luk-In
- Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Tingting Liao
- Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence for Microcirculation, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sumanee Nilgate
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ubolrat Rirerm
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Naris Kueakulpattana
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Matchima Laowansiri
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sukrit Srisakul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Netchanok Muhummudaree
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Teerasit Techawiwattanaboon
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Chula Vaccine Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Lin Gan
- Department of General Surgery, Fuling Center Hospital of Chongqing City, Chongqing, China
| | - Chenchen Xu
- In-Patient Pharmacy, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rosalyn Kupwiwat
- Chulabhorn International College of Medicine, Thammasat University, Thammasat University Hospital, Bangkok, Thailand
| | - Phatthranit Phattharapornjaroen
- Department of Emergency Medicine, Center of Excellence, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 40530, Gothenburg, Sweden
| | - Rojrit Rojanathanes
- Center of Excellence in Materials and Bio-Interfaces, Faculty of Science, Chulalongkorn University, Bangkok, Thailand
| | - Asada Leelahavanichkul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
| | - Tanittha Chatsuwan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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29
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Raj N, Vanathi M, Ahmed NH, Gupta N, Lomi N, Tandon R. Recent Perspectives in the Management of Fungal Keratitis. J Fungi (Basel) 2021; 7:jof7110907. [PMID: 34829196 PMCID: PMC8621027 DOI: 10.3390/jof7110907] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/28/2022] Open
Abstract
Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.
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Affiliation(s)
- Nimmy Raj
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Murugesan Vanathi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
- Correspondence: ; Tel.: +91-11-26593010; Fax: +91-11-26588919
| | - Nishat Hussain Ahmed
- Ocular Microbiology Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India;
| | - Noopur Gupta
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Neiwete Lomi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Radhika Tandon
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
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30
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Arendrup MC, Jørgensen KM, Guinea J, Lagrou K, Chryssanthou E, Hayette MP, Barchiesi F, Lass-Flörl C, Hamal P, Dannaoui E, Chowdhary A, Meletiadis J. Multicentre validation of a EUCAST method for the antifungal susceptibility testing of microconidia-forming dermatophytes. J Antimicrob Chemother 2021; 75:1807-1819. [PMID: 32303059 DOI: 10.1093/jac/dkaa111] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Terbinafine resistance is increasingly reported in Trichophyton, rendering susceptibility testing particularly important in non-responding cases. We performed a multicentre evaluation of six EUCAST-based methods. METHODS Ten laboratories susceptibility tested terbinafine, itraconazole, voriconazole and amorolfine against a blinded panel of 38 terbinafine WT and target gene mutant isolates. E.Def 9.3.1 modifications included: medium with/without addition of chloramphenicol and cycloheximide (CC), incubation at 25°C to 28°C for 5-7 days and three MIC endpoints [visually and spectrophotometrically (90%/50% inhibition)], generating 7829 MICs. Quality control (QC) strains were Aspergillus flavus ATCC 204304 and CNM-CM1813. Eyeball, ECOFFinder (where ECOFF stands for epidemiological cut-off) and derivatization WT upper limits (WT-ULs), very major errors (VMEs; mutants with MICs ≤WT-ULs) and major errors (MEs; WT isolates with MICs >WT-ULs) were determined. RESULTS MICs fell within the QC ranges for ATCC 204304/CNM-CM1813 for 100%/96% (voriconazole) and 84%/84% (itraconazole), respectively. Terbinafine MICs fell within 0.25-1 mg/L for 96%/92%, suggesting high reproducibility. Across the six methods, the number of terbinafine MEs varied from 2 to 4 (2.6%-5.2%) for Trichophyton rubrum and from 0 to 2 (0%-2.0%) for Trichophyton interdigitale. Modes for WT and mutant populations were at least seven 2-fold dilutions apart in all cases. Excluding one I121M/V237I T. rubrum mutant and two mixed WT/mutant T. interdigitale specimens, the numbers of VMEs were as follows: T. rubrum: CC visual, 1/67 (1.5%); CC spectrophotometric 90% inhibition, 3/59 (5.1%); and CC spectrophotometric 50% inhibition, 1/67 (1.5%); and T. interdigitale: none. Voriconazole and amorolfine MICs were quite uniform, but trailing growth complicated determination of itraconazole visual and spectrophotometric 90% inhibition MIC. CONCLUSIONS Although none of the laboratories was experienced in dermatophyte testing, error rates were low. We recommend the CC spectrophotometric 50% inhibition method and provide QC ranges and WT-ULs for WT/non-WT classification.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | | | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain and Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Erja Chryssanthou
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Marie-Pierre Hayette
- Department of Clinical Microbiology, Centre for Interdisciplinary Research on Medicines, University of Liège, Liège, Belgium
| | - Francesco Barchiesi
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, Ancona, Italy.,Malattie Infettive, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Petr Hamal
- Department of Microbiology, University Hospital, Olomouc, Czech Republic
| | - Eric Dannaoui
- Parasitology-Mycology Unit, Microbiology Department, Georges Pompidou European Hospital, University of Paris, Paris, France
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Jørgensen KM, Guinea J, Meletiadis J, Hare RK, Arendrup MC. Revision of EUCAST breakpoints: consequences for susceptibility of contemporary Danish mould isolates to isavuconazole and comparators. J Antimicrob Chemother 2021; 75:2573-2581. [PMID: 32556315 DOI: 10.1093/jac/dkaa212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND EUCAST recently revised the definition of the 'I' category from 'intermediate' to 'susceptible, increased exposure'. Consequently, all current antifungal breakpoints have been reviewed and revised breakpoints (v 10.0) have been released. OBJECTIVES We investigated isavuconazole and comparator MICs (mg/L) against contemporary moulds and the consequences of the breakpoint revision for susceptibility classification. METHODS Six hundred and ninety-six Aspergillus and 46 other moulds were included. EUCAST E.Def 10.1 azole resistance screening was performed for Aspergillus fumigatus and E.Def 9.3.1 testing of non-susceptible A. fumigatus and other moulds. Most non-wildtype/resistant isolates underwent cyp51A sequencing. RESULTS Isavuconazole MIC50/MIC90s were ≤1/≤2 mg/L for Aspergillus flavus, A. fumigatus and Aspergillus nidulans versus 2/4 mg/L for Aspergillus niger and 2/16 mg/L for Aspergillus terreus. For the remaining moulds, MICs were highest for Fusarium (16 to >16 mg/L), lowest for dermatophytes (0.06-0.5 mg/L) and in between for Mucorales and others (1 to >16 mg/L). A very strong isavuconazole-voriconazole MIC correlation was found for A. fumigatus (Pearson r = 0.888) and itraconazole-posaconazole correlation for A. fumigatus (r = 0.905) and A. terreus (r = 0.848). For A. fumigatus, the revised breakpoints lowered isavuconazole resistance (22.6% to 7.7%, P < 0.0001) and increased voriconazole resistance (3.8% to 6.7%, P = 0.025), resulting in similar resistance rates across the four azoles (range: 6.7%-7.7%). For A. terreus, isavuconazole resistance remained unchanged (81.3%) and higher than itraconazole (43.8%, P = 0.004) and posaconazole (53.1%, P = 0.03) resistance. Azole cross-resistance was found in 24/24, 13/20 and 4/90 isolates, and Cyp51A alterations in 16/18, 1/7 and 2/4 sequenced isolates with isavuconazole MICs of >4, 4 and 2 mg/L, respectively. CONCLUSIONS Isavuconazole displays broad anti-mould activity. The revised breakpoints result in fewer misclassifications of wildtype isolates without compromising detection of resistant mutants.
