1
|
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.
Collapse
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
| |
Collapse
|
2
|
Gupta AK, Polla Ravi S, Wang T, Bakotic WL, Shemer A. Mapping the Global Spread of T. indotineae: An Update on Antifungal Resistance, Mutations, and Strategies for Effective Management. Mycopathologia 2024; 189:45. [PMID: 38734753 DOI: 10.1007/s11046-024-00856-z] [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: 01/09/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION The global spread of Trichophyton indotineae presents a pressing challenge in dermatophytosis management. This systematic review explores the current landscape of T. indotineae infections, emphasizing resistance patterns, susceptibility testing, mutational analysis, and management strategies. METHODS A literature search was conducted in November 2023 using Embase, PubMed, Scopus, and Web of Science databases. Inclusion criteria covered clinical trials, observational studies, case series, or case reports with T. indotineae diagnosis through molecular methods. Reports on resistance mechanisms, antifungal susceptibility testing, and management were used for data extraction. RESULTS AND DISCUSSION A total of 1148 articles were identified through the systematic search process, with 45 meeting the inclusion criteria. The global spread of T. indotineae is evident, with cases reported in numerous new countries in 2023. Tentative epidemiological cut-off values (ECOFFs) suggested by several groups provide insights into the likelihood of clinical resistance. The presence of specific mutations, particularly Phe397Leu, correlate with higher minimum inhibitory concentrations (MICs), indicating potential clinical resistance. Azole resistance has also been reported and investigated in T. indotineae, and is a growing concern. Nevertheless, itraconazole continues to be an alternative therapy. Recommendations for management include oral or combination therapies and individualized approaches based on mutational analysis and susceptibility testing. CONCLUSION Trichophyton indotineae poses a complex clinical scenario, necessitating enhanced surveillance, improved diagnostics, and cautious antifungal use. The absence of established clinical breakpoints for dermatophytes underscores the need for further research in this challenging field.
Collapse
Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada.
| | - Shruthi Polla Ravi
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | - Tong Wang
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | | | - Avner Shemer
- Department of Dermatology, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
3
|
Hill RC, Caplan AS, Elewski B, Gold JAW, Lockhart SR, Smith DJ, Lipner SR. Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance. Am J Clin Dermatol 2024; 25:359-389. [PMID: 38494575 PMCID: PMC11201321 DOI: 10.1007/s40257-024-00848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/19/2024]
Abstract
Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.
Collapse
Affiliation(s)
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Boni Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy A W Gold
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shawn R Lockhart
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Dallas J Smith
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY, 10021, USA.
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
De Paepe R, Normand AC, Uhrlaß S, Nenoff P, Piarroux R, Packeu A. Resistance Profile, Terbinafine Resistance Screening and MALDI-TOF MS Identification of the Emerging Pathogen Trichophyton indotineae. Mycopathologia 2024; 189:29. [PMID: 38483637 PMCID: PMC10940462 DOI: 10.1007/s11046-024-00835-4] [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] [Accepted: 01/25/2024] [Indexed: 03/17/2024]
Abstract
The emerging pathogen Trichophyton indotineae, often resistant to terbinafine (TRB), is known to cause severe dermatophytoses such as tinea corporis and tinea cruris. In order to achieve successful treatment for these infections, insight in the resistance profile of T. indotineae strains and rapid, reliable identification is necessary. In this research, a screening medium was tested on T. indotineae strains (n = 20) as an indication tool of TRB resistance. The obtained results were confirmed by antifungal susceptibility testing (AST) for TRB following the in vitro broth microdilution reference method. Additionally, AST was performed for eight other antifungal drugs: fluconazole, itraconazole, voriconazole, ketoconazole, griseofulvin, ciclopirox olamine, naftifine and amorolfine. Forty-five percent of the strains were confirmed to be resistant to terbinafine. The TRB resistant strains showed elevated minimal inhibitory concentration values for naftifine and amorolfine as well. DNA sequencing of the squalene epoxidase-encoding gene showed that TRB resistance was a consequence of missense point mutations in this gene, which led to amino acid substitutions F397L or L393F. MALDI-TOF MS was used as a quick, accurate identification tool for T. indotineae, as it can be challenging to distinguish it from closely related species such as Trichophyton mentagrophytes or Trichophyton interdigitale using morphological characteristics. While MALDI-TOF MS could reliably identify ≥ 95% of the T. indotineae strains (depending on the spectral library), it could not be used to successfully distinguish TRB susceptible from TRB resistant strains.
Collapse
Affiliation(s)
- Roelke De Paepe
- Mycology and Aerobiology Department, Sciensano, 1050, Brussels, Belgium.
| | - Anne-Cécile Normand
- Parasitology/Mycology Department, AP-HP, Hôpitaux de Paris, 75013, Paris, France
| | - Silke Uhrlaß
- Labopart Medical Laboratories Leipzig-Mölbis, 04571, Rötha OT Mölbis, Germany
| | - Pietro Nenoff
- Labopart Medical Laboratories Leipzig-Mölbis, 04571, Rötha OT Mölbis, Germany
| | - Renaud Piarroux
- Parasitology/Mycology Department, AP-HP, Hôpitaux de Paris, 75013, Paris, France
| | - Ann Packeu
- Mycology and Aerobiology Department, Sciensano, 1050, Brussels, Belgium
- BCCM/IHEM Fungal Collection, Mycology and Aerobiology Section, Sciensano, 1050, Brussels, Belgium
| |
Collapse
|
6
|
Teo JWP, Cheng JWS, Chew KL, Lin RTP. Whole genome characterization of Trichophyton indotineae isolated in Singapore. Med Mycol 2024; 62:myae012. [PMID: 38366631 DOI: 10.1093/mmy/myae012] [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: 12/11/2023] [Revised: 01/18/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
Complete genome sequences from two Trichophyton indotineae isolates were obtained from a 23-year-old male presenting with tinea cruris after an overseas recreational water exposure and from a 53-year-old female patient with unknown travel history. Analysis of the squalene epoxidase gene and the cyp51 gene family showed an absence of mutations, correlating with phenotypic drug susceptibility. The Single Nucleotide Polymorphisms (SNPs) distance between both isolates was 92. Within the T. indotineae cluster, SNPs ranged from 7 to 182, suggesting a high genetic relatedness with other South Asian isolates. This study suggests that the prevalence of T. indotineae is under-reported and more widespread than previously thought.
Collapse
Affiliation(s)
- Jeanette W P Teo
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Janet W S Cheng
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Raymond T P Lin
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
7
|
Siopi M, Efstathiou I, Arendrup MC, Meletiadis J. Development of an agar-based screening method for terbinafine, itraconazole, and amorolfine susceptibility testing of Trichophyton spp. J Clin Microbiol 2024; 62:e0130823. [PMID: 38117081 PMCID: PMC10793311 DOI: 10.1128/jcm.01308-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
Resistance in dermatophytes is an emerging global public health issue. We, therefore, developed an agar-based method for screening Trichophyton spp. susceptibility to terbinafine (TRB), itraconazole (ITC), and amorolfine (AMF) and validated it using molecularly characterized isolates. Α total of 40 Trichophyton spp. isolates, 28 TRB wild type (WT) (13 T. rubrum, 10 T. mentagrophytes, 5 T. interdigitale) and 12 TRB non-WT (7 T. rubrum, 5 T. indotineae) with different alterations in the squalene epoxidase (SQLE) gene, were used. The optimal test conditions (inoculum and drug concentrations, incubation time, and temperature) and stability over time were evaluated. The method was then applied for 86 WT Trichophyton spp. clinical isolates (68 T. rubrum, 7 T. interdigitale, 6 T. tonsurans, 5 T. mentagrophytes) and 4 non-WT T. indotineae. Optimal growth of drug-free controls was observed using an inoculum of 20 µL 0.5 McFarland after 5-7 days of incubation at 30°C. The optimal concentrations that prevented the growth of WT isolates were 0.016 mg/L of TRB, 1 mg/L of ITC, and 0.25 mg/L of AMF, whereas 0.125 mg/L of TRB was used for the detection of Trichophyton strong SQLE mutants (MIC ≥0.25 mg/L). The agar plates were stable up to 4 months. Inter-observer and inter-experimental agreement were 100%, and the method successfully detected TRB non-WT Trichophyton spp. strains showing 100% agreement with the reference EUCAST methodology. An agar-based method was developed for screening Trichophyton spp. in order to detect TRB non-WT weak and strong mutant isolates facilitating their detection in non-expert routine diagnostic laboratories.
