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Abstract
Invasive fusariosis is a serious invasive fungal disease, affecting immunocompetent and, more frequently, immunocompromised patients. Localized disease is the typical clinical form in immunocompetent patients. Immunocompromised hosts at elevated risk of developing invasive fusariosis are patients with acute leukemia receiving chemotherapeutic regimens for remission induction, and those undergoing allogeneic hematopoietic cell transplant. In this setting, the infection is usually disseminated with positive blood cultures, multiple painful metastatic skin lesions, and lung involvement. Currently available antifungal agents have poor in vitro activity against Fusarium species, but a clear-cut correlation between in vitro activity and clinical effectiveness does not exist. The outcome of invasive fusariosis is largely dependent on the resolution of immunosuppression, especially neutrophil recovery in neutropenic patients.
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Affiliation(s)
- Marcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Grupo Oncoclínicas, Rio de Janeiro, Brazil
| | - Elias Anaissie
- CTI Clinical Trial and Consulting, Cincinnati, Ohio, USA
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Vahedi-Shahandashti R, Houbraken J, Birch M, Lass-Flörl C. Novel Antifungals and Aspergillus Section Terrei with Potpourri Susceptibility Profiles to Conventional Antifungals. J Fungi (Basel) 2023; 9:649. [PMID: 37367585 DOI: 10.3390/jof9060649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
The epidemiology of invasive fungal infections (IFIs) is currently changing, driven by aggressive immunosuppressive therapy, leading to an expanded spectrum of patients at risk of IFIs. Aspergillosis is a leading cause of IFIs, which usually affects immunocompromised patients. There are a limited number of antifungal medications available for treating IFIs, and their effectiveness is often hindered by rising resistance rates and practical limitations. Consequently, new antifungals, especially those with novel mechanisms of action, are increasingly required. This study assessed the activity of four novel antifungal agents with different mechanisms of activity, namely, manogepix, rezafungin, ibrexafungerp, and olorofim, against 100 isolates of Aspergillus section Terrei, containing amphotericin-B (AmB)-wildtype/non-wildtype and azole-susceptible/-resistant strains, according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) method. In general, all tested agents showed potent and consistent activity against the tested isolates, exhibiting geometric mean (GM) and minimum effective concentration (MEC)/minimum inhibitory concentration (MIC) ranges, respectively, as follows: manogepix (0.048 mg/L, 0.032-0.5 mg/L), rezafungin (0.020 mg/L, 0.016-0.5 mg/L), ibrexafungerp (0.071 mg/L, 0.032-2 mg/L), and olorofim (0.008 mg/L, 0.008-0.032 mg/L). In terms of MIC90/MEC90, olorofim had the lowest values (0.008 mg/L), followed by rezafungin (0.032 mg/L), manogepix (0.125 mg/L), and ibrexafungerp (0.25 mg/L). All the antifungals tested demonstrated promising in vitro activity against Aspergillus section Terrei, including A. terreus as well as azole-resistant and AmB-non-wildtype cryptic species.
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Affiliation(s)
- Roya Vahedi-Shahandashti
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Jos Houbraken
- Westerdijk Fungal Biodiversity Institute, 3584 CT Utrecht, The Netherlands
| | | | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Antifungal Activity of Isavuconazole and Comparator Agents against Contemporaneous Mucorales Isolates from USA, Europe, and Asia-Pacific. J Fungi (Basel) 2023; 9:jof9020241. [PMID: 36836355 PMCID: PMC9960003 DOI: 10.3390/jof9020241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/30/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Isavuconazole is the only US FDA-approved antifungal for treating invasive mucormycosis. We evaluated isavuconazole activity against a global collection of Mucorales isolates. Fifty-two isolates were collected during 2017-2020 from hospitals located in the USA, Europe, and the Asia-Pacific. Isolates were identified by MALDI-TOF MS and/or DNA sequencing and susceptibility tested by the broth microdilution method following CLSI guidelines. Isavuconazole (MIC50/90, 2/>8 mg/L) inhibited 59.6% and 71.2% of all Mucorales isolates at ≤2 mg/L and ≤4 mg/L, respectively. Among comparators, amphotericin B (MIC50/90, 0.5/1 mg/L) displayed the highest activity, followed by posaconazole (MIC50/90, 0.5/8 mg/L). Voriconazole (MIC50/90, >8/>8 mg/L) and the echinocandins (MIC50/90, >4/>4 mg/L) had limited activity against Mucorales isolates. Isavuconazole activity varied by species and this agent inhibited at ≤4 mg/L 85.2%, 72.7%, and 25% of Rhizopus spp. (n = 27; MIC50/90, 1/>8 mg/L), Lichtheimia spp. (n = 11; MIC50/90, 4/8 mg/L), and Mucor spp. (n = 8; MIC50, >8 mg/L) isolates, respectively. Posaconazole MIC50/90 values against Rhizopus, Lichtheimia, and Mucor species were 0.5/8 mg/L, 0.5/1 mg/L, and 2/- mg/L, respectively; amphotericin B MIC50/90 values were 1/1 mg/L, 0.5/1 mg/L, and 0.5/- mg/L, respectively. As susceptibility profiles varied among Mucorales genera, species identification and antifungal susceptibility testing are advised whenever possible to manage and monitor mucormycosis.
