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Wennrich JP, Holzenkamp C, Kolařík M, Maier W, Mándi A, Kurtán T, Ashrafi S, Ebada SS, Stadler M. Dactylfungins and Tetralones: Bioactive Metabolites from a Nematode-Associated Laburnicola nematophila. JOURNAL OF NATURAL PRODUCTS 2024. [PMID: 39012621 DOI: 10.1021/acs.jnatprod.4c00623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
A chemical investigation of Laburnicola nematophila, isolated from cysts of the plant parasitic nematode Heterodera filipjevi, affored three dactylfungin derivatives (1-3) and three tetralone congeners (4-6). Dactylfungin C (1), laburnicolin (4), and laburnicolenone (5) are previously undescribed natural products. Chemical structures of the isolated compounds were determined based on 1D and 2D NMR spectroscopic analyses together with HR-ESI-MS spectrometry and comparison with data reported in the literature. The relative configurations of compounds 1, 2, and 4-6 were determined based on their ROESY data and analysis of their coupling constants (J values). The absolute configurations of 4-6 were determined through the comparison of their measured and calculated TDDFT-ECD spectra. Compounds 1-3 were active against azole-resistant Aspergillus fumigatus.
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Affiliation(s)
- Jan-Peer Wennrich
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI) and German Centre for Infection Research, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Institute of Microbiology, Technische Universität Braunschweig, Spielmannstraße 7, 38106 Braunschweig, Germany
| | - Caren Holzenkamp
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI) and German Centre for Infection Research, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Institute of Microbiology, Technische Universität Braunschweig, Spielmannstraße 7, 38106 Braunschweig, Germany
| | - Miroslav Kolařík
- Institute of Microbiology, Czech Academy of Science, Vídeňská 1083, 14220 Prague, Czech Republic
| | - Wolfgang Maier
- Institute for Epidemiology and Pathogen Diagonstics, Julius Kühn Institut (JKI) - Federal Research Centre for Cultivated Plants, Messeweg 11-12, 38104 Braunschweig, Germany
| | - Attila Mándi
- Department of Organic Chemistry, University of Debrecen, P.O. Box 400, 4002 Debrecen, Hungary
| | - Tibor Kurtán
- Department of Organic Chemistry, University of Debrecen, P.O. Box 400, 4002 Debrecen, Hungary
| | - Samad Ashrafi
- Institute for Epidemiology and Pathogen Diagonstics, Julius Kühn Institut (JKI) - Federal Research Centre for Cultivated Plants, Messeweg 11-12, 38104 Braunschweig, Germany
- Institute for Crop and Soil Science, Julius Kühn Institute (JKI) - Federal Research Centre for Cultivated Plants, Bundesallee 58, 38116 Braunschweig, Germany
| | - Sherif S Ebada
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI) and German Centre for Infection Research, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Department of Pharmacognosy, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt
| | - Marc Stadler
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI) and German Centre for Infection Research, Inhoffenstrasse 7, 38124 Braunschweig, Germany
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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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Ameen F, Alsarraf MJ, Abalkhail T, Stephenson SL. Evaluation of resistance patterns and bioremoval efficiency of hydrocarbons and heavy metals by the mycobiome of petroleum refining wastewater in Jazan with assessment of molecular typing and cytotoxicity of Scedosporium apiospermum JAZ-20. Heliyon 2024; 10:e32954. [PMID: 38994074 PMCID: PMC11238013 DOI: 10.1016/j.heliyon.2024.e32954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 06/03/2024] [Accepted: 06/12/2024] [Indexed: 07/13/2024] Open
Abstract
Jazan Industrial Economic City (JIEC) is located on the Red Sea coast in the province of Jazan, southwest of Saudi Arabia anchors diverse heavy and secondary industries in the energy, water desalination, petroleum, aluminum, copper, refineries, pharmaceuticals and food manufacturing fields. These various industries generate a large quantity of industrial wastewaters containing various toxicants. The present work represents ecologically beneficial alternatives for the advancement of environmental biotechnology, which could help mitigate the adverse impacts of environmental pollution resulting from petroleum refining effluents. The mycobiome (32 fungal strains) isolated from the industrial wastewater of the refinery sector in Jazan were belonged to five fungal genera including Fusarium, Verticillium, Purpureocillium, Clavispora and Scedosporium with a distribution percentage of 31.25, 21.88, 15.63, 12.50 and 18.75 %, respectively. These isolates showed multimetals tolerance and bioremoval efficiency against a large number of heavy metals (Fe2+, Ni2+, Cr6+, Zn2+, As3+, Cu2+, Cd2+, Pb2+, Ag+ and Hg2+) along with potent bioremediation activity toward crude oil and the polycyclic aromatic hydrocarbons. Interestingly, the mycobiome resistance patterns obtained against different classes of fungal antibiotics including azole (fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole and ketoconazole), echinocandin (anidulafungin, caspofungin and micafungin) and polyene (amphotericin B) drugs proved the prevalence of antibiotic resistance among the mycobiome of refinery industry in Saudi Arabia is relatively low. The fungal isolate under isolation code JAZ-20 showed the highest bioremoval efficiency against heavy metals (90.8-100.0 %), crude oil (89.50 %), naphthalene (96.7 %), phenanthrene (92.52 %), fluoranthene (100.0 %), anthracene (90.34 %), pyrene (85.60 %) and chrysene (83.4 %). It showed the highest bioremoval capacity ranging from 85.72 % to 100.0 % against numerous pollutants found in a wide array of industrial effluents, including diclofenac, ibuprofen, carbamazepine, acetaminophen, sulfamethoxazole, bisphenol, bleomycin, vincristine, dicofol, methyl parathion, atrazine, diuron, dieldrin, chlorpyrifos, profenofos and phenanthrene. The isolate JAZ-20 was chosen for molecular typing, cytotoxicity assessment, analysis of volatile compounds and optimization investigations. Based on phenotypic, biochemical and phylogenetic analysis, strain JAZ-20 identified as Scedosporium apiospermum JAZ-20. This strain is newly discovered in industrial effluents in Saudi Arabia. Fungal strain JAZ-20 consistently produced various types of saturated and unsaturated fatty acids. the main fatty acids were C14:0 (1.95 %), iso-C14:0 (2.98 %), anteiso-C14:0 (2.13 %), iso-C15:0 (9.16 %), anteiso-C15:0 (11.75 %), C15:0 (7.42 %), C15:1 (2.37 %), anteiso-C16:0 (3.4 %), C16:0 (10.3 %), iso-C16:0 (9.5 %), C17:1 (1.36 %), anteiso-C17:1 (8.64 %), iso-C18:0 (11.0 %), C18:0 (3.63 %), anteiso-C19:0 (3.78 %), anteiso-C20:0 (2.0 %), iso-C21:0 (2.44 %), C23:0 (1.15 %), and C24:0 (2.17 %). These fatty acids serve as natural and eco-friendly antifungal agents, promoting fungal resistance and inhibiting the production of mycotoxins in the environment. Despite being an environmental isolate, its cytotoxicity was assessed against both normal and cancerous human cell lines. The IC50 values of JAZ-20 extract were 8.92, 10.41, 20.0, 16.5, and 40.0 μg/mL against WI38, MRC5, MCF10A, HEK293 and HDFs normal cells and 43.26, 33.75, and 40.0 μg/mL against liver (HepG2), breast (A549) and cervix (HeLa) cancers, respectively. Based on gas chromatography-mass spectrometry (GC-MS), analysis the extract of S. apiospermum JAZ-20 showed 47 known volatile compounds (VOCs) for varied and significant biological activities. Enhancing the bioremoval efficiency of heavy metals from actual refining wastewater involves optimizing process parameters. The parameters optimized were the contact time, the fungal biomass dosage, pH, temperature and agitation rate.
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Affiliation(s)
- Fuad Ameen
- Department of Botany& Microbiology, College of Science, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Mohammad J Alsarraf
- Department of Science, College of Basic Education, the Public Authority of Applied Education and Training (PAAET), Kuwait
| | - Tarad Abalkhail
- Department of Botany& Microbiology, College of Science, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Steven L Stephenson
- Department of Biological Sciences, University of Arkansas, Fayetteville, USA
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van Dijk MAM, Buil JB, Tehupeiory-Kooreman M, Broekhuizen MJ, Broens EM, Wagenaar JA, Verweij PE. Azole Resistance in Veterinary Clinical Aspergillus fumigatus Isolates in the Netherlands. Mycopathologia 2024; 189:50. [PMID: 38864903 PMCID: PMC11169034 DOI: 10.1007/s11046-024-00850-5] [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: 01/19/2024] [Accepted: 03/14/2024] [Indexed: 06/13/2024]
Abstract
Aspergillus fumigatus is a saprophytic fungal pathogen that causes opportunistic infections in animals and humans. Azole resistance has been reported globally in human A. fumigatus isolates, but the prevalence of resistance in isolates from animals is largely unknown. A retrospective resistance surveillance study was performed using a collection of clinical A. fumigatus isolates from various animal species collected between 2015 and 2020. Agar-based azole resistance screening of all isolates was followed by in vitro antifungal susceptibility testing and cyp51A gene sequencing of the azole-resistant isolates. Over the 5 year period 16 (11.3%) of 142 A. fumigatus culture-positive animals harbored an azole-resistant isolate. Resistant isolates were found in birds (15%; 2/13), cats (21%; 6/28), dogs (8%; 6/75) and free-ranging harbor porpoise (33%; 2/6). Azole-resistance was cyp51A mediated in all isolates: 81.3% (T-67G/)TR34/L98H, 12.5% TR46/Y121F/T289A. In one azole-resistant A. fumigatus isolate a combination of C(-70)T/F46Y/C(intron7)T/C(intron66)T/M172V/E427K single-nucleotide polymorphisms in the cyp51A gene was found. Of the animals with an azole-resistant isolate and known azole exposure status 71.4% (10/14) were azole naive. Azole resistance in A. fumigatus isolates from animals in the Netherlands is present and predominantly cyp51A TR-mediated, supporting an environmental route of resistance selection. Our data supports the need to include veterinary isolates in resistance surveillance programs. Veterinarians should consider azole resistance as a reason for therapy failure when treating aspergillosis and consider resistance testing of relevant isolates.
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Affiliation(s)
- Marloes A M van Dijk
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands.
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marlou Tehupeiory-Kooreman
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marian J Broekhuizen
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Els M Broens
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Jaap A Wagenaar
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
- Wageningen Bioveterinary Research, 8221 RA, Lelystad, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, 6525 GA, Nijmegen, The Netherlands
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Herman TS, da Silva Goersch C, Bocca AL, Fernandes L. Resazurin to determine the minimum inhibitory concentration on antifungal susceptibility assays for Fonsecaea sp. using a modified EUCAST protocol. Braz J Microbiol 2024; 55:1349-1357. [PMID: 38438831 PMCID: PMC11153478 DOI: 10.1007/s42770-024-01293-2] [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: 11/07/2023] [Accepted: 02/27/2024] [Indexed: 03/06/2024] Open
Abstract
Chromoblastomycosis is a fungal chronic disease, which affects humans, especially in cutaneous and subcutaneous tissues. There is no standard treatment for Chromoblastomycosis, and it is a therapeutic challenge, due natural resistance of their causative agents, inadequate response of patients and common cases of relapse. Protocols for determination of antifungal drugs susceptibility are not standardized for chromoblastomycosis agents and endpoint definition is usually based on visual inspection, which depends on the analyst, making it sometimes inaccurate. We presented a colorimetric and quantitative methodology based on resazurin reduction to resofurin to determine the metabolic status of viable cells of Fonsecaea sp. Performing antifungal susceptibility assay by a modified EUCAST protocol allied to resazurin, we validated the method to identify the minimum inhibitory concentrations of itraconazole, fluconazole, amphotericin B, and terbinafine for eight Fonsecaea clinical isolates. According to our data, resazurin is a good indicator of metabolic status of viable cells, including those exposed to antifungal drugs. This work aimed to test resazurin as an indicator of the metabolic activity of Fonsecaea species in susceptibility assays to antifungal drugs. Species of this genus are the main causative agents of Chromoblastomycosis, which affects humans.
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Affiliation(s)
- Tatiana Sobianski Herman
- Postgraduate Program in Molecular Pathology, Faculty of Medicine, University of Brasília, UnB, Brasília, DF, Brazil
- Laboratory of Applied Immunology, Department of Cell Biology, Institute of Biological Sciences, University of Brasília, UnB, Room J1 28/8, Brasília, DF, 70910-900, Brazil
| | - Camila da Silva Goersch
- Laboratory of Applied Immunology, Department of Cell Biology, Institute of Biological Sciences, University of Brasília, UnB, Room J1 28/8, Brasília, DF, 70910-900, Brazil
- Postgraduate Program in Microbial Biology, Institute of Biological Science, University of Brasília, UnB, Brasília, DF, Brazil
| | - Anamelia Lorenzetti Bocca
- Postgraduate Program in Molecular Pathology, Faculty of Medicine, University of Brasília, UnB, Brasília, DF, Brazil
- Laboratory of Applied Immunology, Department of Cell Biology, Institute of Biological Sciences, University of Brasília, UnB, Room J1 28/8, Brasília, DF, 70910-900, Brazil
| | - Larissa Fernandes
- Laboratory of Applied Immunology, Department of Cell Biology, Institute of Biological Sciences, University of Brasília, UnB, Room J1 28/8, Brasília, DF, 70910-900, Brazil.
- Postgraduate Program in Microbial Biology, Institute of Biological Science, University of Brasília, UnB, Brasília, DF, Brazil.
- Faculty of Ceilândia, University of Brasília, UnB, Brasília, DF, Brazil.