Collapse
Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Efstathiou
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maiken C. 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
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, "Attikon" University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
8
|
Kaur A, Sharma K, Sharma N, Aggarwal G. An Insight into the Repurposing of Phytoconstituents obtained from Delhi's Aravalli Biodiversity Park as Antifungal Agents. Infect Disord Drug Targets 2024; 24:e020224226666. [PMID: 38305295 DOI: 10.2174/0118715265282411240119061441] [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: 09/15/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024]
Abstract
The global prevalence of fungal infections is alarming in both the pre- and post- COVID period. Due to a limited number of antifungal drugs, there are hurdles in treatment strategies for fungal infections due to toxic potential, drug interactions, and the development of fungal resistance. All the antifungal targets (existing and newer) and pipeline molecules showing promise against these targets are reviewed. The objective was to predict or repurpose phyto-based antifungal compounds based on a dual target inhibition approach (Sterol-14-α- demethylase and HSP-90) using a case study. In pursuit of repurposing the phytochemicals as antifungal agents, a team of researchers visited Aravalli Biodiversity Park (ABP), Delhi, India, to collect information on available medicinal plants. From 45 plants, a total of 1149 ligands were collected, and virtual screening was performed using Schrodinger Suite 2016 software to get 83 hits against both the target proteins: Sterol-14-α-demethylase and HSP-90. After analysis of docking results, ligands were selected based on their interaction against both the target proteins and comparison with respective standard ligands (fluconazole and ganetespib). We have selected Isocarthamidin, Quercetin and Boeravinone B based on their docking score and binding interaction against the HSP-90 (Docking Score -9.65, -9.22 and -9.21, respectively) and 14-α-demethylase (Docking Score -9.19, -10.76 and -9.74 respectively). The docking protocol was validated and MM/GBSA studies depicted better stability of selected three ligands (Isocarthamidin, Quercetin, Boeravinone B) complex as compared to standard complex. Further, MD simulation studies were performed using the Desmond (67) software package version 2018-4. All the findings are presented as a case study for the prediction of dual targets for the repurposing of certain phytochemicals as antifungal agents.
Collapse
Affiliation(s)
- Amanpreet Kaur
- Delhi Pharmaceutical Sciences and Research University, M.B. Road, Sector III, Pushp Vihar, New Delhi, 110017, India
| | - Kalicharan Sharma
- Delhi Pharmaceutical Sciences and Research University, M.B. Road, Sector III, Pushp Vihar, New Delhi, 110017, India
| | - Neetika Sharma
- Delhi Pharmaceutical Sciences and Research University, M.B. Road, Sector III, Pushp Vihar, New Delhi, 110017, India
| | - Geeta Aggarwal
- Delhi Pharmaceutical Sciences and Research University, M.B. Road, Sector III, Pushp Vihar, New Delhi, 110017, India
| |
Collapse
|
9
|
Gupta AK, Talukder M, Carviel JL, Cooper EA, Piguet V. Combatting antifungal resistance: Paradigm shift in the diagnosis and management of onychomycosis and dermatomycosis. J Eur Acad Dermatol Venereol 2023; 37:1706-1717. [PMID: 37210652 DOI: 10.1111/jdv.19217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
Antifungal resistance has become prevalent worldwide. Understanding the factors involved in spread of resistance allows the formulation of strategies to slow resistance development and likewise identify solutions for the treatment of highly recalcitrant fungal infections. To investigate the recent explosion of resistant strains, a literature review was performed focusing on four main areas: mechanisms of resistance to antifungal agents, diagnosis of superficial fungal infections, management, and stewardship. The use of traditional diagnostic tools such as culture, KOH analysis and minimum inhibitory concentration values on treatment were investigated and compared to the newer techniques such as molecular methods including whole genome sequencing, and polymerase chain reaction. The management of terbinafine-resistant strains is discussed. We have emphasized the need for antifungal stewardship including increasing surveillance for resistant infection.
Collapse
Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, Ontario, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Cañete-Gibas CF, Mele J, Patterson HP, Sanders CJ, Ferrer D, Garcia V, Fan H, David M, Wiederhold NP. Terbinafine-Resistant Dermatophytes and the Presence of Trichophyton indotineae in North America. J Clin Microbiol 2023; 61:e0056223. [PMID: 37432126 PMCID: PMC10446870 DOI: 10.1128/jcm.00562-23] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023] Open
Abstract
Dermatophytes are common causes of skin, hair, and nail infections in humans. The most common species causing infections in humans are Trichophyton rubrum, Trichophyton mentagrophytes, and Trichophyton interdigitale. Outbreaks of recalcitrant dermatophytosis have been reported in parts of South Asia, including those caused by a hypervirulent and resistant species, Trichophyton indotineae. We evaluated the antifungal susceptibility profiles of dermatophytes received by our laboratory from institutions across North America between 2021 and 2022 and performed species identification for isolates deemed to demonstrate in vitro resistance. Susceptibility testing was performed by CLSI broth microdilution methods, and species identification was performed by DNA sequence analysis. During this 2-year period, 271 dermatophyte isolates were included, the majority of which demonstrated low MIC values for terbinafine (geometric mean [GM] and modal MIC, 0.031 μg/mL and 0.008 μg/mL, respectively) and the azoles itraconazole, posaconazole, and voriconazole (0.035 to 0.049 μg/mL and ≤0.03 μg/mL). However, 18.6% of the isolates tested were resistant to terbinafine (MIC ≥ 0.5 μg/mL), including 21 T. rubrum and 21 T. indotineae isolates. These isolates were received from several different states in the United States and two provinces in Canada. In contrast, resistance to itraconazole was relatively rare. We also searched our laboratory database for earlier isolates that were resistant to terbinafine and identified 3 additional T. indotineae isolates, the earliest of which was from 2017. These results demonstrate that terbinafine resistance in dermatophytes was relatively common over this 2-year period and that T. indotineae is present in multiple areas in North America. Continued surveillance is warranted.
Collapse
Affiliation(s)
- Connie F. Cañete-Gibas
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - James Mele
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hoja P. Patterson
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Carmita J. Sanders
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Dora Ferrer
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Victor Garcia
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hongxin Fan
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Marjorie David
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan P. Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| |
Collapse
|
11
|
Jabet A, Normand AC, Brun S, Dannaoui E, Bachmeyer C, Piarroux R, Hennequin C, Moreno-Sabater A. Trichophyton indotineae, from epidemiology to therapeutic. J Mycol Med 2023; 33:101383. [PMID: 37031652 DOI: 10.1016/j.mycmed.2023.101383] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
Trichophyton indotineae is a newly described dermatophyte species. This fungal pathogen has recently emerged in India and is responsible for chronic or recurrent widespread superficial infections. Resistance to terbinafine is frequently associated to this pathogen and is related to point mutations in the gene encoding the squalene epoxidase. T. indotineae infections have been reported outside India, highlighting the risk of worldwide diffusion of this microorganism. Species identification and antifungal susceptibility determination are key points for infection control but still remain challenging. Systemic treatment is usually required and itraconazole is frequently prescribed in case of terbinafine resistance. This review summarizes main features of T. indotineae taxonomy, epidemiology, clinical manifestations, identification, antifungal profile, treatment and prevention.
