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Wang C, Miller N, Vines D, Severns PM, Momany M, Brewer MT. Azole resistance mechanisms and population structure of the human pathogen Aspergillus fumigatus on retail plant products. Appl Environ Microbiol 2024; 90:e0205623. [PMID: 38651929 PMCID: PMC11107156 DOI: 10.1128/aem.02056-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/30/2024] [Indexed: 04/25/2024] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprotroph and human-pathogenic fungus that is life-threatening to the immunocompromised. Triazole-resistant A. fumigatus was found in patients without prior treatment with azoles, leading researchers to conclude that resistance had developed in agricultural environments where azoles are used against plant pathogens. Previous studies have documented azole-resistant A. fumigatus across agricultural environments, but few have looked at retail plant products. Our objectives were to determine if azole-resistant A. fumigatus is prevalent in retail plant products produced in the United States (U.S.), as well as to identify the resistance mechanism(s) and population genetic structure of these isolates. Five hundred twenty-five isolates were collected from retail plant products and screened for azole resistance. Twenty-four isolates collected from compost, soil, flower bulbs, and raw peanuts were pan-azole resistant. These isolates had the TR34/L98H, TR46/Y121F/T289A, G448S, and H147Y cyp51A alleles, all known to underly pan-azole resistance, as well as WT alleles, suggesting that non-cyp51A mechanisms contribute to pan-azole resistance in these isolates. Minimum spanning networks showed two lineages containing isolates with TR alleles or the F46Y/M172V/E427K allele, and discriminant analysis of principle components identified three primary clusters. This is consistent with previous studies detecting three clades of A. fumigatus and identifying pan-azole-resistant isolates with TR alleles in a single clade. We found pan-azole resistance in U.S. retail plant products, particularly compost and flower bulbs, which indicates a risk of exposure to these products for susceptible populations and that highly resistant isolates are likely distributed worldwide on these products.IMPORTANCEAspergillus fumigatus has recently been designated as a critical fungal pathogen by the World Health Organization. It is most deadly to people with compromised immune systems, and with the emergence of antifungal resistance to multiple azole drugs, this disease carries a nearly 100% fatality rate without treatment or if isolates are resistant to the drugs used to treat the disease. It is important to determine the relatedness and origins of resistant A. fumigatus isolates in the environment, including plant-based retail products, so that factors promoting the development and propagation of resistant isolates can be identified.
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Affiliation(s)
- Caroline Wang
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Natalie Miller
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Douglas Vines
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Paul M. Severns
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Michelle Momany
- Fungal Biology Group, Plant Biology Department, University of Georgia, Athens, Georgia, USA
| | - Marin T. Brewer
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
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Zeng M, Zhou X, Yang C, Liu Y, Zhang J, Xin C, Qin G, Liu F, Song Z. Comparative analysis of the biological characteristics and mechanisms of azole resistance of clinical Aspergillus fumigatus strains. Front Microbiol 2023; 14:1253197. [PMID: 38029222 PMCID: PMC10665732 DOI: 10.3389/fmicb.2023.1253197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Aspergillus fumigatus is a common causative pathogen of aspergillosis. At present, triazole resistance of A. fumigatus poses an important challenge to human health globally. In this study, the biological characteristics and mechanisms of azole resistance of five A. fumigatus strains (AF1, AF2, AF4, AF5, and AF8) were explored. There were notable differences in the sporulation and biofilm formation abilities of the five test strains as compared to the standard strain AF293. The ability of strain AF1 to avoid phagocytosis by MH-S cells was significantly decreased as compared to strain AF293, while that of strains AF2, AF4, and AF5 were significantly increased. Fungal burden analysis with Galleria mellonella larvae revealed differences in pathogenicity among the five strains. Moreover, the broth microdilution and E-test assays confirmed that strains AF1 and AF2 were resistant to itraconazole and isaconazole, while strains AF4, AF5, and AF8 were resistant to voriconazole and isaconazole. Strains AF1 and AF2 carried the cyp51A mutations TR34/L98H/V242I/S297T/F495I combined with the hmg1 mutation S541G, whereas strains AF4 and AF8 carried the cyp51A mutation TR46/Y121F/V242I/T289A, while strain AF5 had no cyp51A mutation. Real-time quantitative polymerase chain reaction (RT-qPCR) analysis revealed differences in the expression levels of genes associated with ergosterol synthesis and efflux pumps among the five strains. In addition, transcriptomics, RT-qPCR, and the NAD+/NADH ratio demonstrated that the mechanism of voriconazole resistance of strain AF5 was related to overexpression of genes associated with energy production and efflux pumps. These findings will help to further elucidate the triazole resistance mechanism in A. fumigatus.
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Affiliation(s)
- Meng Zeng
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
- Department of Clinical Laboratory, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Zhou
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Chunhong Yang
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Yanfei Liu
- Department of Clinical Laboratory, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jinping Zhang
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Caiyan Xin
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Gang Qin
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fangyan Liu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Zhangyong Song
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
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Shu Y, Shi Y, Yang Y, Dong Z, Yi Q, Shi H. Progress of triazole antifungal agent posaconazole in individualized therapy. J Clin Pharm Ther 2022; 47:1966-1981. [PMID: 36461759 DOI: 10.1111/jcpt.13821] [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: 10/11/2022] [Revised: 11/04/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Posaconazole is the second-generation triazole antifungal agent with widespread clinical application. Posaconazole exposure is influenced by various factors such as drug interactions, disease state and diet, resulting in a high interindividual variability in many patients and failure to ensure therapeutic efficacy. Therefore, it is necessary to conduct individualized therapy on posaconazole to ensure the efficacy and safety of treatment. METHODS Articles were identified through PubMed using the keywords such as "posaconazole," "therapeutic drug monitoring" and "Population pharmacokinetics" from 1 January 2001 to 30 April 2022. RESULTS AND DISCUSSION In this paper, we review the individualized treatment studies of posaconazole from the three aspects of therapeutic drug monitoring, population pharmacokinetic study and Monte Carlo simulation to provide reference for in-depth individualized posaconazole dosing studies. WHAT IS NEW AND CONCLUSION This review suggests that therapeutic drug monitoring should be performed in patients taking posaconazole to adjust the dosage and assess the efficacy and cost-effectiveness of posaconazole under different clinical conditions and different dosing regimens through Monte Carlo simulations. In the future, a more detailed delineation and comprehensive examination of posaconazole PPK for specific populations requires further study.
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Affiliation(s)
- Yishuo Shu
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yinping Shi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yilei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Zhonghua Dong
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Qiaoyan Yi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Haiyan Shi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
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4
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Fakhim H, Badali H, Dannaoui E, Nasirian M, Jahangiri F, Raei M, Vaseghi N, Ahmadikia K, Vaezi A. Trends in the Prevalence of Amphotericin B-Resistance (AmBR) among Clinical Isolates of Aspergillus Species. J Mycol Med 2022; 32:101310. [PMID: 35907396 DOI: 10.1016/j.mycmed.2022.101310] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
The challenges of the invasive infections caused by the resistant Aspergillus species include the limited access to antifungals for treatment and high mortality. This study aimed to provide a global perspective of the prevalence of amphotericin B resistance (AmBR), geographic distribution, and the trend of AmBR from 2010 to 2020. To analyze the prevalence of in vitro AmBR in clinical Aspergillus species, we reviewed the literature and identified a total of 72 articles. AmBR was observed in 1128 out of 3061 Aspergillus terreus (36.8%), 538 out of 3663 Aspergillus flavus (14.9%), 141 out of 2691 Aspergillus niger (5.2%), and 353 out of 17,494 Aspergillus fumigatus isolates (2.01%). An increasing trend in AmB-resistant isolates of A. fumigatus and a decreasing trend in AmB-resistant A. terreus and A. flavus isolates were observed between 2016 and 2020. AmB-resistant A. terreus and A. niger isolates, accounting for 40.4% and 20.9%, respectively, were the common AmB-resistant Aspergillus species in Asian studies. However, common AmB-resistant Aspergillus species reported by European and American studies were A. terreus and A. flavus isolates, accounting for 40.1% and 14.3% in 31 studies from Europe and 25.1% and 11.7% in 14 studies from America, respectively. The prevalence of AmB-resistant A. niger in Asian isolates was higher than in American and European. We found a low prevalence of A. terreus in American isolates (25.1%) compared to Asian (40.4%) and European (40.1%). Future studies should focus on analyzing the trend of AmBR on a regional basis and using the same methodologies.
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Affiliation(s)
- Hamed Fakhim
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Badali
- Department of Molecular Microbiology & Immunology/South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Eric Dannaoui
- Université de Paris, Faculté de Médecine, APHP, Hôpital Européen Georges Pompidou, Unité de Parasitologie-Mycologie, Service de Microbiologie, Paris, France
| | - Maryam Nasirian
- Infectious Diseases and Tropical Medicine Research Center; and Epidemiology and Biostatistics Department, Health School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fateme Jahangiri
- Department of Medical Laboratory Science, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Maedeh Raei
- Faculty of medicine, Sari branch, Islamic Azad University, Sari, Iran
| | - Narges Vaseghi
- Department of Pathobiology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Kazem Ahmadikia
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsane Vaezi
- Department of Medical Laboratory Science, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran.
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5
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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: 23] [Impact Index Per Article: 11.5] [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.
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Affiliation(s)
| | | | | | | | | | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Macedo D, Leonardelli F, Cabeza MS, Gamarra S, Garcia-Effron G. The natural occurring Y129F polymorphism in Rhizopus oryzae (R. arrhizus) Cyp51Ap accounts for its intrinsic voriconazole resistance. Med Mycol 2021; 59:1202-1209. [PMID: 34550395 DOI: 10.1093/mmy/myab052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/14/2021] [Indexed: 11/12/2022] Open
Abstract
Rhizopus oryzae (heterotypic synonym: R. arrhizus) intrinsic voriconazole and fluconazole resistance has been linked to its CYP51A gene. However, the amino acid residues involved in this phenotype have not yet been established. A comparison between R. oryzae and Aspergillus fumigatus Cyp51Ap sequences showed differences in several amino acid residues. Some of them were already linked with voriconazole resistance in A. fumigatus. The objective of this work was to analyze the role of two natural polymorphisms in the intrinsic voriconazole resistance phenotype of R. oryzae (Y129F and T290A, equivalent to Y121F and T289A seen in triazole-resistant A. fumigatus). We have generated A. fumigatus chimeric strains harboring different R. oryzae CYP51A genes (wild-type and mutants). These mutant R. oryzae CYP51A genes were designed to carry nucleotide changes that produce mutations at Cyp51Ap residues 129 and 290 (emulating the Cyp51Ap protein of azole susceptible A. fumigatus). Antifungal susceptibilities were evaluated for all the obtained mutants. The polymorphism T290A (alone or in combination with Y129F) had no impact on triazole MIC. On the other hand, a > 8-fold decrease in voriconazole MICs was observed in A. fumigatus chimeric strains harboring the RoCYP51Ap-F129Y. This phenotype supports the assumption that the naturally occurring polymorphism Y129F at R. oryzae Cyp51Ap is responsible for its voriconazole resistance phenotype. In addition, these chimeric mutants were posaconazole hypersusceptible. Thus, our experimental data demonstrate that the RoCYP51Ap-F129 residue strongly impacts VRC susceptibility and that it would be related with posaconazole-RoCYP51Ap interaction. LAY SUMMARY Rhizopus oryzae is intrinsically resistant to voriconazole, a commonly used antifungal agent. In this work, we analyze the role of two natural polymorphisms present in the target of azole drugs. We established that F129 residue is responsible of the intrinsic voriconazole resistance in this species.