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Wang C, Miller N, Vines D, Severns PM, Momany M, Brewer MT. Azole resistance mechanisms and population structure of the human pathogen Aspergillus fumigatus on retail plant products. Appl Environ Microbiol 2024; 90:e0205623. [PMID: 38651929 PMCID: PMC11107156 DOI: 10.1128/aem.02056-23] [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: 11/14/2023] [Accepted: 03/30/2024] [Indexed: 04/25/2024] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprotroph and human-pathogenic fungus that is life-threatening to the immunocompromised. Triazole-resistant A. fumigatus was found in patients without prior treatment with azoles, leading researchers to conclude that resistance had developed in agricultural environments where azoles are used against plant pathogens. Previous studies have documented azole-resistant A. fumigatus across agricultural environments, but few have looked at retail plant products. Our objectives were to determine if azole-resistant A. fumigatus is prevalent in retail plant products produced in the United States (U.S.), as well as to identify the resistance mechanism(s) and population genetic structure of these isolates. Five hundred twenty-five isolates were collected from retail plant products and screened for azole resistance. Twenty-four isolates collected from compost, soil, flower bulbs, and raw peanuts were pan-azole resistant. These isolates had the TR34/L98H, TR46/Y121F/T289A, G448S, and H147Y cyp51A alleles, all known to underly pan-azole resistance, as well as WT alleles, suggesting that non-cyp51A mechanisms contribute to pan-azole resistance in these isolates. Minimum spanning networks showed two lineages containing isolates with TR alleles or the F46Y/M172V/E427K allele, and discriminant analysis of principle components identified three primary clusters. This is consistent with previous studies detecting three clades of A. fumigatus and identifying pan-azole-resistant isolates with TR alleles in a single clade. We found pan-azole resistance in U.S. retail plant products, particularly compost and flower bulbs, which indicates a risk of exposure to these products for susceptible populations and that highly resistant isolates are likely distributed worldwide on these products.IMPORTANCEAspergillus fumigatus has recently been designated as a critical fungal pathogen by the World Health Organization. It is most deadly to people with compromised immune systems, and with the emergence of antifungal resistance to multiple azole drugs, this disease carries a nearly 100% fatality rate without treatment or if isolates are resistant to the drugs used to treat the disease. It is important to determine the relatedness and origins of resistant A. fumigatus isolates in the environment, including plant-based retail products, so that factors promoting the development and propagation of resistant isolates can be identified.
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Affiliation(s)
- Caroline Wang
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Natalie Miller
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Douglas Vines
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Paul M. Severns
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Michelle Momany
- Fungal Biology Group, Plant Biology Department, University of Georgia, Athens, Georgia, USA
| | - Marin T. Brewer
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
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Celia-Sanchez BN, Mangum B, Gómez Londoño LF, Wang C, Shuman B, Brewer MT, Momany M. Pan-azole- and multi-fungicide-resistant Aspergillus fumigatus is widespread in the United States. Appl Environ Microbiol 2024; 90:e0178223. [PMID: 38557086 PMCID: PMC11022549 DOI: 10.1128/aem.01782-23] [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: 10/06/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
Aspergillus fumigatus is an important global fungal pathogen of humans. Azole drugs are among the most effective treatments for A. fumigatus infection. Azoles are also widely used in agriculture as fungicides against fungal pathogens of crops. Azole-resistant A. fumigatus has been increasing in Europe and Asia for two decades where clinical resistance is thought to be driven by agricultural use of azole fungicides. The most prevalent mechanisms of azole resistance in A. fumigatus are tandem repeats (TR) in the cyp51A promoter coupled with mutations in the coding region which result in resistance to multiple azole drugs (pan-azole resistance). Azole-resistant A. fumigatus has been isolated from patients in the United States (U.S.), but little is known about its environmental distribution. To better understand the distribution of azole-resistant A. fumigatus in the U.S., we collected isolates from agricultural sites in eight states and tested 202 isolates for sensitivity to azoles. We found azole-resistant A. fumigatus in agricultural environments in seven states showing that it is widespread in the U.S. We sequenced environmental isolates representing the range of U.S. sample sites and compared them with publicly available environmental worldwide isolates in phylogenetic, principal component, and ADMIXTURE analyses. We found worldwide isolates fell into three clades, and TR-based pan-azole resistance was largely in a single clade that was strongly associated with resistance to multiple agricultural fungicides. We also found high levels of gene flow indicating recombination between clades highlighting the potential for azole-resistance to continue spreading in the U.S.IMPORTANCEAspergillus fumigatus is a fungal pathogen of humans that causes over 250,000 invasive infections each year. It is found in soils, plant debris, and compost. Azoles are the first line of defense antifungal drugs against A. fumigatus. Azoles are also used as agricultural fungicides to combat other fungi that attack plants. Azole-resistant A. fumigatus has been a problem in Europe and Asia for 20 years and has recently been reported in patients in the United States (U.S.). Until this study, we did not know much about azole-resistant A. fumigatus in agricultural settings in the U.S. In this study, we isolated azole-resistant A. fumigatus from multiple states and compared it to isolates from around the world. We show that A. fumigatus which is resistant to azoles and to other strictly agricultural fungicides is widespread in the U.S.
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Affiliation(s)
| | - B. Mangum
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | | | - C. Wang
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | - B. Shuman
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
| | - M. T. Brewer
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | - M. Momany
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
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Gautier C, Maciel EI, Ene IV. Approaches for identifying and measuring heteroresistance in azole-susceptible Candida isolates. Microbiol Spectr 2024; 12:e0404123. [PMID: 38483474 PMCID: PMC10986555 DOI: 10.1128/spectrum.04041-23] [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: 11/27/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024] Open
Abstract
Heteroresistance to antifungal agents poses a significant challenge in the treatment of fungal infections. Currently, the absence of established methods for detecting and measuring heteroresistance impedes progress in understanding this phenomenon in fungal pathogens. In response to this gap, we present a comprehensive set of new and optimized methods designed to detect and quantify azole heteroresistance in Candida albicans. Here, we define two primary assays for measuring heteroresistance: population analysis profiling, based on growth on solid medium, and single-cell assays, based on growth in liquid culture. We observe good correlations between the measurements obtained with liquid and solid assays, validating their utility for studying azole heteroresistance. We also highlight that disk diffusion assays could serve as an additional tool for the rapid detection of heteroresistance. These methods collectively provide a versatile toolkit for researchers seeking to assess heteroresistance in C. albicans. They also serve as a critical step forward in the characterization of antifungal heteroresistance, providing a framework for investigating this phenomenon in diverse fungal species and in the context of other antifungal agents. Ultimately, these advancements will enhance our ability to effectively measure antifungal drug responses and combat fungal infections.IMPORTANCEHeteroresistance involves varying antimicrobial susceptibility within a clonal population. This phenomenon allows the survival of rare resistant subpopulations during drug treatment, significantly complicating the effective management of infections. However, the absence of established detection methods hampers progress in understanding this phenomenon in human fungal pathogens. We propose a comprehensive toolkit to address this gap in the yeast Candida albicans, encompassing population analysis profiling, single-cell assays, and disk diffusion assays. By providing robust and correlated measurements through both solid and liquid assays, this work will provide a framework for broader applications across clinically relevant Candida species. These methods will enhance our ability to understand this phenomenon and the failure of antifungal therapy.
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Affiliation(s)
- Cécile Gautier
- Fungal Heterogeneity Group, Institut Pasteur, Université Paris Cité, Paris, France
| | - Eli I. Maciel
- Fungal Heterogeneity Group, Institut Pasteur, Université Paris Cité, Paris, France
| | - Iuliana V. Ene
- Fungal Heterogeneity Group, Institut Pasteur, Université Paris Cité, Paris, France
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9
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Mikulska M, Melchio M, Signori A, Ullah N, Miletich F, Sepulcri C, Limongelli A, Giacobbe DR, Balletto E, Russo C, Magnasco L, Vena A, Di Grazia C, Raiola AM, Portunato F, Dentone C, Battaglini D, Ball L, Robba C, Angelucci E, Brunetti I, Bassetti M. Lower blood levels of isavuconazole in critically ill patients compared with other populations: possible need for therapeutic drug monitoring. J Antimicrob Chemother 2024; 79:835-845. [PMID: 38366368 DOI: 10.1093/jac/dkae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/25/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Isavuconazole is first-line treatment of invasive aspergillosis. Therapeutic drug monitoring (TDM) is deemed not necessary, since most patients reached therapeutic levels (>1 mg/L) in large studies. Low levels were reported in some critically ill patients admitted to the ICU. The aim was to compare isavuconazole levels between critically ill and non-critically ill patients. MATERIALS AND METHODS Retrospective analysis of data from all patients treated with standard-dose isavuconazole between 1 January 2019 and 26 October 2022 was performed. The following data were collected: TDM results from the first 30 days of therapy; ward of admission; demographic and clinical characteristics; continuous renal replacement therapy; extracorporeal membrane oxygenation; and co-administered drugs. RESULTS Seventy-two patients (median age 65 years) and 188 TDM measurements (mean number of samples per patient 2.6 ± 1.7) were included; 33 (45.8%) were ICU patients (3 also had haematological disorders); 39 (54.2%) were non-ICU patients, of whom 31 had haematological disorders. In all patients, the mean isavuconazole blood level was 3.33 ± 2.26 mg/L. Significantly lower levels were observed in the ICU versus the non-ICU population: mean 2.02 ± 1.22 versus 4.15 ± 2.31 mg/L (P < 0.001). Significantly higher rates of subtherapeutic levels were observed in ICU patients compared with the non-ICU population: all determinations <2 mg/L in 33.3% versus 7.7%, and all determinations <1 mg/L in 12.1% versus 0%, respectively. Predictors of lower isavuconazole levels were admission to the ICU, BMI > 25 kg/m2, bilirubin > 1.2 mg/dL and the absence of haematological disorder. CONCLUSIONS ICU patients had significantly lower isavuconazole blood levels compared to non-ICU population. The TDM of isavuconazole for efficacy should be performed in ICU.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Monica Melchio
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, Genova, Italy
| | - Nadir Ullah
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
| | - Franca Miletich
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Sepulcri
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
| | - Alessandro Limongelli
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniele Roberto Giacobbe
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Balletto
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Russo
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Laura Magnasco
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Di Grazia
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Anna Maria Raiola
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federica Portunato
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Dentone
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Emanuele Angelucci
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences, University of Genova, Genova, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Lucio J, Alcazar-Fuoli L, Gil H, Cano-Pascual S, Hernandez-Egido S, Cuetara MS, Mellado E. Distribution of Aspergillus species and prevalence of azole resistance in clinical and environmental samples from a Spanish hospital during a three-year study period. Mycoses 2024; 67:e13719. [PMID: 38551063 DOI: 10.1111/myc.13719] [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: 10/24/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Surveillance studies are crucial for updating trends in Aspergillus species and antifungal susceptibility information. OBJECTIVES Determine the Aspergillus species distribution and azole resistance prevalence during this 3-year prospective surveillance study in a Spanish hospital. MATERIALS AND METHODS Three hundred thirty-five Aspergillus spp. clinical and environmental isolates were collected during a 3-year study. All isolates were screened for azole resistance using an agar-based screening method and resistance was confirmed by EUCAST antifungal susceptibility testing. The azole resistance mechanism was confirmed by sequencing the cyp51A gene and its promoter. All Aspergillus fumigatus strains were genotyped using TRESPERG analysis. RESULTS Aspergillus fumigatus was the predominant species recovered with a total of 174 strains (51.94%). The rest of Aspergillus spp. were less frequent: Aspergillus niger (14.93%), Aspergillus terreus (9.55%), Aspergillus flavus (8.36%), Aspergillus nidulans (5.37%) and Aspergillus lentulus (3.28%), among other Aspergillus species (6.57%). TRESPERG analysis showed 99 different genotypes, with 72.73% of the strains being represented as a single genotype. Some genotypes were common among clinical and environmental A. fumigatus azole-susceptible strains, even when isolated months apart. We describe the occurrence of two azole-resistant A. fumigatus strains, one clinical and another environmental, that were genotypically different and did not share genotypes with any of the azole-susceptible strains. CONCLUSIONS Aspergillus fumigatus strains showed a very diverse population although several genotypes were shared among clinical and environmental strains. The isolation of azole-resistant strains from both settings suggest that an efficient analysis of clinical and environmental sources must be done to detect azole resistance in A. fumigatus.
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Affiliation(s)
- Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Laura Alcazar-Fuoli
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
| | - Horacio Gil
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Samuel Cano-Pascual
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Sara Hernandez-Egido
- Microbiology Department, University Hospital Severo Ochoa, Leganés, Madrid, Spain
| | | | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 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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11
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Gupta AK, Mann A, Polla Ravi S, Wang T. An update on antifungal resistance in dermatophytosis. Expert Opin Pharmacother 2024; 25:511-519. [PMID: 38623728 DOI: 10.1080/14656566.2024.2343079] [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: 02/01/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION The reports of resistance to antifungal agents used for treating onychomycosis and other superficial fungal infections are increasing. This rise in antifungal resistance poses a public health challenge that requires attention. AREAS COVERED This review explores the prevalence of dermatophytes and the current relationship between dermatophyte species, their minimum inhibitory concentrations (MICs) for terbinafine (an allylamine) and itraconazole (an azole), and various mutations prevalent in these species. The most frequently isolated dermatophyte associated with resistance in patients with onychomycosis and dermatophytosis was T. mentagrophytes. However, T. indotineae emerged as the most prevalent isolate with mutations in the SQLE gene, exhibiting the highest MIC of 8 µg/ml for terbinafine and MICs of 8 µg/ml and ≥ 32 µg/ml for itraconazole.Overall, the most prevalent SQLE mutations were Phe397Leu, Leu393Phe, Ala448Thr, Phe397Leu/Ala448Thr, and Lys276Asn/Leu415Phe (relatively recent). EXPERT OPINION Managing dermatophyte infections requires a personalized approach. A detailed history should be obtained including details of travel, home and occupational exposure, and clinical examination of the skin, nails and other body systems. Relevant testing includes mycological examination (traditional and molecular). Additional testing, where available, includes MIC evaluation and detection of SQLE mutations. In case of suspected terbinafine resistance, itraconazole or voriconazole (less commonly) should be considered.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research Inc, London, Ontario, Canada
| | | | | | - Tong Wang
- Mediprobe Research Inc, London, Ontario, Canada
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12
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Venezia V, Prieto C, Verrillo M, Grumi M, Silvestri B, Vitiello G, Luciani G, Lagaron JM. Electrospun films incorporating humic substances of application interest in sustainable active food packaging. Int J Biol Macromol 2024; 263:130210. [PMID: 38365144 DOI: 10.1016/j.ijbiomac.2024.130210] [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: 12/01/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
Sustainable active food packaging is essential to reduce the use of plastics, preserve food quality and minimize the environmental impact. Humic substances (HS) are rich in redox-active compounds, such as quinones, phenols, carboxyl, and hydroxyl moieties, making them functional additives for biopolymeric matrices, such as poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV). Herein, composites made by incorporating different amounts of HS into PHBV were developed using the electrospinning technology and converted into homogeneous and continuous films by a thermal post-treatment to obtain a bioactive and biodegradable layer which could be part of a multilayer food packaging solution. The morphology, thermal, optical, mechanical, antioxidant and barrier properties of the resulting PHBV-based films have been evaluated, as well as the antifungal activity against Aspergillus flavus and Candida albicans and the antimicrobial properties against both Gram (+) and Gram (-) bacterial strains. HS show great potential as natural additives for biopolymer matrices, since they confer antioxidant, antimicrobial, and antifungal properties to the resulting materials. In addition, barrier, optical and mechanical properties highlighted that the obtained films are suitable for sustainable active packaging. Therefore, the electrospinning methodology is a promising and sustainable approach to give biowaste a new life through the development of multifunctional materials suitable in the active bio-packaging.