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Affiliation(s)
| | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Athens, Greece
| | | | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Arendrup MC, Jørgensen KM, Hanemaaijer N, Verweij PE. ISO standard 20776-1 or serial 2-fold dilution for antifungal susceptibility plate preparation: that is the question! J Antimicrob Chemother 2021; 76:1793-1799. [PMID: 33734364 DOI: 10.1093/jac/dkab088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/26/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Since the ISO standard 20776-1 and serial dilution procedures were compared in 2010 for fluconazole and itraconazole, several new antifungals that are hydrophobic and highly potent have been introduced. OBJECTIVES To investigate the impact of the number of tip changes during serial dilution, and ISO and serial dilution for nine antifungals. METHODS EUCAST E.Def 7.3.2 with serial (0-10 tip changes) and ISO dilution. Candida parapsilosis ATCC 22019, Candida albicans ATCC 64548, C. albicans CNM CL-F8555, Candida krusei ATCC 6258, Aspergillus flavus ATCC 204304 and clinical isolates (n = 5) of C. albicans, Candida dubliniensis, Candida glabrata, C. krusei, A. flavus and Aspergillus terreus were included. GM MICs were compared for ISO and serial dilution and with QC values where available. RESULTS Increasing the number of tip changes (0/1/2/10 times) during serial dilution for plate preparation increased the MICs 1 to >2 dilutions for amphotericin B, anidulafungin, micafungin, fluconazole, voriconazole and isavuconazole against C. albicans ATCC 64548 but only isavuconazole MICs against C. parapsilosis ATCC 22019 (3 dilutions). ISO and serial dilution (two tip changes) were compared for eight compounds and four Candida QC strains (352 MICs). Six/41 GM MIC pairs deviated with 1-1.8 dilution (14.6%). Comparing the GM MIC with the QC values, the ISO method GM MIC was closest to the target in 30.8%, the serial dilution in 34.6% and the methods identical in 34.6% of the cases. Finally, ISO and serial dilution MICs were compared for clinical isolates (920 MICs). Five/23 GM MIC pairs (21.7%) deviated 1.0-1.1 dilutions. CONCLUSIONS The ISO and serial dilution (two tip changes) method were in acceptable agreement and thus equally applicable for EUCAST testing.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Nicolien Hanemaaijer
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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Lestrade PPA, Buil JB, van der Beek MT, Kuijper EJ, van Dijk K, Kampinga GA, Rijnders BJA, Vonk AG, de Greeff SC, Schoffelen AF, van Dissel J, Meis JF, Melchers WJG, Verweij PE. Paradoxal Trends in Azole-Resistant Aspergillus fumigatus in a National Multicenter Surveillance Program, the Netherlands, 2013-2018. Emerg Infect Dis 2021; 26:1447-1455. [PMID: 32568033 PMCID: PMC7323544 DOI: 10.3201/eid2607.200088] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We investigated the prevalence of azole resistance of Aspergillus fumigatus isolates in the Netherlands by screening clinical A. fumigatus isolates for azole resistance during 2013-2018. We analyzed azole-resistant isolates phenotypically by in vitro susceptibility testing and for the presence of resistance mutations in the Cyp51A gene. Over the 6-year period, 508 (11%) of 4,496 culture-positive patients harbored an azole-resistant isolate. Resistance frequency increased from 7.6% (95% CI 5.9%-9.8%) in 2013 (58/760 patients) to 14.7% (95% CI 12.3%-17.4%) in 2018 (112/764 patients) (p = 0.0001). TR34/L98H (69%) and TR46/Y121F/T289A (17%) accounted for 86% of Cyp51A mutations. However, the mean voriconazole MIC of TR34/L98H isolates decreased from 8 mg/L (2013) to 2 mg/L (2018), and the voriconazole-resistance frequency was 34% lower in 2018 than in 2013 (p = 0.0001). Our survey showed changing azole phenotypes in TR34/L98H isolates, which hampers the use of current PCR-based resistance tests.