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Affiliation(s)
- Daiana Macedo
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, C.P. 3000, Argentina.,Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, C.P. 3000, Argentina
| | - Florencia Leonardelli
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, C.P. 3000, Argentina.,Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, C.P. 3000, Argentina
| | - Matias S Cabeza
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, C.P. 3000, Argentina.,Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, C.P. 3000, Argentina
| | - Soledad Gamarra
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, C.P. 3000, Argentina
| | - Guillermo Garcia-Effron
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, C.P. 3000, Argentina.,Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, C.P. 3000, Argentina
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7
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Long Terminal Repeat Retrotransposon Afut4 Promotes Azole Resistance of Aspergillus fumigatus by Enhancing the Expression of sac1 Gene. Antimicrob Agents Chemother 2021; 65:e0029121. [PMID: 34516252 DOI: 10.1128/aac.00291-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aspergillus fumigatus causes a series of invasive diseases, including the high-mortality invasive aspergillosis, and has been a serious global health threat because of its increased resistance to the first-line clinical triazoles. We analyzed the whole-genome sequence of 15 A. fumigatus strains from China and found that long terminal repeat retrotransposons (LTR-RTs), including Afut1, Afut2, Afut3, and Afut4, are most common and have the largest total nucleotide length among all transposable elements in A. fumigatus. Deleting one of the most enriched Afut4977-sac1 in azole-resistant strains decreased azole resistance and downregulated its nearby gene, sac1, but it did not significantly affect the expression of genes of the ergosterol synthesis pathway. We then discovered that 5'LTR of Afut4977-sac1 had promoter activity and enhanced the adjacent sac1 gene expression. We found that sac1 is important to A. fumigatus, and the upregulated sac1 caused elevated resistance of A. fumigatus to azoles. Finally, we showed that Afut4977-sac1 has an evolution pattern similar to that of the whole genome of azole-resistant strains due to azoles; phylogenetic analysis of both the whole genome and Afut4977-sac1 suggests that the insertion of Afut4977-sac1 might have preceded the emergence of azole-resistant strains. Taking these data together, we found that the Afut4977-sac1 LTR-RT might be involved in the regulation of azole resistance of A. fumigatus by upregulating its nearby sac1 gene.
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Takahashi H, Oiki S, Kusuya Y, Urayama SI, Hagiwara D. Intimate genetic relationships and fungicide resistance in multiple strains of Aspergillus fumigatus isolated from a plant bulb. Environ Microbiol 2021; 23:5621-5638. [PMID: 34464008 PMCID: PMC9292267 DOI: 10.1111/1462-2920.15724] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022]
Abstract
Fungal infections are increasingly dangerous because of environmentally dispersed resistance to antifungal drugs. Azoles are commonly used antifungal drugs, but they are also used as fungicides in agriculture, which may enable enrichment of azole‐resistant strains of the human pathogen Aspergillus fumigatus in the environment. Understanding of environmental dissemination and enrichment of genetic variation associated with azole resistance in A. fumigatus is required to suppress resistant strains. Here, we focused on eight strains of azole‐resistant A. fumigatus isolated from a single tulip bulb for sale in Japan. This set includes strains with TR34/L98H/T289A/I364V/G448S and TR46/Y121F/T289A/S363P/I364V/G448S mutations in the cyp51A gene, which showed higher tolerance to several azoles than strains harbouring TR46/Y121F/T289A mutation. The strains were typed by microsatellite typing, single nucleotide polymorphism profiles, and mitochondrial and nuclear genome analyses. The strains grouped differently using each typing method, suggesting historical genetic recombination among the strains. Our data also revealed that some strains isolated from the tulip bulb showed tolerance to other classes of fungicides, such as QoI and carbendazim, followed by related amino acid alterations in the target proteins. Considering spatial–temporal factors, plant bulbs are an excellent environmental niche for fungal strains to encounter partners, and to obtain and spread resistance‐associated mutations.
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Affiliation(s)
- Hiroki Takahashi
- Medical Mycology Research Center, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8673, Japan.,Molecular Chirality Research Center, Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba, 263-8522, Japan.,Plant Molecular Science Center, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8675, Japan
| | - Sayoko Oiki
- Faculty of Life and Environmental Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Yoko Kusuya
- Medical Mycology Research Center, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8673, Japan
| | - Syun-Ichi Urayama
- Faculty of Life and Environmental Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.,Microbiology Research Center for Sustainability, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Daisuke Hagiwara
- Faculty of Life and Environmental Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.,Microbiology Research Center for Sustainability, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
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9
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Trabasso P, Matsuzawa T, Arai T, Hagiwara D, Mikami Y, Moretti ML, Watanabe A. Development and validation of LAMP primer sets for rapid identification of Aspergillus fumigatus carrying the cyp51A TR 46 azole resistance gene. Sci Rep 2021; 11:17087. [PMID: 34429488 PMCID: PMC8384855 DOI: 10.1038/s41598-021-96651-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/09/2021] [Indexed: 11/09/2022] Open
Abstract
Infections due to triazole-resistant Aspergillus fumigatus are increasingly reported worldwide and are associated with treatment failure and mortality. The principal class of azole-resistant isolates is characterized by tandem repeats of 34 bp or 46 bp within the promoter region of the cyp51A gene. Loop-mediated isothermal amplification (LAMP) is a widely used nucleic acid amplification system that is fast and specific. Here we describe a LAMP assay method to detect the 46 bp tandem repeat insertion in the cyp51A gene promoter region based on novel LAMP primer sets. It also differentiated strains with TR46 tandem repeats from those with TR34 tandem repeats. These results showed this TR46-LAMP method is specific, rapid, and provides crucial insights to develop novel antifungal therapeutic strategies against severe fungal infections due to A. fumigatus with TR46 tandem repeats.
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Affiliation(s)
- Plinio Trabasso
- School of Medical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil.
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Rua Tessalia Vieira de Camargo, Campinas, Sao Paulo, 126, Brazil.
| | | | - Teppei Arai
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Daisuke Hagiwara
- Medical Mycology Research Center, Chiba University, Chiba, Japan
- Faculty of Life and Environmental Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Microbiology Research Center for Sustainability, University of Tsukuba, Ibaraki, Japan
| | - Yuzuru Mikami
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Maria Luiza Moretti
- School of Medical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Akira Watanabe
- Medical Mycology Research Center, Chiba University, Chiba, Japan
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10
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Antifungal susceptibilities of opportunistic filamentous fungal pathogens from the Asia and Western Pacific Region: data from the SENTRY Antifungal Surveillance Program (2011-2019). J Antibiot (Tokyo) 2021; 74:519-527. [PMID: 34188199 PMCID: PMC8241534 DOI: 10.1038/s41429-021-00431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
Antifungal surveillance is an important tool to monitor the prevalence of uncommon fungal species and increasing antifungal resistance throughout the world, but data comparing results across several different Asian countries are scarce. In this study, 372 invasive molds collected in the Asia-Western Pacific region in 2011-2019 were susceptibility tested for mold-active triazoles (isavuconazole, posaconazole, voriconazole, and itraconazole). The collection includes 318 Aspergillus spp. isolates and 53 non-Aspergillus molds. The MIC values using CLSI methods for isavuconazole versus Aspergillus fumigatus ranged from 0.25 to 2 mg l-1. Isavuconazole, itraconazole, posaconazole, and voriconazole acted similarly against A. fumigatus. The mold-active triazoles exhibited a wildtype phenotype to most of the Aspergillus spp. isolates tested (>94%), but poor activity against Fusarium solani species complex and Lomentospora prolificans. Voriconazole was most active against the Scedosporium spp. and posaconazole was most active against the Mucorales. In summary, isavuconazole displayed excellent activity against most species of Aspergillus and was comparable to other mold-active triazoles against non-Aspergillus molds.
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11
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Vehreschild JJ, Koehler P, Lamoth F, Prattes J, Rieger C, Rijnders BJA, Teschner D. Future challenges and chances in the diagnosis and management of invasive mould infections in cancer patients. Med Mycol 2021; 59:93-101. [PMID: 32898264 PMCID: PMC7779224 DOI: 10.1093/mmy/myaa079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 11/15/2022] Open
Abstract
Diagnosis, treatment, and management of invasive mould infections (IMI) are challenged by several risk factors, including local epidemiological characteristics, the emergence of fungal resistance and the innate resistance of emerging pathogens, the use of new immunosuppressants, as well as off-target effects of new oncological drugs. The presence of specific host genetic variants and the patient's immune system status may also influence the establishment of an IMI and the outcome of its therapy. Immunological components can thus be expected to play a pivotal role not only in the risk assessment and diagnosis, but also in the treatment of IMI. Cytokines could improve the reliability of an invasive aspergillosis diagnosis by serving as biomarkers as do serological and molecular assays, since they can be easily measured, and the turnaround time is short. The use of immunological markers in the assessment of treatment response could be helpful to reduce overtreatment in high risk patients and allow prompt escalation of antifungal treatment. Mould-active prophylaxis could be better targeted to individual host needs, leading to a targeted prophylaxis in patients with known immunological profiles associated with high susceptibility for IMI, in particular invasive aspergillosis. The alteration of cellular antifungal immune response through oncological drugs and immunosuppressants heavily influences the outcome and may be even more important than the choice of the antifungal treatment. There is a need for the development of new antifungal strategies, including individualized approaches for prevention and treatment of IMI that consider genetic traits of the patients. Lay Abstract Anticancer and immunosuppressive drugs may alter the ability of the immune system to fight invasive mould infections and may be more important than the choice of the antifungal treatment. Individualized approaches for prevention and treatment of invasive mold infections are needed.
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Affiliation(s)
- Jörg Janne Vehreschild
- Department of Internal Medicine, Hematology, and Oncology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany; German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratories, Lausanne University Hospital, Lausanne, Switzerland
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Bart J A Rijnders
- Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Daniel Teschner
- Department of Hematology, Medical Oncology, and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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12
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Buil JB, Brüggemann RJM, Bedin Denardi L, Melchers WJG, Verweij PE. In vitro interaction of isavuconazole and anidulafungin against azole-susceptible and azole-resistant Aspergillus fumigatus isolates. J Antimicrob Chemother 2021; 75:2582-2586. [PMID: 32516368 PMCID: PMC7443724 DOI: 10.1093/jac/dkaa185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/24/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
Background The voriconazole and echinocandin combination has been found to be synergistic in vitro and in vivo against most Aspergillus fumigatus isolates, both with a WT azole phenotype and an azole-resistant phenotype. The interaction between isavuconazole and echinocandins is less well studied. This is especially true for azole-resistant isolates. Objectives We investigated the in vitro interaction between isavuconazole and anidulafungin for 30 A. fumigatus isolates including 18 azole-resistant isolates with various isavuconazole resistance phenotypes. Methods The isavuconazole/anidulafungin interaction was studied by using an adapted EUCAST-based 2D (12 × 8) chequerboard broth microdilution colorimetric assay using XTT. The interaction was analysed by FIC index (FICi) analysis and Bliss independence (BI) interaction analysis. Results Both the FICi analysis and the BI analysis showed synergistic interaction between isavuconazole and anidulafungin for the majority of WT and azole-resistant isolates. As we did not see significant beneficial effects of combination therapy in TR46/Y121F/T289A isolates at clinically achievable drug concentrations, it is unlikely that TR46/Y121F/T289A infections would benefit from isavuconazole and anidulafungin combination therapy. Conclusions In regions with high azole resistance rates this combination may benefit patients with WT disease, azole-resistant invasive aspergillosis and those with mixed azole-susceptible and azole-resistant infection, but may not be beneficial for aspergillosis due to isolates with high isavuconazole resistance, such as TR46/Y121F/T289A isolates.