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Affiliation(s)
- Virginia Venezia
- DICMaPI, Department of Chemical, Materials and Industrial Production Engineering, University of Naples Federico II, Naples, Italy; DiSt, Department of Structures for Engineering and Architecture, University of Naples Federico II, Naples, Italy.
| | - Cristina Prieto
- Novel Materials and Nanotechnology Group, Institute of Agrochemistry and Food Technology (IATA), Spanish Council for Scientific Research (CSIC), Paterna, Spain
| | | | - Mattia Grumi
- Novel Materials and Nanotechnology Group, Institute of Agrochemistry and Food Technology (IATA), Spanish Council for Scientific Research (CSIC), Paterna, Spain
| | - Brigida Silvestri
- Department of Civil, Architectural and Environmental Engineering, University of Naples Federico II, Italy
| | - Giuseppe Vitiello
- DICMaPI, Department of Chemical, Materials and Industrial Production Engineering, University of Naples Federico II, Naples, Italy; CSGI-Center for Colloid and Surface Science, Via Della Lastruccia 3, 50019 Florence, Italy
| | - Giuseppina Luciani
- DICMaPI, Department of Chemical, Materials and Industrial Production Engineering, University of Naples Federico II, Naples, Italy.
| | - Jose M Lagaron
- Novel Materials and Nanotechnology Group, Institute of Agrochemistry and Food Technology (IATA), Spanish Council for Scientific Research (CSIC), Paterna, Spain
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13
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Gupta AK, Mann A, Polla Ravi S, Wang T. Navigating fungal infections and antifungal stewardship: drug resistance, susceptibility testing, therapeutic drug monitoring and future directions. Ital J Dermatol Venerol 2024; 159:105-117. [PMID: 38088126 DOI: 10.23736/s2784-8671.23.07694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Antifungal stewardship refers to the rational use of antifungal agents. Historically, in some instances, the misuse or overuse of antifungal agents has predisposed patients to an elevated risk of systemic side-effects and treatment resistance, as well as increased healthcare costs. Superficial mycoses, such as onychomycosis, are sometimes treated without any diagnostic testing and is associated with a high likelihood of self-diagnosis and self-treatment, potentially leading to the emergence of resistance against commonly used antifungals like terbinafine. Practitioners need to ensure that a proper clinical diagnosis is backed up by appropriate testing. This may include the traditional light microscopy and culture; additionally, molecular techniques (such as polymerase chain reaction, terbinafine gene mutational analysis) and antifungal susceptibility testing are considerations as appropriate. The choice of antifungal agent should be guided by what is the standard of care in the location where the clinician practices as well as more broadly state and national prescription patterns. Recently, reports of treatment resistance concerning both superficial and deep fungal infections have added another layer of difficulty to clinical practice. This review aims to explore the phenomenon of antifungal drug resistance, and highlights the importance of adopting antifungal stewardship programs. We provide an overview of treatment resistance and mechanisms of resistance reported thus far in dermatophytes. Challenges of performing antifungal susceptibility testing and therapeutic drug monitoring are discussed, as well as principles, recommendations and future directions of antifungal stewardship programs.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada -
- Mediprobe Research Inc, London, ON, Canada -
| | | | | | - Tong Wang
- Mediprobe Research Inc, London, ON, Canada
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14
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Lass-Flörl C, Kanj SS, Govender NP, Thompson GR, Ostrosky-Zeichner L, Govrins MA. Invasive candidiasis. Nat Rev Dis Primers 2024; 10:20. [PMID: 38514673 DOI: 10.1038/s41572-024-00503-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
Invasive candidiasis is an important fungal disease caused by Candida albicans and, increasingly, non-albicans Candida pathogens. Invasive Candida infections originate most frequently from endogenous human reservoirs and are triggered by impaired host defences. Signs and symptoms of invasive candidiasis are non-specific; candidaemia is the most diagnosed manifestation, with disseminated candidiasis affecting single or multiple organs. Diagnosis poses many challenges, and conventional culture techniques are frequently supplemented by non-culture-based assays. The attributable mortality from candidaemia and disseminated infections is ~30%. Fluconazole resistance is a concern for Nakaseomyces glabratus, Candida parapsilosis, and Candida auris and less so in Candida tropicalis infection; acquired echinocandin resistance remains uncommon. The epidemiology of invasive candidiasis varies in different geographical areas and within various patient populations. Risk factors include intensive care unit stay, central venous catheter use, broad-spectrum antibiotics use, abdominal surgery and immune suppression. Early antifungal treatment and central venous catheter removal form the cornerstones to decrease mortality. The landscape of novel therapeutics is growing; however, the application of new drugs requires careful selection of eligible patients as the spectrum of activity is limited to a few fungal species. Unanswered questions and knowledge gaps define future research priorities and a personalized approach to diagnosis and treatment of invasive candidiasis is of paramount importance.
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Affiliation(s)
- Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, ECMM Excellence Centres of Medical Mycology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Souha S Kanj
- Infectious Diseases Division, and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nelesh P Govender
- Faculty of Health Sciences, University of the Witwatersrand and National Institute for Communicable Diseases, Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - George R Thompson
- UC Davis Health Medical Center, Division of Infectious Diseases, Sacramento, CA, USA
| | | | - Miriam Alisa Govrins
- Institute of Hygiene and Medical Microbiology, ECMM Excellence Centres of Medical Mycology, Medical University of Innsbruck, Innsbruck, Austria
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15
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Chastain DB, White BP, Tu PJ, Chan S, Jackson BT, Kubbs KA, Bandali A, McDougal S, Henao-Martínez AF, Cluck DB. Candidemia in Adult Patients in the ICU: A Reappraisal of Susceptibility Testing and Antifungal Therapy. Ann Pharmacother 2024; 58:305-321. [PMID: 37272474 DOI: 10.1177/10600280231175201] [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: 06/06/2023] Open
Abstract
OBJECTIVE To provide updates on the epidemiology and recommendations for management of candidemia in patients with critical illness. DATA SOURCES A literature search using the PubMed database (inception to March 2023) was conducted using the search terms "invasive candidiasis," "candidemia," "critically ill," "azoles," "echinocandin," "antifungal agents," "rapid diagnostics," "antifungal susceptibility testing," "therapeutic drug monitoring," "antifungal dosing," "persistent candidemia," and "Candida biofilm." STUDY SELECTION/DATA EXTRACTION Clinical data were limited to those published in the English language. Ongoing trials were identified through ClinicalTrials.gov. DATA SYNTHESIS A total of 109 articles were reviewed including 25 pharmacokinetic/pharmacodynamic studies and 30 studies including patient data, 13 of which were randomized controlled clinical trials. The remaining 54 articles included fungal surveillance data, in vitro studies, review articles, and survey data. The current 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Management of Candidiasis provides recommendations for selecting empiric and definitive antifungal therapies for candidemia, but data are limited regarding optimized dosing strategies in critically ill patients with dynamic pharmacokinetic changes or persistent candidemia complicated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Outcomes due to candidemia remain poor despite improved diagnostic platforms, antifungal susceptibility testing, and antifungal therapy selection for candidemia in critically ill patients. Earlier detection and identification of the species causing candidemia combined with recognition of patient-specific factors leading to dosing discrepancies are crucial to improving outcomes in critically ill patients with candidemia. CONCLUSIONS Treatment of candidemia in critically ill patients must account for the incidence of non-albicans Candida species and trends in antifungal resistance as well as overcome the complex pathophysiologic changes to avoid suboptimal antifungal exposure.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Bryan P White
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Patrick J Tu
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Sophea Chan
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
- Department of Pharmacy, Phoebe Putney Memorial Hospital, Albany, GA, USA
| | | | - Kara A Kubbs
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Aiman Bandali
- Overlook Medical Center, Atlantic Health System, Summit, NJ, USA
| | | | - Andrés F Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David B Cluck
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
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Mesquida A, Alcoceba E, Padilla E, Ramírez A, Merino P, González-Romo F, De Carolis E, Sanguinetti M, Mantecón-Vallejo MDLÁ, Muñoz-Algarra M, Durán-Valle T, Pérez-Ayala A, Gómez-García-de-la-Pedrosa E, Del Carmen Martínez-Jiménez M, Sánchez-Castellano MÁ, Quiles-Melero I, Cuétara MS, Sánchez-García A, Muñoz P, Escribano P, Guinea J. Fluconazole-resistant Candida parapsilosis genotypes from hospitals located in five Spanish cities and one in Italy: Description of azole-resistance profiles associated with the Y132F ERG11p substitution. Mycoses 2024; 67:e13706. [PMID: 38438313 DOI: 10.1111/myc.13706] [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: 12/22/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Fluconazole-resistant Candida parapsilosis is a matter of concern. OBJECTIVES To describe fluconazole-resistant C. parapsilosis genotypes circulating across hospitals in Spain and Rome and to study their azole-resistance profile associated with ERG11p substitutions. PATIENTS/METHODS We selected fluconazole-resistant C. parapsilosis isolates (n = 528 from 2019 to 2023; MIC ≥8 mg/L according to EUCAST) from patients admitted to 13 hospitals located in five Spanish cities and Rome. Additionally, we tested voriconazole, posaconazole, isavuconazole, amphotericin B, micafungin, anidulafungin and ibrexafungerp susceptibility. RESULTS Of the 53 genotypes found, 49 harboured the Y132F substitution, five of which were dominating city-specific genotypes involving almost half the isolates. Another genotype involved isolates harbouring the G458S substitution. Finally, we found two genotypes with the wild-type ERG11 gene sequence and one with the R398I substitution. All isolates were fully susceptible/wild-type to amphotericin B, anidulafungin, micafungin and ibrexafungerp. The azole-resistance patterns found were: voriconazole-resistant (74.1%) or voriconazole-intermediate (25.2%), posaconazole-resistant (10%) and isavuconazole non-wild-type (47.5%). Fluconazole-resistant and voriconazole non-wild-type isolates were likely to harbour substitution Y132F if posaconazole was wild type; however, if posaconazole was non-wild type, substitution G458S was indicated if isavuconazole MIC was >0.125 mg/L or substitution Y132F if isavuconazole MIC was ≤0.125 mg/L. CONCLUSIONS We detected a recent clonal spread of fluconazole-resistant C. parapsilosis across some cities in Spain, mostly driven by dominating city-specific genotypes, which involved a large number of isolates harbouring the Y132F ERG11p substitution. Isolates harbouring substitution Y132F can be suspected because they are non-susceptible to voriconazole and rarely posaconazole-resistant.
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Affiliation(s)
- Aina Mesquida
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Eva Alcoceba
- Clinical Microbiology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Aída Ramírez
- Clinical Microbiology Department, Hospital del Mar, Barcelona, Spain
| | - Paloma Merino
- Clinical Microbiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos IdISSC, Madrid, Spain
| | - Fernando González-Romo
- Clinical Microbiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos IdISSC, Madrid, Spain
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - María Muñoz-Algarra
- Clinical Microbiology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Teresa Durán-Valle
- Clinical Microbiology Department, Hospital Universitario de Móstoles, Móstoles, Spain
| | - Ana Pérez-Ayala
- Clinical Microbiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital 12 de Octubre, Madrid, Spain
| | - Elia Gómez-García-de-la-Pedrosa
- Clinical Microbiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | | | - María Soledad Cuétara
- Clinical Microbiology Department, Hospital Universitario Severo Ochoa, Leganés, Spain
| | - Aída Sánchez-García
- Laboratorio Central de la CAM-UR Salud-Hospital Infanta Sofía, Madrid, Spain
| | - Patricia Muñoz
- 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
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Faculty of Health Sciences - HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
| | - Jesús 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
- Faculty of Health Sciences - HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
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Pintye A, Bacsó R, Kovács GM. Trans-kingdom fungal pathogens infecting both plants and humans, and the problem of azole fungicide resistance. Front Microbiol 2024; 15:1354757. [PMID: 38410389 PMCID: PMC10896089 DOI: 10.3389/fmicb.2024.1354757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
Azole antifungals are abundantly used in the environment and play an important role in managing fungal diseases in clinics. Due to the widespread use, azole resistance is an emerging global problem for all applications in several fungal species, including trans-kingdom pathogens, capable of infecting plants and humans. Azoles used in agriculture and clinics share the mode of action and facilitating cross-resistance development. The extensive use of azoles in the environment, e.g., for plant protection and wood preservation, contributes to the spread of resistant populations and challenges using these antifungals in medical treatments. The target of azoles is the cytochrome p450 lanosterol 14-α demethylase encoded by the CYP51 (called also as ERG11 in the case of yeasts) gene. Resistance mechanisms involve mainly the mutations in the coding region in the CYP51 gene, resulting in the inadequate binding of azoles to the encoded Cyp51 protein, or mutations in the promoter region causing overexpression of the protein. The World Health Organization (WHO) has issued the first fungal priority pathogens list (FPPL) to raise awareness of the risk of fungal infections and the increasingly rapid spread of antifungal resistance. Here, we review the main issues about the azole antifungal resistance of trans-kingdom pathogenic fungi with the ability to cause serious human infections and included in the WHO FPPL. Methods for the identification of these species and detection of resistance are summarized, highlighting the importance of these issues to apply the proper treatment.