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Georgacopoulos O, Nunnally NS, Ransom EM, Law D, Birch M, Lockhart SR, Berkow EL. In Vitro Activity of Novel Antifungal Olorofim against Filamentous Fungi and Comparison to Eight Other Antifungal Agents. J Fungi (Basel) 2021; 7:jof7050378. [PMID: 34065811 PMCID: PMC8150786 DOI: 10.3390/jof7050378] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 12/21/2022] Open
Abstract
Olorofim is a novel antifungal drug that belongs to the orotomide drug class which inhibits fungal dihydroorotate dehydrogenase (DHODH), thus halting pyrimidine biosynthesis and ultimately DNA synthesis, cell growth and division. It is being developed at a time when many invasive fungal infections exhibit antifungal resistance or have limited treatment options. The goal of this study was to evaluate the in vitro effectiveness of olorofim against a large collection of recently isolated, clinically relevant American mold isolates. In vitro antifungal activity was determined for 246 azole-susceptible Aspergillus fumigatus isolates, five A. fumigatus with TR34/L98H-mediated resistance, 19 Rhizopus species isolates, 21 Fusarium species isolates, and one isolate each of six other species of molds. Olorofim minimum inhibitory concentrations (MICs) were compared to antifungal susceptibility testing profiles for amphotericin B, anidulafungin, caspofungin, isavuconazole, itraconazole, micafungin, posaconazole, and voriconazole. Olorofim MICs were significantly lower than those of the echinocandin and azole drug classes and amphotericin B. A. fumigatus wild type and resistant isolates shared the same MIC50 = 0.008 μg/mL. In non-Aspergillus susceptible isolates (MIC ≤ 2 μg/mL), the geometric mean (GM) MIC to olorofim was 0.54 μg/mL with a range of 0.015–2 μg/mL. Olorofim had no antifungal activity (MIC ≥ 2 μg/mL) against 10% of the collection (31 in 297), including some isolates from Rhizopus spp. and Fusarium spp. Olorofim showed promising activity against A. fumigatus and other molds regardless of acquired azole resistance.
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Affiliation(s)
- Ourania Georgacopoulos
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA; (N.S.N.); (S.R.L.); (E.L.B.)
- Correspondence:
| | - Natalie S. Nunnally
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA; (N.S.N.); (S.R.L.); (E.L.B.)
| | - Eric M. Ransom
- Association of Public Health Laboratories, Silver Springs, MD 20910, USA;
| | - Derek Law
- F2G Ltd., Manchester M30 0LX, UK; (D.L.); (M.B.)
| | - Mike Birch
- F2G Ltd., Manchester M30 0LX, UK; (D.L.); (M.B.)
| | - Shawn R. Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA; (N.S.N.); (S.R.L.); (E.L.B.)
| | - Elizabeth L. Berkow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA; (N.S.N.); (S.R.L.); (E.L.B.)
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Johnson MD, Lewis RE, Dodds Ashley ES, Ostrosky-Zeichner L, Zaoutis T, Thompson GR, Andes DR, Walsh TJ, Pappas PG, Cornely OA, Perfect JR, Kontoyiannis DP. Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium. J Infect Dis 2021; 222:S175-S198. [PMID: 32756879 DOI: 10.1093/infdis/jiaa394] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.
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Affiliation(s)
- Melissa D Johnson
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - David R Andes
- Department of Medicine and Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Oliver A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.,Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
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Jørgensen KM, Helleberg M, Hare RK, Jørgensen LN, Arendrup MC. Dissection of the Activity of Agricultural Fungicides against Clinical Aspergillus Isolates with and without Environmentally and Medically Induced Azole Resistance. J Fungi (Basel) 2021; 7:jof7030205. [PMID: 33799556 PMCID: PMC8001900 DOI: 10.3390/jof7030205] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Azole resistance is an emerging problem in patients with aspergillosis. The role of fungicides for resistance development and occurrence is not fully elucidated. EUCAST reference MICs of 17 fungicides (11 azoles and 6 others), five azole fungicide metabolites and four medical triazoles were examined against two reference and 28 clinical isolates of A. fumigatus, A. flavus and A. terreus with (n = 12) and without (n = 16) resistance mutations. Eight/11 azole fungicides were active against wild-type A. fumigatus, A. flavus and A. terreus, including four (metconazole, prothioconazole-desthio, prochloraz and imazalil) with low MIC50 (≤2 mg/L) against all three species and epoxiconazole, propiconazole, tebuconazole and difenoconazole also against wild-type A. terreus. Mefentrifluconazole, azole metabolites and non-azole fungicides MICs were >16 mg/L against A. fumigatus although partial growth inhibition was found with mefentrifluconazole. Moreover, mefentrifluconazole and axozystrobin were active against wild-type A. terreus. Increased MICs (≥3 dilutions) were found for TR34/L98H, TR34(3)/L98H, TR46/Y121F/T289A and G432S compared to wild-type A. fumigatus for epoxiconazole, propiconazole, tebuconazole, difenoconazole, prochloraz, imazalil and metconazole (except G432S), and for prothioconazole-desthio against TR46/Y121F/T289A, specifically. Increased MICs were found in A. fumigatus harbouring G54R, M220K and M220R alterations for five, one and one azole fungicides, respectively, compared to MICs against wild-type A. fumigatus. Similarly, increased MICs wer found for A. terreus with G51A, M217I and Y491H alterations for five, six and two azole fungicides, respectively. Azole fungicides showed activity against wild-type A. fumigatus, A. terreus and A. flavus, but not against all mutant isolates, suggesting the environmental route of azole resistance may have a role for all three species.