Collapse
Affiliation(s)
- Arnaud Jabet
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France.
| | - Anne-Cécile Normand
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Sophie Brun
- Service de Parasitologie-Mycologie, Hôpital Avicenne, AP-HP, 93009 Bobigny, France
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Hôpital Necker, AP-HP, 75015 Paris, France; UR Dynamic 7380, UPEC, EnvA, USC ANSES, Faculté de Santé, 94000 Créteil, France; Faculté de Médecine, Université Paris Cité, 75006 Paris, France
| | - Claude Bachmeyer
- Service de Médecine interne, Hôpital Tenon, AP-HP, 75020 Paris, France
| | - Renaud Piarroux
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique, Inserm, Sorbonne Université, 75013 Paris, France
| | - Christophe Hennequin
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Centre de Recherche Saint-Antoine, CRSA, Inserm, Sorbonne Université, 75012 Paris, France
| | - Alicia Moreno-Sabater
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Centre d'Immunologie et des Maladies Infectieuses, (CIMI-PARIS), Inserm U1135, Sorbonne, 75013 Paris, France
| |
Collapse
|
12
|
Russo G, Toutous Trellu L, Fontao L, Ninet B. Towards an Early Clinical and Biological Resistance Detection in Dermatophytosis: About 2 Cases of Trichophyton indotineae. J Fungi (Basel) 2023; 9:733. [PMID: 37504722 PMCID: PMC10381761 DOI: 10.3390/jof9070733] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Trichophyton indotineae causes resistant dermatophytosis to terbinafine. The global spread of terbinafine-resistant Trichophyton indotineae strains with mutations in the squalene epoxidase gene is a major issue. This emerging species is now more frequently isolated in Europe and we report here two cases of T. indotineae tinea corporis in Switzerland, one with in vitro resistance to terbinafine and a second with in vitro susceptibility but a clinical resistance. Mycology isolation from cultures and sequencing ITS gene were used to confirm T. indotineae infection. In vitro antifungal susceptibility was tested in a microplate with a colorimetric detection of fungal viability for the determination of the minimal inhibitory concentration (MIC). Facing these emerging resistances and since there are a limited number of antifungal agents available to treat dermatophytosis, the early detection of terbinafine resistance should be a prerequisite in the management of T. indotineae infections.
Collapse
Affiliation(s)
- Giuseppe Russo
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Laurence Toutous Trellu
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Lionel Fontao
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Béatrice Ninet
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| |
Collapse
|
13
|
Bidaud AL, Moreno-Sabater A, Normand AC, Cremer G, Foulet F, Brun S, Ayachi A, Imbert S, Chowdhary A, Dannaoui E. Evaluation of Gradient Concentration Strips for Detection of Terbinafine Resistance in Trichophyton spp. Antimicrob Agents Chemother 2023; 67:e0171622. [PMID: 37162356 PMCID: PMC10269145 DOI: 10.1128/aac.01716-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/14/2023] [Indexed: 05/11/2023] Open
Abstract
The number of dermatophytosis cases resistant to terbinafine is increasing all over the world. Therefore, there is a need for antifungal susceptibility testing of dermatophytes for better management of the patients. In the present study, we have evaluated a gradient test (GT) method for testing the susceptibility of dermatophytes to terbinafine. MIC values to terbinafine determined by the EUCAST reference technique and by gradient test were compared for 79 Trichophyton spp. isolates. Overall, MICs were lower with gradient test (MIC50 of 0.002 μg/mL) than with EUCAST (MIC50 of 0.016 μg/mL). Good categorical agreement (>90%) between the 2 techniques was obtained but the essential agreement was variable depending on the batch of gradient test.
Collapse
Affiliation(s)
- Anne-Laure Bidaud
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
| | - Alicia Moreno-Sabater
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, Paris, France
- Centre d'Immunologie et des Maladies Infectieuses, (CIMI-PARIS), Inserm U1135, Sorbonne Université, Paris, France
| | - Anne-Cécile Normand
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, Paris, France
| | | | - Françoise Foulet
- Service de Parasitologie-Mycologie, Hôpitaux Universitaires Henri Mondor, AP-HP, Créteil, France
- EA 7380 Dynamic, UPEC, EnvA, USC ANSES, Faculté de Santé, Créteil, France
| | - Sophie Brun
- Service de Parasitologie-Mycologie, Hôpital Avicenne, AP-HP, Bobigny, France
- Faculté de Médecine, Université Sorbonne Paris Nord, Bobigny, France
| | - Aymen Ayachi
- Service de Parasitologie-Mycologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Sébastien Imbert
- Service de Parasitologie-Mycologie, CHU Bordeaux, Bordeaux, France
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
- EA 7380 Dynamic, UPEC, EnvA, USC ANSES, Faculté de Santé, Créteil, France
| |
Collapse
|
14
|
Bortoluzzi P, Prigitano A, Sechi A, Boneschi V, Germiniasi F, Esposto MC, Romanò L, Pavan G, Matinato C, Veraldi S, Marzano AV, Grancini A. Report of terbinafine resistant Trichophyton spp. in Italy: Clinical presentations, molecular identification, antifungal susceptibility testing and mutations in the squalene epoxidase gene. Mycoses 2023. [PMID: 37139949 DOI: 10.1111/myc.13597] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/21/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Numerous reports of resistance to terbinafine in Trichophyton spp. from all over the world are arousing justified attention and concern. Point mutations in the gene that encodes the squalene epoxidase (SQLE) enzyme are responsible for these therapeutic resistances. OBJECTIVES Primary objective of the study was to describe first isolates of Trichophyton spp. resistant to terbinafine among the patients treated between September 2019 and June 2022 at the Dermatology Units of Ospedale Maggiore Policlinico and San Bortolo Hospital. Secondary objective was to study the resistance mechanism. METHODS Patients with confirmed Trichophyton spp. infection has been treated with systemic and topical terbinafine. Patients were then re-evaluated 12 weeks after the therapy. Patients with incomplete or absent response to terbinafine underwent a new skin scraping for direct mycological examination, new identification of dermatophyte species from culture and MALDI-TOF, molecular species identification, antifungal susceptibility testing and molecular analysis of SQLE gene. RESULTS We identified five patients without clinical response to treatment with terbinafine. The DNA sequencing of the ITS region identified one Trichophyton rubrum and four Trichophyton indotineae. The T. rubrum strain showed minimum inhibitory concentration (MIC) (90% growth inhibition) of 4 mg/L for terbinafine. The four T. indotineae strains showed a MICs range of 0.25-4 mg/L for terbinafine. The analysis of the SQLE gene in the T. rubrum strain showed a nucleotide substitution generating a missense mutation (L393F). The SQLE gene sequencing in the T. indotineae strains showed a nucleotide substitution generating a missense mutation (F397L) in two strains, a nucleotide substitution L393S in one strain and a nucleotide substitution F415C in another strain. CONCLUSIONS We report the first cases of terbinafine-resistant Trichophyton isolates in the Italian population. Solid antifungal management programs will be needed to promote more responsible use of antimycotics and preserve their therapeutic efficacy to control antifungal resistance.
Collapse
Affiliation(s)
- P Bortoluzzi
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Prigitano
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - A Sechi
- Dermatology Unit, San Bortolo Hospital, Vicenza, Italy
| | - V Boneschi
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Germiniasi
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M C Esposto
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - L Romanò
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - G Pavan
- Department of Microbiology, San Bortolo Hospital, Vicenza, Italy
| | - C Matinato
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - S Veraldi
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
- Dermatology Unit, San Bortolo Hospital, Vicenza, Italy
- Department of Microbiology, San Bortolo Hospital, Vicenza, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - A V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
- Dermatology Unit, San Bortolo Hospital, Vicenza, Italy
- Department of Microbiology, San Bortolo Hospital, Vicenza, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - A Grancini
- Laboratorio Analisi - Laboratorio di Batteriologia, Parassitologia e Micologia, Fondazione IRCCS O. Maggiore Policlinico, Milan, Italy
| |
Collapse
|
15
|
Durdu M, Ilkit M. Strategies to improve the diagnosis and clinical treatment of dermatophyte infections. Expert Rev Anti Infect Ther 2023; 21:29-40. [PMID: 36329574 DOI: 10.1080/14787210.2023.2144232] [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: 11/06/2022]
Abstract
INTRODUCTION Significant problems are associated with the diagnosis and treatment of dermatophyte infections, which constitute the most common fungal infections of the skin. Although this is a common problem in the community, there are no adequate guidelines for the management of all forms of dermatophyte infections. Even if dermatophytes are correctly diagnosed, they sometimes exhibit poor susceptibility to several antifungal compounds. Therefore, long-term treatment may be needed, especially in immunosuppressed patients, for whom antifungal pharmacotherapy may be inconvenient owing to allergies and undesirable drug interaction-related effects. AREAS COVERED In this review article, problems related to the diagnosis and treatment of dermatophyte infections have been discussed, and suggestions to resolve these problems have been presented. EXPERT OPINION Pretreatment microscopic or mycological examinations should be performed for dermatophyte infections. In treatment-refractory cases, antifungal-resistant strains should be determined using antifungal susceptibility testing or via molecular methods. Natural herbal, laser, and photodynamic treatments can be used as alternative treatments in patients who cannot tolerate topical and systemic antifungal treatments.