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Abstract
Isavuconazole is the newest of the clinically available advanced generation triazole antifungals and is active against a variety of yeasts, molds, and dimorphic fungi. Its current FDA-approved indications include the management of invasive aspergillosis as well as mucormycosis, though the latter indication is supported by limited clinical data. Isavuconazole did not achieve noninferiority to caspofungin for the treatment of invasive candidiasis and therefore lacks an FDA-approved indication for this invasive disease. Significant advantages of isavuconazole, primarily over voriconazole but in some circumstances posaconazole as well, make it an appealing option for the management of complex patients with invasive fungal infections. These potential advantages include lack of QTc interval prolongation, more predictable pharmacokinetics, a less complicated drug interaction profile, and improved tolerability, particularly when compared to voriconazole. This review discusses these topics in addition to addressing the in vitro activity of the compound against a variety of fungi and provides insight into other distinguishing factors among isavuconazole, voriconazole, and posaconazole. The review concludes with an opinion section in which the authors provide the reader with a framework for the current role of isavuconazole in the antifungal armamentarium and where further data are required.
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Fisher MC, Alastruey-Izquierdo A, Berman J, Bicanic T, Bignell EM, Bowyer P, Bromley M, Brüggemann R, Garber G, Cornely OA, Gurr SJ, Harrison TS, Kuijper E, Rhodes J, Sheppard DC, Warris A, White PL, Xu J, Zwaan B, Verweij PE. Tackling the emerging threat of antifungal resistance to human health. Nat Rev Microbiol 2022; 20:557-571. [PMID: 35352028 PMCID: PMC8962932 DOI: 10.1038/s41579-022-00720-1] [Citation(s) in RCA: 319] [Impact Index Per Article: 159.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 12/12/2022]
Abstract
Invasive fungal infections pose an important threat to public health and are an under-recognized component of antimicrobial resistance, an emerging crisis worldwide. Across a period of profound global environmental change and expanding at-risk populations, human-infecting pathogenic fungi are evolving resistance to all licensed systemic antifungal drugs. In this Review, we highlight the main mechanisms of antifungal resistance and explore the similarities and differences between bacterial and fungal resistance to antimicrobial control. We discuss the research and innovation topics that are needed for risk reduction strategies aimed at minimizing the emergence of resistance in pathogenic fungi. These topics include links between the environment and One Health, surveillance, diagnostics, routes of transmission, novel therapeutics and methods to mitigate hotspots for fungal adaptation. We emphasize the global efforts required to steward our existing antifungal armamentarium, and to direct the research and development of future therapies and interventions.
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Affiliation(s)
- Matthew C Fisher
- MRC Centre for Global Infectious Disease Outbreak Analysis, Imperial College London, London, UK.
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Judith Berman
- Shmunis School of Biomedical and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Ramat Aviv, Israel
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK
| | - Elaine M Bignell
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Paul Bowyer
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Michael Bromley
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Roger Brüggemann
- Department of Pharmacy, Radboudumc Institute for Health Sciences and Radboudumc - CWZ Centre of Expertise for Mycology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Gary Garber
- Department of Medicine and the School of Public Health and Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Ed Kuijper
- Centre for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
| | - Johanna Rhodes
- MRC Centre for Global Infectious Disease Outbreak Analysis, Imperial College London, London, UK
| | - Donald C Sheppard
- Infectious Disease in Global Health Program and McGill Interdisciplinary Initiative in Infection and Immunity, McGill University Health Centre, Montreal, Québec, Canada
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - P Lewis White
- Public Health Wales Mycology Reference Laboratory, University Hospital of Wales, Cardiff, UK
| | - Jianping Xu
- Department of Biology, McMaster University, Hamilton, Ontario, Canada
| | - Bas Zwaan
- Department of Plant Science, Laboratory of Genetics, Wageningen University & Research, Wageningen, Netherlands
| | - Paul E Verweij
- Centre for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
- Department of Medical Microbiology and Radboudumc - CWZ Centre of Expertise for Mycology, Radboud University Medical Centre, Nijmegen, Netherlands.