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Affiliation(s)
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Rasmus Krøger Hare
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
| | - Lise Nistrup Jørgensen
- Department of Agroecology—Crop Health, Aarhus University-Flakkebjerg, 4200 Slagelse, Denmark;
| | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
- Department of Clinical Medicine, Copenhagen University, 2100 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
- Correspondence:
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Espinel-Ingroff A, Cantón E, Pemán J. Antifungal Resistance among Less Prevalent Candida Non- albicans and Other Yeasts versus Established and under Development Agents: A Literature Review. J Fungi (Basel) 2021; 7:jof7010024. [PMID: 33406771 PMCID: PMC7824324 DOI: 10.3390/jof7010024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023] Open
Abstract
Fungal diseases and antifungal resistance continue to increase, including those caused by rare or emerging species. However, the majority of the published in vitro susceptibility data are for the most common fungal species. We reviewed the literature in order to pool reference minimal inhibitory concentration (MIC) data (Clinical and Laboratory Standards Institute—CLSI and European Committee on Antimicrobial Susceptibility—EUCAST) for rare/non-prevalent Candida and other yeast species. MIC results were compared with those for Candida albicans, C. glabrata, and C. krusei. Data were listed for twenty rare and emerging Candida spp., including C. auris, as well as two Cryptococcus spp., two Trichosporon spp., Saccharomyces cerevisiae and five Malassezia spp. The best detectors of antimicrobial resistance are the breakpoints, which are not available for the less common Candida species. However, epidemiological cutoff values (ECVs/ECOFFs) have been calculated using merely in vitro data for both reference methods for various non-prevalent yeasts and recently the CLSI has established ECVs for other Candida species. The ECV could identify the non-wild type (NWT or mutants) isolates with known resistance mechanisms. Utilizing these ECVs, we were able to report additional percentages of NWT, especially for non-prevalent species, by analyzing the MIC distributions in the literature. In addition, since several antifungal drugs are under development, we are listing MIC data for some of these agents.
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Affiliation(s)
- Ana Espinel-Ingroff
- Department of Medicine, VCU Medical Center, Richmond, VA 23298, USA
- Correspondence:
| | - Emilia Cantón
- Severe Infection Research Group, Health Research Institute Hospital La Fe, 46026 Valencia, Spain; (E.C.); (J.P.)
| | - Javier Pemán
- Severe Infection Research Group, Health Research Institute Hospital La Fe, 46026 Valencia, Spain; (E.C.); (J.P.)
- Microbiology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
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Olorofim Susceptibility Testing of 1,423 Danish Mold Isolates Obtained in 2018-2019 Confirms Uniform and Broad-Spectrum Activity. Antimicrob Agents Chemother 2020; 65:AAC.01527-20. [PMID: 33020160 DOI: 10.1128/aac.01527-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/01/2020] [Indexed: 01/22/2023] Open
Abstract
Olorofim is a novel antifungal drug in phase 2 trials. It has shown promising in vitro activity against various molds, except for Mucorales. Initially, we observed a broad range of EUCAST MICs for Aspergillus fumigatus Here, we explored the MIC variability in more detail and prospectively investigated the susceptibility of contemporary clinical mold isolates, as population data are needed for future epidemiological cutoff (ECOFF) settings. Fifteen A. fumigatus isolates previously found with low/medium/high MICs (≤0.002 to 0.25 mg/liter) were tested repeatedly and EUCAST MICs read in a blinded fashion by three observers. pyrE, encoding the olorofim target enzyme dihydroorotate dehydrogenase (DHODH), was sequenced. A total of 1,423 mold isolates (10 Aspergillus species complexes [including 1,032 A. fumigatus isolates] and 105 other mold/dermatophyte isolates) were examined. Olorofim susceptibility (modal MIC, MIC50, MIC90, and wild-type upper limits [WT-ULs] [species complexes with ≥15 isolates]) was determined and compared to that of four comparators. MICs (mg/liter) were within two 2-fold dilutions (0.016 to 0.03) for 473/476 determinations. The MIC range spanned four dilutions (0.008 to 0.06). No significant pyrE mutations were found. Modal MIC/WT-UL97.5 (mg/liter) values were 0.03/0.06 (A. terreus and A. flavus), 0.06/0.125 (A. fumigatus and Trichophyton rubrum), and 0.06/0.25 (A. niger and A. nidulans). The MIC range for Scedosporium spp. was 0.008 to 0.25. Olorofim susceptibility was similar for azole-resistant and -susceptible isolates of A. fumigatus but reduced for A. montevidensis and A. chevalieri (MICs of >1). With experience, olorofim susceptibility testing is robust. The testing of isolates from our center showed uniform and broad-spectrum activity. Single-center WT-ULs are suggested.
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Arastehfar A, Gabaldón T, Garcia-Rubio R, Jenks JD, Hoenigl M, Salzer HJF, Ilkit M, Lass-Flörl C, Perlin DS. Drug-Resistant Fungi: An Emerging Challenge Threatening Our Limited Antifungal Armamentarium. Antibiotics (Basel) 2020; 9:antibiotics9120877. [PMID: 33302565 PMCID: PMC7764418 DOI: 10.3390/antibiotics9120877] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/02/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
