1
|
Hassoun N, Kassem II, Hamze M, El Tom J, Papon N, Osman M. Antifungal Use and Resistance in a Lower-Middle-Income Country: The Case of Lebanon. Antibiotics (Basel) 2023; 12:1413. [PMID: 37760710 PMCID: PMC10525119 DOI: 10.3390/antibiotics12091413] [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: 08/19/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Antimicrobial resistance is a serious threat, particularly in low- and middle-income countries (LMICs). Antifungal resistance is often underestimated in both healthcare and non-clinical settings. In LMICs, it is believed that the inappropriate use of antifungals, limited surveillance systems, and low diagnostic capacities are significant drivers of resistance. Like other LMICs, Lebanon lacks antifungal use and resistance surveillance programs, and the impact of antifungal resistance in the country remains unclear, especially during the unfolding economic crisis that has severely affected medical care and access to safe food and water. Interestingly, the widespread use of antifungals in medicine and agriculture has raised concerns about the development of antifungal resistance in Lebanon. In this light, we aimed to survey available antifungal drugs in the country and evaluate susceptibility patterns of prevalent fungal species to guide empiric treatments and develop antifungal stewardship programs in Lebanon. We noted that the economic crisis resulted in significant increases in antifungal drug prices. Additionally, a comprehensive literature search across PubMed, ScienceDirect, and Google Scholar databases identified 15 studies on fungal infections and antifungal resistance conducted from 1998 to 2023 in Lebanon. While data on antifungal resistance are limited, 87% of available studies in Lebanon focused on candidiasis, while the remaining 13% were on aspergillosis. Overall, we observed a marked antimicrobial resistance among Candida and Aspergillus species. Additionally, incidences of Candida auris infections have increased in Lebanese hospitals during the COVID-19 pandemic, with a uniform resistance to fluconazole and amphotericin-B. Taken together, a One Health approach, reliable diagnostics, and prudent antifungal use are required to control the spread of resistant fungal pathogens in healthcare and agricultural settings.
Collapse
Affiliation(s)
- Nesrine Hassoun
- Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon;
| | - Issmat I. Kassem
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA;
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon;
| | - Jad El Tom
- School of Pharmacy, Lebanese American University, Byblos 1401, Lebanon;
| | - Nicolas Papon
- University of Angers, University of Brest, IRF, SFR ICAT, F-49000 Angers, France;
| | - Marwan Osman
- Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, NY 14853, USA
- Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| |
Collapse
|
2
|
Awad A, El Khoury P, Geukgeuzian G, Khalaf RA. Cell Wall Proteome Profiling of a Candida albicans Fluconazole-Resistant Strain from a Lebanese Hospital Patient Using Tandem Mass Spectrometry-A Pilot Study. Microorganisms 2021; 9:microorganisms9061161. [PMID: 34071222 PMCID: PMC8229660 DOI: 10.3390/microorganisms9061161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Candida albicans is an opportunistic pathogenic fungus responsible for high mortality rates in immunocompromised individuals. Azole drugs such as fluconazole are the first line of therapy in fungal infection treatment. However, resistance to azole treatment is on the rise. Here, we employ a tandem mass spectrometry approach coupled with a bioinformatics approach to identify cell wall proteins present in a fluconazole-resistant hospital isolate upon drug exposure. The isolate was previously shown to have an increase in cell membrane ergosterol and cell wall chitin, alongside an increase in adhesion, but slightly attenuated in virulence. We identified 50 cell wall proteins involved in ergosterol biosynthesis such as Erg11, and Erg6, efflux pumps such as Mdr1 and Cdr1, adhesion proteins such as Als1, and Pga60, chitin deposition such as Cht4, and Crh11, and virulence related genes including Sap5 and Lip9. Candidial proteins identified in this study go a long way in explaining the observed phenotypes. Our pilot study opens the way for a future large-scale analysis to identify novel proteins involved in drug-resistance mechanisms.