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Affiliation(s)
- Alexandra Pintye
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
- Department of Plant Anatomy, Institute of Biology, Eötvös Loránd University, Budapest, Hungary
| | - Renáta Bacsó
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
| | - Gábor M. Kovács
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
- Department of Plant Anatomy, Institute of Biology, Eötvös Loránd University, Budapest, Hungary
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18
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Correia JL, Fiuza JG, Ferreira G, Almeida MD, Moreira D, Neto VD. Embolic stroke and misidentification candida species endocarditis: Case presentation and literature review. Diagn Microbiol Infect Dis 2024; 108:116133. [PMID: 37984110 DOI: 10.1016/j.diagmicrobio.2023.116133] [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: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
Fungal endocarditis is a rare but serious form of infective endocarditis associated with high morbidity and mortality. Among fungal pathogens, Candida species are the most frequently isolated and commonly found in individuals with predisposing factors, such as prosthetic heart valves. The clinical presentation of endocarditis is highly variable and nonspecific, often including symptoms and signs of embolization. In this paper, we present a case of fungal prosthetic valve endocarditis in which the initial presentation was an acute ischemic stroke. The initial misidentification of Candida famata was attributed to limitations in the presumptive methodology used through selective chromogenic culture identification. However, the surgical specimen underwent mass spectrometry, leading to the correct identification of Candida guilliermondii instead of Candida famata. Furthermore, we conducted a non-systematic narrative review of the literature on Candida endocarditis. Our findings underscore the importance of considering fungal endocarditis in the differential diagnosis of patients with possible extracardiac complications, particularly those with a history of heart valve replacement. Early diagnosis and a comprehensive treatment strategy tailored by species identification and antifungal susceptibility testing are crucial in improving patient outcomes.
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Affiliation(s)
| | | | | | | | | | - Vanda Devesa Neto
- Tondela-Viseu Hospital Center, Viseu, Portugal; Faculty of Health Sciences - University of Beira Interior, Covilhã, Portugal
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19
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Verweij PE, Song Y, Buil JB, Zhang J, Melchers WJG. Antifungal Resistance in Pulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:32-40. [PMID: 38196063 DOI: 10.1055/s-0043-1776997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Aspergilli may cause various pulmonary diseases in humans, including allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA), and acute invasive pulmonary aspergillosis (IPA). In addition, chronic colonization may occur in cystic fibrosis (CF). Aspergillus fumigatus represents the main pathogen, which may employ different morphotypes, for example, conidia, hyphal growth, and asexual sporulation, in the various Aspergillus diseases. These morphotypes determine the ease by which A. fumigatus can adapt to stress by antifungal drug exposure, usually resulting in one or more resistance mutations. Key factors that enable the emergence of resistance include genetic variation and selection. The ability to create genetic variation depends on the reproduction mode, including, sexual, parasexual, and asexual, and the population size. These reproduction cycles may take place in the host and/or in the environment, usually when specific conditions are present. Environmental resistance is commonly characterized by tandem repeat (TR)-mediated mutations, while in-host resistance selection results in single-resistance mutations. Reported cases from the literature indicate that environmental resistance mutations are almost exclusively present in patients with IA indicating that the risk for in-host resistance selection is very low. In aspergilloma, single-point mutations are the dominant resistance genotype, while in other chronic Aspergillus diseases, for example, ABPA, CPA, and CF, both TR-mediated and single-resistance mutations are reported. Insights into the pathogenesis of resistance selection in various Aspergillus diseases may help to improve diagnostic and therapeutic strategies.
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Affiliation(s)
- Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Yinggai Song
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Dermatology and Venerology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, China
- National Clinical Research Center For Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
| | - Jianhua Zhang
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
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20
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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, Oliveira LD, de Araújo LS, Fava WS, Bonfietti LX, Paniago AMM, Venturini J, Espinel-Ingroff A. Antifungal Resistance in Cryptococcal Infections. Pathogens 2024; 13:128. [PMID: 38392866 PMCID: PMC10891860 DOI: 10.3390/pathogens13020128] [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: 10/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.
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Affiliation(s)
- Marcia S C Melhem
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | | | - Juliana P F Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | | | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Wellington S Fava
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Lucas X Bonfietti
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Anamaria M M Paniago
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Ana Espinel-Ingroff
- Central Public Health Laboratory-LACEN, Campo Grande 79074-460, MS, Brazil
- VCU Medical Center, Richmond, VA 23284, USA
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21
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Govrins M, Lass-Flörl C. Candida parapsilosis complex in the clinical setting. Nat Rev Microbiol 2024; 22:46-59. [PMID: 37674021 DOI: 10.1038/s41579-023-00961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
Representatives of the Candida parapsilosis complex are important yeast species causing human infections, including candidaemia as one of the leading diseases. This complex comprises C. parapsilosis, Candida orthopsilosis and Candida metapsilosis, and causes a wide range of clinical presentations from colonization to superficial and disseminated infections with a high prevalence in preterm-born infants and the potential to cause outbreaks in hospital settings. Compared with other Candida species, the C. parapsilosis complex shows high minimal inhibitory concentrations for echinocandin drugs due to a naturally occurring FKS1 polymorphism. The emergence of clonal outbreaks of strains with resistance to commonly used antifungals, such as fluconazole, is causing concern. In this Review, we present the latest medical data covering epidemiology, diagnosis, resistance and current treatment approaches for the C. parapsilosis complex. We describe its main clinical manifestations in adults and children and highlight new treatment options. We compare the three sister species, examining key elements of microbiology and clinical characteristics, including the population at risk, disease manifestation and colonization status. Finally, we provide a comprehensive resource for clinicians and researchers focusing on Candida species infections and the C. parapsilosis complex, aiming to bridge the emerging translational knowledge and future therapeutic challenges associated with this human pathogen.
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Affiliation(s)
- Miriam Govrins
- 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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22
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Feng Y, Lu H, Whiteway M, Jiang Y. Understanding fluconazole tolerance in Candida albicans: implications for effective treatment of candidiasis and combating invasive fungal infections. J Glob Antimicrob Resist 2023; 35:314-321. [PMID: 37918789 DOI: 10.1016/j.jgar.2023.10.019] [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: 05/04/2023] [Revised: 10/07/2023] [Accepted: 10/22/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES Fluconazole (FLC) tolerant phenotypes in Candida species contribute to persistent candidemia and the emergence of FLC resistance. Therefore, making FLC fungicidal and eliminating FLC tolerance are important for treating invasive fungal diseases (IFDs) caused by Candida species. However, the mechanisms of FLC tolerance in Candida species remain to be fully explored. METHODS This review discusses the high incidence of FLC tolerance in Candida species and the importance of successfully clearing FLC tolerance in treating candidiasis. We further define and characterize FLC tolerance in C. albicans. RESULTS This review identifies global factors affecting FLC tolerance and suggest that FLC tolerance is a strategy of C. albicans response to FLC damage whose mechanism differs from FLC resistance. CONCLUSIONS This review highlights the significance of the cell membrane and cell wall integrity in FLC tolerance, guiding approaches to combat IFDs caused by Candida species..
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Affiliation(s)
- Yanru Feng
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hui Lu
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Yuanying Jiang
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
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23
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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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24
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Zhou S, Ismail MAI, Buil JB, Gabr A, Verweij PE, Mahgoub ES, de Hoog S, Kang Y, Ahmed SA. Fungi involved in rhinosinusitis in arid regions: insights from molecular identification and antifungal susceptibility. Microbiol Spectr 2023; 11:e0183123. [PMID: 37772821 PMCID: PMC10580872 DOI: 10.1128/spectrum.01831-23] [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: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 09/30/2023] Open
Abstract
Fungal rhinosinusitis (FRS) is a common problem worldwide, with an increasing burden in arid climate regions. Aspergillus species are the most common causative agents involved. In the present study, we investigated the prevalence, molecular characterization, and antifungal susceptibility of opportunists causing FRS in Sudan on the basis of strains collected over a period of 5 years. β-Tubulin and calmodulin sequencing were used for species identification, and antifungal susceptibility profiles were evaluated by the protocol of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Predominant species belonged to the Aspergillus flavus complex (n = 244), A. terreus complex (n = 16), A. fumigatus complex (n = 7), and other fungi (n = 17). Molecular identification of 94 strains of Aspergillus revealed the following species: A. flavus (n = 88), A. terreus (n = 1), A. citrinoterreus (n = 2), A. fumigatus (n = 1), A. caespitosus (n = 1), and A. sydowii (n = 1). Several A. flavus and an A. fumigatus isolates showed reduced susceptibility to azoles (minimum inhibitory concentrations above the clinical breakpoints or epidemiological cutoff values). Despite several mutations revealed in cyp51A of these isolates, none could be directly linked to azole resistance. Molecular identification of fungi causing FRS is useful to identify cryptic species and for epidemiologic studies. IMPORTANCE Fungal rhinosinusitis (FRS) is a significant clinical problem in arid regions. This study provides new insights into the prevalence, etiology, and antifungal susceptibility of FRS pathogens in Sudan, where the disease burden is high. Aspergillus species, particularly the A. flavus complex, were identified as the primary FRS pathogens in the region, with some evidence of antifungal resistance. The molecular identification of fungal species causing FRS is useful for detecting antifungal resistance, identifying cryptic species, and characterizing the epidemiology of the disease. The emergence of Azole resistance Aspergilli in Sudan highlights the need for continued surveillance and appropriate use of antifungal agents. These findings have important implications for clinical management, public health policy, and future research on FRS. Publishing this study in Microbiology Spectrum would enable other researchers and clinicians to build on these findings, ultimately improving the diagnosis, treatment, and prevention of FRS.
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Affiliation(s)
- Shaoqin Zhou
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, School of Basic Medical Science, Guizhou Medical University, Guiyang, China
- Radboudumc-CWZ Centre of Expertise for Mycology, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | | | - Jochem B. Buil
- Radboudumc-CWZ Centre of Expertise for Mycology, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Aida Gabr
- Mycology Reference Laboratory, University of Khartoum, Khartoum, Sudan
| | - Paul E. Verweij
- Radboudumc-CWZ Centre of Expertise for Mycology, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - El-Sheikh Mahgoub
- Mycology Reference Laboratory, University of Khartoum, Khartoum, Sudan
| | - Sybren de Hoog
- Radboudumc-CWZ Centre of Expertise for Mycology, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
- Foundation Atlas of Clinical Fungi, Hilversum, the Netherlands
| | - Yingqian Kang
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, School of Basic Medical Science, Guizhou Medical University, Guiyang, China
| | - Sarah A. Ahmed
- Radboudumc-CWZ Centre of Expertise for Mycology, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
- Foundation Atlas of Clinical Fungi, Hilversum, the Netherlands
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Alabi PE, Gautier C, Murphy TP, Gu X, Lepas M, Aimanianda V, Sello JK, Ene IV. Small molecules restore azole activity against drug-tolerant and drug-resistant Candida isolates. mBio 2023; 14:e0047923. [PMID: 37326546 PMCID: PMC10470600 DOI: 10.1128/mbio.00479-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/13/2023] [Indexed: 06/17/2023] Open
Abstract
Each year, fungi cause more than 1.5 billion infections worldwide and have a devastating impact on human health, particularly in immunocompromised individuals or patients in intensive care units. The limited antifungal arsenal and emerging multidrug-resistant species necessitate the development of new therapies. One strategy for combating drug-resistant pathogens is the administration of molecules that restore fungal susceptibility to approved drugs. Accordingly, we carried out a screen to identify small molecules that could restore the susceptibility of pathogenic Candida species to azole antifungals. This screening effort led to the discovery of novel 1,4-benzodiazepines that restore fluconazole susceptibility in resistant isolates of Candida albicans, as evidenced by 100-1,000-fold potentiation of fluconazole activity. This potentiation effect was also observed in azole-tolerant strains of C. albicans and in other pathogenic Candida species. The 1,4-benzodiazepines selectively potentiated different azoles, but not other approved antifungals. A remarkable feature of the potentiation was that the combination of the compounds with fluconazole was fungicidal, whereas fluconazole alone is fungistatic. Interestingly, the potentiators were not toxic to C. albicans in the absence of fluconazole, but inhibited virulence-associated filamentation of the fungus. We found that the combination of the potentiators and fluconazole significantly enhanced host survival in a Galleria mellonella model of systemic fungal infection. Taken together, these observations validate a strategy wherein small molecules can restore the activity of highly used anti-infectives that have lost potency. IMPORTANCE In the last decade, we have been witnessing a higher incidence of fungal infections, due to an expansion of the fungal species capable of causing disease (e.g., Candida auris), as well as increased antifungal drug resistance. Among human fungal pathogens, Candida species are a leading cause of invasive infections and are associated with high mortality rates. Infections by these pathogens are commonly treated with azole antifungals, yet the expansion of drug-resistant isolates has reduced their clinical utility. In this work, we describe the discovery and characterization of small molecules that potentiate fluconazole and restore the susceptibility of azole-resistant and azole-tolerant Candida isolates. Interestingly, the potentiating 1,4-benzodiazepines were not toxic to fungal cells but inhibited their virulence-associated filamentous growth. Furthermore, combinations of the potentiators and fluconazole decreased fungal burdens and enhanced host survival in a Galleria mellonella model of systemic fungal infections. Accordingly, we propose the use of novel antifungal potentiators as a powerful strategy for addressing the growing resistance of fungi to clinically approved drugs.