The high clinical mortality and economic burden posed by invasive fungal infections (IFIs), along with significant agricultural crop loss caused by various fungal species, has resulted in the widespread use of antifungal agents. Selective drug pressure, fungal attributes, and host- and drug-related factors have counteracted the efficacy of the limited systemic antifungal drugs and changed the epidemiological landscape of IFIs. Species belonging to Candida, Aspergillus, Cryptococcus, and Pneumocystis are among the fungal pathogens showing notable rates of antifungal resistance. Drug-resistant fungi from the environment are increasingly identified in clinical settings. Furthermore, we have a limited understanding of drug class-specific resistance mechanisms in emerging Candida species. The establishment of antifungal stewardship programs in both clinical and agricultural fields and the inclusion of species identification, antifungal susceptibility testing, and therapeutic drug monitoring practices in the clinic can minimize the emergence of drug-resistant fungi. New antifungal drugs featuring promising therapeutic profiles have great promise to treat drug-resistant fungi in the clinical setting. Mitigating antifungal tolerance, a prelude to the emergence of resistance, also requires the development of effective and fungal-specific adjuvants to be used in combination with systemic antifungals.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Toni Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, 08034 Barcelona, Spain;
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), 08024 Barcelona, Spain
- Catalan Institution for Research and Advanced Studies. Pg. Lluís Companys 23, 08010 Barcelona, Spain
| | - Rocio Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Jeffrey D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA 92103, USA;
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Martin Hoenigl
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | | | - Macit Ilkit
- Division of Mycology, University of Çukurova, 01330 Adana, Turkey
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
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Introduction of a Comprehensive Diagnostic and Interdisciplinary Management Approach in Haematological Patients with Mucormycosis: A Pre and Post-Intervention Analysis. J Fungi (Basel) 2020; 6:jof6040268. [PMID: 33171634 PMCID: PMC7712937 DOI: 10.3390/jof6040268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 12/27/2022] Open
Abstract
Mucormycosis is a life threatening infection in patients with haematological disease. We introduced a Mucorales-PCR and an aggressive, multidisciplinary management approach for mucormycosis during 2016-2017 and evaluated patient outcomes in 13 patients diagnosed and treated in 2012-2019. Management principle: repeated surgical debridement until biopsies from the resection margins were clean as defined by negative Blankophor microscopy, Mucorales-PCR (both reported within 24 h), and cultures. Cultured isolates underwent EUCAST E.Def 9.3.1 susceptibility testing. Antifungal therapy (AFT) (mono/combination) combined with topical AFT (when possible) was given according to the minimal inhibitory concentration (MIC), severity of the infection, and for azoles, specifically, it was guided by therapeutic drug monitoring. The outcome was evaluated by case record review. All patients underwent surgery guided by diagnostic biopsies from tissue and resection margins (195 samples in total). Comparing 2012-2015 and 2016-2019, the median number of patients of surgical debridements was 3 and 2.5 and of diagnostic samples: microscopy/culture/PCR was 3/3/6 and 10.5/10/10.5, respectively. The sensitivity of microscopy (76%) and Mucorales-PCR (70%) were similar and microscopy was superior to that of culture (53%; p = 0.039). Initial systemic AFT was liposomal amphotericin B (n = 12) or posaconazole (n = 1) given as monotherapy (n = 4) or in combination with isavuconazole/posaconazole (n = 3/6) and terbinafine (n = 3). Nine patients received topical amphotericin B. All received isavuconazole or posaconazole consolidation therapy (n = 13). Mucormycosis related six month mortality was 3/5 in 2012-2015 and 0/7 patients in 2016-2019 (one patient was lost for follow-up). Implementation of combination therapy (systemic+topical AFT/combination systemic AFT) and aggressive surgical debridement guided by optimised diagnostic tests may improve the outcome of mucormycosis in haematologic patients.
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Mirhendi H, Charsizadeh A, Eshaghi H, Nikmanesh B, Arendrup MC. Species distribution and antifungal susceptibility profile of Candida isolates from blood and other normally sterile foci from pediatric ICU patients in Tehran, Iran. Med Mycol 2020; 58:201-206. [PMID: 31111910 DOI: 10.1093/mmy/myz047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/27/2019] [Accepted: 04/16/2019] [Indexed: 01/23/2023] Open
Abstract
As data on pediatric invasive candidiasis (IC) and the antifungal susceptibility pattern of associated isolates are scarce in Iran, this study aimed to determine species distribution and antifungal susceptibility profile of Candida species isolated from pediatric patients with suspected or documented IC. A total of 235 yeast strains recovered from normally sterile body fluids of patients admitted at the intensive care units of Children's Medical Centre, Tehran, Iran, were identified using CHROMagar Candida, molecular methods (ITS PCR-RFLP and sequencing), and MALDI-TOF. Susceptibility to amphotericin B, fluconazole, voriconazole, micafungin, and anidulafungin was determined according to the European on Antimicrobial Susceptibility testing reference microdilution method (EUCAST E.Def 7.3.1). Candida albicans (53.6%), C. parapsilosis (24.7%), and C. tropicalis (8.5%) were the most common species, followed by C. lusitaniae (4.3%), C. glabrata (3.0%), C. guilliermondii and C. orthopsilosis (each 1.7%), C. kefyr (1.3%), C. dubliniensis (0.8%), and C. intermedia (0.4%). Amphotericin B MICs were ≤1 mg/l for all Candida isolates. C. albicans isolates were susceptible to all five antifungal agents. All C. parapsilosis isolates categorised as intermediate to micafungin and anidulafungin, except two isolates that had the MICs >2 mg/l for micafungin. MIC50, MIC90, and MIC range for fluconazole were 0.25 mg/l, 1 mg/l, and 0.125 - ≥32 mg/l, respectively. Fluconazole and voriconazole showed 100% activity against the most prevalent Candida species. The low resistance rate, favorable safety profile and low cost of fluconazole make it a reasonable choice for treatment of candidemia/invasive candidemia in Iran.