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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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Synergistic In Vitro Interaction of Isavuconazole and Isoquercitrin against Candida glabrata. J Fungi (Basel) 2022; 8:jof8050525. [PMID: 35628780 PMCID: PMC9147185 DOI: 10.3390/jof8050525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/14/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
In vitro interactions of broad-spectrum azole isavuconazole with flavonoid isoquercitrin were evaluated by a broth microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methodology for antifungal susceptibility testing against 60 Candida strains belonging to the species Candida albicans (n = 10), Candida glabrata (n = 30), Candida kefyr (n = 6), Candida krusei (n = 5), Candida parapsilosis (n = 4), and Candida tropicalis (n = 5). The results were analyzed with the fractional inhibitory concentration index and by response surface analysis based on the Bliss model. Synergy was found for all C. glabrata strains, when the results were interpreted by the fractional inhibitory concentration index, and for 60% of the strains when response surface analysis was used. Interaction for all other species was indifferent for all strains tested, whatever interpretation model used. Importantly, antagonistic interaction was never observed.
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Vermeulen P, Gruez A, Babin AL, Frippiat JP, Machouart M, Debourgogne A. CYP51 Mutations in the Fusarium solani Species Complex: First Clue to Understand the Low Susceptibility to Azoles of the Genus Fusarium. J Fungi (Basel) 2022; 8:jof8050533. [PMID: 35628788 PMCID: PMC9148147 DOI: 10.3390/jof8050533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 02/05/2023] Open
Abstract
Members of Fusarium solani species complex (FSSC) are cosmopolitan filamentous fungi responsible for invasive fungal infections in immunocompromised patients. Despite the treatment recommendations, many strains show reduced sensitivity to voriconazole. The objective of this work was to investigate the potential relationship between azole susceptibility and mutations in CYP51 protein sequences. Minimal inhibitory concentrations (MICs) for azole antifungals have been determined using the CLSI (Clinical and Laboratory Standards Institute) microdilution method on a panel of clinical and environmental strains. CYP51A, CYP51B and CYP51C genes for each strain have been sequenced using the Sanger method. Amino acid substitutions described in multiple azole-resistant Aspergillus fumigatus (mtrAf) strains have been sought and compared with other Fusarium complexes’ strains. Our results show that FSSC exhibit point mutations similar to those described in mtrAf. Protein sequence alignments of CYP51A, CYP51B and CYP51C have highlighted different profiles based on sequence similarity. A link between voriconazole MICs and protein sequences was observed, suggesting that these mutations could be an explanation for the intrinsic azole resistance in the genus Fusarium. Thus, this innovative approach provided clues to understand low azole susceptibility in FSSC and may contribute to improving the treatment of FSSC infection.
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Affiliation(s)
- Pierre Vermeulen
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
| | - Arnaud Gruez
- IMoPA, CNRS, Université de Lorraine, F-54000 Nancy, France;
| | - Anne-Lyse Babin
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
| | - Jean-Pol Frippiat
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
| | - Marie Machouart
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
| | - Anne Debourgogne
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
- Correspondence: ; Tel.: +33-(0)3-83-15-43-96
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Schwarz P, Nikolskiy I, Bidaud AL, Sommer F, Bange G, Dannaoui E. In Vitro Synergy of Isavuconazole Combined With Colistin Against Common Candida Species. Front Cell Infect Microbiol 2022; 12:892893. [PMID: 35573795 PMCID: PMC9100415 DOI: 10.3389/fcimb.2022.892893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 12/16/2022] Open
Abstract
Interactions of isavuconazole and colistin were evaluated against 57 common Candida strains belonging to the species Candida albicans (n = 10), Candida glabrata (n = 10), Candida kefyr (n = 8), Candida krusei (n = 10), Candida parapsilosis (n = 9), and Candida tropicalis (n = 10) by a broth microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methodology for antifungal susceptibility testing. Results were analyzed with the fractional inhibitory concentration index and by the response surface analysis. Interpretation by the fractional inhibitory concentration index showed synergy for 50%, 80%, 90%, and 90% of the C. kefyr, C. krusei, C. glabrata, and C. tropicalis strains, respectively. Combination of isavuconazole with colistin against C. albicans and C. parapsilosis exhibited only indifference for 100% and 90% of the strains, respectively. The results were confirmed by response surface analysis for all species except for C. glabrata, for which an indifferent interaction was found for the majority of strains. Antagonistic interaction was never seen regardless of the interpretation model was used.