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Affiliation(s)
- J B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - R J M Brüggemann
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Bedin Denardi
- Programa de Pós-Graduação em Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria, RS, Brasil
| | - W J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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13
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Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
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14
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Xu Y, Chen M, Zhu J, Gerrits van den Ende B, Chen AJ, Al-Hatmi AMS, Li L, Zhang Q, Xu J, Liao W, Chen Y. Aspergillus Species in Lower Respiratory Tract of Hospitalized Patients from Shanghai, China: Species Diversity and Emerging Azole Resistance. Infect Drug Resist 2020; 13:4663-4672. [PMID: 33402838 PMCID: PMC7778383 DOI: 10.2147/idr.s281288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/28/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose To investigate species diversity and prevalence of antifungal resistance among clinical isolates of Aspergillus spp. in Shanghai, China. Patients and Methods In this study, the Aspergillus spp. isolates were analyzed by multilocus sequence typing (MLST) targeting the internal transcribed spacer (ITS) regions, and partial β-tubulin (BenA) and calmodulin (CaM) genes. The susceptibilities of these isolates to nine antifungal agents were determined according to the protocol in document M38-A3 established by the Clinical and Laboratory Standards Institute (CLSI). Results The most common Aspergillus spp. was A. fumigatus (58.2%), followed by the A. flavus complex (23.5%), and A. niger complex (15.3%). Isolates belonging to A. tamarii and A. effusus of the A. flavus complex and A. tubingensis and A. awamori of the A. niger complex were identified. Moreover, several mutations were found in the azole target cyp51A gene (TR46/Y121F/T289A and F46Y, G89G, M172V, N248T and D255E) in azole-resistant isolates of A. fumigatus. Conclusion The results of our study revealed a diversity of species in the lower respiratory tract of inpatients in Shanghai and approximately 9% of our isolates were resistant to at least one of the triazole antifungals. Formulation of local treatment strategies to combat emerging azole resistance and species diversity in clinically relevant Aspergillus spp. is needed.
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Affiliation(s)
- Yuan Xu
- Department of Dermatology, The Third People's Hospital of Hangzhou, Hangzhou, People's Republic of China.,Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, ChangZheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Min Chen
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, ChangZheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Junhao Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Bert Gerrits van den Ende
- Department of Food and Indoor Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - Amanda Juan Chen
- Department of Medical Mycology, Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Abdullah M S Al-Hatmi
- Centre of Expertise in Mycology, Radboud University Medical Centre, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.,Ministry of Health, Directorate General of Health Services, Ibri, Oman
| | - Li Li
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Qiangqiang Zhang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jianping Xu
- Department of Biology, McMaster University, Hamilton, Canada
| | - Wanqing Liao
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, ChangZheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Yuchong Chen
- Department of Dermatosurgery, Shanghai Skin Diseases Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
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15
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Fraaije B, Atkins S, Hanley S, Macdonald A, Lucas J. The Multi-Fungicide Resistance Status of Aspergillus fumigatus Populations in Arable Soils and the Wider European Environment. Front Microbiol 2020; 11:599233. [PMID: 33384673 PMCID: PMC7770239 DOI: 10.3389/fmicb.2020.599233] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022] Open
Abstract
The evolution and spread of pan-azole resistance alleles in clinical and environmental isolates of Aspergillus fumigatus is a global human health concern. The identification of hotspots for azole resistance development in the wider environment can inform optimal measures to counteract further spread by minimizing exposure to azole fungicides and reducing inoculum build-up and pathogen dispersal. We investigated the fungicide sensitivity status of soil populations sampled from arable crops and the wider environment and compared these with urban airborne populations. Low levels of azole resistance were observed for isolates carrying the CYP51A variant F46Y/M172V/E427K, all belonging to a cluster of related cell surface protein (CSP) types which included t07, t08, t13, t15, t19, and t02B, a new allele. High levels of resistance were found in soil isolates carrying CYP51A variants TR34/L98H and TR46/Y121F/T289A, all belonging to CSP types t01, t02, t04B, or t11. TR46/Y121F/M172V/T289A/G448S (CSP t01) and TR46/Y121F/T289A/S363P/I364V/G448S (CSP t01), a new haplotype associated with high levels of resistance, were isolated from Dutch urban air samples, indicating azole resistance evolution is ongoing. Based on low numbers of pan-azole resistant isolates and lack of new genotypes in soils of fungicide-treated commercial and experimental wheat crops, we consider arable crop production as a coldspot for azole resistance development, in contrast to previously reported flower bulb waste heaps. This study also shows that, in addition to azole resistance, several lineages of A. fumigatus carrying TR-based CYP51A variants have also developed acquired resistance to methyl benzimidazole carbamate, quinone outside inhibitor and succinate dehydrogenase (Sdh) inhibitor fungicides through target-site alterations in the corresponding fungicide target proteins; beta-tubulin (F200Y), cytochrome b (G143A), and Sdh subunit B (H270Y and H270R), respectively. Molecular typing showed that several multi-fungicide resistant strains found in agricultural soils in this study were clonal as identical isolates have been found earlier in the environment and/or in patients. Further research on the spread of different fungicide-resistant alleles from the wider environment to patients and vice versa can inform optimal practices to tackle the further spread of antifungal resistance in A. fumigatus populations and to safeguard the efficacy of azoles for future treatment of invasive aspergillosis.
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Affiliation(s)
- Bart Fraaije
- NIAB, Cambridge, United Kingdom.,Rothamsted Research, Harpenden, United Kingdom
| | | | | | | | - John Lucas
- Rothamsted Research, Harpenden, United Kingdom
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16
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Cao D, Wu R, Dong S, Wang F, Ju C, Yu S, Xu S, Fang H, Yu Y. Triazole resistance in Aspergillus fumigatus in crop plant soil after tebuconazole applications. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2020; 266:115124. [PMID: 32673931 DOI: 10.1016/j.envpol.2020.115124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/30/2020] [Accepted: 06/26/2020] [Indexed: 06/11/2023]
Abstract
Aspergillus fumigatus is the primary agent of invasive aspergillosis (IA) causing high morbidity and mortality in immunocompromised patients. Triazole resistance in A. fumigatus and its sources have gained wide attention. For several years, environmental fungicides use has been proposed as the major cause for triazole resistance in A. fumigatus. However, there are few studies on azole-resistant A. fumigatus (ARAF) selected by triazole fungicides in agricultural systems. We studied the possible emergence of ARAF in the field after exposure to triazole fungicide tebuconazole. Our results showed that exposure to tebuconazole in soil selects for resistance to triazoles in A. fumigatus. The probability of ARAF developing in soils depends upon the concentrations of tebuconazole after application. We suggest that tebuconazole applications should be minimized to reduce selective pressure for the generation of ARAFs.
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Affiliation(s)
- Duantao Cao
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Ruilin Wu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Suxia Dong
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Feiyan Wang
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Chao Ju
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Sumei Yu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Shiji Xu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Hua Fang
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Yunlong Yu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China.
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17
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Arastehfar A, Lass-Flörl C, Garcia-Rubio R, Daneshnia F, Ilkit M, Boekhout T, Gabaldon T, Perlin DS. The Quiet and Underappreciated Rise of Drug-Resistant Invasive Fungal Pathogens. J Fungi (Basel) 2020; 6:E138. [PMID: 32824785 PMCID: PMC7557958 DOI: 10.3390/jof6030138] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/22/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
Human fungal pathogens are attributable to a significant economic burden and mortality worldwide. Antifungal treatments, although limited in number, play a pivotal role in decreasing mortality and morbidities posed by invasive fungal infections (IFIs). However, the recent emergence of multidrug-resistant Candida auris and Candida glabrata and acquiring invasive infections due to azole-resistant C. parapsilosis, C. tropicalis, and Aspergillus spp. in azole-naïve patients pose a serious health threat considering the limited number of systemic antifungals available to treat IFIs. Although advancing for major fungal pathogens, the understanding of fungal attributes contributing to antifungal resistance is just emerging for several clinically important MDR fungal pathogens. Further complicating the matter are the distinct differences in antifungal resistance mechanisms among various fungal species in which one or more mechanisms may contribute to the resistance phenotype. In this review, we attempt to summarize the burden of antifungal resistance for selected non-albicansCandida and clinically important Aspergillus species together with their phylogenetic placement on the tree of life. Moreover, we highlight the different molecular mechanisms between antifungal tolerance and resistance, and comprehensively discuss the molecular mechanisms of antifungal resistance in a species level.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Rocio Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
| | - Farnaz Daneshnia
- Westerdijk Fungal Biodiversity Institute, 3584 CT Utrecht, The Netherlands; (F.D.); (T.B.)
| | - Macit Ilkit
- Division of Mycology, University of Çukurova, 01330 Adana, Turkey;
| | - Teun Boekhout
- Westerdijk Fungal Biodiversity Institute, 3584 CT Utrecht, The Netherlands; (F.D.); (T.B.)
- Institute of Biodiversity and Ecosystem Dynamics (IBED), University of Amsterdam, 1012 WX Amsterdam, The Netherlands
| | - Toni Gabaldon
- Life Sciences Programme, Barcelona, Supercomputing Center (BSC-CNS), Jordi Girona, 08034 Barcelona, Spain;
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), 08024 Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), 08010 Barcelona, Spain
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
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Chadeganipour M, Mohammadi R. A 9-Year Experience of Aspergillus Infections from Isfahan, Iran. Infect Drug Resist 2020; 13:2301-2309. [PMID: 32765006 PMCID: PMC7368557 DOI: 10.2147/idr.s259162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/25/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose Aspergillosis is an important fungal disease affecting millions of individuals worldwide. The genus of Aspergillus consist of various complexes, causing a wide spectrum of diseases from superficial infections in immunocompetent hosts to life-threatening disseminated infections among immunocompromised patients. This study aimed to identify Aspergillus species by phenotypic (total isolates) and molecular tests (35 isolates), obtained from patients in Isfahan (the third-largest city of Iran) between 2010 and 2018, and determine the susceptibility of 35 clinical isolates to itraconazole (ITR), amphotericin-B (AMB), and voriconazole (VOR). Patients and Methods Based on clinical signs, a total of 2385 suspected cases were included in this retrospective study from January 2010 to December 2018. Direct microscopic examination with potassium hydroxide, sabouraud dextrose agar with chloramphenicol, and czapekdox agar media was applied to identify etiologic agents. Thirty-five Aspergillus species collected from January 2016 to December 2018 were identified by PCR-sequencing of ITS1-5.8SrDNA-ITS2 region, and their susceptibility to ITR, AMB, and VOR was determined using E-test. Results Based on direct microscopy and positive culture, 132 out of 2385 suspected cases had Aspergillus infection (5.5%). Fifty-four patients were male, and 78 patients were female. Patients in the age groups of 41–50 and 21–30 years had the highest and lowest frequencies, respectively. Aspergillus flavus/oryzae (n=54), A. fumigatus (n=24), A. niger (n=15), and A. terreus (n=12) were the most prevalent Aspergillus species, respectively. Among 35 Aspergillus species, the MIC ranges of AMB, ITR, and VOR for A. flavus/oryzae, A. niger, and A. terreus were (0.5–4 μg/mL; 0.5–16 μg/mL; 0.25–8 μg/mL), (1 μg/mL, 1 μg/mL, 1 μg/mL), and (4–4 μg/mL, 0.5–1 μg/mL, 0.5–1 μg/mL), respectively. Conclusion Aspergillus infections have a wide spectrum of clinical manifestations and often occur in immunocompromised patients. Accurate identification at the species level is essential since the emergence of cryptic species is connected to different patterns of AFST that affect patient treatment outcomes. Azole-resistant Aspergillus spp. is a global concern, and the detection of the route of resistance is pivotal to prevent and control infection.