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Affiliation(s)
- Hossein Mirhendi
- Departments of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arezoo Charsizadeh
- Immunology, Asthma, and Allergy Research Institute, Tehran University of Medical Sciences, Tehran Iran
| | - Hamid Eshaghi
- Infectious Disease Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Nikmanesh
- Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
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Risum M, Hare RK, Gertsen JB, Kristensen L, Johansen HK, Helweg-Larsen J, Abou-Chakra N, Pressler T, Skov M, Jensen-Fangel S, Arendrup MC. Azole-Resistant Aspergillus fumigatus Among Danish Cystic Fibrosis Patients: Increasing Prevalence and Dominance of TR 34/L98H. Front Microbiol 2020; 11:1850. [PMID: 32903400 PMCID: PMC7438406 DOI: 10.3389/fmicb.2020.01850] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
Azole-resistant (azole-R) Aspergillus is an increasing challenge worldwide. Patients with cystic fibrosis (CF) are at risk of Aspergillus colonization and disease due to a favorable lung environment for microorganisms. We performed a nationwide study in 2018 of azole-non-susceptible Aspergillus in CF patients and compared with data from two prior studies. All airway samples with mold isolates from patients monitored at the two CF centers in Denmark (RH, Jan-Sept and AUH, Jan-Jun) were included. Classical species identification (morphology and thermo-tolerance) was performed and MALDI-TOF/β-tubulin sequencing was performed if needed. Susceptibility was determined using EUCAST E.Def 10.1, and E.Def 9.3.2. cyp51A sequencing and STRAf genotyping were performed for azole-non-susceptible isolates and relevant sequential isolates. In total, 340 mold isolates from 159 CF patients were obtained. The most frequent species were Aspergillus fumigatus (266/340, 78.2%) and Aspergillus terreus (26/340, 7.6%). Azole-R A. fumigatus was cultured from 7.3% (10/137) of patients, including 9.5% (9/95) of patients at RH and 2.4% at AUH (1/42), respectively. In a 10-year perspective, azole-non-susceptibility increased numerically among patients at RH (10.5% in 2018 vs 4.5% in 2007-2009). Cyp51A resistance mechanisms were found in nine azole-R A. fumigatus from eight CF patients. Five were of environmental origin (TR34/L98H), three were human medicine-driven (two M220K and one M220R), and one was novel (TR34 3/L98H) and found in a patient who also harbored a TR34/L98H isolate. STRAf genotyping identified 27 unique genotypes among 45 isolates and ≥2 genotypes in 8 of 12 patients. This included one patient carrying two unique TR34/L98H isolates, a rare phenomenon. Genotyping of sequential TR34 3/L98H and TR34/L98H isolates from the same patient showed only minor differences in 1/9 markers. Finally, azole-R A. terreus was found in three patients including two with Cyp51A alterations (M217I and G51A, respectively). Azole-R A. fumigatus is increasing among CF patients in Denmark with the environmentally associated resistance TR34/L98H mechanism being dominant. Mixed infections (wildtype/non-wildtype and several non-wildtypes) and a case of potential additional tandem repeat acquisition in vivo were found. However, similar genotypes were identified from another patient (and outside this study), potentially suggesting a predominant TR34/L98H clone in DK. These findings suggest an increasing prevalence and complexity of azole resistance in A. fumigatus.
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Affiliation(s)
- Malene Risum
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Jan Berg Gertsen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Kristensen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helle Krogh Johansen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Tacjana Pressler
- Cystic Fibrosis Center Copenhagen, Department of Pediatrics and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Skov
- Cystic Fibrosis Center Copenhagen, Department of Pediatrics and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Marcos-Zambrano LJ, Gómez A, Sánchez-Carrillo C, Bouza E, Muñoz P, Escribano P, Guinea J. Isavuconazole is highly active in vitro against Candida species isolates but shows trailing effect. Clin Microbiol Infect 2020; 26:1589-1592. [PMID: 32712246 DOI: 10.1016/j.cmi.2020.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Isavuconazole is a triazole previously shown to have potent in vitro activity against Aspergillus spp., Mucorales, and Candida spp. Unlike for other azoles, it is unclear if isavuconazole may induce a trailing effect. We studied isavuconazole MICs for a large collection of Candida isolates from blood samples and determined the extent of the trailing effect when using the EUCAST Edef 7.3.1 method. METHODS 761 molecularly identified Candida isolates from blood samples of 742 patients admitted to the hospital (January 2007 to September 2017) were evaluated and further tested for in vitro susceptibility to isavuconazole following the EUCAST E.Def 7.3.1 test method. RESULTS C. albicans showed the highest susceptibility, followed by C. parapsilosis and C. tropicalis (geometric mean MIC 0.003 vs 0.005/0.006, respectively; P < 0.001). In contrast, C. glabrata, and C. krusei had significantly higher MIC values (geometric mean MIC 0.094 vs 0.093, respectively). Isavuconazole MIC distributions were not truncated at the lowest concentration tested, except for C. albicans. Overall, the mean percentage of trailing was 12.9% but differences among species were observed: C. glabrata, C. albicans, and C. tropicalis exhibited higher trailing in comparison to C. parapsilosis and non-Candida yeasts (P < 0.001). The percentage of non-wild-type C. albicans (considering the heavy trailer isolates as wild-type), C. parapsilosis and C. glabrata isolates were 0.56% (2/355), 1.5% (3/200), and 4.65% (4/86), respectively. CONCLUSIONS Isavuconazole showed high in vitro activity against Candida spp., particularly against C. albicans. Trailing effect is commonly observed with isavuconazole, particularly with C. glabrata.
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Affiliation(s)
- Laura Judith Marcos-Zambrano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Gómez
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Carlos Sánchez-Carrillo
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain.
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Manogepix (APX001A) Displays Potent In Vitro Activity against Human Pathogenic Yeast, but with an Unexpected Correlation to Fluconazole MICs. Antimicrob Agents Chemother 2020; 64:AAC.00429-20. [PMID: 32366708 DOI: 10.1128/aac.00429-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/25/2020] [Indexed: 12/17/2022] Open
Abstract
Manogepix (APX001A) is the active moiety of the novel drug candidate fosmanogepix (APX001). We previously reported the broad-spectrum activity of manogepix but also observed a correlation between increased manogepix and fluconazole MICs. Here, we extended this study and included isolates with acquired fluconazole resistance. Isolates (n = 835) were identified using CHROMagar, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and, when needed, internal transcribed spacer (ITS) sequencing. EUCAST E.Def 7.3.1 susceptibility testing included manogepix, amphotericin B, anidulafungin, micafungin, fluconazole, and voriconazole. Manogepix wild-type-upper-limit (WT-UL) values were established following EUCAST principles for the epidemiological cutoff value (ECOFF) setting allowing wild-type/non-wild-type classification. Drug-specific MIC correlations were investigated using Pearson's correlation. Manogepix modal MICs were low (range, 0.004 to 0.06 mg/liter against 16/20 included species). Exceptions were Candida krusei and Candida inconspicua and, to a lesser extent, Candida kefyr and Pichia kluyveri The activity was independent of Fks echinocandin hot spot alterations (n = 17). Adopting the WT-UL established for Candida albicans, Candida dubliniensis, Candida glabrata, Candida parapsilosis, and Candida tropicalis, 14/724 (1.9%) isolates were non-wild type for manogepix. Twelve of these (85.7%) were also non-wild type for fluconazole. A statistically significant correlation was observed between manogepix and fluconazole MICs for C. albicans, C. dubliniensis, C. glabrata, C. parapsilosis, and C. tropicalis (Pearson's r = 0.401 to 0.575) but not between manogepix and micafungin or amphotericin B MICs for any species except C. tropicalis (r = 0.519 for manogepix versus micafungin). Broad-spectrum activity was confirmed for manogepix against contemporary yeast. However, a 1 to 4 2-fold dilutions increase in manogepix MICs is observed in a subset of isolates with acquired fluconazole resistance. Further studies on the potential underlying mechanism and implication for optimal dosing are warranted.