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Affiliation(s)
- Patrick Schwarz
- Department of Internal Medicine, Respiratory and Critical Care Medicine, University Hospital Marburg, Marburg, Germany
- Center for Invasive Mycoses and Antifungals, Faculty of Medicine, Philipps University Marburg, Marburg, Germany
| | - Ilya Nikolskiy
- Center for Invasive Mycoses and Antifungals, Faculty of Medicine, Philipps University Marburg, Marburg, Germany
- Center for Synthetic Microbiology (SYNMIKRO), Department of Chemistry, Philipps University Marburg, Marburg, Germany
| | - Anne-Laure Bidaud
- Unité de Parasitologie-Mycologie, Hôpital Européen Georges-Pompidou, Paris, France
| | - Frank Sommer
- Department of Microbiology, University Hospital Marburg, Marburg, Germany
| | - Gert Bange
- Center for Synthetic Microbiology (SYNMIKRO), Department of Chemistry, Philipps University Marburg, Marburg, Germany
- Max Planck Fellow Group, Molecular Physiology of Microbes, Max Planck Institute for Terrestrial Microbiology, Marburg, Germany
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Hôpital Européen Georges-Pompidou, Paris, France
- Dynamyc Research Group (EA 7380), Faculté de Médecine de Créteil, Université Paris-Est-Créteil-Val-de-Marne, Créteil, France
- Faculté de Médecine, Université de Paris, Paris, France
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Sivasubramanian G, Chandrasekar PH. Efficacy and safety of Isavuconazole for the treatment of invasive Aspergillus infection - an update of the literature. Expert Opin Pharmacother 2022; 23:543-549. [PMID: 35099351 DOI: 10.1080/14656566.2022.2032645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Invasive aspergillosis is associated with high morbidity and mortality in immunocompromised patients. It is now increasingly reported in critically ill patients, including those with respiratory viral infections, such as influenza and COVID-19. Antifungal management is challenging due to diagnostic delay, adverse drug reactions, drug-drug interactions, narrow therapeutic window, and the emergence of resistance. Isavuconazole is the most recent FDA approved azole for the treatment of invasive aspergillosis, with data continuing to accumulate. AREAS COVERED The authors review the safety and efficacy of isavuconazole in the management of invasive aspergillosis based on the currently available evidence. The authors also report on the structure, mechanism of action, pharmacokinetic properties, in vitro and in vivo studies as well as clinical safety and efficacy reports of isavuconazole since its FDA approval. EXPERT OPINION Isavuconazole is non-inferior to voriconazole and is a safe, effective, and better tolerated option for the treatment of invasive aspergillosis. It offers several advantages over other antifungal agents, including having a better adverse event profile with respect to hepatotoxicity, neuro-visual toxicity, QTc prolongation, as well as a stable pharmacokinetic profile obviating the need for therapeutic drug monitoring. Further studies are needed to evaluate its performance in prophylaxis against invasive aspergillosis as well as in the treatment of aspergillosis in critically ill patients without underlying cancer or transplant.
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Affiliation(s)
- Geetha Sivasubramanian
- Division of Infectious Diseases, University of California, San Francisco, Fresno, CA, USA
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Mechanisms of Azole Resistance and Trailing in Candida tropicalis Bloodstream Isolates. J Fungi (Basel) 2021; 7:jof7080612. [PMID: 34436151 PMCID: PMC8396981 DOI: 10.3390/jof7080612] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives: Azole-resistant Candida tropicalis has emerged in Asia in the context of its trailing nature, defined by residual growth above minimum inhibitory concentrations (MICs). However, limited investigations in C. tropicalis have focused on the difference of genotypes and molecular mechanisms between these two traits. Methods: Sixty-four non-duplicated C. tropicalis bloodstream isolates collected in 2017 were evaluated for azole MICs by the EUCAST E.def 7.3.1 method, diploid sequence type (DST) by multilocus sequencing typing, and sequences and expression levels of genes encoding ERG11, its transcription factor, UPC2, and efflux pumps (CDR1, CDR2 and MDR1). Results: Isavuconazole showed the highest in vitro activity and trailing against C. tropicalis, followed by voriconazole and fluconazole (geometric mean [GM] MIC, 0.008, 0.090, 1.163 mg/L, respectively; trailing GM, 27.4%, 20.8% and 19.5%, respectively; both overall p < 0.001). Fourteen (21.9%) isolates were non-WT to fluconazole/voriconazole, 12 of which were non-WT to isavuconazole and clustered in clonal complex (CC) 3. Twenty-five (39.1%) isolates were high trailing WT, including all CC2 isolates (44.0%) (containing DST140 and DST98). All azole non-WT isolates carried the ERG11 mutations A395T/W and/or C461T/Y, and most carried the UPC2 mutation T503C/Y. These mutations were not identified in low and high trailing WT isolates. Azole non-WT and high trailing WT isolates exhibited the highest expression levels of ERG11 and MDR1, 3.91- and 2.30-fold, respectively (both overall p < 0.01). Conclusions: Azole resistance and trailing are phenotypically and genotypically different in C. tropicalis. Interference with azole binding and MDR1 up-regulation confer azole resistance and trailing, respectively.