Collapse
|
3
|
Fattouh N, Hdayed D, Geukgeuzian G, Tokajian S, Khalaf RA. Molecular mechanism of fluconazole resistance and pathogenicity attributes of Lebanese Candida albicans hospital isolates. Fungal Genet Biol 2021; 153:103575. [PMID: 34033880 DOI: 10.1016/j.fgb.2021.103575] [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: 12/21/2020] [Revised: 04/11/2021] [Accepted: 05/14/2021] [Indexed: 12/15/2022]
Abstract
Hospital infections caused by the opportunistic fungus Candida albicans are increasingly common and life threatening. The first line of defense consists of administering antifungal drugs such as azoles including fluconazole that prevent ergosterol biosynthesis. C. albicans is rapidly developing resistance towards antifungal drugs through various mechanisms including mutations in ERG11 which is a gene involved in the ergosterol biosynthesis pathway. These mutations prevent the binding of the drug and inactivate ergosterol synthesis. Alternatively, upregulation of cell membrane ergosterol content generates resistance by countering the effect of the drug. In this study we sequenced the ERG11 gene in 6 fluconazole sensitive and 8 fluconazole resistant C. albicans isolates recovered from clinical settings in Lebanon and quantified the ergosterol content of their plasma membranes to identify mechanisms linked to fluconazole resistance. A number of pathogenicity attributes were also analyzed to determine any correlation with fluconazole resistance. Our results revealed an increase in ergosterol content in the fluconazole resistant isolates. In addition, we identified both novel and previously reported amino acid substitutions in ERG11 as well as frameshift mutations that might contribute to resistance. The fluconazole resistant isolates did not exhibit an increased virulence potential in a mouse model of systemic infection and showed decreased in vitro potential to form biofilms. No discrepancy between drug resistant and sensitive isolates to cell surface disrupting agents was observed. This approach is the first of its kind to be carried out in Lebanon to identify possible mechanisms and phenotypes of drug resistant C. albicans isolates.
Collapse
Affiliation(s)
- Nour Fattouh
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Dana Hdayed
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Geovanni Geukgeuzian
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Sima Tokajian
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Roy A Khalaf
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon.
| |
Collapse
|
4
|
Khalaf RA, Fattouh N, Medvecky M, Hrabak J. Whole genome sequencing of a clinical drug resistant Candida albicans isolate reveals known and novel mutations in genes involved in resistance acquisition mechanisms. J Med Microbiol 2021; 70:001351. [PMID: 33909551 PMCID: PMC8289213 DOI: 10.1099/jmm.0.001351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/15/2021] [Indexed: 11/18/2022] Open
Abstract
Candida albicans is an opportunistic pathogen accounting for the majority of cases of Candida infections. Currently, C. albicans are developing resistance towards different classes of antifungal drugs and this has become a global health burden that does not spare Lebanon. This study aims at determining point mutations in genes known to be involved in resistance acquisition and correlating resistance to virulence and ergosterol content in the azole resistant C. albicans isolate CA77 from Lebanon. This pilot study is the first of its kind to be implemented in Lebanon. We carried out whole genome sequencing of the azole resistant C. albicans isolate CA77 and examined 18 genes involved in antifungal resistance. To correlate genotype to phenotype, we evaluated the virulence potential of this isolate by injecting it into BALB/c mice and we quantified membrane ergosterol. Whole genome sequencing revealed that eight out of 18 genes involved in antifungal resistance were mutated in previously reported and novel residues. These genotypic changes were associated with an increase in ergosterol content but no discrepancy in virulence potential was observed between our isolate and the susceptible C. albicans control strain SC5314. This suggests that antifungal resistance and virulence potential in this antifungal resistant isolate are not correlated and that resistance is a result of an increase in membrane ergosterol content and the occurrence of point mutations in genes involved in the ergosterol biosynthesis pathway.