Collapse
Affiliation(s)
- Murat Durdu
- Department of Dermatology, Faculty of Medicine, Başkent University Adana Hospital, Adana, Turkey
| | - Macit Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Çukurova, Adana, Turkey
| |
Collapse
|
16
|
Batvandi A, Pchelin IM, Kiasat N, Kharazi M, Mohammadi R, Zomorodian K, Rezaei‐Matehkolaei A. Time and Cost‐efficient Identification of
Trichophyton indotineae. Mycoses 2022; 66:75-81. [DOI: 10.1111/myc.13530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Abolfazl Batvandi
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| | - Ivan M. Pchelin
- Laboratory of Innovative Methods in Microbiological Monitoring Research Centre for Personalized Medicine, Institute of Experimental Medicine Saint Petersburg Russia
| | - Neda Kiasat
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| | - Mahboobeh Kharazi
- Department of Parasitology and Mycology School of Medicine, Shiraz University of Medical Sciences Shiraz Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology School of Medicine, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences Isfahan Iran
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology School of Medicine, Shiraz University of Medical Sciences Shiraz Iran
| | - Ali Rezaei‐Matehkolaei
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| |
Collapse
|
17
|
Ward H, Parkes N, Smith C, Kluzek S, Pearson R. Consensus for the Treatment of Tinea Pedis: A Systematic Review of Randomised Controlled Trials. J Fungi (Basel) 2022; 8:jof8040351. [PMID: 35448582 PMCID: PMC9027577 DOI: 10.3390/jof8040351] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023] Open
Abstract
Objective: To systematically review literature enabling the comparison of the efficacy of pharmaceutical treatments for tinea pedis in adults. Design: Systematic review of randomised controlled trials (RCTs) with mycological cure as the primary outcome. Secondary outcomes did include the clinical assessment of resolving infection or symptoms, duration of treatment, adverse events, adherence, and recurrence. Eligibility Criteria: Study participants suffering from only tinea pedis that were treated with a pharmaceutical treatment. The study must have been conducted using an RCT study design and recording age of the participant > 16 years of age. Results: A total of seven studies met the inclusion criteria, involving 1042 participants. The likelihood of resolution in study participants treated with terbinafine was RR 3.9 (95% CI: 2.0−7.8) times those with a placebo. Similarly, the allylamine butenafine was effective by RR 5.3 (95% CI: 1.4−19.6) compared to a placebo. Butenafine was similarly efficacious to terbinafine RR 1.3 (95% CI: 0.4−4.4). Terbinafine was marginally more efficacious than itraconazole, RR 1.3 (95% CI: 1.1−1.5). Summary/Conclusion: Topical terbinafine and butenafine treatments of tinea pedis were more efficacious than placebo. Tableted terbinafine and itraconazole administered orally were efficacious in the drug treatment of tinea pedis fungal infection. We are concerned about how few studies were available that reported the baseline characteristics for each treatment arm and that did not suffer greater than 20% loss to follow-up. We would like to see improved reporting of clinical trials in academic literature. Registration name: Treatment’s for athlete’s foot—systematic review with meta-analysis [CRD42020162078].
Collapse
Affiliation(s)
- Harry Ward
- Versus Arthritis Centre for Sport, Exercise and Osteoarthritis Research, University of Nottingham, Nottingham NG7 2UH, UK;
- Bodleian Health Care Libraries, Oxford University, Oxford OX3 9DU, UK;
- Correspondence:
| | - Nicholas Parkes
- Versus Arthritis Centre for Sport, Exercise and Osteoarthritis Research, University of Nottingham, Nottingham NG7 2UH, UK;
- Bodleian Health Care Libraries, Oxford University, Oxford OX3 9DU, UK;
| | - Carolyn Smith
- Bodleian Health Care Libraries, Oxford University, Oxford OX3 9DU, UK;
| | - Stefan Kluzek
- Orthopaedics, Trauma and Sports Medicine, School of Medicine, Queen’s Medical, Centre University of Nottingham, Nottingham NG7 2UH, UK; (S.K.); (R.P.)
| | - Richard Pearson
- Orthopaedics, Trauma and Sports Medicine, School of Medicine, Queen’s Medical, Centre University of Nottingham, Nottingham NG7 2UH, UK; (S.K.); (R.P.)
| |
Collapse
|
18
|
Denning DW. Antifungal drug resistance: an update. Eur J Hosp Pharm 2022; 29:109-112. [PMID: 35190454 PMCID: PMC8899664 DOI: 10.1136/ejhpharm-2020-002604] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/06/2021] [Indexed: 12/13/2022] Open
Abstract
The number of antifungal classes is small, and resistance is becoming a much more frequent problem. Much greater emphasis needs to be placed on susceptibility testing and antifungal stewardship. Such efforts demonstrably improve survival and overall clinical outcomes. Positively diagnosing a fungal infection with laboratory markers often allows antibacterial therapy to be stopped (ie, anti-tuberculous therapy in chronic pulmonary aspergillosis or antibiotics other than cotrimoxazole in Pneumocystis pneumonia), contributing to antimicrobial resistance control generally. Non-culture based diagnostics for fungal disease are transformational in terms of sensitivity and speed, but only occasionally identify antifungal resistance.
Collapse
|
19
|
Terbinafine Resistance in Dermatophytes: A French Multicenter Prospective Study. J Fungi (Basel) 2022; 8:jof8030220. [PMID: 35330222 PMCID: PMC8948947 DOI: 10.3390/jof8030220] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
In recent years, we have moved from the sporadic description of terbinafine-resistant (TerR) Trichophyton spp. isolates to the Indian outbreak due to T. indotineae. Population flows have spread TerR worldwide, altering local epidemiology. We conducted a prospective multicentric study to determine the relative frequency of TerR isolates in France (Paris area) and of the newly introduced T. indotineae species. TerR isolates were screened by the terbinafine-containing-agar-medium (TCAM) method and confirmed by EUCAST. Sequencing methods were used to identify isolates to the species/genotype level and to analyze substitutions in the squalene epoxidase gene (SQLE). In total, 3 isolates out of 580 (T. rubrumn = 1; T. interdigitalen = 1; T. indotineaen = 1) grew on TCAM, showed terbinafine resistance by EUCAST and harbored the Phe397Leu (n = 2) or Leu393Ser (n = 1) substitution in the SQLE. ITS-sequencing of isolates of the T. mentagrophytes/interdigitale complex (n = 125) revealed a relative frequency of 4.8% for T. indotineae and the presence of T. mentagrophytes genotype VII. Despite the detection of terbinafine resistance, isolates from this complex remained susceptible to itraconazole, voriconazole and amorolfine. Terbinafine resistance is present in France and the dermatophyte epidemiology is changing. Efficient systems must be implemented to survey the evolution of newly introduced species and to identify TerR isolates.
Collapse
|
20
|
Increasing Terbinafine Resistance in Danish Trichophyton Isolates 2019–2020. J Fungi (Basel) 2022; 8:jof8020150. [PMID: 35205904 PMCID: PMC8879722 DOI: 10.3390/jof8020150] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/21/2022] [Accepted: 01/28/2022] [Indexed: 11/25/2022] Open
Abstract
Terbinafine resistance in Trichophyton species has emerged and appears to be increasing. A new EUCAST susceptibility testing method and tentative ECOFFs were recently proposed for Trichophyton. Terbinafine resistance and target gene mutations were detected in 16 Danish isolates in 2013–2018. In this study, samples/isolates submitted for dermatophyte susceptibility testing 2019–2020 were examined. Species identification (ITS sequencing for T. mentagrophytes/T. interdigitale species complex (SC) isolates), EUCAST MICs and squalene epoxidase (SQLE) profiles were obtained. Sixty-three isolates from 59 patients were included. T. rubrum accounted for 81% and T. mentagrophytes/T. interdigitale SC for 19%. Approximately 60% of T. rubrum and T. mentagrophytes/interdigitale SC isolates were terbinafine non-wildtype and/or had known/novel SQLE mutations with possible implications for terbinafine MICs. All infections with terbinafine-resistant T. mentagrophytes/interdigitale SC isolates were caused by Trichophyton indotineae. Compared to 2013–2018, the number of patients with terbinafine-resistant Trichophyton isolates increased. For T. rubrum, this is partly explained by an increase in number of requests for susceptibility testing. Terbinafine-resistant T. indotineae was first detected in 2018, but accounted for 19% of resistance (4 of 21 patients) in 2020. In conclusion, terbinafine resistance is an emerging problem in Denmark. Population based studies are warranted and susceptibility testing is highly relevant in non-responding cases.