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Affiliation(s)
- Philip E. Alabi
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Cécile Gautier
- Institut Pasteur, Université Paris Cité, Fungal Heterogeneity Group, Paris, France
| | - Thomas P. Murphy
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, USA
| | - Xilin Gu
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Mathieu Lepas
- Institut Pasteur, Université Paris Cité, CNRS UMR2000, Molecular Mycology Unit, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, Université Paris Cité, CNRS UMR2000, Molecular Mycology Unit, Paris, France
| | - Jason K. Sello
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Iuliana V. Ene
- Institut Pasteur, Université Paris Cité, Fungal Heterogeneity Group, Paris, France
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, USA
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26
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Zhu G, Chen S, Zhang Y, Lu L. Mitochondrial Membrane-Associated Protein Mba1 Confers Antifungal Resistance by Affecting the Production of Reactive Oxygen Species in Aspergillus fumigatus. Antimicrob Agents Chemother 2023; 67:e0022523. [PMID: 37428039 PMCID: PMC10433838 DOI: 10.1128/aac.00225-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Azole resistance in the human fungal pathogen Aspergillus fumigatus is becoming a major threat to global health. To date, mutations in the azole target-encoding cyp51A gene have been implicated in conferring azole resistance, but a steady increase in the number of A. fumigatus isolates with azole resistance resulting from non-cyp51A mutations has been recognized. Previous studies have revealed that some isolates with non-cyp51A mutation-induced azole resistance are related to mitochondrial dysfunction. However, knowledge of the molecular mechanism underlying the involvement of non-cyp51A mutations is limited. In this study, using next-generation sequencing, we found that nine independent azole-resistant isolates without cyp51A mutations had normal mitochondrial membrane potential. Among these isolates, a mutation in a mitochondrial ribosome-binding protein, Mba1, conferred multidrug resistance to azoles, terbinafine, and amphotericin B but not caspofungin. Molecular characterization verified that the TIM44 domain of Mba1 was crucial for drug resistance and that the N terminus of Mba1 played a major role in growth. Deletion of mba1 had no effect on Cyp51A expression but decreased the fungal cellular reactive oxygen species (ROS) content, which contributed to mba1-mediated drug resistance. The findings in this study suggest that some non-cyp51A proteins drive drug resistance mechanisms that result from reduced ROS production induced by antifungals.
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Affiliation(s)
- Guoxing Zhu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Center for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Shu Chen
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Center for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Yuanwei Zhang
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Center for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Ling Lu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Center for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
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27
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Qiao Y, Tao Z, Hao F, Huang Y, Sun H, Guo P. Epidemiological Characteristics, Antifungal Susceptibility, Risk Factors, and Outcomes of Candida Bloodstream Infection: A Ten-Year Surveillance in a Teaching Hospital in China. Infect Drug Resist 2023; 16:4769-4778. [PMID: 37496692 PMCID: PMC10368108 DOI: 10.2147/idr.s411283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023] Open
Abstract
Background Candida is one of the most important pathogens of hospital-acquired bloodstream infections. Its morbidity and mortality are still high, which is a serious global public problem. Purpose To investigate the strain distribution, drug susceptibility, clinical characteristics of patients, and risk factors affecting the prognosis of Candida bloodstream infection (BSI). Materials and Methods We retrospectively collected the clinical data, infection-related indicators, prognosis, strain prevalence and drug susceptibility of 163 patients with Candida BSI in a teaching hospital from January 2012 to December 2022. Univariate and multivariate logistic regression were used to analyze the risk factors affecting the prognosis. Results In 163 cases of Candida BSI, Candida albicans accounted for 48.47%, and Candida non-albicans accounted for 51.53%. A total of 163 patients with Candida BSI were mainly distributed in intensive care unit (ICU) and emergency department, accounting for 40.49% and 14.72%, respectively. The resistance rate of Candida albicans to fluconazole, itraconazole and voriconazole was less than 10%, and the sensitivity rate of Candida tropicalis to fluconazole, itraconazole and voriconazole was less than 80%. The mortality rate of 163 patients with Candida BSI was 33.13%, with Candida non-albicans higher than that of Candida albicans (p = 0.04). Multivariate analysis showed that hemodialysis (OR = 0.199, 95% CI: 0.059-0.673, P = 0.009), arteriovenous catheters (OR = 0.344, 95% CI: 0.130-0.913, P = 0.032), elevated neutrophil count (OR = 0.409, 95% CI: 0.194-0.862, P = 0.019) and APACHE II score (OR = 0.848, 95% CI: 0.789~0.911, P < 0.001) were independent risk factors for death in patients with candidemia. Conclusion The blood flow infection rate of Candida non-albicans is increasing, and the mortality rate and resistance to antifungal drugs are higher than that of Candida albicans. Hemodialysis, arteriovenous catheters, elevated neutrophil count and APACHE II score were associated with death in patients with Candida BSI.
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Affiliation(s)
- Yan Qiao
- Department of Infectious Disease, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233004, People’s Republic of China
| | - Zhaoyu Tao
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China
| | - Feiran Hao
- Department of Clinical Medicine, School of Basic Medicine, Qiqihar Medical college, Hei Longjiang Qiqihar, 161006, People’s Republic of China
| | - Yongqiang Huang
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China
| | - Hong Sun
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China
| | - Pu Guo
- Department of Clinical Laboratory Science, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China
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28
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Caballero U, Eraso E, Quindós G, Vozmediano V, Schmidt S, Jauregizar N. PK/PD modeling and simulation of the in vitro activity of the combinations of isavuconazole with echinocandins against Candida auris. CPT Pharmacometrics Syst Pharmacol 2023; 12:770-782. [PMID: 36915233 PMCID: PMC10272309 DOI: 10.1002/psp4.12949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
In vitro combination of echinocandins and isavuconazole against the emerging species Candida auris is mainly synergistic. However, this combination has not been evaluated in clinical settings. A pharmacokinetic/pharmacodynamic modeling and simulation approach based on in vitro data may be helpful to further study the therapeutic potential of these combinations. Therefore, the aims of this study were to characterize the time course of growth and killing of C. auris in response to the combination of the three approved echinocandins and isavuconazole using a semimechanistic model and to perform model-based simulations in order to predict the in vivo response to combination therapy. In vitro static time-kill curve data for isavuconazole and echinocandins combinations against six blood isolates of C. auris were best modeled considering the total killing of the fungal population as dependent on the additive effects of both drugs. Once assessed, the predictive performance of the model using simulations of different dosing and fungal susceptibility scenarios were conducted. Model-based simulations revealed that none of the combinations at standard or higher dosages would be effective against the studied isolates of C. auris and it was predicted that the combinations of isavuconazole with anidulafungin or caspofungin would be effective for minimum inhibitory concentrations up to 0.03 and 0.06 mg/L respectively, whereas the combination with micafungin would lead to treatment failure. The current approach highlights the importance of bridging the in vitro results to the clinic.
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Affiliation(s)
- Unai Caballero
- Department of Pharmacology, Faculty of Medicine and NursingUniversity of the Basque Country (UPV/EHU)LeioaSpain
| | - Elena Eraso
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and NursingUniversity of the Basque Country (UPV/EHU)LeioaSpain
| | - Guillermo Quindós
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and NursingUniversity of the Basque Country (UPV/EHU)LeioaSpain
| | - Valvanera Vozmediano
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of PharmacyUniversity of FloridaOrlandoFloridaUSA
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of PharmacyUniversity of FloridaOrlandoFloridaUSA
| | - Nerea Jauregizar
- Department of Pharmacology, Faculty of Medicine and NursingUniversity of the Basque Country (UPV/EHU)LeioaSpain
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29
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Sobel JD. Resistance to Fluconazole of Candida albicans in Vaginal Isolates: a 10-Year Study in a Clinical Referral Center. Antimicrob Agents Chemother 2023; 67:e0018123. [PMID: 37093005 PMCID: PMC10190554 DOI: 10.1128/aac.00181-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/23/2023] [Indexed: 04/25/2023] Open
Abstract
Review of vaginal isolates of Candida albicans that caused clinical failure in a 10-year collection of vaginal C. albicans specimens obtained in a university vaginitis referral clinic indicated an increase in fluconazole resistance. Factors contributing to azole resistance are discussed, including treatment choice associated with fluconazole-resistant C. albicans vaginal infection.
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Affiliation(s)
- J. D. Sobel
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA
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30
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Otto WR, Arendrup MC, Fisher BT. A Practical Guide to Antifungal Susceptibility Testing. J Pediatric Infect Dis Soc 2023; 12:214-221. [PMID: 36882026 PMCID: PMC10305799 DOI: 10.1093/jpids/piad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/06/2023] [Indexed: 03/09/2023]
Abstract
We review antifungal susceptibility testing and the development of clinical breakpoints, and detail an approach to using antifungal susceptibility results when breakpoints have not been defined. This information may prove helpful when selecting therapy for invasive fungal infections in children.
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Affiliation(s)
- William R Otto
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Cincinnati Children’s Hospital and Medical Center, Cincinnati, Ohio, USA
| | - 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
| | - Brian T Fisher
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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31
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Charria-Girón E, Stchigel AM, Čmoková A, Kolařík M, Surup F, Marin-Felix Y. Amesia hispanica sp. nov., Producer of the Antifungal Class of Antibiotics Dactylfungins. J Fungi (Basel) 2023; 9:jof9040463. [PMID: 37108917 PMCID: PMC10141101 DOI: 10.3390/jof9040463] [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: 02/27/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
During a study of the diversity of soilborne fungi from Spain, a strain belonging to the family Chaetomiaceae (Sordariales) was isolated. The multigene phylogenetic inference using five DNA loci showed that this strain represents an undescribed species of the genus Amesia, herein introduced as A. hispanica sp. nov. Investigation of its secondary metabolome led to the isolation of two new derivatives (2 and 3) of the known antifungal antibiotic dactylfungin A (1), together with the known compound cochliodinol (4). The planar structures of 1-4 were determined by ultrahigh performance liquid chromatography coupled with diode array detection and ion mobility tandem mass spectrometry (UHPLC-DAD-IM-MS/MS) and extensive 1D and 2D nuclear magnetic resonance (NMR) spectroscopy after isolation by HPLC. All isolated secondary metabolites were tested for their antimicrobial and cytotoxic activities. Dactylfungin A (1) showed selective and strong antifungal activity against some of the tested human pathogens (Aspergillus fumigatus and Cryptococcus neoformans). The additional hydroxyl group in 2 resulted in the loss of activity against C. neoformans but still retained the inhibition of As. fumigatus in a lower concentration than that of the respective control, without showing any cytotoxic effects. In contrast, 25″-dehydroxy-dactylfungin A (3) exhibited improved activity against yeasts (Schizosaccharomyces pombe and Rhodotorula glutinis) than 1 and 2, but resulted in the appearance of slight cytotoxicity. The present study exemplifies how even in a well-studied taxonomic group such as the Chaetomiaceae, the investigation of novel taxa still brings chemistry novelty, as demonstrated in this first report of this antibiotic class for chaetomiaceous and sordarialean taxa.
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Affiliation(s)
- Esteban Charria-Girón
- Department Microbial Drugs, Helmholtz Centre for Infection Research (HZI), German Centre for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Institute of Microbiology, Technische Universität Braunschweig, Spielmannstraße 7, 38106 Braunschweig, Germany
| | - Alberto Miguel Stchigel
- Mycology Unit, Medical School, Universitat Rovira i Virgili, C/Sant Llorenç 21, 43201 Tarragona, Spain
| | - Adéla Čmoková
- Institute of Microbiology, Czech Academy of Sciences, Vídeňská 1083, 14220 Prague, Czech Republic
| | - Miroslav Kolařík
- Institute of Microbiology, Czech Academy of Sciences, Vídeňská 1083, 14220 Prague, Czech Republic
| | - Frank Surup
- Department Microbial Drugs, Helmholtz Centre for Infection Research (HZI), German Centre for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Institute of Microbiology, Technische Universität Braunschweig, Spielmannstraße 7, 38106 Braunschweig, Germany
| | - Yasmina Marin-Felix
- Department Microbial Drugs, Helmholtz Centre for Infection Research (HZI), German Centre for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Inhoffenstrasse 7, 38124 Braunschweig, Germany
- Institute of Microbiology, Technische Universität Braunschweig, Spielmannstraße 7, 38106 Braunschweig, Germany
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32
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Mead ME, de Castro PA, Steenwyk JL, Gangneux JP, Hoenigl M, Prattes J, Rautemaa-Richardson R, Guegan H, Moore CB, Lass-Flörl C, Reizine F, Valero C, Van Rhijn N, Bromley MJ, Rokas A, Goldman GH, Gago S. COVID-19-Associated Pulmonary Aspergillosis Isolates Are Genomically Diverse but Similar to Each Other in Their Responses to Infection-Relevant Stresses. Microbiol Spectr 2023; 11:e0512822. [PMID: 36946762 PMCID: PMC10100753 DOI: 10.1128/spectrum.05128-22] [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: 12/15/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
Secondary infections caused by the pulmonary fungal pathogen Aspergillus fumigatus are a significant cause of mortality in patients with severe coronavirus disease 19 (COVID-19). Even though epithelial cell damage and aberrant cytokine responses have been linked to susceptibility to COVID-19-associated pulmonary aspergillosis (CAPA), little is known about the mechanisms underpinning copathogenicity. Here, we analyzed the genomes of 11 A. fumigatus isolates from patients with CAPA in three centers from different European countries. CAPA isolates did not cluster based on geographic origin in a genome-scale phylogeny of representative A. fumigatus isolates. Phenotypically, CAPA isolates were more similar to the A. fumigatus A1160 reference strain than to the Af293 strain when grown in infection-relevant stresses, except for interactions with human immune cells wherein macrophage responses were similar to those induced by the Af293 reference strain. Collectively, our data indicate that CAPA isolates are genomically diverse but are more similar to each other in their responses to infection-relevant stresses. A larger number of isolates from CAPA patients should be studied to better understand the molecular epidemiology of CAPA and to identify genetic drivers of copathogenicity and antifungal resistance in patients with COVID-19. IMPORTANCE Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has been globally reported as a life-threatening complication in some patients with severe COVID-19. Most of these infections are caused by the environmental mold Aspergillus fumigatus, which ranks third in the fungal pathogen priority list of the WHO. However, little is known about the molecular epidemiology of Aspergillus fumigatus CAPA strains. Here, we analyzed the genomes of 11 A. fumigatus isolates from patients with CAPA in three centers from different European countries, and carried out phenotypic analyses with a view to understanding the pathophysiology of the disease. Our data indicate that A. fumigatus CAPA isolates are genomically diverse but are more similar to each other in their responses to infection-relevant stresses.