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Affiliation(s)
- Mostafa Chadeganipour
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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19
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Bustamante B, Illescas LR, Posadas A, Campos PE. Azole resistance among clinical isolates of Aspergillus fumigatus in Lima-Peru. Med Mycol 2020; 58:54-60. [PMID: 31329931 DOI: 10.1093/mmy/myz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
Azole resistance among Aspergillus fumigatus isolates, which is mainly related to mutations in the cyp51A gene, is a concern because it is rising, worldwide disseminated, and associated with treatment failure and death. Data on azole resistance of aspergillus from Latin American countries is very scarce and do not exist for Peru. Two hundred and seven Aspergillus clinical isolates collected prospectively underwent mycology and molecular testing for specie identification, and 143 isolates were confirmed as A. fumigatus sensu stricto (AFSS). All AFSS were tested for in vitro azole susceptibility, and resistant isolates underwent PCR amplification and sequencing of the whole cyp51A gene and its promoter. The in vitro susceptibility showed a minimal inhibitory concentration (MIC) range, MIC50 and MIC90 of 0.125 to >16, 0.25, and 0.5 μg/ml for itraconazole; 0.25 to 2, 0.5, and 0.5 μg/ml for voriconazole; and 0.003 to 1, 0.06, and 0.125 μg/ml for posaconazole. Three isolates (2%) showed resistance to itraconazole and exhibited different mutations of the cyp51A gene. One isolate harbored the mutation M220K, while a second one exhibited the G54 mutation plus a modification in the cyp51A gene promoter. The third isolate, from an azole naive patient, presented an integration of a 34-bp tandem repeat (TR34) in the promoter region of the gene and a substitution of leucine 98 by histidine (L98H). The three source patients had a diagnosis or suspicion of chronic pulmonary aspergillosis.
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Affiliation(s)
- Beatriz Bustamante
- Nacional Cayetano Heredia, Lima, Perú, and Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Andrés Posadas
- Unidad de Epidemiología Molecular-Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
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In vitro activity of isavuconazole versus opportunistic filamentous fungal pathogens from the SENTRY Antifungal Surveillance Program, 2017–2018. Diagn Microbiol Infect Dis 2020; 97:115007. [DOI: 10.1016/j.diagmicrobio.2020.115007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
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21
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Comparison of the MICs Obtained by Gradient Concentration Strip and EUCAST Methods for Four Azole Drugs and Amphotericin B against Azole-Susceptible and -Resistant Aspergillus Section Fumigati Clinical Isolates. Antimicrob Agents Chemother 2020; 64:AAC.01597-19. [PMID: 31844011 DOI: 10.1128/aac.01597-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/07/2019] [Indexed: 01/21/2023] Open
Abstract
Reference methods used to assess the drug susceptibilities of Aspergillus fumigatus isolates consisted of EUCAST and CLSI standardized broth microdilution techniques. Considering the increasing rate and the potential impact on the clinical outcome of azole resistance in A. fumigatus, more suitable techniques for routine testing are needed. The gradient concentration strip (GCS) method has been favorably evaluated for yeast testing. The aim of this study was to compare the CGS test with EUCAST broth microdilution for amphotericin B (AMB), posaconazole (PCZ), itraconazole (ITZ), voriconazole (VRZ), and isavuconazole (ISA). A total of 121 Aspergillus section Fumigati strains were collected, including 24 A. fumigatus sensu stricto strains that were resistant to at least one azole drug. MICs were determined using GCS and EUCAST methods. Essential agreement between the 2 methods was considered when MICs fell within ±1 dilution or ±2 dilutions of the 2-fold dilution scale. Categorical agreement was defined as the percentage of strains classified in the same category (susceptible, intermediate, or resistant) with both methods. Essential agreements with ±1 dilution and ±2 dilutions were 96.7, 93.4, 90.0, 89.3, and 95% and 100, 99.2, 100, 97.5, and 100% for AMB, PCZ, ITZ, VRZ, and ISA, respectively. Categorical agreements were 94.3, 86.1, 89.3, and 88.5% for AMB, PCZ, ITZ, and VRZ, respectively. Detection of resistance was missed with the GCS for one strain (4.1%) for PCZ and for 2 strains (8.3%) for ISA. Determination of ITZ MICs using the GCS allowed the detection of 91.7% of azole-resistant strains. The GCS test appears to be a valuable method for screening azole-resistant A. fumigatus clinical isolates.
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Spadaro D, Matic S, Prencipe S, Ferrero F, Borreani G, Gisi U, Gullino ML. Aspergillus fumigatus population dynamics and sensitivity to demethylation inhibitor fungicides in whole-crop corn, high moisture corn and wet grain corn silages. PEST MANAGEMENT SCIENCE 2020; 76:685-694. [PMID: 31347787 DOI: 10.1002/ps.5566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/22/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Aspergillus fumigatus, the causal agent of aspergillosis in humans, is commonly present as a saprophyte in various organic substrates, such as spoiled silages. Aspergillosis is generally combated with demethylation inhibitor (DMI) fungicides, but the recent appearance of resistant medical and environmental strains made current treatment strategies less reliable. The goal of this study was to determine the evolution of A. fumigatus populations during the ensiling process of whole-crop corn, high moisture corn and wet grain corn, and to monitor the sensitivity of isolates from treated and untreated fields to one medical and one agricultural DMI fungicide. RESULTS A. fumigatus was isolated from fresh forage at harvest at rather low concentrations (102 cfu g-1 ). The low frequency lingered during the silage process (at 60 and 160 days), whereas it significantly increased during air exposure (at 7 and 14 days of air exposure). Field treatment of corn with a mixture of prothioconazole and tebuconazole did not affect the sensitivity of A. fumigatus isolates. One of 29 isolates from the untreated plot was resistant to voriconazole. A unique amino acid substitution (E427K) was detected in the cyp51A gene of 10 of 12 sequenced isolates, but was not associated with DMI resistance. CONCLUSION A. fumigatus significantly increased during aerobic deterioration of ensilaged corn after silo opening, compared with the low presence in fresh corn and during ensiling. Field treatment of corn with DMI fungicides did not affect the sensitivity of A. fumigatus isolates collected from fresh and ensiled corn. © 2019 Society of Chemical Industry.
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Affiliation(s)
- Davide Spadaro
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, Italy
| | - Slavica Matic
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, Italy
| | - Simona Prencipe
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, Italy
| | - Francesco Ferrero
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, Italy
| | - Giorgio Borreani
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, Italy
| | - Ulrich Gisi
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, Italy
| | - Maria Lodovica Gullino
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, Italy
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Rivero-Menendez O, Soto-Debran JC, Medina N, Lucio J, Mellado E, Alastruey-Izquierdo A. Molecular Identification, Antifungal Susceptibility Testing, and Mechanisms of Azole Resistance in Aspergillus Species Received within a Surveillance Program on Antifungal Resistance in Spain. Antimicrob Agents Chemother 2019; 63:e00865-19. [PMID: 31285229 PMCID: PMC6709457 DOI: 10.1128/aac.00865-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/30/2019] [Indexed: 12/24/2022] Open
Abstract
Antifungal resistance is one of the major causes of the increasing mortality rates for fungal infections, especially for those caused by Aspergillus spp. A surveillance program was established in 2014 in the Spanish National Center for Microbiology for tracking resistance in the most prevalent Aspergillus species. A total of 273 samples were included in the study and were initially classified as susceptible or resistant according to EUCAST breakpoints. Several Aspergillus cryptic species were found within the molecularly identified isolates. Cyp51 mutations were characterized for Aspergillus fumigatus, Aspergillus terreus, and Aspergillus flavussensu stricto strains that were classified as resistant. Three A. fumigatus sensu stricto strains carried the TR34/L98H resistance mechanism, while two harbored G54R substitution and one harbored the TR46/Y121F/T289A mechanism. Seventeen strains had no mutations in cyp51A, with ten of them resistant only to isavuconazole. Three A. terreussensu stricto strains harbored D344N substitution in cyp51A, one of them combined with M217I, and another carried an A249G novel mutation. Itraconazole-resistant A. flavussensu stricto strains harbored P220L and H349R alterations in cyp51A and cyp51C, respectively, that need further investigation on their implication in azole resistance.
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Affiliation(s)
- Olga Rivero-Menendez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Juan Carlos Soto-Debran
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Narda Medina
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
- Spanish Network for the Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
- Spanish Network for the Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), Instituto de Salud Carlos III, Madrid, Spain
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Azole-resistant Aspergillus fumigatus: A global phenomenon originating in the environment? Med Mal Infect 2019; 50:389-395. [PMID: 31472992 DOI: 10.1016/j.medmal.2019.07.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/09/2018] [Accepted: 07/24/2019] [Indexed: 11/22/2022]
Abstract
Aspergillus fumigatus is the predominant etiological agent of invasive aspergillosis (IA), a difficult-to-manage fungal disease associated with a high case fatality rate. Azole antifungals, particularly voriconazole, have significantly improved the survival rate of patients with IA. However, the clinical advances made possible through the use of medical azoles could be threatened by the emergence of azole-resistant strains which has been reported in an ever-increasing number of countries over the last 10 years. The major resistance mechanism, that combines point mutation(s) in the coding sequence of cyp51A gene and an insertion of a tandem repeat in the promoter region of this gene which leads to its overexpression (TR34/L98H and TR46/Y121F/T289A), is presumed to be of environmental origin. However, the emergence of clinical and environmental azole-resistant strains without the cyp51A gene mutation suggests that other mechanisms could also be responsible for azole resistance (for example, overexpression of efflux pumps). The development of resistance may be linked to either long-term use of azole antifungals in patients with chronic aspergillosis (patient-acquired route) or selection pressure of the fungicides in the environment (environmental route). The fungicide-driven route could be responsible for resistance in azole-naive patients with IA. This literature review aims to summarize recent findings, focusing on the current situation of azole-resistance in A. fumigatus, and provides better understanding of the importance of the environmental route in resistance acquisition.
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25
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Echinocandins for the Treatment of Invasive Aspergillosis: from Laboratory to Bedside. Antimicrob Agents Chemother 2019; 63:AAC.00399-19. [PMID: 31138565 DOI: 10.1128/aac.00399-19] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Echinocandins (caspofungin, micafungin, anidulafungin), targeting β-1,3-glucan synthesis of the cell wall, represent one of the three currently available antifungal drug classes for the treatment of invasive fungal infections. Despite their limited antifungal activity against Aspergillus spp., echinocandins are considered an alternative option for the treatment of invasive aspergillosis (IA). This drug class exhibits several advantages, such as excellent tolerability and its potential for synergistic interactions with some other antifungals. The objective of this review is to discuss the in vitro and clinical efficacy of echinocandins against Aspergillus spp., considering the complex interactions between the drug, the mold, and the host. The antifungal effect of echinocandins is not limited to direct inhibition of hyphal growth but also induces an immunomodulatory effect on the host's response. Moreover, Aspergillus spp. have developed important adaptive mechanisms of tolerance to survive and overcome the action of echinocandins, such as paradoxical growth at increased concentrations. This stress response can be abolished by several compounds that potentiate the activity of echinocandins, such as drugs targeting the heat shock protein 90 (Hsp90)-calcineurin axis, opening perspectives for adjuvant therapies. Finally, the present and future places of echinocandins as prophylaxis, monotherapy, or combination therapy of IA are discussed in view of the emergence of pan-azole resistance among Aspergillus fumigatus isolates, the occurrence of breakthrough IA, and the advent of new long-lasting echinocandins (rezafungin) or other β-1,3-glucan synthase inhibitors (ibrexafungerp).