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Jørgensen KM, Guinea J, Meletiadis J, Hare RK, Arendrup MC. Revision of EUCAST breakpoints: consequences for susceptibility of contemporary Danish mould isolates to isavuconazole and comparators. J Antimicrob Chemother 2021; 75:2573-2581. [PMID: 32556315 DOI: 10.1093/jac/dkaa212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND EUCAST recently revised the definition of the 'I' category from 'intermediate' to 'susceptible, increased exposure'. Consequently, all current antifungal breakpoints have been reviewed and revised breakpoints (v 10.0) have been released. OBJECTIVES We investigated isavuconazole and comparator MICs (mg/L) against contemporary moulds and the consequences of the breakpoint revision for susceptibility classification. METHODS Six hundred and ninety-six Aspergillus and 46 other moulds were included. EUCAST E.Def 10.1 azole resistance screening was performed for Aspergillus fumigatus and E.Def 9.3.1 testing of non-susceptible A. fumigatus and other moulds. Most non-wildtype/resistant isolates underwent cyp51A sequencing. RESULTS Isavuconazole MIC50/MIC90s were ≤1/≤2 mg/L for Aspergillus flavus, A. fumigatus and Aspergillus nidulans versus 2/4 mg/L for Aspergillus niger and 2/16 mg/L for Aspergillus terreus. For the remaining moulds, MICs were highest for Fusarium (16 to >16 mg/L), lowest for dermatophytes (0.06-0.5 mg/L) and in between for Mucorales and others (1 to >16 mg/L). A very strong isavuconazole-voriconazole MIC correlation was found for A. fumigatus (Pearson r = 0.888) and itraconazole-posaconazole correlation for A. fumigatus (r = 0.905) and A. terreus (r = 0.848). For A. fumigatus, the revised breakpoints lowered isavuconazole resistance (22.6% to 7.7%, P < 0.0001) and increased voriconazole resistance (3.8% to 6.7%, P = 0.025), resulting in similar resistance rates across the four azoles (range: 6.7%-7.7%). For A. terreus, isavuconazole resistance remained unchanged (81.3%) and higher than itraconazole (43.8%, P = 0.004) and posaconazole (53.1%, P = 0.03) resistance. Azole cross-resistance was found in 24/24, 13/20 and 4/90 isolates, and Cyp51A alterations in 16/18, 1/7 and 2/4 sequenced isolates with isavuconazole MICs of >4, 4 and 2 mg/L, respectively. CONCLUSIONS Isavuconazole displays broad anti-mould activity. The revised breakpoints result in fewer misclassifications of wildtype isolates without compromising detection of resistant mutants.
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Affiliation(s)
| | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Athens, Greece
| | | | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Siopi M, Rivero-Menendez O, Gkotsis G, Panara A, Thomaidis NS, Alastruey-Izquierdo A, Pournaras S, Meletiadis J. Nationwide surveillance of azole-resistant Aspergillus fumigatus environmental isolates in Greece: detection of pan-azole resistance associated with the TR46/Y121F/T289A cyp51A mutation. J Antimicrob Chemother 2021; 75:3181-3188. [PMID: 32814940 DOI: 10.1093/jac/dkaa316] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/15/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Acquired azole resistance (AR) in Aspergillus fumigatus emphasizes the importance of the One Health multisectorial approach. The prevalence of azole-resistant A. fumigatus in the environment of Greece is unknown. METHODS Between October 2016 and September 2017, a total of 716 soil samples were collected from 23 provinces and screened for AR using azole-containing agar plates. Recovered isolates were macro-/microscopically identified and colonies were counted. Azole susceptibility testing of A. fumigatus species complex (SC) isolates was performed (EUCAST E.DEF9.3.1). Azole-resistant A. fumigatus isolates were subjected to confirmatory molecular identification and sequencing of the cyp51A gene. RESULTS No yeasts were recovered, while multiple moulds grew on 695 (97%) samples. Overall, zygomycetes (most non-Mucor genera) grew on 432 (60%) samples, while Aspergillus spp. grew on 500 (70%) [410 (57%) Aspergillus niger SC; 120 (17%) Aspergillus terreus SC; 101 (14%) A. fumigatus SC; 34 (5%) Aspergillus flavus SC]. The mean ± SD soil load of Aspergillus spp. was 2.23 ± 0.41 log10 cfu/g (no differences among species). No azole-resistant