Collapse
|
21
|
Ahmed SA, Engel T, Zoll J, Godschalk PCR, Klaasen R, Moreno L, van der Lee H, Verweij PE, de Hoog S. Meanderella rijsii, a new opportunist in the fungal order Pleosporales. Microbes Infect 2022; 24:104932. [PMID: 35032673 DOI: 10.1016/j.micinf.2022.104932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
Subcutaneous phaeohyphomycosis is an implantation disease caused by melanized fungi and affect both immunocompetent as well as immunocompromised individuals. Diagnosis and treatment require proper isolation and accurate identification of the causative pathogen. We isolated a novel fungus from a case of subcutaneous phaeohyphomycosis in an immunocompetent patient. The 56-year-old patient suffered from a slowly progressive swelling on the metatarsophalangeal join of the left food. The isolated fungus lacked sporulation and sequences of the ribosomal operon did not match with any known species. In a multi-locus phylogenetic analysis involving five markers, the fungus formed a unique lineage in the order Pleosporales, family Trematosphaeriaceae. A new genus, Meanderella and a new species, M. rijsii are here proposed to accommodate the clinical isolate. Whole genome analysis of M. rijsii revealed a number of genes that can be linked to pathogenicity and virulence. Further studies are however needed to understand the role of each gene in the pathogenic process and to determine the origin of pathogenicity in the family of Trematosphaeriaceae.
Collapse
Affiliation(s)
- Sarah A Ahmed
- Department of Medical Microbiology, Radboud University Medical Center and Radboudumc - CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands; Foundation Atlas of Clinical Fungi, Hilversum, the Netherlands.
| | - Tobias Engel
- Laboratory for Medical Microbiology and Public Health, Hengelo, the Netherlands
| | - Jan Zoll
- Department of Medical Microbiology, Radboud University Medical Center and Radboudumc - CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
| | - Peggy C R Godschalk
- Department of Medical Microbiology and Medical Immunology, Meander Medical Center, Amersfoort, the Netherlands
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Center, Amersfoort, the Netherlands
| | | | - Henrich van der Lee
- Department of Medical Microbiology, Radboud University Medical Center and Radboudumc - CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center and Radboudumc - CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
| | - Sybren de Hoog
- Department of Medical Microbiology, Radboud University Medical Center and Radboudumc - CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands; Foundation Atlas of Clinical Fungi, Hilversum, the Netherlands; Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou & Guizhou Talent Base for Microbiology and Human Health, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, China
| |
Collapse
|
22
|
Rogers TR, Verweij PE, Castanheira M, Dannaoui E, White PL, Arendrup MC. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2053-2073. [PMID: 35703391 PMCID: PMC9333407 DOI: 10.1093/jac/dkac161] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The increasing incidence and changing epidemiology of invasive fungal infections continue to present many challenges to their effective management. The repertoire of antifungal drugs available for treatment is still limited although there are new antifungals on the horizon. Successful treatment of invasive mycoses is dependent on a mix of pathogen-, host- and antifungal drug-related factors. Laboratories need to be adept at detection of fungal pathogens in clinical samples in order to effectively guide treatment by identifying isolates with acquired drug resistance. While there are international guidelines on how to conduct in vitro antifungal susceptibility testing, these are not performed as widely as for bacterial pathogens. Furthermore, fungi generally are recovered in cultures more slowly than bacteria, and often cannot be cultured in the laboratory. Therefore, non-culture-based methods, including molecular tests, to detect fungi in clinical specimens are increasingly important in patient management and are becoming more reliable as technology improves. Molecular methods can also be used for detection of target gene mutations or other mechanisms that predict antifungal drug resistance. This review addresses acquired antifungal drug resistance in the principal human fungal pathogens and describes known resistance mechanisms and what in-house and commercial tools are available for their detection. It is emphasized that this approach should be complementary to culture-based susceptibility testing, given the range of mutations, resistance mechanisms and target genes that may be present in clinical isolates, but may not be included in current molecular assays.
Collapse
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
| |
Collapse
|
23
|
Jabet A, Brun S, Normand AC, Imbert S, Akhoundi M, Dannaoui E, Audiffred L, Chasset F, Izri A, Laroche L, Piarroux R, Bachmeyer C, Hennequin C, Sabater AM. Extensive Dermatophytosis Caused by Terbinafine-Resistant Trichophyton indotineae, France. Emerg Infect Dis 2022; 28:229-233. [PMID: 34932456 PMCID: PMC8714191 DOI: 10.3201/eid2801.210883] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Extensive dermatophytosis caused by terbinafine-resistant Trichophyton indotineae harboring Phe397Leu and Leu393Ser substitutions in the squalene epoxidase enzyme was diagnosed in France. Analysis of internal transcribed spacer sequences revealed the wide spread of this species in Asia and Europe. Detection of T. indotineae in animals suggests their possible role as reservoirs.
Collapse
|
24
|
|
25
|
Brasch J, Gräser Y, Beck-Jendroscheck V, Voss K, Torz K, Walther G, Schwarz T. „Indische“
Trichophyton mentagrophytes
‐Stämme mit reduzierter Itraconazol‐Empfindlichkeit in Deutschland. J Dtsch Dermatol Ges 2021; 19:1723-1728. [PMID: 34894184 DOI: 10.1111/ddg.14626_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Jochen Brasch
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Yvonne Gräser
- Nationales Konsiliarlabor für Dermatophyten, Institut für Mikrobiologie und Infektionsimmunologie, Charité - Universitätsmedizin Berlin
| | - Vera Beck-Jendroscheck
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Karen Voss
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Kaspar Torz
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Grit Walther
- Nationales Referenzzentrum für invasive Pilzinfektionen (NRZMyk), Leibniz-Institut für Naturstoff-Forschung und Infektionsbiologie - Hans-Knöll-Institut, Jena
| | - Thomas Schwarz
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| |
Collapse
|
26
|
Brasch J, Gräser Y, Beck-Jendroscheck V, Voss K, Torz K, Walther G, Schwarz T. "Indian" strains of Trichophyton mentagrophytes with reduced itraconazole susceptibility in Germany. J Dtsch Dermatol Ges 2021; 19:1723-1727. [PMID: 34850554 DOI: 10.1111/ddg.14626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 01/23/2023]
Abstract
We use published reports and three of our own tinea cases as an opportunity to report on "Indian" strains of Trichophyton (T.) mentagrophytes with ITS genotype VIII and reduced susceptibility to itraconazole due to the mutation c.1342G>A in the SQLE gene in Germany. In vitro measurements of resistance revealed normal susceptibility to terbinafine, but markedly reduced susceptibility to itraconazole - although no valid breakpoints are currently defined and minimum inhibitory concentrations (MICs) depend on the methods used. Problems related to the determination and interpretation of MICs are outlined. Our cases show that azole-resistant "Indian" strains of T. mentagrophytes with ITS genotype VIII occurred in Germany as early as 2011, which is earlier than was previously assumed. This variant of the pathogen cannot be phenotypically distinguished from customary strains of T. mentagrophytes; its identification is based on genetics. The taxonomic classification is still under debate. This variant is anthropophilic and causes only mildly inflammatory tinea lesions with many fungal elements. Its further dissemination must therefore be expected. Prerequisites for rapid and valid antimycotic testing against dermatophytes need to be developed.