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Affiliation(s)
- Matthew E. Mead
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Patrícia Alves de Castro
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jacob L. Steenwyk
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Jean-Pierre Gangneux
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
- Biotech Med, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Hélène Guegan
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
| | - Caroline B. Moore
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Cornelia Lass-Flörl
- European Excellence Center for Medical Mycology (ECMM), Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
| | - Florian Reizine
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
| | - Clara Valero
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Norman Van Rhijn
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Michael J. Bromley
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Antonis Rokas
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sara Gago
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - on behalf of the ECMM CAPA Study Group
- Department of Biological Sciences and Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
- University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail), Rennes, France
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
- Biotech Med, Graz, Austria
- Mycology Reference Centre Manchester and Department of Infectious Diseases, Manchester University, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- European Excellence Center for Medical Mycology (ECMM), Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Austria
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
- Manchester Fungal Infection Group, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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33
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Jia Y, Wang Z, Zhu S, Wang Z, Liu Y. Disinfectants facilitate the transformation of exogenous antibiotic resistance genes via multiple pathways. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2023; 253:114678. [PMID: 36857920 DOI: 10.1016/j.ecoenv.2023.114678] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
The prevalence and spread of multidrug-resistant (MDR) bacteria pose a global challenge to public health. Natural transformation is one of the essential ways for horizontal transfer of antibiotic resistance genes (ARGs). Although disinfectants are frequently used during COVID-19, little is known about whether these disinfectants are associated with the transformation of plasmid-borne ARGs. In our study, we assessed the effect of some disinfectants on bacterial transformation using resistance plasmids as extracellular DNA and E. coli DH5α as the recipient bacteria. The results showed that these disinfectants at environmentally relevant concentrations, including benzalkonium bromide (BB), benzalkonium chloride (BC) and polyhexamethylene guanidine hydrochloride (PHMG), significantly enhanced the transformation of plasmid-encoded ARGs. Furthermore, we investigated the mechanisms underlying the promotive effect of disinfectants on transformation. We revealed that the addition of disinfectants significantly increased the membrane permeability and promoted membrane-related genes expression. Moreover, disinfectants led to the boosted bacterial respiration, ATP production and flagellum motility, as well as increased expression of bacterial secretion system-related genes. Together, our findings shed insights into the spread of ARGs through bacterial transformation and indicate potential risks associated with the widespread use of disinfectants.
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Affiliation(s)
- Yuqian Jia
- College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu, China
| | - Zeyu Wang
- College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu, China
| | - Shuyao Zhu
- College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu, China
| | - Zhiqiang Wang
- College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu, China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, Jiangsu, China.
| | - Yuan Liu
- College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu, China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, Jiangsu, China; Institute of Comparative Medicine, Yangzhou University, Yangzhou, Jiangsu, China.
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Pulmonary Aspergillosis in Humboldt Penguins—Susceptibility Patterns and Molecular Epidemiology of Clinical and Environmental Aspergillus fumigatus Isolates from a Belgian Zoo, 2017–2022. Antibiotics (Basel) 2023; 12:antibiotics12030584. [PMID: 36978451 PMCID: PMC10044460 DOI: 10.3390/antibiotics12030584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Aspergillus fumigatus is the main causative agent of avian aspergillosis and results in significant health problems in birds, especially those living in captivity. The fungal contamination by A. fumigatus in the environment of Humboldt penguins (Spheniscus humboldti), located in a Belgian zoo, was assessed through the analysis of air, water, sand and nest samples during four non-consecutive days in 2021–2022. From these samples, potential azole-resistant A. fumigatus (ARAF) isolates were detected using a selective culture medium. A total of 28 veterinary isolates obtained after necropsy of Humboldt penguins and other avian species from the zoo were also included. All veterinary and suspected ARAF isolates from the environment were characterized for their azole-resistance profile by broth microdilution. Isolates displaying phenotypic resistance against at least one medical azole were systematically screened for mutations in the cyp51A gene. A total of 14 (13.6%) ARAF isolates were identified from the environment (n = 8) and from Humboldt penguins (n = 6). The TR34/L98H mutation was observed in all resistant environmental strains, and in two resistant veterinary strains. To the best of our knowledge, this is the first description of this mutation in A. fumigatus isolates from Humboldt penguins. During the period 2017–2022, pulmonary aspergillosis was confirmed in 51 necropsied penguins, which reflects a death rate due to aspergillosis of 68.0%, mostly affecting adults. Microsatellite polymorphism analysis revealed a high level of diversity among environmental and veterinary A. fumigatus isolates. However, a cluster was observed between one veterinary isolate and six environmental strains, all resistant to medical azoles. In conclusion, the environment of the Humboldt penguins is a potential contamination source of ARAF, making their management even more complex.
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Zhang W, Zhan M, Wang N, Fan J, Han X, Li C, Liu J, Li J, Hou Y, Wang X, Zhang Z. In vitro susceptibility profiles of Candida parapsilosis species complex subtypes from deep infections to nine antifungal drugs. J Med Microbiol 2023; 72. [PMID: 36920840 DOI: 10.1099/jmm.0.001640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Introduction. The Candida parapsilosis complex can be divided into C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis subtypes. It is uncommon for drug sensitivity tests to type them.Gap Statement. In routine susceptibility reports, drug susceptibility of C. parapsilosis complex subtypes is lacking.Aim. The aim of this study is to investigate the antifungal susceptibility and clinical distribution characteristics of the C. parapsilosis complex subtypes causing deep infection in patients.Methodology. Non-repetitive strains of C. parapsilosis complex isolated from deep infection from 2017 to 2019 were collected. Species-level identification was performed using a matrix-assisted laser desorption/ionization time-of-flight mass spectrometer and confirmed using ITS gene sequencing, when necessary. Antifungal susceptibility testing was performed using the Sensititre YeastOne system method.Results. A total of 244 cases were included in the study, including 176 males (72.13 %, 60.69±13.43 years) and 68 females (27.87 %, 60.21±10.59 years). The primary diseases were cancer (43.44 %), cardiovascular disease (25.00 %), digestive system diseases, (18.44 %), infection (6.97 %), and nephropathy (6.15 %). Strains were isolated from the bloodstream (63.11 %), central venous catheters (15.16 %), pus (6.56 %), ascites (5.74 %), sterile body fluid (5.33 %), and bronchoalveolar lavage fluid (BALF, 4.09 %). Of the 244 C. parapsilosis complex strains, 179 (73.26 %) were identified as C. parapsilosis sensu stricto, 62 (25.41 %) were C. orthopsilosis, and three (1.23 %) were C. metapsilosis. Only one C. parapsilosis sensu stricto strain was resistant to anidulafungin, micafungin, caspofungin, and voriconazole, and it was non-wild-type (NWT) to amphotericin B. Furthermore, six C. parapsilosis sensu stricto strains were resistant to fluconazole, and one was dose-dependent susceptible. Five C. parapsilosis sensu stricto strains were NWT to posaconazole. Only one C. orthopsilosis strain was NWT for anidulafungin, micafungin, caspofungin, fluconazole, voriconazole, amphotericin B, and posaconazole, while the rest of the strains were wild-type.Conclusion. C. parapsilosis sensu stricto was the main clinical isolate from the C. parapsilosis complex in our hospital. Most strains were isolated from the bloodstream. The susceptibility rate to commonly used antifungal drugs was more than 96 %. Furthermore, most of the infected patients were elderly male cancer patients.
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Affiliation(s)
- Wei Zhang
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China.,Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, PR China, Beijing, 100730
| | - Minghua Zhan
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China.,Clinical Laboratory Diagnostics, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, PR China
| | - Na Wang
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Jingjing Fan
- Infectious Disease Department, The First Affiliated Hospital of Hebei North University, No. 12, 15 Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Xuying Han
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Caiqing Li
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Jinlu Liu
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Jia Li
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Yongwang Hou
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Xinsheng Wang
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
| | - Zhihua Zhang
- Respiratory and Critical Care Medicine Intensive Care Unit, The First Affiliated Hospital of Hebei North University, No. 12, Changqing Road, Qiaoxi District, Zhangjiakou City, 075000, Hebei Province, PR China
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Sarigüzel FM, Koç AN, Sağiroğlu P, Atalay MA, Borlu A, Canöz Ö, Dinç B. Molecular epidemiology and antifungal susceptibilities of Aspergillus species isolated from patients with invasive aspergillosis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:44-50. [PMID: 36820712 PMCID: PMC9937602 DOI: 10.1590/1806-9282.20220441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/15/2022] [Indexed: 02/19/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the demographic data, molecular epidemiology, and in vitro antifungal susceptibility results of patients with Aspergillus isolated from various clinical specimens. METHODS A total of 44 Aspergillus strains were studied. The definition of invasive aspergillosis in patients was made according to European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria. Strains were phenotypically and molecularly identified. Demographic characteristics of patients and genotypes of strains were evaluated. Phylogenetic analysis was done by the The Unweighted Pair-Group Method with Arithmetic Mean (UPGMA). Antifungal susceptibility of strains was determined according to The Clinical and Laboratory Standards Institute (CLSI)-M61-Ed2 and The European Committee on Antimicrobial Susceptibility Testing (EUCAST). RESULTS A total of 11 patients were classified as proven and 33 as probable invasive aspergillosis. There was a statistically significant difference in age groups, subdisease, neutropenic, and receiving chemotherapy between groups. A total of 23 strains were identified as Aspergillus fumigatus, 12 as Aspergillus niger, 6 as Aspergillus flavus, and 3 as Aspergillus terreus. Phylogenetic analysis revealed five different genotypes. No statistical difference was found in the comparisons between patients groups and genotype groups. There was a statistically significant difference between genotype groups and voriconazole, posaconazole, and itraconazole Minimum Inhibition Concentration (MIC). CONCLUSION Accurate identification of strains and antifungal susceptibility studies should be performed due to azole and amphotericin B resistance. Genotyping studies are important in infection control due to identifying sources of infection and transmission routes.
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Affiliation(s)
- Fatma Mutlu Sarigüzel
- Erciyes Üniversitesi, Faculty of Medicine, Department of Medical Microbiology – Kayseri, Turkey.,Corresponding author:
| | - Ayse Nedret Koç
- Erciyes Üniversitesi, Faculty of Medicine, Department of Medical Microbiology – Kayseri, Turkey
| | - Pınar Sağiroğlu
- Erciyes Üniversitesi, Faculty of Medicine, Department of Medical Microbiology – Kayseri, Turkey
| | - Mustafa Altay Atalay
- Erciyes Üniversitesi, Faculty of Medicine, Department of Medical Microbiology – Kayseri, Turkey
| | - Arda Borlu
- Erciyes Üniversitesi, Faculty of Medicine, Department of Public Health – Kayseri, Turkey
| | - Özlem Canöz
- Erciyes Üniversitesi, Faculty of Medicine, Department of Medical Pathology – Kayseri, Turkey
| | - Bedia Dinç
- Ankara Bilkent City Hospital, Department of Medical Microbiology – Ankara, Turkey
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Comparison between EUCAST Broth Microdilution and MIC Strip Test in Defining Isavuconazole In Vitro Susceptibility against Candida and Rare Yeast Clinical Isolates. Antibiotics (Basel) 2023; 12:antibiotics12020251. [PMID: 36830162 PMCID: PMC9952283 DOI: 10.3390/antibiotics12020251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Isavuconazole is a new broad-spectrum triazole, with significant in vitro activity against yeasts. Isavuconazole in vitro susceptibility can be evaluated through broth microdilution as a reference method. Considering difficulties in equipping such methods in a laboratory routine, a commercial MIC Strip test has been designed. This study aims to implement data about isavuconazole in vitro activity and compare EUCAST broth microdilution and MIC Strip test in defining yeast isavuconazole susceptibility. The study involved 629 isolates from positive blood cultures (January 2017-December 2021). The identified species were C. albicans (283), C. glabrata (53), C. krusei (23), C. tropicalis (68), C. parapsilosis complex (151), C. guilliermondii (12), C. famata (6), S. cerevisiae (12), C. neoformans (5), S. capitata (12), and Rhodotorula species (4). All the isolates were tested with EUCAST microdilution and MIC Strip methods. The total essential agreement between these two methods was 99.3%. As a result, we can consider that both methods are useful in testing isavuconazole susceptibility. Proposed cut-off values (P-ECOFF) were calculated using ECOFFinder software. Further studies could lead to either definitive E-COFF or clinical breakpoints, which represent the most important categorization tool of the laboratory data, allowing a better insertion of an antimicrobial drug in clinical practice.
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Systemic Antifungal Therapy for Invasive Pulmonary Infections. J Fungi (Basel) 2023; 9:jof9020144. [PMID: 36836260 PMCID: PMC9966409 DOI: 10.3390/jof9020144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.