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Arendrup MC, Friberg N, Mares M, Kahlmeter G, Meletiadis J, Guinea J. How to interpret MICs of antifungal compounds according to the revised clinical breakpoints v. 10.0 European committee on antimicrobial susceptibility testing (EUCAST). Clin Microbiol Infect 2020; 26:1464-1472. [PMID: 32562861 DOI: 10.1016/j.cmi.2020.06.007] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND EUCAST has revised the definition of the susceptibility category I from 'Intermediate' to 'Susceptible, Increased exposure'. This implies that I can be used where the drug concentration at the site of infection is high, either because of dose escalation or through other means to ensure efficacy. Consequently, I is no longer used as a buffer zone to prevent technical factors from causing misclassifications and discrepancies in interpretations. Instead, an Area of Technical Uncertainty (ATU) has been introduced for MICs that cannot be categorized without additional information as a warning to the laboratory that decision on how to act has to be made. To implement these changes, the EUCAST-AFST (Subcommittee on Antifungal Susceptibility Testing) reviewed all, and revised some, clinical antifungal breakpoints. OBJECTIVES The aim was to present an overview of the current antifungal breakpoints and supporting evidence behind the changes. SOURCES This document is based on the ten recently updated EUCAST rationale documents, clinical breakpoint and breakpoint ECOFF documents. CONTENT The following breakpoints (in mg/L) have been revised or established for Candida species: micafungin against C. albicans (ATU = 0.03); amphotericin B (S ≤/> R = 1/1), fluconazole (S ≤/> R = 2/4), itraconazole (S ≤/> R = 0.06/0.06), posaconazole (S ≤/> R = 0.06/0.06) and voriconazole (S ≤/> R = 0.06/0.25) against C. dubliniensis; fluconazole against C. glabrata (S ≤/> R = 0.001/16); and anidulafungin (S ≤/> R = 4/4) and micafungin (S ≤/> R = 2/2) against C. parapsilosis. For Aspergillus, new or revised breakpoints include itraconazole (ATU = 2) and isavuconazole against A. flavus (S ≤/> R = 1/2, ATU = 2); amphotericin B (S ≤/> R = 1/1), isavuconazole (S ≤ /> R = 1/2, ATU = 2), itraconazole (S ≤/> R = 1/1, ATU = 2), posaconazole (ATU = 0.25) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. fumigatus; itraconazole (S ≤/> R = 1/1, ATU = 2) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. nidulans; amphotericin B against A. niger (S ≤/> R = 1/1); and itraconazole (S ≤/> R = 1/1, ATU = 2) and posaconazole (ATU = 0.25) against A. terreus. IMPLICATIONS EUCAST-AFST has released ten new documents summarizing existing and new breakpoints and MIC ranges for control strains. A failure to adopt the breakpoint changes may lead to misclassifications and suboptimal or inappropriate therapy of patients with fungal infections.
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Affiliation(s)
- M C Arendrup
- Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - N Friberg
- Division of Clinical Microbiology, Helsinki University Hospital, HUSLAB, Finland
| | - M Mares
- Laboratory of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, Iasi, Romania
| | - G Kahlmeter
- The EUCAST Development Laboratory, Clinical Microbiology, Växjö, Sweden
| | - J Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - J Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Fenbendazole Controls In Vitro Growth, Virulence Potential, and Animal Infection in the Cryptococcus Model. Antimicrob Agents Chemother 2020; 64:AAC.00286-20. [PMID: 32253211 DOI: 10.1128/aac.00286-20] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/29/2020] [Indexed: 12/17/2022] Open
Abstract
The human diseases caused by the fungal pathogens Cryptococcus neoformans and Cryptococcus gattii are associated with high indices of mortality and toxic and/or cost-prohibitive therapeutic protocols. The need for affordable antifungals to combat cryptococcal disease is unquestionable. Previous studies suggested benzimidazoles as promising anticryptococcal agents combining low cost and high antifungal efficacy, but their therapeutic potential has not been demonstrated so far. In this study, we investigated the antifungal potential of fenbendazole, the most effective anticryptococcal benzimidazole. Fenbendazole was inhibitory against 17 different isolates of C. neoformans and C. gattii at a low concentration. The mechanism of anticryptococcal activity of fenbendazole involved microtubule disorganization, as previously described for human parasites. In combination with fenbendazole, the concentrations of the standard antifungal amphotericin B required to control cryptococcal growth were lower than those required when this antifungal was used alone. Fenbendazole was not toxic to mammalian cells. During macrophage infection, the anticryptococcal effects of fenbendazole included inhibition of intracellular proliferation rates and reduced phagocytic escape through vomocytosis. Fenbendazole deeply affected the cryptococcal capsule. In a mouse model of cryptococcosis, the efficacy of fenbendazole to control animal mortality was similar to that observed for amphotericin B. These results indicate that fenbendazole is a promising candidate for the future development of an efficient and affordable therapeutic tool to combat cryptococcosis.