Collapse
Affiliation(s)
- Jochen Brasch
- Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Yvonne Gräser
- National Consultative Laboratory for Dermatophytes, Institute for Microbiology and Infection Immunology, Charité - Universitätsmedizin Berlin
| | - Vera Beck-Jendroscheck
- Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Karen Voss
- Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Kaspar Torz
- Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Grit Walther
- National Reference Center for Invasive Fungal Infections (NRZMyk), Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena
| | - Thomas Schwarz
- Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel
| |
Collapse
|
27
|
Brescini L, Fioriti S, Morroni G, Barchiesi F. Antifungal Combinations in Dermatophytes. J Fungi (Basel) 2021; 7:jof7090727. [PMID: 34575765 PMCID: PMC8469868 DOI: 10.3390/jof7090727] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/19/2022] Open
Abstract
Dermatophytes are the most common cause of fungal infections worldwide, affecting millions of people annually. The emergence of resistance among dermatophytes along with the availability of antifungal susceptibility procedures suitable for testing antifungal agents against this group of fungi make the combinatorial approach particularly interesting to be investigated. Therefore, we reviewed the scientific literature concerning the antifungal combinations against dermatophytes. A literature search on the subject performed in PubMed yielded 68 publications: 37 articles referring to in vitro studies and 31 articles referring to case reports or clinical studies. In vitro studies involved over 400 clinical isolates of dermatophytes (69% Trichophyton spp., 29% Microsporum spp., and 2% Epidermophyton floccosum). Combinations included two antifungal agents or an antifungal agent plus another chemical compound including plant extracts or essential oils, calcineurin inhibitors, peptides, disinfectant agents, and others. In general, drug combinations yielded variable results spanning from synergism to indifference. Antagonism was rarely seen. In over 700 patients with documented dermatophyte infections, an antifungal combination approach could be evaluated. The most frequent combination included a systemic antifungal agent administered orally (i.e., terbinafine, griseofulvin, or azole-mainly itraconazole) plus a topical medication (i.e., azole, terbinafine, ciclopirox, amorolfine) for several weeks. Clinical results indicate that association of antifungal agents is effective, and it might be useful to accelerate the clinical and microbiological healing of a superficial infection. Antifungal combinations in dermatophytes have gained considerable scientific interest over the years and, in consideration of the interesting results available so far, it is desirable to continue the research in this field.
Collapse
Affiliation(s)
- Lucia Brescini
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, 60020 Ancona, Italy; (L.B.); (S.F.); (G.M.)
| | - Simona Fioriti
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, 60020 Ancona, Italy; (L.B.); (S.F.); (G.M.)
| | - Gianluca Morroni
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, 60020 Ancona, Italy; (L.B.); (S.F.); (G.M.)
| | - Francesco Barchiesi
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, 60020 Ancona, Italy; (L.B.); (S.F.); (G.M.)
- Malattie Infettive, Azienda Ospedaliera Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy
- Correspondence: ; Tel.: +39-721-36-5505
| |
Collapse
|
28
|
Lysková P, Dobiáš R, Čmoková A, Kolařík M, Hamal P, Šmatláková K, Hušek J, Mencl K, Mallátová N, Poláčková Z, Krnáčová A, Palkovičová K, Jablonská D, Macháčová J, Drlík Z, Bázsóová D, Jaworská P, Svobodová L, Hubka V. An Outbreak of Trichophyton quinckeanum Zoonotic Infections in the Czech Republic Transmitted from Cats and Dogs. J Fungi (Basel) 2021; 7:684. [PMID: 34575722 PMCID: PMC8465542 DOI: 10.3390/jof7090684] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/07/2021] [Accepted: 08/19/2021] [Indexed: 01/18/2023] Open
Abstract
Trichophyton quinckeanum, a zoophilic dermatophyte mostly known as the causative agent of rodent favus, is relatively rarely reported to cause human infections. Indeed, no infections were detected in Czechia between 2012 and 2015 despite routine verification of species identification by ITS rDNA sequencing. By contrast, 25 human and 11 animal cases of infection were documented from December 2016 to December 2020 and the rates tended to grow every following year. Interestingly, most of the cases were reported in the Olomouc region, suggesting a local outbreak. We bring the evidence that human T. quinckeanum infections are most commonly contracted from infected cats or, less frequently, dogs. Although rodents or contaminated soil and environment could be the source of infection to cats and dogs, the occurrence of infections in multiple animals in the same household suggests direct transmission among animals. Confirmation of the identification by molecular methods is highly recommended due to morphological similarity with T. mentagrophytes/T. interdigitale. Antifungal susceptibility testing of isolates to eight antifungals was performed using EUCAST methodology (E.Def 11.0). Among the tested antifungals, terbinafine, amorolfine, ciclopirox and efinaconazole were most potent in vitro and elevated minimum inhibitory concentrations were obtained for fluconazole and ketoconazole.
Collapse
Affiliation(s)
- Pavlína Lysková
- Department of Parasitology, Mycology and Mycobacteriology, Public Health Institute in Ústí nad Labem, 186 00 Prague, Czech Republic;
| | - Radim Dobiáš
- Department of Bacteriology and Mycology, Public Health Institute Ostrava, 702 00 Ostrava, Czech Republic; (R.D.); (D.B.); (P.J.)
- Department of Biomedical Sciences, Institute of Microbiology and Immunology, Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic
| | - Adéla Čmoková
- Department of Botany, Faculty of Science, Charles University, 128 01 Prague, Czech Republic; (A.Č.); (M.K.)
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, 142 20 Prague, Czech Republic
| | - Miroslav Kolařík
- Department of Botany, Faculty of Science, Charles University, 128 01 Prague, Czech Republic; (A.Č.); (M.K.)
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, 142 20 Prague, Czech Republic
| | - Petr Hamal
- Department of Microbiology, University Hospital Olomouc, 775 15 Olomouc, Czech Republic;
| | - Kateřina Šmatláková
- Veterinární Klinika MVDr. Vlastimil Pospíšil, 68 201 Vyškov, Czech Republic;
| | - Jan Hušek
- Veterinární Klinika Veterix, 79 601 Prostějov, Czech Republic;
| | - Karel Mencl
- Department of Clinical Microbiology, Pardubice Regional Hospital, 53 203 Pardubice, Czech Republic;
| | - Nad’a Mallátová
- Laboratory of Mycology and Parasitology, Hospital České Budějovice, 370 01 České Budějovice, Czech Republic;
| | - Zora Poláčková
- Department of Skin and Venereal Diseases, University Hospital Olomouc, 775 15 Olomouc, Czech Republic; (Z.P.); (Z.D.)
| | - Anežka Krnáčová
- Department of Dermatology, Přerov Hospital, 751 52 Přerov, Czech Republic;
| | | | - Daniela Jablonská
- Dermatology Center, Hranice Hospital, 753 22 Hranice, Czech Republic;
| | - Jitka Macháčová
- Dermatology Center, 757 01 Valašské Meziříčí, Czech Republic;
| | - Zdeněk Drlík
- Department of Skin and Venereal Diseases, University Hospital Olomouc, 775 15 Olomouc, Czech Republic; (Z.P.); (Z.D.)
- Dr. Drlik Dermatovenereology, 789 85 Mohelnice, Czech Republic
| | - Denisa Bázsóová
- Department of Bacteriology and Mycology, Public Health Institute Ostrava, 702 00 Ostrava, Czech Republic; (R.D.); (D.B.); (P.J.)
| | - Pavla Jaworská
- Department of Bacteriology and Mycology, Public Health Institute Ostrava, 702 00 Ostrava, Czech Republic; (R.D.); (D.B.); (P.J.)
| | - Lucie Svobodová
- Department of Microbiology, University Hospital Olomouc, 775 15 Olomouc, Czech Republic;
| | - Vit Hubka
- Department of Botany, Faculty of Science, Charles University, 128 01 Prague, Czech Republic; (A.Č.); (M.K.)