non-A. fumigatus spp. isolate was detected. Itraconazole, voriconazole, isavuconazole and posaconazole MIC50/MIC90 (MIC range) of A. fumigatus SC strains were 0.25/0.5 (0.25 to >8), 0.5/1 (0.25 to >8), 1/1 (0.125 to >8) and 0.06/0.125 (0.06-1) mg/L, respectively. Overall, 1/500 (0.2%) of Aspergillus isolates, and 1/101 (1%) of A. fumigatus SC isolates, was pan-azole-resistant (itraconazole, voriconazole, isavuconazole and posaconazole MIC >8, >8, >8 and 1 mg/L, respectively). The resistant isolate was recovered from organically grown raisin grapes treated with homemade compost and it was an A. fumigatus sensu stricto isolate harbouring the TR46/Y121F/T289A mutation. The soil's load was higher compared with azole-susceptible strains (3.74 versus 2.09 log10 cfu/g). CONCLUSIONS This is the first known report of environmental pan-azole-resistant A. fumigatus in Greece. Since data on Greek clinical isolates are lacking, this finding must alarm the systematic local surveillance of AR in medical settings.
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Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Olga Rivero-Menendez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Georgios Gkotsis
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Anthi Panara
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos S Thomaidis
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Lahmer T, Batres Baires G, Schmid RM, Wiessner JR, Ulrich J, Reichert M, Huber W, Sörgel F, Kinzig M, Rasch S, Mayr U. Penetration of Isavuconazole in Ascites Fluid of Critically Ill Patients. J Fungi (Basel) 2021; 7:jof7050376. [PMID: 34064945 PMCID: PMC8150505 DOI: 10.3390/jof7050376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 01/10/2023] Open
Abstract
Fungal peritonitis is a life-threatening condition which is not only difficult to diagnose, but also to treat. Following recent guidelines, echinocandins and azoles are the recommended antimycotics for the management of intra-abdominal Candida spp. infections, with a favor for echinocandins in critically ill patients. However, the new extended spectrum triazole isavuconazole also has a broad spectrum against Candida spp. Data on its target-site penetration are sparse. Therefore, we assessed isavuconazole concentrations and penetration ratios in ascites fluid of critically ill patients. Obtaining of Isavuconazole plasma and ascites fluid levels as well penetration ratios using paracentesis in critically ill patients. Isavuconazole concentrations were quantified in human plasma and ascites by a liquid chromatography/tandem mass spectrometry (LC-MS/MS) method. Isavuconazole concentrations in plasma and ascites fluid were measured in sixteen critically ill patients. Isavuconazol levels in ascites fluid (1.06 µg/mL) were lower than plasma levels (3.08 µg/mL). Penetration ratio was 36%. In two out of sixteen patients, Candida spp., in detail C. glabrata and C. tropicalis, could be isolated. Cmax/MIC Ratio in plasma of 560 for C. glabrata and 2166 for C. tropicalis could be observed. Following our results, isavuconazole penetrates into ascites. Successful treatment in Candida spp. peritonitis depends on pathogen susceptibility.
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Affiliation(s)
- Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
- Correspondence: ; Tel.: +49-89-4140-9345; Fax: +49-89-4140-6243
| | - Gonzalo Batres Baires
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Johannes R. Wiessner
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Jörg Ulrich
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Maximilian Reichert
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Fritz Sörgel
- IBMP—Institute for Biomedical and Pharmaceutical Research, Paul-Ehrlich-Straße 19, 90562 Nürnberg-Heroldsberg, Germany; (F.S.); (M.K.)
- Faculty of Medicine, Institute of Pharmacology, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Martina Kinzig
- IBMP—Institute for Biomedical and Pharmaceutical Research, Paul-Ehrlich-Straße 19, 90562 Nürnberg-Heroldsberg, Germany; (F.S.); (M.K.)
| | - Sebastian Rasch
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
| | - Ulrich Mayr
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany; (G.B.B.); (R.M.S.); (J.R.W.); (J.U.); (M.R.); (W.H.); (S.R.); (U.M.)