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26
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Buil JB, Snelders E, Denardi LB, Melchers WJG, Verweij PE. Trends in Azole Resistance in Aspergillus fumigatus, the Netherlands, 1994-2016. Emerg Infect Dis 2019; 25:176-178. [PMID: 30561296 PMCID: PMC6302600 DOI: 10.3201/eid2501.171925] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We investigated azole resistance in Aspergillus fumigatus in a tertiary reference hospital in the Netherlands during 1994-2016. The 5-year patient-adjusted proportion of resistance increased from 0.79% for 1996-2001 to 4.25% for 2002-2006, 7.17% for 2007-2011, and 7.04% for 2012-2016. However, we observed substantial variation between years.
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27
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Triazole resistance in Aspergillus fumigatus: recent insights and challenges for patient management. Clin Microbiol Infect 2019; 25:799-806. [DOI: 10.1016/j.cmi.2018.11.027] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/07/2018] [Accepted: 11/30/2018] [Indexed: 01/18/2023]
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28
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Antifungal Resistance Analysis of Environmental Isolates of Aspergillus in North India. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.1.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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29
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Hagiwara D. Current Status of Azole-resistant Aspergillus fumigatus Isolates in East Asia. Med Mycol J 2019; 59:E71-E76. [PMID: 30504618 DOI: 10.3314/mmj.18.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspergillus fumigatus is a saprophytic fungus that is a major causative pathogen for aspergillosis. Only a few classes of antifungals are used for treating this life-threatening fungal infection. Azoles are the first-line drugs and are widely used for the management and prophylaxis of aspergillosis. An emerging issue is the increasing incidence of resistant isolates worldwide. In particular, environmentally derived tandem-repeat-type azole-resistant mutations, such as Cyp51A TR34/L98H, and Cyp51A TR46/Y121F/T289A, have emerged over the last decade. In particular, azole-resistant isolates were prevalent in clinical settings in European countries; many of the reports are from the Netherlands, UK, and Germany. In contrast, reports on azole-resistant A. fumigatus isolates from East Asian countries are still few and have only recently begun to increase. Herein, all literature on East Asian azole-resistant A. fumigatus isolates were reviewed, and a complete list of resistant isolates from China, Japan, Taiwan, and Korea is provided. As of this report, the total numbers of tandem-repeat-type azole-resistant isolates are 26, 3, 32, and 1 in China, Japan, Taiwan, and Korea, respectively.
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Affiliation(s)
- Daisuke Hagiwara
- Faculty of Life and Environmental Sciences, University of Tsukuba.,Medical Mycology Research Center, Chiba University
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30
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Comparison of the Sensititre YeastOne and CLSI M38-A2 Microdilution Methods in Determining the Activity of Amphotericin B, Itraconazole, Voriconazole, and Posaconazole against Aspergillus Species. J Clin Microbiol 2018; 56:JCM.00780-18. [PMID: 30093391 DOI: 10.1128/jcm.00780-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/30/2018] [Indexed: 11/20/2022] Open
Abstract
This study compared the YeastOne and reference CLSI M38-A2 broth microdilution methods for antifungal susceptibility testing of Aspergillus species. The MICs of antifungal agents were determined for 100 Aspergillus isolates, including 54 Aspergillus fumigatus (24 TR34/L98H isolates), 23 A. flavus, 13 A. terreus, and 10 A. niger isolates. The overall agreement (within 2 2-fold dilutions) between the two methods was 100%, 95%, 92%, and 90% for voriconazole, posaconazole, itraconazole, and amphotericin B, respectively. The voriconazole geometric mean (GM) MICs were nearly identical for all isolates using both methods, whereas the itraconazole and posaconazole GM MICs obtained using the YeastOne method were approximately 1 dilution lower than those obtained using the reference method. In contrast, the amphotericin B GM MIC obtained using the YeastOne method was 3.3-fold higher than that observed using the reference method. For the 24 A. fumigatus TR34/L98H isolates assayed, the categorical agreement (classified according to the CLSI epidemiological cutoff values) was 100%, 87.5%, and 83.3% for itraconazole, voriconazole, and posaconazole, respectively. For four A. niger isolates, the itraconazole MICs were >8 μg/ml using the M38-A2 method due to trailing growth, whereas the corresponding itraconazole MICs obtained using the YeastOne method were all ≤0.25 μg/ml without trailing growth. These data suggest that the YeastOne method can be used as an alternative for azole susceptibility testing of Aspergillus species and for detecting the A. fumigatus TR34/L98H isolates but that this method fails to detect A. niger isolates exhibiting trailing growth with itraconazole. Additionally, for isolates with azole MICs that approach or that are at susceptibility breakpoints or with high amphotericin B MICs detected using the YeastOne method, further MIC confirmation using the reference CLSI method is needed.
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31
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Valdes ID, van den Berg J, Haagsman A, Escobar N, Meis JF, Hagen F, Haas PJ, Houbraken J, Wösten HAB, de Cock H. Comparative genotyping and phenotyping of Aspergillus fumigatus isolates from humans, dogs and the environment. BMC Microbiol 2018; 18:118. [PMID: 30223790 PMCID: PMC6142626 DOI: 10.1186/s12866-018-1244-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/21/2018] [Indexed: 12/26/2022] Open
Abstract
Background Aspergillus fumigatus is a ubiquitous saprotrophic fungus and an opportunistic pathogen of humans and animals. Humans and animals can inhale hundreds of A. fumigatus spores daily. Normally this is harmless for humans, but in case of immunodeficiency, invasive pulmonary aspergillosis (IPA) can develop with a high mortality rate. A. fumigatus also causes non-invasive mycoses like sino-nasal aspergillosis (SNA) in dogs. Results In this study we compared A. fumigatus isolates from humans with suspected IPA, dogs with SNA, and a set of environmental isolates. Phylogenetic inference based on calmodulin (CaM) and beta-tubulin (benA) sequences did not reveal A. fumigatus sub-groups linked to the origin of the isolates. Genotyping and microsatellite analysis showed that each dog was infected by one A. fumigatus genotype, whereas human patients had mixed infections. Azole resistance was determined by antifungal susceptibility testing and sequencing of the cyp51A gene. A total of 12 out of 29 human isolates and 1 out of 27 environmental isolates were azole resistant. Of the azole resistant strains, 11 human isolates showed TR34/L98H (n = 6) or TR46/Y121F/T289A (n = 5). Phenotypically, isolates from dogs were more variable in growth speed and morphology when compared to those isolated from human and the environment. Conclusions A. fumigatus from dogs with SNA are phenotypically very diverse in contrast to their environmental and human counterparts. Phenotypic variability can be induced during the chronic infection process in the sinus of the dogs. The basis of this heterogeneity might be due to genomic differences and/or epigenetic variations. Differences in dogs is a could be a result of within-host adaption and might be triggered by environmental factors in the sinus, however this hypothesis still needs to be tested.
Electronic supplementary material The online version of this article (10.1186/s12866-018-1244-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ivan D Valdes
- Microbiology, Department of Biology, Utrecht University, Utrecht, The Netherlands.
| | - Joris van den Berg
- Microbiology, Department of Biology, Utrecht University, Utrecht, The Netherlands
| | - Annika Haagsman
- Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Natalia Escobar
- Microbiology, Department of Biology, Utrecht University, Utrecht, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Ferry Hagen
- Westerdijk Institute, Utrecht, The Netherlands
| | | | | | - Han A B Wösten
- Microbiology, Department of Biology, Utrecht University, Utrecht, The Netherlands
| | - Hans de Cock
- Microbiology, Department of Biology, Utrecht University, Utrecht, The Netherlands
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Buil JB, Hagen F, Chowdhary A, Verweij PE, Meis JF. Itraconazole, Voriconazole, and Posaconazole CLSI MIC Distributions for Wild-Type and Azole-Resistant Aspergillus fumigatus Isolates. J Fungi (Basel) 2018; 4:E103. [PMID: 30158470 PMCID: PMC6162657 DOI: 10.3390/jof4030103] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022] Open
Abstract
Azole resistance in Aspergillus fumigatus is most frequently conferred by mutations in the cyp51A gene encoding 14α-sterol demethylases. TR34/L98H and TR46/Y121F/T289A are the two most common mutations associated with environmental resistance selection. We studied the minimal inhibitory concentration (MIC) distribution of clinical A. fumigatus isolates to characterize the Clinical and Laboratory Standards Institute (CLSI) susceptibility profiles of isolates with the wild-type (WT) cyp51A genotype, and isolates with the TR34/L98H and TR46/Y121F/T289A cyp51A mutations. Susceptibility testing was performed according to CLSI M38-A2. The MICs of 363 A. fumigatus isolates were used in this study. Based on the CLSI epidemiological cut-off values (ECVs), 141 isolates were phenotypically non-WT and 222 isolates had a phenotypically WT susceptibility. All isolates with the TR34/L98H mutation had an itraconazole MIC > 1 mg/L which is above the CLSI ECV. Eighty-six of 89 (97%) isolates with the TR34/L98H mutation had voriconazole and posaconazole MICs above the CLSI ECV, i.e., MICs of 1 and 0.25 mg/L, respectively. The isolates with a TR46/Y121F/T289A mutation showed a different phenotype. All 37 isolates with a TR46/Y121F/T289A mutation had a voriconazole MIC above the CLSI ECV, while 28/37 (76%) isolates had an itraconazole MIC > 1 mg/L. Interestingly, only 13 of 37 (35%) isolates had a posaconazole MIC > 0.25 mg/L.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
- Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, 3584 Utrecht, The Netherlands.
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110021, India.
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Jacques F Meis
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
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Beardsley J, Halliday CL, Chen SCA, Sorrell TC. Responding to the emergence of antifungal drug resistance: perspectives from the bench and the bedside. Future Microbiol 2018; 13:1175-1191. [PMID: 30113223 PMCID: PMC6190174 DOI: 10.2217/fmb-2018-0059] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
The incidence of serious fungal infections is increasing rapidly, and yet the rate of new drugs becoming available to treat them is slow. The limited therapeutic armamentarium is a challenge for clinicians, because the available drugs are often toxic, expensive, difficult to administer, ineffective or a combination of all four. Given this setting, the emergence of resistance is especially concerning, and a review of the topic is timely. Here we discuss antifungal drug resistance in Candida spp. and Aspergillus spp. with reference to the most commonly used first-line antifungal agents - azoles and echinocandins. We review the resistance mechanisms of the leading pathogens, how resistance can be identified in the diagnostic lab and the clinical implications of resistance once detected.