Collapse
Affiliation(s)
- Roy A. Khalaf
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Nour Fattouh
- Department of Natural Sciences, Lebanese American University, PO Box 36, Byblos, Lebanon
| | - Matej Medvecky
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Jaroslav Hrabak
- Department of Microbiology, Faculty of Medicine, University Hospital in Pilsen, Charles University, 32300 Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 32300 Pilsen, Czech Republic
| |
Collapse
|
5
|
Osman M, Al Bikai A, Rafei R, Mallat H, Dabboussi F, Hamze M. Species distribution and antifungal susceptibility patterns of clinical Candida isolates in North Lebanon: A pilot cross-sectional multicentric study. J Mycol Med 2020; 30:100986. [PMID: 32417178 DOI: 10.1016/j.mycmed.2020.100986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 01/13/2023]
Affiliation(s)
- M Osman
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - A Al Bikai
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - R Rafei
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - H Mallat
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - F Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - M Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Science and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon.
| |
Collapse
|
6
|
Genotypic and phenotypic characterization of Candida albicans Lebanese hospital isolates resistant and sensitive to caspofungin. Fungal Genet Biol 2019; 127:12-22. [DOI: 10.1016/j.fgb.2019.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 12/11/2022]
|
7
|
Christophy R, Osman M, Mallat H, Achkar M, Ziedeh A, Moukaddem W, Dabboussi F, Hamze M. Prevalence, antibiotic susceptibility and characterization of antibiotic resistant genes among carbapenem-resistant Gram-negative bacilli and yeast in intestinal flora of cancer patients in North Lebanon. J Infect Public Health 2017; 10:716-720. [DOI: 10.1016/j.jiph.2016.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 08/08/2016] [Accepted: 10/01/2016] [Indexed: 11/28/2022] Open
|
8
|
Feng W, Yang J, Xi Z, Qiao Z, Lv Y, Wang Y, Ma Y, Wang Y, Cen W. Mutations and/or Overexpressions ofERG4andERG11Genes in Clinical Azoles-Resistant Isolates ofCandida albicans. Microb Drug Resist 2017; 23:563-570. [PMID: 27976986 DOI: 10.1089/mdr.2016.0095] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wenli Feng
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Jing Yang
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Zhiqin Xi
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Zusha Qiao
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yaping Lv
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yiru Wang
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yan Ma
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Yanqing Wang
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| | - Wen Cen
- Department of Dermatovenereology, The Second Hospital of Shanxi Medical University, Taiyuan City, Shanxi Province, China
| |
Collapse
|
9
|
Binding Sites in the EFG1 Promoter for Transcription Factors in a Proposed Regulatory Network: A Functional Analysis in the White and Opaque Phases of Candida albicans. G3-GENES GENOMES GENETICS 2016; 6:1725-37. [PMID: 27172219 PMCID: PMC4889668 DOI: 10.1534/g3.116.029785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In Candida albicans the transcription factor Efg1, which is differentially expressed in the white phase of the white-opaque transition, is essential for expression of the white phenotype. It is one of six transcription factors included in a proposed interactive transcription network regulating white-opaque switching and maintenance of the alternative phenotypes. Ten sites were identified in the EFG1 promoter that differentially bind one or more of the network transcription factors in the white and/or opaque phase. To explore the functionality of these binding sites in the differential expression of EFG1, we generated targeted deletions of each of the 10 binding sites, combinatorial deletions, and regional deletions using a Renillareniformis luciferase reporter system. Individually targeted deletion of only four of the 10 sites had minor effects consistent with differential expression of EFG1, and only in the opaque phase. Alternative explanations are considered.