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Knabl L, Lass-Flörl C. Antifungal susceptibility testing in Candida species: current methods and promising new tools for shortening the turnaround time. Expert Rev Anti Infect Ther 2020; 18:779-787. [PMID: 32324090 DOI: 10.1080/14787210.2020.1760841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) have received attention as an emerging public health threat, are difficult to diagnose and to treat, and are associated with substantial morbidity and mortality. The standard of care in IFD management requires an early and targeted antifungal treatment, hence covers - amongst others - species identification and antifungal susceptibility testing (AFST). AREAS COVERED This review gives an overview of methods currently applied in AFST and highlights promising new tools for shortening the turnaround time focusing on Candida species. EXPERT OPINION The performance of the broth microdilution reference methods for AFST is not suitable for daily laboratory practice as they are too labor-intensive and time-consuming. Other conventional approaches such as disk diffusion assays, epsilometer tests, colorimetric or automated approaches are easier in handling, and in part, show good correlations with the reference methods. Promising results for shortening the turnaround time in providing MIC data or resistance detection include matrix-assisted laser desorption/ionization-time of flight mass spectrometer (MALDI-TOF MS) assisted AFST, molecular-based techniques and modified conventional approaches applying direct inoculation methods. These underlying AFST concepts are promising but in part completely different, have their own advantages and disadvantages, and need further clinical validation.
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Affiliation(s)
- Ludwig Knabl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck , Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck , Innsbruck, Austria
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Abstract
Although not as ubiquitous as antibacterial susceptibility testing, antifungal susceptibility testing (AFST) is a tool of increasing importance in clinical microbiology laboratories. The goal of AFST is to reliably produce MIC values that may be used to guide patient therapy, inform epidemiological studies, and track rates of antifungal drug resistance. There are three methods that have been standardized by standards development organizations: broth dilution, disk diffusion, and azole agar screening for Aspergillus Other commonly used methods include gradient diffusion and the use of rapid automated instruments. Novel methodologies for susceptibility testing are in development. It is important for laboratories to consider not only the method of testing but also the interpretation (or lack thereof) of in vitro data.
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Identification of Off-Patent Drugs That Show Synergism with Amphotericin B or That Present Antifungal Action against Cryptococcus neoformans and Candida spp. Antimicrob Agents Chemother 2020; 64:AAC.01921-19. [PMID: 31988099 DOI: 10.1128/aac.01921-19] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/18/2020] [Indexed: 12/11/2022] Open
Abstract
Amphotericin B (AmB) is the antifungal with the strongest fungicidal activity, but its use has several limitations, mainly associated with its toxicity. Although some lipidic and liposomal formulations that present reduced toxicity are available, their price limits their application in developing countries. Flucytosine (5FC) has shown synergistic effect with AmB for treatment of some fungal infections, such as cryptococcosis, but again, its price is a limitation for its use in many regions. In the present work, we aimed to identify new drugs that have a minor effect on Cryptococcus neoformans, reducing its growth in the presence of subinhibitory concentrations of AmB. In the initial screening, we found fourteen drugs that had this pattern. Later, checkerboard assays of selected compounds, such as erythromycin, riluzole, nortriptyline, chenodiol, nisoldipine, promazine, chlorcyclizine, cloperastine, and glimepiride, were performed and all of them confirmed for their synergistic effect (fractional inhibitory concentration index [FICI] < 0.5). Additionally, toxicity of these drugs in combination with AmB was tested in mammalian cells and in zebrafish embryos. Harmless compounds, such as the antibiotic erythromycin, were found to have synergic activity with AmB, not only against C. neoformans but also against some Candida spp., in particular against Candida albicans In parallel, we identified drugs that had antifungal activity against C. neoformans and found 43 drugs that completely inhibited the growth of this fungus, such as ciclopirox and auranofin. Our results expand our knowledge about antifungal compounds and open new perspectives in the treatment of invasive mycosis based on repurposing off-patent drugs.
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Rezafungin In Vitro Activity against Contemporary Nordic Clinical Candida Isolates and Candida auris Determined by the EUCAST Reference Method. Antimicrob Agents Chemother 2020; 64:AAC.02438-19. [PMID: 32015032 DOI: 10.1128/aac.02438-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/31/2020] [Indexed: 01/21/2023] Open
Abstract
Rezafungin (formerly CD101) is a novel echinocandin in clinical development. EUCAST epidemiological cutoff values (ECOFFs) have not yet been established. We determined the in vitro activity of rezafungin and comparators against 1,293 Nordic yeast isolates and 122 Indian Candida auris isolates and established single-center wild-type upper limits (WT-UL). The isolates (19 Candida spp. and 13 other yeast species) were identified using Chromagar; matrix-assisted laser desorption ionization-time of flight (MALDI-TOF); and, when needed, internal transcribed spacer sequencing. EUCAST E.Def 7.3.1 susceptibility testing included rezafungin, anidulafungin, micafungin, amphotericin B, and fluconazole. WT-UL were established following EUCAST principles for visual and statistical ECOFF setting. fks target genes were sequenced for rezafungin non-wild-type isolates. EUCAST clinical breakpoints for fungi version 9.0 were adopted for susceptibility classification. Rezafungin had species-specific activity similar to that of anidulafungin and micafungin. On a milligram-per-liter basis, rezafungin was overall less active than anidulafungin and micafungin but equally or more active than fluconazole and amphotericin B against the most common Candida species, except C. parapsilosis We identified 37 (3.1%) rezafungin non-wild-type isolates of C. albicans (1.9%), C. glabrata (3.0%), C. tropicalis (2.7%), C. dubliniensis (2.9%), C. krusei (1.2%), and C. auris (14.8%). Alterations in Fks hot spots were found in 26/26 Nordic and 8/18 non-wild-type C. auris isolates. Rezafungin displayed broad in vitro activity against Candida spp., including C. auris Adopting WT-UL established here, few Nordic strains, but a significant proportion of C. auris isolates, had elevated MICs with mutations in fks target genes that conferred echinocandin cross-resistance. fks1 mutations raised rezafungin MICs notably less than anidulafungin and micafungin MICs in C. auris.
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