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Affiliation(s)
- Justin Beardsley
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catriona L Halliday
- The Center for Infectious Diseases & Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Sharon C-A Chen
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
- The Center for Infectious Diseases & Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
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34
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Lee HJ, Cho SY, Lee DG, Park C, Chun HS, Park YJ. TR34/L98H Mutation in CYP51A Gene in Aspergillus fumigatus Clinical Isolates During Posaconazole Prophylaxis: First Case in Korea. Mycopathologia 2018; 183:731-736. [PMID: 29858759 PMCID: PMC6096900 DOI: 10.1007/s11046-018-0271-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/12/2018] [Indexed: 12/03/2022]
Abstract
Azole resistance in Aspergillus fumigatus is an emerging problem, especially in immunocompromised patients. It has been reported worldwide, including in Asia, but has not yet been reported in Korea. Here, we report a case of invasive pulmonary aspergillosis (IPA) caused by azole-resistant A. fumigatus that developed in a hematopoietic stem cell transplantation recipient during posaconazole prophylaxis for immunosuppressive therapy of graft-versus-host diseases. We identified TR34/L98H/S297T/F495L mutation in the CYP51A gene of A. fumigatus clinical isolate obtained from bronchial washing fluid. Minimal inhibitory concentrations for itraconazole, voriconazole, and posaconazole were > 16, 1, and 4 μg/mL, respectively. While IPA improved partially under voriconazole treatment, the patient died from carbapenemase-producing Klebsiella pneumoniae bacteremia. Further epidemiological surveillance studies are warranted.
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Affiliation(s)
- Hyeon-Jeong Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic Blood and Marrow Transplantation Center, Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
- Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic Blood and Marrow Transplantation Center, Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
- Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
- The Catholic Blood and Marrow Transplantation Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic Blood and Marrow Transplantation Center, Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
- Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
- The Catholic Blood and Marrow Transplantation Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
| | - Chulmin Park
- Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
| | - Hye-Sun Chun
- Vaccine Bio Research Institute, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591 Republic of Korea
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Buil JB, Brüggemann RJM, Wasmann RE, Zoll J, Meis JF, Melchers WJG, Mouton JW, Verweij PE. Isavuconazole susceptibility of clinical Aspergillus fumigatus isolates and feasibility of isavuconazole dose escalation to treat isolates with elevated MICs. J Antimicrob Chemother 2018; 73:134-142. [PMID: 29048485 DOI: 10.1093/jac/dkx354] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/30/2017] [Indexed: 11/15/2022] Open
Abstract
Introduction Isavuconazole is a new triazole approved for the treatment of invasive aspergillosis. We investigated isavuconazole MIC distributions, isavuconazole MIC correlations with those of other azoles and pharmacodynamics of isavuconazole in low-level resistant Aspergillus fumigatus isolates. Methods Isavuconazole, voriconazole, itraconazole and posaconazole susceptibility of 487 clinical A. fumigatus isolates was determined by EUCAST broth microdilution methodology. Using an in vivo estimation of the pharmacodynamic target and a previously published pharmacokinetic model, the probability of target attainment (PTA) was determined for a range of isavuconazole MICs using three dosing regimens (I, 200 mg once daily; II, 300 mg once daily; and III, 400 mg once daily). Results Two hundred and seventy-nine of 487 isolates were phenotypically WT based on epidemiological cut-offs of voriconazole, itraconazole and posaconazole. Twenty-five of 279 phenotypically WT isolates and 196 of 208 non-WT isolates were classified as isavuconazole resistant based on the EUCAST breakpoint of 1 mg/L. Isavuconazole MICs showed very high correlation with voriconazole MICs, but moderate and low correlation with itraconazole and posaconazole MICs. The PTA for isolates with an isavuconazole MIC of 1 mg/L was 92%-99% for 90% effective concentration (EC90) for the three dosing regimens. For isolates with an MIC of 2 mg/L the PTA decreased to 64%-92% for EC90. Conclusions Our study indicated that isavuconazole and voriconazole MICs are highly correlated and that high-dose isavuconazole treatment might be an option in patients infected with an A. fumigatus isolate with an isavuconazole MIC of 2 mg/L.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roeland E Wasmann
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Zoll
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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Molecular Confirmation of the Linkage between the Rhizopus oryzae CYP51A Gene Coding Region and Its Intrinsic Voriconazole and Fluconazole Resistance. Antimicrob Agents Chemother 2018; 62:AAC.00224-18. [PMID: 29891608 DOI: 10.1128/aac.00224-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/11/2018] [Indexed: 12/13/2022] Open
Abstract
Rhizopus oryzae is the most prevalent causative agent of mucormycosis, an increasingly reported opportunistic fungal infection. These Mucorales are intrinsically resistant to Candida- and Aspergillus-active antifungal azole drugs, such as fluconazole (FLC) and voriconazole, respectively. Despite its importance, the molecular mechanisms of its intrinsic azole resistance have not been elucidated yet. The aim of this work was to establish if the Rhizopus oryzaeCYP51 genes are uniquely responsible for intrinsic voriconazole and fluconazole resistance in these fungal pathogens. Two CYP51 genes were identified in the R. oryzae genome. We classified them as CYP51A and CYP51B based on their sequence similarity with other known fungal CYP51 genes. Later, we obtained a chimeric Aspergillus fumigatus strain harboring a functional R. oryzae CYP51A gene expressed under the regulation of the wild-type A. fumigatusCYP51A promoter and terminator. The mutant was selected after transformation by using a novel procedure taking advantage of the FLC hypersusceptibility of the A. fumigatusCYP51A deletion mutant used as the recipient strain. The azole susceptibility patterns of the A. fumigatus transformants harboring R. oryzae CYP51A mimicked exactly the azole susceptibility patterns of this mucormycete. The data presented in this work demonstrate that the R. oryzae CYP51A coding sequence is uniquely responsible for the R. oryzae azole susceptibility patterns.
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Schauwvlieghe AFAD, de Jonge N, van Dijk K, Verweij PE, Brüggemann RJ, Biemond BJ, Bart A, von dem Borne PA, Verbon A, van der Beek MT, Demandt AMP, Oudhuis GJ, Cornelissen JJ, van der Velden WJFM, Span LFR, Kampinga GA, Bruns AH, Vonk AG, Haas PJA, Doorduijn JK, Rijnders BJA. The diagnosis and treatment of invasive aspergillosis in Dutch haematology units facing a rapidly increasing prevalence of azole-resistance. A nationwide survey and rationale for the DB-MSG 002 study protocol. Mycoses 2018; 61:656-664. [PMID: 29687483 DOI: 10.1111/myc.12788] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 02/05/2023]
Abstract
Patients with haematological malignancies are at risk for invasive fungal diseases (IFD). A survey was conducted in all Dutch academic haematology centres on their current diagnostic, prophylactic and therapeutic approach towards IFD in the context of azole-resistance. In all 8 centres, a haematologist and microbiologist filled in the questionnaire that focused on different subgroups of haematology patients. Fungal prophylaxis during neutropaenia was directed against Candida and consisted of fluconazole and/or amphotericin B suspension. Mould-active prophylaxis was given to acute myeloid leukaemia patients during chemotherapy in 2 of 8 centres. All centres used azole prophylaxis in a subset of patients with graft-versus-host disease. A uniform approach towards the diagnosis and treatment of IFD and in particular azole-resistant Aspergillus fumigatus was lacking. In 2017, all centres agreed to implement a uniform diagnostic and treatment algorithm regarding invasive aspergillosis with a central role for comprehensive diagnostics and PCR-based detection of azole-resistance. This study (DB-MSG 002) will re-evaluate this algorithm when 280 patients have been treated. A heterogeneous approach towards antifungal prophylaxis, diagnosis and treatment was apparent in the Netherlands. Facing triazole-resistance, consensus was reached on the implementation of a uniform diagnostic approach in all 8 centres.
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Affiliation(s)
- Alexander F A D Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nick de Jonge
- Department of Haematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart J Biemond
- Department of Haematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Aldert Bart
- Department of Medical Microbiology (CINIMA), Academic Medical Center, Amsterdam, The Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelies Verbon
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Martha T van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Astrid M P Demandt
- Department of Haematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Guy J Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan J Cornelissen
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Lambert F R Span
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anke H Bruns
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alieke G Vonk
- Department of Medical Microbiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter-Jan A Haas
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeanette K Doorduijn
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
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38
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Pugliese M, Matić S, Prethi S, Gisi U, Gullino ML. Molecular characterization and sensitivity to demethylation inhibitor fungicides of Aspergillus fumigatus from orange-based compost. PLoS One 2018; 13:e0200569. [PMID: 30001414 PMCID: PMC6042770 DOI: 10.1371/journal.pone.0200569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/28/2018] [Indexed: 01/05/2023] Open
Abstract
Aspergillus fumigatus, the causal agent of human aspergilloses, is known to be non-pathogenic in plants. It is present as saprophyte in different types of organic matter and develops rapidly during the high-temperature phase of the composting process. Aspergilloses are treated with demethylation inhibitor (DMI) fungicides and resistant isolates have been recently reported. The present study aims to estimate the abundance, genetic diversity and DMI sensitivity of A. fumigatus during the composting process of orange fruits. Composting of orange fruits resulted in a 100-fold increase in A. fumigatus frequency already after 1 week, demonstrating that the degradation of orange fruits favoured the growth of A. fumigatus in compost. Most of A. fumigatus isolates belonged to mating type 2, including those initially isolated from the orange peel, whereas mating type 1 evolved towards the end of the composting process. None of the A. fumigatus isolates expressed simultaneously both mating types. The 52 investigated isolates exhibited moderate SSR polymorphisms by formation of one major (47 isolates) and one minor cluster (5 isolates). The latter included mating type 1 isolates from the last sampling and the DMI-resistant reference strains. Only few isolates showed cyp51A polymorphisms but were sensitive to DMIs as all the other isolates. None of the A. fumigatus isolates owned any of the mutations associated with DMI resistance. This study documents a high reproduction rate of A. fumigatus during the composting process of orange fruits, requesting specific safety precautions in compost handling. Furthermore, azole residue concentrations in orange-based compost were not sufficient to select A. fumigatus resistant genotypes.
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Affiliation(s)
- Massimo Pugliese
- AGROINNOVA–Centre of Competence for the Innovation in the Agro-Environmental Sector, Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
- Agricultural, Forestry and Food Sciences Department (DISAFA), Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
| | - Slavica Matić
- AGROINNOVA–Centre of Competence for the Innovation in the Agro-Environmental Sector, Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
| | - Sanila Prethi
- Alexander Technological Institute of Thessaloniki, Sindos, Thessaloniki, Greece
| | - Ulrich Gisi
- AGROINNOVA–Centre of Competence for the Innovation in the Agro-Environmental Sector, Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
| | - Maria Lodovica Gullino
- AGROINNOVA–Centre of Competence for the Innovation in the Agro-Environmental Sector, Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
- Agricultural, Forestry and Food Sciences Department (DISAFA), Turin University, Largo P. Braccini 2, Grugliasco, Turin, Italy
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39
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Azole Resistance of Environmental and Clinical Aspergillus fumigatus Isolates from Switzerland. Antimicrob Agents Chemother 2018; 62:AAC.02088-17. [PMID: 29437612 PMCID: PMC5913999 DOI: 10.1128/aac.02088-17] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/22/2018] [Indexed: 11/21/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous opportunistic pathogen. This fungus can acquire resistance to azole antifungals due to mutations in the azole target (cyp51A). Recently, cyp51A mutations typical for environmental azole resistance acquisition (for example, TR34/L98H) have been reported. These mutations can also be found in isolates recovered from patients. Environmental azole resistance acquisition has been reported on several continents. Here we describe, for the first time, the occurrence of azole-resistant A. fumigatus isolates of environmental origin in Switzerland with cyp51A mutations, and we show that these isolates can also be recovered from a few patients. While the TR34/L98H mutation was dominant, a single azole-resistant isolate exhibited a cyp51A mutation (G54R) that was reported only for clinical isolates. In conclusion, our study demonstrates that azole resistance with an environmental signature is present in environments and patients of Swiss origin and that mutations believed to be unique to clinical settings are now also observed in the environment.