Collapse
|
10
|
Identification, typing, antifungal resistance profile, and biofilm formation of Candida albicans isolates from Lebanese hospital patients. BIOMED RESEARCH INTERNATIONAL 2014; 2014:931372. [PMID: 24982915 PMCID: PMC4058652 DOI: 10.1155/2014/931372] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/28/2014] [Accepted: 05/01/2014] [Indexed: 01/08/2023]
Abstract
As leading opportunistic fungal pathogens identification and subtyping of Candida species are crucial in recognizing outbreaks of infection, recognizing particularly virulent strains, and detecting the emergence of drug resistant strains. In this study our objective was to compare identification of Candida albicans by the hospitals through the use of conventional versus identification based on the ITS (Internal Transcribed Spacer) and to assess biofilm forming capabilities, drug resistance patterns and correlate these with MLST typing. ITS typing revealed a 21.2% hospital misidentification rate. Multidrug resistance to three drugs out of four tested was detected within 25% of the isolates raising concerns about the followed treatment regimens. Drug resistant strains as well as biofilm formers were phylogenetically related, with some isolates with significant biofilm forming capabilities being correlated to those that were multidrug resistant. Such isolates were grouped closely together in a neighbor-joining tree generated by MLST typing indicating phylogenetic relatedness, microevolution, or recurrent infection. In conclusion, this pilot study gives much needed insight concerning C. albicans isolates circulating in Lebanese hospitals and is the first study of its kind correlating biofilm formation, antifungal resistance, and evolutionary relatedness.
Collapse
|
11
|
Sidrim JJC, Maia DCBDSC, Brilhante RSN, Soares GDP, Cordeiro RA, Monteiro AJ, Rocha MFG. Candida species isolated from the gastrointestinal tract of cockatiels (Nymphicus hollandicus): In vitro antifungal susceptibility profile and phospholipase activity. Vet Microbiol 2010; 145:324-8. [DOI: 10.1016/j.vetmic.2010.04.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 04/07/2010] [Accepted: 04/09/2010] [Indexed: 11/24/2022]
|
12
|
Siikala E, Rautemaa R, Richardson M, Saxen H, Bowyer P, Sanglard D. Persistent Candida albicans colonization and molecular mechanisms of azole resistance in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) patients. J Antimicrob Chemother 2010; 65:2505-13. [PMID: 20876623 DOI: 10.1093/jac/dkq354] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS-I) suffer from chronic candidosis caused mainly by Candida albicans, and repeated courses of azole antifungals have led to the development of resistance in the APECED patient population in Finland. The aim of our study was to address whether the patients are persistently colonized with the same or genetically closely related strains, whether epidemic strains are present and which molecular mechanisms account for azole resistance. METHODS Sets of C. albicans (n = 19) isolates from nine APECED patients reported with decreased susceptibility to fluconazole isolated up to 9 years apart were included. The strains were typed by multilocus sequence typing. CDR1/2, MDR1 and ERG11 mRNA expression was analysed by northern blotting and Cdr1, Cdr2 and Mdr1 protein expression by western blotting, and TAC1 and ERG11 genes were sequenced. RESULTS All seven patients with multiple C. albicans isolates analysed were persistently colonized with the same or a genetically closely related strain for a mean of 5 years. All patients were colonized with different strains and no epidemic strains were found. The major molecular mechanisms behind the azole resistance were mutations in TAC1 contributing to overexpression of CDR1 and CDR2. Six new TAC1 mutations were found, one of which (N740S) is likely to be a gain-of-function mutation. Most isolates were found to have gained multiple TAC1 and ERG11 point mutations. CONCLUSIONS Despite clinically successful treatment leading to relief of symptoms, colonization by C. albicans strains is persistent within APECED patients. Microevolution and point mutations occur within strains, leading to the development of azole-resistant isolates.
Collapse
Affiliation(s)
- Emilia Siikala
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, Helsinki, Finland.
| | | | | | | | | | | |
Collapse
|
13
|
Fungal infections of the nervous system: Current perspective and controversies in management. Int J Surg 2010; 8:591-601. [DOI: 10.1016/j.ijsu.2010.07.293] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 06/06/2010] [Accepted: 07/21/2010] [Indexed: 01/23/2023]
|
14
|
Current awareness on yeast. Yeast 2009. [DOI: 10.1002/yea.1623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|