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Giordano ALPL, Pontes L, Beraquet CAG, Lyra L, Schreiber AZ. Matrix-assisted laser desorption/ionisation-time of flight mass spectrometry azole susceptibility assessment in Candida and Aspergillus species. Mem Inst Oswaldo Cruz 2023; 118:e220213. [PMID: 36921145 PMCID: PMC10014031 DOI: 10.1590/0074-02760220213] [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: 09/15/2022] [Accepted: 01/26/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Matrix-assisted laser desorption/ionisation-time of flight mass spectrometry (MALDI-TOF MS) allows rapid pathogen identification and potentially can be used for antifungal susceptibility testing (AFST). OBJECTIVES We evaluated the performance of the MALDI-TOF MS in assessing azole susceptibility, with reduced incubation time, by comparing the results with the reference method Broth Microdilution. METHODS Resistant and susceptible strains of Candida (n = 15) were evaluated against fluconazole and Aspergillus (n = 15) against itraconazole and voriconazole. Strains were exposed to serial dilutions of the antifungals for 15 h. Microorganisms' protein spectra against all drug concentrations were acquired and used to generate a composite correlation index (CCI) matrix. The comparison of autocorrelations and cross-correlations between spectra facilitated by CCI was used as a similarity parameter between them, enabling the inference of a minimum profile change concentration breakpoint. Results obtained with the different AFST methods were then compared. FINDINGS The overall agreement between methods was 91.11%. Full agreement (100%) was reached for Aspergillus against voriconazole and Candida against fluconazole, and 73.33% of agreement was obtained for Aspergillus against itraconazole. MAIN CONCLUSIONS This study demonstrates MALDI-TOF MS' potential as a reliable and faster alternative for AFST. More studies are necessary for method optimisation and standardisation for clinical routine application.
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Affiliation(s)
| | - Lais Pontes
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | | | - Luzia Lyra
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
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Severe Sporotrichosis Caused by Sporothrix brasiliensis: Antifungal Susceptibility and Clinical Outcomes. J Fungi (Basel) 2022; 9:jof9010049. [PMID: 36675870 PMCID: PMC9864959 DOI: 10.3390/jof9010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022] Open
Abstract
Itraconazole is the first choice for treating sporotrichosis. Amphotericin B is indicated for severe and disseminated forms. The aim of the study was to evaluate the antifungal susceptibility of Sporothrix brasiliensis strains isolated from patients with severe sporotrichosis treated with amphotericin B and correlate with clinical outcomes. Clinical and epidemiological data were obtained from severe sporotrichosis cases caused by S. brasiliensis. Antifungal susceptibility tests against amphotericin B, itraconazole, terbinafine, posaconazole, and 5-flucytosine were performed. Moreover, possible synergisms between amphotericin B and posaconazole or 5-flucytosine were assessed. Relationships between clinical and laboratorial data were then analyzed. Forty-six S. brasiliensis isolates from 37 patients were studied. Clinical forms included disseminated (94.6%) and disseminated cutaneous sporotrichosis (5.4%). The median treatment time was 784 days (range: 7 to 3115 days). Cure occurred in 45.9% of the cases and death due to sporotrichosis in 24.3%. Forty-three (93.5%) S. brasiliensis isolates were classified as wild-type for all the antifungals tested according to their in vitro antifungal susceptibility. There was no synergism for the combinations studied. Finally, we found no association between higher Minimal Inhibitory Concentration (MIC) values of amphotericin B or itraconazole with unfavorable outcomes; however, there were higher MIC values of itraconazole in strains isolated from alcoholic patients. Possibly, clinical factors, such as the extent of dissemination, immunosuppression, and late treatment onset, are the main determinants of patient outcomes, rather than antifungal resistance. The current study suggests that the need to use amphotericin B therapy is not associated with the emergence of S. brasiliensis resistant strains.
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Bagirova NS, Petukhova IN, Grigorievskaya ZV, Sytov AV, Slukin PV, Goremykina EA, Khokhlova OE, Fursova NK, Kazimov AE. Oral microbiota in patients with oropharyngeal cancer with an emphasis on <i>Candida</i> spp. HEAD AND NECK TUMORS (HNT) 2022. [DOI: 10.17650/2222-1468-2022-12-3-71-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction. Interactions between the 2 microbiota components – bacteria and fungi – are of interest as diagnostic and prognostic markers in selection of treatment tactics for oncological patients.Aim. To study microbiota of the oral cavity in patients with primary squamous cell carcinoma of the oropharyngeal area before and after surgical intervention to find biomarkers for rational selection of antifungal drugs.Materials and methods. At the Surgical Department of Head and Neck Tumors of the N. N. Blokhin National Research Center of Oncology, three-component study was performed: investigations of spectrum of Candida spp. isolates, Candida spp. strains’ resistance to antifungals, and oral washes in primary patients before and after surgery. mALDI-Tof microflex LT (Biotyper, Bruker Daltonics, germany) was used for strain identification; Sensititre Yeast ONE, YO10 (Trek Diagnostic System, united kingdom) plates were used for determination of minimal inhibiting concentrations of anti fungals. values of minimal inhibiting concentrations were evaluated based on the European Committee on Antimicrobial Susceptibility Testing (EuCAST) criteria (version 10.0).Results. four-year observation of patients at the surgical department of head and neck tumors of the N. N. Blokhin National Research Center of Oncology showed that the most common species of Candida is C. albicans (73.5 % of cases). Candida spp. resistance to antifungals was detected only for fluconazole (9.3 % of cases) and micafungin (8.0 % of cases), mostly among C. albicans strains. In 31.8 % of primary patients, oral washes prior to surgery showed growth of Candida spp. (probably, tissue colonization). After surgical intervention, Candida spp. growth was detected in 36.4 % of cases, only 1 of which was diagnosed as invasive mycosis. In 54.5 % of cases before and in 72.7 % of cases after surgery, gram-negative rods were detected. After surgical intervention, percentage of enterobacteria and non-fermenters significantly increased: 59.1 % versus 27.3 % (p <0.05) and 63.6 % versus 27.3 % (p <0.02), respectively. prior to surgery, non-fermenting gram-negative bacteria were represented only by P. aeruginosa; after surgery, the spectrum of non-fermenting gram-negative bacteria became wider but percentage of P. aeruginosa remained high: 71.4 %. ERG11 gene was identified only in 1 strain: C. albicans. FKS1 gene also was identified only in 1 strain: C. inconspicua. virulence factor genes were detected in 57.1 % of strains.Conclusion. Surgical intervention is associated with changes in bacterial microbiota but not fugal microbiota. presence of virulence factor genes and resistance genes in Candida spp. strains should be considered a biomarker allowing to differentiate between colonization and candida infection and can be used for rational selection of antifungal drugs in prevention and treatment of invasive candidiasis, especially in the absence of criteria for interpretation of measured minimal inhibiting concentrations of antifungals.
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Affiliation(s)
- N. S. Bagirova
- N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia
| | - I. N. Petukhova
- N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia
| | - Z. V. Grigorievskaya
- N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia
| | - A. V. Sytov
- N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia
| | - P. V. Slukin
- State Scientific Center of Applied Microbiology and Biotechnology of Rospotrebnadzor
| | - E. A. Goremykina
- State Scientific Center of Applied Microbiology and Biotechnology of Rospotrebnadzor; Pushchinsky State Natural Science Institute
| | - O. E. Khokhlova
- State Scientific Center of Applied Microbiology and Biotechnology of Rospotrebnadzor; Pushchinsky State Natural Science Institute
| | - N. K. Fursova
- State Scientific Center of Applied Microbiology and Biotechnology of Rospotrebnadzor; Pushchinsky State Natural Science Institute
| | - A. E. Kazimov
- N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia
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Mercier V, Letscher-Bru V, Bougnoux ME, Delhaes L, Botterel F, Maubon D, Dalle F, Alanio A, Houzé S, Dannaoui E, Cassagne C, Cassaing S, Durieux MF, Fekkar A, Bouchara JP, Gangneux JP, Bonhomme J, Dupont D, Costa D, Sendid B, Chouaki T, Bourgeois N, Huguenin A, Brun S, Mahinc C, Hasseine L, Le Gal S, Bellanger AP, Bailly E, Morio F, Nourrisson C, Desbois-Nogard N, Perraud-Cateau E, Debourgogne A, Yéra H, Lachaud L, Sasso M. Gradient concentration strip-specific epidemiological cut-off values of antifungal drugs in various yeast species and five prevalent Aspergillus species complexes. Clin Microbiol Infect 2022; 29:652.e9-652.e15. [PMID: 36509375 DOI: 10.1016/j.cmi.2022.11.030] [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: 06/25/2022] [Revised: 10/16/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the epidemiological cut-off values (ECVs) of ten antifungal agents in a wide range of yeasts and Aspergillus spp. using gradient concentration strips. METHODS The minimum inhibitory concentrations for amphotericin B, anidulafungin, caspofungin, micafungin, flucytosine, fluconazole, itraconazole, isavuconazole, posaconazole, and voriconazole, determined with gradient concentration strips at 35 French microbiology laboratories between 2002 and 2020, were retrospectively collected. Then, the ECVs were calculated using the iterative method and a cut-off value of 97.5%. RESULTS Minimum inhibitory concentrations were available for 17 653 clinical isolates. In total, 48 ECVs (including 32 new ECVs) were determined: 29 ECVs for frequent yeast species (e.g. Candida albicans and itraconazole/flucytosine, and Candida glabrata species complex [SC] and flucytosine) and rare yeast species (e.g. Candida dubliniensis, Candida inconspicua, Saccharomyces cerevisiae, and Cryptococcus neoformans) and 19 ECVs for Aspergillusflavus SC, Aspergillusfumigatus SC, Aspergillusnidulans SC, Aspergillusniger SC, and Aspergillusterreus SC. CONCLUSIONS These ECVs can be added to the already available gradient concentration strip-specific ECVs to facilitate minimum inhibitory concentration interpretation and streamline the identification of nonwild type isolates.
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Affiliation(s)
- Victor Mercier
- Laboratoire de Parasitologie-Mycologie, CHU Nîmes & Université de Montpellier, CNRS, IRD, MiVEGEC, Montpellier, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et Mycologie Médicale, Les Hôpitaux Universitaires de Strasbourg, Institut de Parasitologie et Pathologie Tropicale, UR7292 Dynamique des interactions hôte pathogène, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Marie-Elisabeth Bougnoux
- Laboratoire de Parasitologie-Mycologie, Hôpital Necker Enfants Malades, AP-HP, Unité Biologie et Pathogénicité Fongiques, Institut Pasteur, Université de Paris, INRAE, USC2019, Paris, France
| | - Laurence Delhaes
- Laboratoire de Parasitologie-Mycologie, CHU de Bordeaux, Inserm U1045, Université de Bordeaux, Bordeaux, France
| | - Francoise Botterel
- Laboratoire de Parasitologie-Mycologie, CHU Henri Mondor, AP-HP, Paris, France
| | - Danièle Maubon
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Frédéric Dalle
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Alexandre Alanio
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Institut Pasteur, Université Paris Cité, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR2000, Paris, France
| | - Sandrine Houzé
- Université Paris Cité, IRD, MERIT, F 75006 Paris et Service de Parasitologie, AP-HP, Hôpital Bichat, Paris, France
| | - Eric Dannaoui
- Laboratoire de Parasitologie-Mycologie, département de Microbiologie, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris Cité, Faculté de Médecine, Paris, France
| | - Carole Cassagne
- Laboratoire de Parasitologie-Mycologie, AP-MH, IHU Méditerranée Infection, Aix Marseille Univ., Marseille, France
| | - Sophie Cassaing
- Service de Parasitologie-Mycologie, CHU Toulouse, Université Paul Sabatier, Toulouse, France
| | | | - Arnaud Fekkar
- Laboratoire de Parasitologie-Mycologie, AP-HP La Pitié-Salpêtrière, France. Sorbonne Université, Inserm, CNRS, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, F-75013, Paris, France
| | | | - Jean-Pierre Gangneux
- Laboratoire de Parasitologie-Mycologie, CHU de Rennes, Institut de Recherche en Santé Environnement et Travail, UMR U1085 Inserm-Université Rennes 1, Rennes, France
| | - Julie Bonhomme
- Laboratoire de Microbiologie, CHU Caen, Université de Normandie Unicaen, ToxEMAC-ABTE, Caen, France
| | - Damien Dupont
- Laboratoire de Parasitologie-Mycologie Médicale, Hospices Civils de Lyon, Institut des Agents Infectieux, Université Lyon 1, Lyon, France
| | - Damien Costa
- Département de Parasitologie-Mycologie, CHU de Rouen, France
| | - Boualem Sendid
- Service de Parasitologie-Mycologie, CHU Lille, Inserm U1285, CNRS UMR 8576, Université de Lille, Lille, France
| | - Taieb Chouaki
- Laboratoire de Mycologie-Parasitologie, CHU d'Amiens-Picardie, Amiens, France
| | - Nathalie Bourgeois
- Service de Parasitologie-Mycologie, CHU de Montpellier, & Université de Montpellier, CNRS, IRD, MiVEGEC, Montpellier, France
| | - Antoine Huguenin
- Laboratoire de Parasitologie-Mycologie, CHU de Rennes, Université de Reims Champagne Ardenne, ESCAPE EA7510, Reims, France
| | - Sophie Brun
- Service de Parasitologie-Mycologie, Hôpital Universitaire Avicenne, AP-HP, Bobigny, France
| | - Caroline Mahinc
- Unité de Parasitologie-Mycologie, Laboratoire des Agents Infectieux et d'Hygiène CHU de St-Etienne, Saint Priest en Jarez, France
| | | | - Solène Le Gal
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, France
| | | | - Eric Bailly
- Service de Parasitologie-Mycologie, CHU de Tours, France
| | - Florent Morio
- Laboratoire de Parasitologie et Mycologie, Nantes Université, CHU de Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR1155, Nantes, France
| | - Céline Nourrisson
- Service de Parasitologie-Mycologie, 3IHP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicole Desbois-Nogard
- Laboratoire de Parasitologie-Mycologie, CHU de la Martinique, Fort de France, Martinique, France
| | - Estelle Perraud-Cateau
- Laboratoire de Parasitologie-Mycologie, CHU de Poitiers, Écologie et Biologie des Interactions UMR CNRS 7267 - equipe Microbiologie de l'Eau, Poitiers, France
| | - Anne Debourgogne
- Laboratoire de Microbiologie, CHRU de Nancy, UR 7300 Stress Immunité Pathogène, Université de Lorraine, Vandoeuvre les Nancy, France
| | - Hélène Yéra
- Laboratoire de Parasitologie-Mycologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre Université Paris Cité, Institut Cochin (U1016 Inserm/UMR8104 CNRS/UMR-S8104), Paris, France
| | - Laurence Lachaud
- Service de Parasitologie-Mycologie, CHU de Montpellier, & Université de Montpellier, CNRS, IRD, MiVEGEC, Montpellier, France
| | - Milène Sasso
- Laboratoire de Parasitologie-Mycologie, CHU Nîmes & Université de Montpellier, CNRS, IRD, MiVEGEC, Montpellier, France.