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40
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Gamaletsou MN, Walsh TJ, Sipsas NV. Invasive Fungal Infections in Patients with Hematological Malignancies: Emergence of Resistant Pathogens and New Antifungal Therapies. Turk J Haematol 2018; 35:1-11. [PMID: 29391334 PMCID: PMC5843768 DOI: 10.4274/tjh.2018.0007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Invasive fungal infections caused by drug-resistant organisms are an emerging threat to heavily immunosuppressed patients with hematological malignancies. Modern early antifungal treatment strategies, such as prophylaxis and empirical and preemptive therapy, result in long-term exposure to antifungal agents, which is a major driving force for the development of resistance. The extended use of central venous catheters, the nonlinear pharmacokinetics of certain antifungal agents, neutropenia, other forms of intense immunosuppression, and drug toxicities are other contributing factors. The widespread use of agricultural and industrial fungicides with similar chemical structures and mechanisms of action has resulted in the development of environmental reservoirs for some drug-resistant fungi, especially azole-resistant Aspergillus species, which have been reported from four continents. The majority of resistant strains have the mutation TR34/L98H, a finding suggesting that the source of resistance is the environment. The global emergence of new fungal pathogens with inherent resistance, such as Candida auris, is a new public health threat. The most common mechanism of antifungal drug resistance is the induction of efflux pumps, which decrease intracellular drug concentrations. Overexpression, depletion, and alteration of the drug target are other mechanisms of resistance. Mutations in the ERG11 gene alter the protein structure of C-demethylase, reducing the efficacy of antifungal triazoles. Candida species become echinocandin-resistant by mutations in FKS genes. A shift in the epidemiology of Candida towards resistant non-albicans Candida spp. has emerged among patients with hematological malignancies. There is no definite association between antifungal resistance, as defined by elevated minimum inhibitory concentrations, and clinical outcomes in this population. Detection of genes or mutations conferring resistance with the use of molecular methods may offer better predictive values in certain cases. Treatment options for resistant fungal infections are limited and new drugs with novel mechanisms of actions are needed. Prevention of resistance through antifungal stewardship programs is of paramount importance.
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Affiliation(s)
- Maria N Gamaletsou
- The Leeds Teaching Hospitals NHS Trust, St James University Hospital, Department of Infection and Travel Medicine, Leeds, United Kingdom
| | - Thomas J Walsh
- Weill Cornell Medicine of Cornell University, Department of Medicine, Pediatrics, and Microbiology and Immunology, New York, United States of America
| | - Nikolaos V Sipsas
- National and Kapodistrian University of Athens Faculty of Medicine, Department of Pathophysiology, Athens, Greece
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41
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Lestrade PP, van der Velden WJFM, Bouwman F, Stoop FJ, Blijlevens NMA, Melchers WJG, Verweij PE, Donnelly JP. Epidemiology of invasive aspergillosis and triazole-resistant Aspergillus fumigatus in patients with haematological malignancies: a single-centre retrospective cohort study. J Antimicrob Chemother 2018; 73:1389-1394. [DOI: 10.1093/jac/dkx527] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/14/2017] [Indexed: 01/30/2023] Open
Affiliation(s)
- P P Lestrade
- Department of Medical Microbiology, Viecuri Medical Centre Venlo, Nijmegen, The Netherlands
| | | | - F Bouwman
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - F J Stoop
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - N M A Blijlevens
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - W J G Melchers
- Department of Medical Microbiology, Viecuri Medical Centre Venlo, Nijmegen, The Netherlands
- Centre of Expertise in Mycology, Radboudumc/CWZ, Nijmegen, The Netherlands
| | - P E Verweij
- Department of Medical Microbiology, Viecuri Medical Centre Venlo, Nijmegen, The Netherlands
- Centre of Expertise in Mycology, Radboudumc/CWZ, Nijmegen, The Netherlands
| | - J P Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Centre of Expertise in Mycology, Radboudumc/CWZ, Nijmegen, The Netherlands
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Wang HC, Huang JC, Lin YH, Chen YH, Hsieh MI, Choi PC, Lo HJ, Liu WL, Hsu CS, Shih HI, Wu CJ, Chen YC. Prevalence, mechanisms and genetic relatedness of the human pathogenic fungus Aspergillus fumigatus exhibiting resistance to medical azoles in the environment of Taiwan. Environ Microbiol 2017; 20:270-280. [PMID: 29124846 DOI: 10.1111/1462-2920.13988] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 11/03/2017] [Accepted: 11/04/2017] [Indexed: 12/01/2022]
Abstract
Emerging azole resistance in Aspergillus fumigatus poses a serious threat to human health. This nationwide surveillance study investigated the prevalence and molecular characteristics of azole-resistant A. fumigatus environmental isolates in Taiwan, an island country with increasing use of azole fungicides. Of the 2760 air and soil samples screened from 2014 to 2016, 451 A. fumigatus isolates were recovered from 266 samples and 34 isolates from 29 samples displayed resistance to medical azoles (itraconazole, voriconazole or posaconazole). The resistance prevalence was 10.9% and 7.5% in A. fumigatus-positive samples and isolates respectively. Most (29, 85.3%) azole-resistant isolates harboured TR34 /L98H mutations, which were widely distributed, clustered genetically with clinical isolates, and had growth rates that were similar to those of the wild-type isolates. Microsatellite genotyping revealed both the global spread of the TR34 /L98H isolates and the occurrence of TR34 /L98H/S297T/F495I isolates belonging to local microsatellite genotypes. AfuMDR3 and atrF, two efflux transporter genes, were constitutively upregulated in two individual resistant isolates without cyp51A mutations, highlighting their potential roles in azole resistance. These results emphasize the need for periodic environmental surveillance at the molecular level in regions in which azole fungicides are applied, and agricultural fungicide management strategies that generate less selective pressure should be investigated.
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Affiliation(s)
- Hsuan-Chen Wang
- Division of Infectious Diseases, National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zunan, Taiwan
| | - Jui-Chang Huang
- Division of Crop Environment, Tainan District Agricultural Research and Extension Station, Council of Agriculture, Executive Yuan, Tainan, Taiwan
| | - Yong-Hong Lin
- Division of Crop Environment, Kaohsiung District Agricultural Research and Extension Station, Council of Agriculture, Executive Yuan, Pingtung, Taiwan
| | - Yu-Hsin Chen
- Division of Crop Improvement, Taichung District Agricultural Research and Extension Station, Council of Agriculture, Executive Yuan, Changhua, Taiwan
| | - Ming-I Hsieh
- Division of Infectious Diseases, National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zunan, Taiwan
| | - Pui-Ching Choi
- Division of Infectious Diseases, National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zunan, Taiwan
| | - Hsiu-Jung Lo
- Division of Infectious Diseases, National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zunan, Taiwan.,School of Dentistry, China Medical University, Taichung, Taiwan
| | - Wei-Lun Liu
- Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, New Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Ching-Shan Hsu
- Department of Environmental Resource Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hsin-I Shih
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Jung Wu
- Division of Infectious Diseases, National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zunan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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43
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Santoro K, Matić S, Gisi U, Spadaro D, Pugliese M, Gullino ML. Abundance, genetic diversity and sensitivity to demethylation inhibitor fungicides of Aspergillus fumigatus isolates from organic substrates with special emphasis on compost. PEST MANAGEMENT SCIENCE 2017; 73:2481-2494. [PMID: 28618166 DOI: 10.1002/ps.4642] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/10/2017] [Accepted: 06/12/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Aspergillus fumigatus is a widespread fungus that colonizes dead organic substrates but it can also cause fatal human diseases. Aspergilloses are treated with demethylation inhibitor (DMI) fungicides; however, resistant isolates appeared recently in the medical and also environmental area. The present study aims at molecular characterizing and quantifying A. fumigatus in major environmental habitats and determining its sensitivity to medical and agricultural DMI fungicides. RESULTS A. fumigatus was isolated only rarely from soil and meadow/forest organic matter but high concentrations (103 to 107 cfu/g) were detected in substrates subjected to elevated temperatures, such as compost and silage. High genetic diversity of A. fumigatus from compost was found based on SSR markers, distinguishing among fungal isolates even when coming from the same substrate sample, while subclustering was observed based on mutations in cyp51A gene. Several cyp51A amino acid substitutions were found in 15 isolates, although all isolates were fully sensitive to the tested DMI fungicides, with exception of one isolate in combination with one fungicide. CONCLUSION This study suggests that the tested A. fumigatus isolates collected in Italy, Spain and Hungary from the fungus' major living habitats (compost) and commercial growing substrates are not potential carriers for DMI resistance in the environment. © 2017 Society of Chemical Industry.
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Affiliation(s)
- Karin Santoro
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, (TO), Italy
| | - Slavica Matić
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
| | - Ulrich Gisi
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
| | - Davide Spadaro
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, (TO), Italy
| | - Massimo Pugliese
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, (TO), Italy
- AgriNewTech srl, Torino, (TO), Italy
| | - Maria L Gullino
- AGROINNOVA - Centre of Competence for the Innovation in the Agro-environmental Sector, Università di Torino, Grugliasco, (TO), Italy
- Dept. Agricultural, Forestry and Food Sciences (DISAFA), Università di Torino, Grugliasco, (TO), Italy
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Development and Validation of a High-Resolution Melting Assay To Detect Azole Resistance in Aspergillus fumigatus. Antimicrob Agents Chemother 2017; 61:AAC.01083-17. [PMID: 28893791 DOI: 10.1128/aac.01083-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/03/2017] [Indexed: 01/04/2023] Open
Abstract
The global emergence of azole-resistant Aspergillus fumigatus strains is a growing public health concern. Different patterns of azole resistance are linked to mutations in cyp51A Therefore, accurate characterization of the mechanisms underlying azole resistance is critical to guide selection of the most appropriate antifungal agent for patients with aspergillosis. This study describes a new sequencing-free molecular screening tool for early detection of the most frequent mutations known to be associated with azole resistance in A. fumigatus PCRs targeting cyp51A mutations at positions G54, Y121, G448, and M220 and targeting different tandem repeats (TRs) in the promoter region were designed. All PCRs were performed simultaneously, using the same cycling conditions. Amplicons were then distinguished using a high-resolution melting assay. For standardization, 30 well-characterized azole-resistant A. fumigatus strains were used, yielding melting curve clusters for different resistance mechanisms for each target and allowing detection of the most frequent azole resistance mutations, i.e., G54E, G54V, G54R, G54W, Y121F, M220V, M220I, M220T, M220K, and G448S, and the tandem repeats TR34, TR46, and TR53 Validation of the method was performed using a blind panel of 80 A. fumigatus azole-susceptible or azole-resistant strains. All strains included in the blind panel were properly classified as susceptible or resistant with the developed method. The implementation of this screening method can reduce the time needed for the detection of azole-resistant A. fumigatus isolates and therefore facilitate selection of the best antifungal therapy in patients with aspergillosis.