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Borman AM, Fraser M, Patterson Z, Palmer MD, Johnson EM. In Vitro Antifungal Drug Resistance Profiles of Clinically Relevant Members of the Mucorales (Mucoromycota) Especially with the Newer Triazoles. J Fungi (Basel) 2021; 7:271. [PMID: 33918216 PMCID: PMC8065934 DOI: 10.3390/jof7040271] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 12/23/2022] Open
Abstract
Mucoromycoses (infections caused by members of the order Mucorales, phylum Mucoromycota [ex-Zygomycota]) are highly destructive, rapidly progressive infections, with dire prognoses especially when they occur in immunocompromised hosts. Current treatment guidelines recommend liposomal formulations of amphotericin B with adjunctive surgery as first line therapy, with the newer triazoles posaconazole or isavuconazole as alternative treatments, or as salvage therapy. Among the many organisms belonging to this order, a limited number of species in the genera Rhizopus, Mucor, Lichtheimia and Rhizomucor are responsible for most cases of human infection. Here, we present the minimum inhibitory concentration data (MICs) for amphotericin B, posaconazole, isavuconazole, itraconazole and voriconazole with a panel of over 300 isolates of the five most common agents of human infection (Lichtheimia corymbifera, Rhizopus arrhizus, R. microsporus, Rhizomucor pusillus and Mucor spp.) determined using the CLSI broth microdilution method. In agreement with previous studies, the most active antifungal drug for all Mucorales was amphotericin B, with MICs within the range that would predict susceptibility with Aspergillus fumigatus. Conversely, MICs for voriconazole against all species tested were high, and above the range associated with clinical efficacy with A. fumigatus. Interestingly, whilst isavuconazole and posaconazole MIC distributions indicated in vitro activity against some members of the Mucorales, activity was species-dependent for both agents. These data underscore the importance of accurate identification of the causative agents of mucoromycosis, coupled with antifungal susceptibility testing of individual isolates, in determining the optimal treatment of infections caused by these aggressive opportunistic human fungal pathogens.
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Affiliation(s)
- Andrew M. Borman
- UK National Mycology Reference Laboratory, Public Health England, Science Quarter, Southmead Hospital, Bristol BS10 5NB, UK; (M.F.); (Z.P.); (M.D.P.)
- Medical Research Council Centre for Medical Mycology (MRC CMM), University of Exeter, Exeter EX4 4QD, UK
| | - Mark Fraser
- UK National Mycology Reference Laboratory, Public Health England, Science Quarter, Southmead Hospital, Bristol BS10 5NB, UK; (M.F.); (Z.P.); (M.D.P.)
| | - Zoe Patterson
- UK National Mycology Reference Laboratory, Public Health England, Science Quarter, Southmead Hospital, Bristol BS10 5NB, UK; (M.F.); (Z.P.); (M.D.P.)
| | - Michael D. Palmer
- UK National Mycology Reference Laboratory, Public Health England, Science Quarter, Southmead Hospital, Bristol BS10 5NB, UK; (M.F.); (Z.P.); (M.D.P.)
| | - Elizabeth M. Johnson
- UK National Mycology Reference Laboratory, Public Health England, Science Quarter, Southmead Hospital, Bristol BS10 5NB, UK; (M.F.); (Z.P.); (M.D.P.)
- Medical Research Council Centre for Medical Mycology (MRC CMM), University of Exeter, Exeter EX4 4QD, UK
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Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:life11020095. [PMID: 33514007 PMCID: PMC7912256 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
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Olorofim Susceptibility Testing of 1,423 Danish Mold Isolates Obtained in 2018-2019 Confirms Uniform and Broad-Spectrum Activity. Antimicrob Agents Chemother 2020; 65:AAC.01527-20. [PMID: 33020160 DOI: 10.1128/aac.01527-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/01/2020] [Indexed: 01/22/2023] Open
Abstract
Olorofim is a novel antifungal drug in phase 2 trials. It has shown promising in vitro activity against various molds, except for Mucorales. Initially, we observed a broad range of EUCAST MICs for Aspergillus fumigatus Here, we explored the MIC variability in more detail and prospectively investigated the susceptibility of contemporary clinical mold isolates, as population data are needed for future epidemiological cutoff (ECOFF) settings. Fifteen A. fumigatus isolates previously found with low/medium/high MICs (≤0.002 to 0.25 mg/liter) were tested repeatedly and EUCAST MICs read in a blinded fashion by three observers. pyrE, encoding the olorofim target enzyme dihydroorotate dehydrogenase (DHODH), was sequenced. A total of 1,423 mold isolates (10 Aspergillus species complexes [including 1,032 A. fumigatus isolates] and 105 other mold/dermatophyte isolates) were examined. Olorofim susceptibility (modal MIC, MIC50, MIC90, and wild-type upper limits [WT-ULs] [species complexes with ≥15 isolates]) was determined and compared to that of four comparators. MICs (mg/liter) were within two 2-fold dilutions (0.016 to 0.03) for 473/476 determinations. The MIC range spanned four dilutions (0.008 to 0.06). No significant pyrE mutations were found. Modal MIC/WT-UL97.5 (mg/liter) values were 0.03/0.06 (A. terreus and A. flavus), 0.06/0.125 (A. fumigatus and Trichophyton rubrum), and 0.06/0.25 (A. niger and A. nidulans). The MIC range for Scedosporium spp. was 0.008 to 0.25. Olorofim susceptibility was similar for azole-resistant and -susceptible isolates of A. fumigatus but reduced for A. montevidensis and A. chevalieri (MICs of >1). With experience, olorofim susceptibility testing is robust. The testing of isolates from our center showed uniform and broad-spectrum activity. Single-center WT-ULs are suggested.