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, 142 20 Prague, Czech Republic
| |
Collapse
|
29
|
Antifungal Susceptibility and Mutations in the Squalene Epoxidase Gene in Dermatophytes of the Trichophyton mentagrophytes Species Complex. Antimicrob Agents Chemother 2021; 65:e0005621. [PMID: 33972254 PMCID: PMC8284460 DOI: 10.1128/aac.00056-21] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
During the past decade, a prolonged and serious outbreak of dermatophytosis due to a terbinafine-resistant novel species in the Trichophyton mentagrophytes-T. interdigitale complex has been ongoing in India, and it has spread to several European countries. The objective of this study was to investigate the molecular background of the squalene epoxidase (SQLE) gene in order to understand the risk of emergence and spread of multiresistance in dermatophytes. Antifungal susceptibility to fluconazole, griseofulvin, itraconazole, ketoconazole, miconazole, naftifine, sertaconazole, and terbinafine was tested in 135 isolates from India, China, Australia, Germany, and The Netherlands. Based on the latest taxonomic insights, strains were identified as three species: T. mentagrophytessensu stricto (n = 35), T. indotineae (n = 64, representing the Indian clone), and T. interdigitalesensu stricto (n = 36). High MICs of terbinafine (>16 mg/liter) were found in 34 (53%) T. indotineae isolates. These isolates showed an amino acid substitution in the 397th position of the SQLE gene. Elevated MICs of terbinafine (0.5 mg/liter) were noted in 2 (3%) T. indotineae isolates; these isolates lead to Phe415Val and Leu393Ser of the SQLE gene. The stability of the effect of the mutations was proven by serial transfer on drug-free medium. Lys276Asn and Leu419Phe substitutions were found in susceptible T. mentagrophytes strains. The Phe377Leu/Ala448Thr double mutant showed higher MIC values for triazoles. High MICs of terbinafine are as yet limited to T. indotineae and are unlikely to be distributed throughout the T. mentagrophytes species complex by genetic exchange.
Collapse
|
30
|
Abstract
BACKGROUND AND OBJECTIVE With the widespread use of antifungals to treat superficial mycoses, reports of antifungal resistance are increasing. Antifungal resistance is becoming a public health challenge and needs to be addressed in parallel with antibacterial and antiviral resistance. METHODS We review the growing resistance of fungal pathogens such as Trichophyton species and the emergence of novel pathogens, including multidrug-resistant strains in superficial mycoses. We also discuss the importance of laboratory diagnosis and antifungal susceptibility testing (AFST) in the management of recalcitrant infections. RESULTS AND CONCLUSION Antifungal resistance can occur naturally or develop over time when fungi are exposed to antifungals. The frequency of terbinafine-resistant Trichophyton isolates is increasing. Opportunistic pathogens such as Aspergillus and Candida species have developed resistance to classic azoles such as itraconazole and fluconazole, and the newer azoles such as posaconazole and voriconazole. Although uncommon, topical antifungals such as efinaconazole and tavaborole have shown to induce resistance in Trichophyton rubrum. The emergence of multidrug-resistant Trichophyton mentagrophytes/interdigitale, Candida auris, and Aspergillus species causing severe infections is highly concerning. Routine AFST should be considered to determine the most effective treatment, especially if there is failure to therapy. Combination treatment of oral and topical antifungals may be a consideration for managing recalcitrant infections.
Collapse
Affiliation(s)
- Aditya K Gupta
- Department of Medicine, Division of Dermatology, University of Toronto School of Medicine, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | |
Collapse
|
31
|
Shen JJ, Arendrup MC, Verma S, Saunte DML. The Emerging Terbinafine-Resistant Trichophyton Epidemic: What Is the Role of Antifungal Susceptibility Testing? Dermatology 2021; 238:60-79. [PMID: 34058736 DOI: 10.1159/000515290] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dermatophytosis is commonly encountered in the dermatological clinics. The main aetiological agents in dermatophytosis of skin and nails in humans are Trichophyton (T.) rubrum, T. mentagrophytes and T. interdigitale (former T. mentagrophytes-complex). Terbinafine therapy is usually effective in eradicating infections due to these species by inhibiting their squalene epoxidase (SQLE) enzyme, but increasing numbers of clinically resistant cases and mutations in the SQLE gene have been documented recently. Resistance to antimycotics is phenotypically determined by antifungal susceptibility testing (AFST). However, AFST is not routinely performed for dermatophytes and no breakpoints classifying isolates as susceptible or resistant are available, making it difficult to interpret the clinical impact of a minimal inhibitory concentration (MIC). SUMMARY PubMed was systematically searched for terbinafine susceptibility testing of dermatophytes on October 20, 2020, by two individual researchers. The inclusion criteria were in vitro terbinafine susceptibility testing of Trichophyton (T.) rubrum, T. mentagrophytes and T. interdigitale with the broth microdilution technique. The exclusion criteria were non-English written papers. Outcomes were reported as MIC range, geometric mean, modal MIC and MIC50 and MIC90 in which 50 or 90% of isolates were inhibited, respectively. The reported MICs ranged from <0.001 to >64 mg/L. The huge variation in MIC is partly explained by the heterogeneity of the Trichophyton isolates, where some originated from routine specimens (wild types) whereas others came from non-responding patients with a known SQLE gene mutation. Another reason for the great variation in MIC is the use of different AFST methods where MIC values are not directly comparable. High MICs were reported particularly in isolates with SQLE gene mutation. The following SQLE alterations were reported: F397L, L393F, L393S, H440Y, F393I, F393V, F415I, F415S, F415V, S443P, A448T, L335F/A448T, S395P/A448T, L393S/A448T, Q408L/A448T, F397L/A448T, I121M/V237I and H440Y/F484Y in terbinafine-resistant isolates.
Collapse
Affiliation(s)
- Julia J Shen
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Unit of Mycology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Maiken C Arendrup
- Unit of Mycology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Shyam Verma
- 'Nirvan' and 'In skin' Clinics, Vadodara, India
| | - Ditte Marie L Saunte
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Unit of Mycology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
32
|
Siopi M, Efstathiou I, Theodoropoulos K, Pournaras S, Meletiadis J. Molecular Epidemiology and Antifungal Susceptibility of Trichophyton Isolates in Greece: Emergence of Terbinafine-Resistant Trichophytonmentagrophytes Type VIII Locally and Globally. J Fungi (Basel) 2021; 7:jof7060419. [PMID: 34072049 PMCID: PMC8229535 DOI: 10.3390/jof7060419] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023] Open
Abstract
Trichophyton isolates with reduced susceptibility to antifungals are now increasingly reported worldwide. We therefore studied the molecular epidemiology and the in vitro antifungal susceptibility patterns of Greek Trichophyton isolates over the last 10 years with the newly released EUCAST reference method for dermatophytes. Literature was reviewed to assess the global burden of antifungal resistance in Trichophyton spp. The in vitro susceptibility of 112 Trichophyton spp. molecularly identified clinical isolates (70 T. rubrum, 24 T. mentagrophytes, 12 T. interdigitale and 6 T. tonsurans) was tested against terbinafine, itraconazole, voriconazole and amorolfine (EUCAST E.DEF 11.0). Isolates were genotyped based on the internal transcribed spacer (ITS) sequences and the target gene squalene epoxidase (SQLE) was sequenced for isolates with reduced susceptibility to terbinafine. All T. rubrum, T. interdigitale and T. tonsurans isolates were classified as wild-type (WT) to all antifungals, whereas 9/24 (37.5%) T. mentagrophytes strains displayed elevated terbinafine MICs (0.25–8 mg/L) but not to azoles and amorolfine. All T. interdigitale isolates belonged to ITS Type II, while T. mentagrophytes isolates belonged to ITS Type III* (n = 11), VIII (n = 9) and VII (n = 4). All non-WT T. mentagrophytes isolates belonged to Indian Genotype VIII and harbored Leu393Ser (n = 5) and Phe397Leu (n = 4) SQLE mutations. Terbinafine resistance rates ranged globally from 0–44% for T. rubrum and 0–76% for T. interdigitale/T. mentagrophytes with strong endemicity. High incidence (37.5%) of terbinafine non-WT T. mentagrophytes isolates (all belonging to ITS Type VIII) without cross-resistance to other antifungals was found for the first time in Greece. This finding must alarm for susceptibility testing of dermatophytes at a local scale particularly in non-responding dermatophytoses.
Collapse
Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Ioanna Efstathiou
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Konstantinos Theodoropoulos
- Second Department of Dermatology & Venereology, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece;
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Medical School, “Attikon” University General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (M.S.); (I.E.); (S.P.)