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Bedin Denardi L, Hoch Dalla-Lana B, Pantella Kunz de Jesus F, Bittencourt Severo C, Morais Santurio J, Zanette RA, Hartz Alves S. In vitro antifungal susceptibility of clinical and environmental isolates of Aspergillus fumigatus and Aspergillus flavus in Brazil. Braz J Infect Dis 2017; 22:30-36. [PMID: 29172033 PMCID: PMC9425663 DOI: 10.1016/j.bjid.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/20/2017] [Accepted: 10/22/2017] [Indexed: 11/17/2022] Open
Abstract
The in vitro susceptibility of 105 clinical and environmental strains of Aspergillus fumigatus and Aspergillus flavus to antifungal drugs, such as amphotericin B, azoles, and echinocandins was evaluated by the broth microdilution method proposed by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Following the EUCAST-proposed breakpoints, 20% and 25% of the clinical and environmental isolates of A. fumigatus, respectively, were found to be resistant to itraconazole (Minimal Inhibitory Concentration, MIC > 2.0 mg/L). Voriconazole showed good activity against A. fumigatus and A. flavus strains, except for one clinical strain of A. fumigatus whose MIC was 4.0 mg/L. Posaconazole (≤0.25 mg/L) also showed appreciable activity against both species of Aspergillus, except for six A. fumigatus strains with relatively higher MICs (0.5 mg/L). The MICs for Amphotericin B ranged from 0.06 to 1.0 mg/L for A. fumigatus, but were much higher (0.5–8.0 mg/L) for A. flavus. Among the echinocandins, caspofungin showed a geometric mean of 0.078 and 0.113 against the clinical and environmental strains of A. flavus, respectively, but had elevated minimal effective concentrations (MECs) for seven of the A. fumigatus strains. Anidulafungin and micafungin exhibited considerable activity against both A. fumigatus and A. flavus isolates, except for one environmental isolate of A. fumigatus that showed an MEC of 1 mg/L to micafungin. Our study proposes that a detailed investigation of the antifungal susceptibility of the genus Aspergillus from different regions of Brazil is necessary for establishing a response profile against the different classes of antifungal agents used in the treatment of aspergillosis.
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Affiliation(s)
- Laura Bedin Denardi
- Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Programa de Pós-Graduação em Ciências Farmacêuticas, Santa Maria, RS, Brazil; Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Departamento de Microbiologia e Parasitologia, Laboratório de Pesquisas Micológicas, Santa Maria, RS, Brazil.
| | - Bianca Hoch Dalla-Lana
- Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Departamento de Microbiologia e Parasitologia, Laboratório de Pesquisas Micológicas, Santa Maria, RS, Brazil
| | - Francielli Pantella Kunz de Jesus
- Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Departamento de Microbiologia e Parasitologia, Laboratório de Pesquisas Micológicas, Santa Maria, RS, Brazil; Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia, Santa Maria, RS, Brazil
| | | | - Janio Morais Santurio
- Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Departamento de Microbiologia e Parasitologia, Laboratório de Pesquisas Micológicas, Santa Maria, RS, Brazil; Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia, Santa Maria, RS, Brazil
| | - Régis Adriel Zanette
- Universidade Federal do Rio Grande do Sul, Programa de Pós Graduação em Ciências Biológicas: Farmacologia e Terapêutica, Porto Alegre, RS, Brazil
| | - Sydney Hartz Alves
- Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Programa de Pós-Graduação em Ciências Farmacêuticas, Santa Maria, RS, Brazil; Universidade Federal de Santa Maria (UFSM), Centro de Ciências da Saúde, Departamento de Microbiologia e Parasitologia, Laboratório de Pesquisas Micológicas, Santa Maria, RS, Brazil
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46
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Ashu EE, Kim GY, Roy-Gayos P, Dong K, Forsythe A, Giglio V, Korfanty G, Yamamura D, Xu J. Limited evidence of fungicide-driven triazole-resistant Aspergillus fumigatus in Hamilton, Canada. Can J Microbiol 2017; 64:119-130. [PMID: 29156151 DOI: 10.1139/cjm-2017-0410] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aspergillus fumigatus is a ubiquitous opportunistic fungal pathogen that can cause aspergillosis in humans. Over the last decade there have been increasing global reports of treatment failure due to triazole resistance. An emerging hypothesis states that agricultural triazole fungicide use causes clinical triazole resistance. Here we test this hypothesis in Hamilton, Ontario, Canada, by examining a total of 195 agricultural, urban, and clinical isolates using 9 highly polymorphic microsatellite markers. For each isolate, the in vitro susceptibilities to itraconazole and voriconazole, 2 triazole drugs commonly used in the management of patients, were also determined. Our analyses suggested frequent gene flow among the agricultural, urban environmental, and clinical populations of A. fumigatus and found evidence for widespread sexual recombination within and among the different populations. Interestingly, all 195 isolates analyzed in this study were susceptible to both triazoles tested. However, compared with the urban population, agricultural and clinical populations showed significantly reduced susceptibility to itraconazole and voriconazole, consistent with ecological niche-specific selective pressures on A. fumigatus populations in Hamilton. Frequent gene flow and genetic recombination among these populations suggest greater attention should be paid to monitor A. fumigatus populations in Hamilton and other similar jurisdictions.
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Affiliation(s)
- Eta Ebasi Ashu
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Ga Young Kim
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Patrick Roy-Gayos
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Kelly Dong
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Adrian Forsythe
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Victoria Giglio
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Gregory Korfanty
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Deborah Yamamura
- b Department of Pathology and Molecular Medicine, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Jianping Xu
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
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47
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Molecular Tools for the Detection and Deduction of Azole Antifungal Drug Resistance Phenotypes in Aspergillus Species. Clin Microbiol Rev 2017; 30:1065-1091. [PMID: 28903985 DOI: 10.1128/cmr.00095-16] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The incidence of azole resistance in Aspergillus species has increased over the past years, most importantly for Aspergillus fumigatus. This is partially attributable to the global spread of only a few resistance alleles through the environment. Secondary resistance is a significant clinical concern, as invasive aspergillosis with drug-susceptible strains is already difficult to treat, and exclusion of azole-based antifungals from prophylaxis or first-line treatment of invasive aspergillosis in high-risk patients would dramatically limit drug choices, thus increasing mortality rates for immunocompromised patients. Management options for invasive aspergillosis caused by azole-resistant A. fumigatus strains were recently reevaluated by an international expert panel, which concluded that drug resistance testing of cultured isolates is highly indicated when antifungal therapy is intended. In geographical regions with a high environmental prevalence of azole-resistant strains, initial therapy should be guided by such analyses. More environmental and clinical screening studies are therefore needed to generate the local epidemiologic data if such measures are to be implemented on a sound basis. Here we propose a first workflow for evaluating isolates from screening studies, and we compile the MIC values correlating with individual amino acid substitutions in the products of cyp51 genes for interpretation of DNA sequencing data, especially in the absence of cultured isolates.
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Chowdhary A, Sharma C, Meis JF. Azole-Resistant Aspergillosis: Epidemiology, Molecular Mechanisms, and Treatment. J Infect Dis 2017; 216:S436-S444. [PMID: 28911045 DOI: 10.1093/infdis/jix210] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Aspergillus fumigatus remains the most common species in all pulmonary syndromes, followed by Aspergillus flavus which is a common cause of allergic rhinosinusitis, postoperative aspergillosis and fungal keratitis. The manifestations of Aspergillus infections include invasive aspergillosis, chronic pulmonary aspergillosis and bronchitis. Allergic manifestations of inhaled Aspergillus include allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization. Triazoles are the mainstay of therapy against Aspergillus infections for treatment and prophylaxis. Lately, increased azole resistance in A. fumigatus has become a significant challenge in effective management of aspergillosis. Earlier studies have brought to light the contribution of non-cyp51 mutations along with alterations in cyp51A gene resulting in azole-resistant phenotypes of A. fumigatus. This review highlights the magnitude of azole-resistant aspergillosis and resistance mechanisms implicated in the development of azole-resistant A. fumigatus and address the therapeutic options available.
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, India
| | - Cheshta Sharma
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, India
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital.,Centre of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Kimura G, Nakaoki T, Nishimoto Y, Suzuki Y, Rapeport G, Strong P, Ito K, Kizawa Y. Effects of intranasally dosed posaconazole on fungal load and biomarkers in Aspergillus fumigatus infected immunocompromised mice. Mycoses 2017; 60:728-735. [PMID: 28699245 DOI: 10.1111/myc.12653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/01/2017] [Accepted: 06/07/2017] [Indexed: 12/29/2022]
Abstract
Although anti-fungal triazoles are dosed orally or systemically for Aspergillus fumigatus infection, systemic adverse events and limited exposure of the lung cavity would make a topical treatment for the lung an attractive option. In this study, we examined the effects of intranasally dosed posaconazole on survival rates and biomarkers in A. fumigatus (itraconazole susceptible: ATCC13073 [Af]; or resistant: NCPF7100 [AfR]) infected, temporarily neutropenic A/J mice. Once daily treatment produced a dose-dependent improvement of survival of Af-infected mice (ED50 : 0.019 mg/mouse [approx. 0.755 mg/kg, in]), similar to its potency (ED50 : 0.775 mg/kg, po) after once daily oral dosing. For AfR infection, either intranasal or oral posaconazole was largely ineffective on survival, although the highest dose of intranasal treatment (0.35 mg/mouse) achieved 75% survival rate. Early intervention (treated on days 0, 1, 2 and 3 postinfection) and late intervention (treated on days 1, 2 and 3) with intranasal posaconazole (0.014-0.35 mg/mouse) demonstrated potent inhibition of lung fungal load and galactomannan levels in both bronchoalveolar lavage fluid (BALF) and serum as well as inflammatory cells, IFN-γ, IL-17 and malondialdehyde (MDA) in BALF. Thus, posaconazole when dosed intranasally once daily showed an improvement of survival equivalent to or better than oral treatment, and produced potent inhibition of fungal load and biomarkers.
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Affiliation(s)
- Genki Kimura
- Laboratory of Physiology and Anatomy, Nihon University School of Pharmacy, Funabashi, Japan
| | - Takahiro Nakaoki
- Laboratory of Physiology and Anatomy, Nihon University School of Pharmacy, Funabashi, Japan
| | - Yuki Nishimoto
- Laboratory of Physiology and Anatomy, Nihon University School of Pharmacy, Funabashi, Japan
| | - Yuto Suzuki
- Laboratory of Physiology and Anatomy, Nihon University School of Pharmacy, Funabashi, Japan
| | | | | | | | - Yasuo Kizawa
- Laboratory of Physiology and Anatomy, Nihon University School of Pharmacy, Funabashi, Japan
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50
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Bunskoek PE, Seyedmousavi S, Gans SJ, van Vierzen PB, Melchers WJ, van Elk CE, Mouton JW, Verweij PE. Successful treatment of azole-resistant invasive aspergillosis in a bottlenose dolphin with high-dose posaconazole. Med Mycol Case Rep 2017; 16:16-19. [PMID: 28409094 PMCID: PMC5382031 DOI: 10.1016/j.mmcr.2017.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 11/18/2022] Open
Abstract
Invasive aspergillosis due to azole-resistant Aspergillus fumigatus is difficult to manage. We describe a case of azole-resistant invasive aspergillosis in a female bottlenose dolphin, who failed to respond to voriconazole and posaconazole therapy. As intravenous therapy was precluded, high dose posaconazole was initiated aimed at achieving trough levels exceeding 3 mg/l. Posaconazole serum levels of 3–9.5 mg/l were achieved without significant side-effects. Follow-up bronchoscopy and computed tomography showed complete resolution of the lesions.
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Affiliation(s)
| | | | - Steven J.M. Gans
- Departments of Pulmonology and Radiology, St Jansdal Hospital, Harderwijk, The Netherlands
| | - Peter B.J. van Vierzen
- Departments of Pulmonology and Radiology, St Jansdal Hospital, Harderwijk, The Netherlands
| | - Willem J.G. Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | | | - Johan W. Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
- Corresponding author.
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