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Nyuykonge B, Siddig EE, Mhmoud NA, Nyaoke BA, Zijlstra EE, Verbon A, Bakhiet S, Fahal AH, van de Sande WWJ. Epidemiological cut-off values for itraconazole and ravuconazole for Madurella mycetomatis, the most common causative agent of mycetoma. Mycoses 2022; 65:1170-1178. [PMID: 36005544 PMCID: PMC9804462 DOI: 10.1111/myc.13509] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/16/2022] [Accepted: 07/26/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Eumycetoma is a neglected tropical disease. It is a chronic inflammatory subcutaneous infection characterised by painless swellings which produce grains. It is currently treated with a combination of itraconazole and surgery. In an ongoing clinical study, the efficacy of fosravuconazole, the prodrug of ravuconazole, is being investigated. For both itraconazole and ravuconazole, no clinical breakpoints or epidemiological cut-off values (ECV) to guide treatment are currently available. OBJECTIVE To determine tentative ECVs for itraconazole and ravuconazole in Madurella mycetomatis, the main causative agent of eumycetoma. MATERIALS AND METHODS Minimal inhibitory concentrations (MICs) for itraconazole and ravuconazole were determined in 131 genetically diverse clinical M. mycetomatis isolates with the modified CLSI M38 broth microdilution method. The MIC distributions were established and used to determine ECVs with the ECOFFinder software. CYP51A sequences were sequenced to determine whether mutations occurred in this azole target gene, and comparisons were made between the different CYP51A variants and the MIC distributions. RESULTS The MICs ranged from 0.008 to 1 mg/L for itraconazole and from 0.002 to 0.125 mg/L for ravuconazole. The M. mycetomatis ECV for itraconazole was 1 mg/L and for ravuconazole 0.064 mg/L. In the wild-type population, two CYP51A variants were found for M. mycetomatis, which differed in one amino acid at position 499 (S499G). The MIC distributions for itraconazole and ravuconazole were similar between the two variants. No mutations linked to decreased susceptibility were found. CONCLUSION The proposed M. mycetomatis ECV for itraconazole is 1 mg/L and for ravuconazole 0.064 mg/L.
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Affiliation(s)
- Bertrand Nyuykonge
- Department of Medical Microbiology and Infectious DiseasesErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
| | | | | | | | | | - Annelies Verbon
- Department of Medical Microbiology and Infectious DiseasesErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
| | - Sahar Bakhiet
- Mycetoma Research CentreUniversity of KhartoumKhartoumSudan
| | - Ahmed H. Fahal
- Mycetoma Research CentreUniversity of KhartoumKhartoumSudan
| | - Wendy W. J. van de Sande
- Department of Medical Microbiology and Infectious DiseasesErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
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Rizzo M, Soisangwan N, Vega-Estevez S, Price RJ, Uyl C, Iracane E, Shaw M, Soetaert J, Selmecki A, Buscaino A. Stress combined with loss of the Candida albicans SUMO protease Ulp2 triggers selection of aneuploidy via a two-step process. PLoS Genet 2022; 18:e1010576. [PMID: 36574460 PMCID: PMC9829183 DOI: 10.1371/journal.pgen.1010576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/09/2023] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
A delicate balance between genome stability and instability ensures genome integrity while generating genetic diversity, a critical step for evolution. Indeed, while excessive genome instability is harmful, moderated genome instability can drive adaptation to novel environments by maximising genetic variation. Candida albicans, a human fungal pathogen that colonises different parts of the human body, adapts rapidly and frequently to different hostile host microenvironments. In this organism, the ability to generate large-scale genomic variation is a key adaptative mechanism triggering dangerous infections even in the presence of antifungal drugs. Understanding how fitter novel karyotypes are selected is key to determining how C. albicans and other microbial pathogens establish infections. Here, we identified the SUMO protease Ulp2 as a regulator of C. albicans genome integrity through genetic screening. Deletion of ULP2 leads to increased genome instability, enhanced genome variation and reduced fitness in the absence of additional stress. The combined stress caused by the lack of ULP2 and antifungal drug treatment leads to the selection of adaptive segmental aneuploidies that partially rescue the fitness defects of ulp2Δ/Δ cells. Short and long-read genomic sequencing demonstrates that these novel genotypes are selected via a two-step process leading to the formation of novel chromosomal fragments with breakpoints at microhomology regions and DNA repeats.
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Affiliation(s)
- Marzia Rizzo
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
| | - Natthapon Soisangwan
- University of Minnesota, Department of Microbiology and Immunology, Minneapolis, Minnesota, United States of America
| | - Samuel Vega-Estevez
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
| | | | - Chloe Uyl
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
| | - Elise Iracane
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
| | - Matt Shaw
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
| | - Jan Soetaert
- Blizard Advanced Light Microscopy (BALM), Queen Mary University of London, United Kingdom
| | - Anna Selmecki
- University of Minnesota, Department of Microbiology and Immunology, Minneapolis, Minnesota, United States of America
| | - Alessia Buscaino
- University of Kent, School of Biosciences, Kent Fungal Group, Canterbury Kent, United Kingdom
- * E-mail:
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Takesue Y, Hanai Y, Oda K, Hamada Y, Ueda T, Mayumi T, Matsumoto K, Fujii S, Takahashi Y, Miyazaki Y, Kimura T. Clinical Practice Guideline for the Therapeutic Drug Monitoring of Voriconazole in Non-Asian and Asian Adult Patients: Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Clin Ther 2022; 44:1604-1623. [DOI: 10.1016/j.clinthera.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022]
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Štěpánek O, Čmoková A, Procházková E, Grobárová V, Černý J, Sklapničková M, Zíková AP, Kolařík M, Baszczynski O. Piperazine‐modified ketoconazole derivatives show increased activity against fungal and trypanosomatid pathogens. ChemMedChem 2022; 17:e202200385. [DOI: 10.1002/cmdc.202200385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/14/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Ondřej Štěpánek
- Charles University: Univerzita Karlova Department of Organic Chemistry CZECH REPUBLIC
| | - Adéla Čmoková
- Institute of Microbiology Mikrobiologický ústav AV ČR, v.v.i. CZECH REPUBLIC
| | - Eliška Procházková
- IOCB CAS: Ustav organicke chemie a biochemie Akademie ved Ceske republiky NMR department CZECH REPUBLIC
| | - Valéria Grobárová
- Charles University: Univerzita Karlova Department of Cell Biology CZECH REPUBLIC
| | - Jan Černý
- Charles University: Univerzita Karlova Department of Cell Biology CZECH REPUBLIC
| | - Martina Sklapničková
- Institute of Parasitology Czech Academy of Sciences: Biologicke centrum Akademie ved Ceske republiky Parazitologicky ustav Parazitologicky ustav CZECH REPUBLIC
| | - Alena Panicucci Zíková
- Institute of Parasitology Czech Academy of Sciences: Biologicke centrum Akademie ved Ceske republiky Parazitologicky ustav Parazitologicky ustav CZECH REPUBLIC
| | - Miroslav Kolařík
- Institute of Microbiology Czech Academy of Sciences: Mikrobiologicky ustav Akademie ved Ceske republiky Mikrobiologicky ustav CZECH REPUBLIC
| | - Ondrej Baszczynski
- Univerzita Karlova Prirodovedecka fakulta Department of Organic Chemistry Hlavova 8/2030 12800 Prague CZECH REPUBLIC
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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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Characteristics of bacterial infections and prevalence of multidrug-resistant bacteria in hospitalized patients with liver cirrhosis in Germany. Ann Hepatol 2022; 27:100719. [PMID: 35460883 DOI: 10.1016/j.aohep.2022.100719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Bacterial infections are associated with a dismal prognosis in patients with liver cirrhosis. Data on their prevalence and the associated pathogen spectra in Germany are scarce. This study aimed to evaluate the impact of bacterial infections on mortality in hospitalized patients with liver cirrhosis and to analyze the prevalence of multidrug-resistant (MDR) bacteria in a German tertiary care center. PATIENTS AND METHODS Consecutive, non-electively hospitalized patients with liver cirrhosis were enrolled in this study between 03/2019-06/2021. All patients underwent clinical, laboratory and microbiological testing to detect potential bacterial infections. Patients were followed for 30 days regarding the composite endpoint of death or liver transplantation (mortality). RESULTS In total, 239 patients were recruited (median MELD 18). Bacterial infection was detected in 81 patients (33.9%) at study inclusion. A total of 70 patients (29.3%) developed a hospital-acquired infection. When comparing community-acquired and hospital-acquired infections, the pathogen pattern shifted from a gram-negative to a more gram-positive spectrum and showed an increase of Staphylococcus spp.. MDR bacteria were detected in seven infected patients (5.8%). 34 patients reached the composite endpoint during 30-days follow-up. In multivariable logistic regression analysis, the presence of infection during hospitalization remained independently associated with higher mortality (OR 2.522, 95% CI 1.044 - 6.091, p = 0.040). CONCLUSIONS This study demonstrates that bacterial infections are common in hospitalized patients with liver cirrhosis in Germany and are a major determinant of short-term mortality. Our data highlight the importance of regional differences in MDR bacteria and may guide physicians' decision-making regarding calculated antibiotic treatment.
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Ye N, Liu Z, Tang W, Li X, Chu W, Zhou Q. Systematic Characterization of Epidemiology, Antifungal Susceptibility, Risk Factors and Outcomes of Candidaemia: A Six-Year Chinese Study. Infect Drug Resist 2022; 15:4887-4898. [PMID: 36051656 PMCID: PMC9426866 DOI: 10.2147/idr.s378629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Background Candida bloodstream infection (BSI), the fourth most common nosocomial BSI, is an urgent global health challenge with the tremendous growth in antifungal resistance rate and mortality rate. Purpose To establish the epidemiology, species distribution, risk factors, and 30-day mortality of candidaemia among 115 patients in this 6-year surveillance study. Materials and Methods We retrospectively analyzed the clinical characteristics, epidemiology, antifungal susceptibility patterns, and risk factors for morbidity and mortality of 115 candidaemia cases diagnosed in one tertiary care hospital from January 2016 through December 2021. Results Of the 115 candidaemia cases, the most prevalent species were Candida tropicalis (33.0%), followed by Candida albicans (27.8%), Candida parapsilosis complex (19.1%), and others. The overall incidence was 0.21 cases/1000 admissions. The overall crude resistance rate of Candida spp. against azoles was 20.0% (23/115), while Candida tropicalis showed a significant increase in the resistance rate to azoles (from 1/6, 16.7% in 2017 to 6/10, 60.0% in 2021). Multivariate analyses demonstrated that hematological malignancy and neutropenia were significantly associated with Candida tropicalis BSI than Candida non-tropicalis BSI. Candida albicans BSI had a significantly higher rate of previous surgery than Candida non-albicans BSI. Candida parapsilosis BSI had a significantly higher rate of receiving total parenteral nutrition (TPN). The overall 30-day mortality rate was 27.0% (31/115). The presence of high age-adjusted Charlson comorbidity index (aCCI), neutropenia, and septic shock were factors independently associated with increased 30-day mortality. Conclusion Candida tropicalis are emerging as the predominant isolate in candidaemia. Of note, the unexpectedly increased resistance rate to azoles in Candida tropicalis BSI was observed. The aCCI scores, neutropenia, and septic shock were independently associated with 30-day mortality. Prompt, adequate antifungal treatment among high-risk patients may lead to a reduction in mortality.
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Affiliation(s)
- Naifang Ye
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
| | - Zhou Liu
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
| | - Wei Tang
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
| | - Xin Li
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
| | - Wenwen Chu
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
| | - Qiang Zhou
- Department of Clinical Laboratory Medicine, The Second Hospital of Anhui Medical University, Anhui Medical University, Hefei, People's Republic of China
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50
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Overview on the Infections Related to Rare Candida species. Pathogens 2022; 11:pathogens11090963. [PMID: 36145394 PMCID: PMC9505029 DOI: 10.3390/pathogens11090963] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
Atypical Candida spp. infections are rising, mostly due to the increasing numbers of immunocompromised patients. The most common Candida spp. is still Candida albicans; however, in the last decades, there has been an increase in non-Candida albicans Candida species infections (e.g., Candida glabrata, Candida parapsilosis, and Candida tropicalis). Furthermore, in the last 10 years, the reports on uncommon yeasts, such as Candida lusitaniae, Candida intermedia, or Candida norvegensis, have also worryingly increased. This review summarizes the information, mostly related to the last decade, regarding the infections, diagnosis, treatment, and resistance of these uncommon Candida species. In general, there has been an increase in the number of articles associated with the incidence of these species. Additionally, in several cases, there was a suggestive antifungal resistance, particularly with azoles, which is troublesome for therapeutic success.
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