- Correspondence: ; Tel.: +30-210-583-1909; Fax: +30-210-532-6421
| |
Collapse
|
33
|
Singh A, Singh P, Dingemans G, Meis JF, Chowdhary A. Evaluation of DermaGenius ® resistance real-time polymerase chain reaction for rapid detection of terbinafine-resistant Trichophyton species. Mycoses 2021; 64:721-726. [PMID: 33760310 DOI: 10.1111/myc.13271] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Treatment-resistant dermatophytosis caused by Trichophyton mentagrophytes/interdigitale complex has emerged as a global public health threat, particularly in endemic countries like India and has spread to many other countries. This veritable spread is alarming due to increase in resistance to terbinafine, which targets the ergosterol biosynthetic pathway by inhibiting the enzyme squalene epoxidase (SQLE). About two third of studies worldwide have reported amino acid substitutions Phe397Leu and Leu393Phe in the SQLE protein to be responsible for high terbinafine MICs. OBJECTIVES We evaluated the efficacy of the newly developed DermaGenius® Resistance real-time PCR assay to rapidly identify Trichophyton isolates harbouring most common SQLE mutant (Phe397Leu and Leu393Phe) conferring high terbinafine resistance from wild-type susceptible isolates. METHODS A total of 97 Trichophyton isolates confirmed by ITS sequencing as T. mentagrophytes/interdigitale (recently named T. indotineae n = 90), T. rubrum/T. soudanense (n = 3), T mentagrophytes (n = 2) and T tonsurans (n = 2) were analysed to evaluate DermaGenius® Resistance real-time PCR assay. All 40 T. indotineae isolates exhibiting amino acid substitutions Phe397Leu or Leu393Phe identified by SQLE gene sequencing were evaluated for detection of non-wild-type strains by real-time PCR. Antifungal susceptibility testing for terbinafine was done by CLSI microbroth dilution method. RESULTS All terbinafine-resistant isolates harbouring amino acid substitutions Phe397Leu or Leu393Phe in SQLE gene were correctly recorded as SQLE mutants by the DermaGenius® Resistance real-time PCR assay. CONCLUSIONS The DermaGenius® Resistance real-time PCR assay effectively identified Trichophyton species and distinguished wild-type from SQLE mutant genotype that harbour Phe397Leu and Leu393Phe amino acid substitutions.
Collapse
Affiliation(s)
- Ashutosh Singh
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, India
| | - Prerna Singh
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, India
| | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, India
| |
Collapse
|
34
|
Saunte D, Pereiro‐Ferreirós M, Rodríguez‐Cerdeira C, Sergeev A, Arabatzis M, Prohić A, Piraccini B, Lecerf P, Nenoff P, Kotrekhova L, Bosshard P, Padovese V, Szepietowski J, Sigurgeirsson B, Nowicki R, Schmid‐Grendelmeier P, Hay R. Emerging antifungal treatment failure of dermatophytosis in Europe: take care or it may become endemic. J Eur Acad Dermatol Venereol 2021; 35:1582-1586. [DOI: 10.1111/jdv.17241] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022]
Affiliation(s)
- D.M.L. Saunte
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology Zealand University Hospital Roskilde Denmark
- Department of Clinical Medicine Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - M. Pereiro‐Ferreirós
- European Academy of Dermatology and Venereology TASK force on Mycology
- Dermatología Faculty of Medicine University of Santiago de Compostela A Coruña Spain
| | - C. Rodríguez‐Cerdeira
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology Meixoeiro Hospital and University of Vigo Vigo Spain
| | - A.Y. Sergeev
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Clinical Immunology Sechenov University Moscow Russia
| | - M. Arabatzis
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology Medical School Aristotle University Thessaloniki Greece
| | - A. Prohić
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatovenereology University Sarajevo School of Science and TechnologySarajevo Medical School Sarajevo Bosnia and Herzegovina
| | - B.M. Piraccini
- European Academy of Dermatology and Venereology TASK force on Mycology
- Dermatology ‐IRCCS Policlinico di Sant’Orsola Department of Experimental, Diagnostic and Specialty Medicine (DIMES) Alma Mater Studiorum University of Bologna Bologna Italy
| | - P. Lecerf
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology University Hospital Brugmann & Saint‐PierreUniversité Libre de Bruxelles Brussels Belgium
| | - P. Nenoff
- European Academy of Dermatology and Venereology TASK force on Mycology
- Laboratory for Medical Microbiology Mölbis Germany
| | - L.P. Kotrekhova
- Department of Dermatovenereology North Western State Medical University Saint Petersburg Russia
| | - P.P. Bosshard
- Department of Dermatology University Hospital Zurich and Medical Faculty University of Zurich Zurich Switzerland
| | - V. Padovese
- Department of Dermatology and Venereology Genitourinary ClinicMater Dei Hospital Msida Malta
| | - J.C. Szepietowski
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology, Venereology and Allergology Wroclaw Medical University Wroclaw Poland
| | - B. Sigurgeirsson
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology Faculty of Medicine University of Iceland Reykjavik Iceland
| | - R.J. Nowicki
- European Academy of Dermatology and Venereology TASK force on Mycology
- Department of Dermatology, Venereology & Allergology Medical University of Gdansk Gdansk Poland
| | - P. Schmid‐Grendelmeier
- European Academy of Dermatology and Venereology TASK force on Mycology
- Allergy Unit Department of Dermatology University Hospital Zurich and Medical Faculty University of Zurich Zurich Switzerland
| | - R.J. Hay
- European Academy of Dermatology and Venereology TASK force on Mycology
- St John’s Institute of DermatologyKings College London London UK
| |
Collapse
|
35
|
The Growing Problem of Antifungal Resistance in Onychomycosis and Other Superficial Mycoses. Am J Clin Dermatol 2021; 22:149-157. [PMID: 33354740 DOI: 10.1007/s40257-020-00580-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 01/06/2023]
Abstract
Superficial mycoses are becoming increasingly resistant to current antifungal medications. As alternative therapeutic options are limited, the increasing frequency of reports of antifungal resistance is alarming. This epidemic parallels the rise of antibiotic resistance; however, the significance of this problem has yet to gain global attention. Here, we discuss the reports of antifungal resistance from around the world, present our own experience with treatment-resistant infections, and examine alternative treatment strategies. The majority of reports of recalcitrant infections indicate terbinafine resistance as the causative factor. Single-point mutations in the squalene oxidase gene is the most reported mechanism of resistance to terbinafine. Mixed infections of dermatophytes with non-dermatophyte molds and/or yeasts are becoming more prevalent and contributing to the resistant nature of these infections. The key to selecting an effective antifungal therapy for a recalcitrant infection is identification of the infectious organisms(s) and testing susceptibility of the organism(s) to antifungal drugs. Combination and sequential therapy regimens are options, but both require active monitoring for hepatic and renal function, drug interactions, and other adverse effects. Selected topical antifungals with a wide spectrum of activity may also be considerations in some clinical presentations. Innovative treatment regimens and novel therapeutics are needed to overcome the rising epidemic of antifungal resistance.
Collapse
|
36
|
Belgian National Survey on Tinea Capitis: Epidemiological Considerations and Highlight of Terbinafine-Resistant T. mentagrophytes with a Mutation on SQLE Gene. J Fungi (Basel) 2020; 6:jof6040195. [PMID: 33003309 PMCID: PMC7712443 DOI: 10.3390/jof6040195] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background: In this last decade, a huge increase in African anthropophilic strains causing tinea capitis has been observed in Europe. The Belgian National Reference Center for Mycosis (NRC) conducted a surveillance study on tinea capitis in 2018 to learn the profile of circulating dermatophytes. Methods: Belgian laboratories were invited to send all dermatophyte strains isolated from the scalp with epidemiological information. Strain identification was confirmed by ITS (Internal Transcribed Spacer) sequencing. Mutation in the squalene epoxidase (SQLE) gene was screened by PCR. Results: The main population affected by tinea capitis was children from 5–9 years. Males were more affected than females. The majority of the strains were collected in the Brussels area followed by the Liege area. Among known ethnic origins, African people were more affected by tinea capitis than European people. The major aetiological agent was Microsporum audouinii, followed by Trichophyton soudanense. One strain of Trichophyton mentagrophytes has been characterized to have a mutation on the squalene epoxidase gene and to be resistant to terbinafine. Conclusions: African anthropophilic dermatophytes are mainly responsible for tinea capitis in Belgium. People of African origin are most affected by tinea capitis. The monitoring of terbinafine resistance among dermatophytes seems necessary as we have demonstrated the emergence of resistance in T. mentagrophytes.
Collapse
|