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Isavuconazole: Mechanism of Action, Clinical Efficacy, and Resistance. J Fungi (Basel) 2020; 6:jof6040324. [PMID: 33260353 PMCID: PMC7712939 DOI: 10.3390/jof6040324] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 02/07/2023] Open
Abstract
Increasing incidence of invasive fungal infections combined with a growing population of immunocompromised hosts has created a rising need for antifungal agents. Isavuconazole, a second-generation broad-spectrum triazole with activity against yeasts, dimorphic fungi, and molds, has a favorable safety profile and predictable pharmacokinetics. Patients typically tolerate isavuconazole well with fewer drug-drug interactions. Clinical trials have found it to be noninferior to voriconazole for invasive aspergillosis, an alternative therapy for salvage treatment of mucormycosis, and suitable for stepdown therapy with invasive candidiasis. Cross-resistance with other triazoles is common. More studies are needed to determine the role of isavuconazole in anti-mold prophylaxis in high-risk patients.
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In Vitro Activity of Manogepix against Multidrug-Resistant and Panresistant Candida auris from the New York Outbreak. Antimicrob Agents Chemother 2020; 64:AAC.01124-20. [PMID: 32839219 DOI: 10.1128/aac.01124-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/18/2020] [Indexed: 02/07/2023] Open
Abstract
An ongoing Candida auris outbreak in the New York metropolitan area is the largest recorded to date in North America. Laboratory surveillance revealed NY C. auris isolates are resistant to fluconazole, with variable resistance to other currently used broad-spectrum antifungal drugs, and that several isolates are panresistant. Thus, there is an urgent need for new drugs with a novel mechanism of action to combat the resistance challenge. Manogepix (MGX) is a first-in-class agent that targets the fungal Gwt1 enzyme. The prodrug fosmanogepix is currently in phase 2 clinical development for the treatment of fungal infections. We evaluated the susceptibility of 200 New York C. auris isolates to MGX and 10 comparator drugs using CLSI methodology. MGX demonstrated lower MICs than comparators (MIC50 and MIC90, 0.03 mg/liter; range, 0.004 to 0.06 mg/liter). The local epidemiological cutoff value (ECV) for MGX indicated all C. auris isolates were within the population of wild-type (WT) strains; 0.06 mg/liter defines the upper limit of wild type (UL-WT). MGX was 8- to 32-fold more active than the echinocandins, 16- to 64-fold more active than the azoles, and 64-fold more active than amphotericin B. No differences were found in the MGX or comparators' MIC50, MIC90, or geometric mean (GM) values when subsets of clinical, surveillance, and environmental isolates were evaluated. The range of MGX MIC values for six C. auris panresistant isolates was 0.008 to 0.015 mg/liter, and the median and mode MIC values were 0.015 mg/liter, demonstrating that MGX retains activity against these isolates. These data support further clinical evaluation of fosmanogepix for the treatment of C. auris infections, including highly resistant isolates.
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Hagemann JB, Furitsch M, Wais V, Bunjes D, Walther G, Kurzai O, Essig A. First case of fatal Rhizomucor miehei endocarditis in an immunocompromised patient. Diagn Microbiol Infect Dis 2020; 98:115106. [PMID: 32629298 DOI: 10.1016/j.diagmicrobio.2020.115106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
Rhizomucor miehei is a cause of bovine mycotic abortion and mastitis and has rarely been described in human disease. Here, we report the first isolation of R. miehei from native mitral valve tissue in a fatal case of endocarditis that substantiates its pathogenic potential. Apart from morphological criteria, molecular methods were a cornerstone for definite diagnosis.
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Affiliation(s)
- Jürgen Benjamin Hagemann
- Institute of Medical Microbiology and Hygiene, University Hospital of Ulm, Albert-Einstein-Allee 23, D-89081 Ulm, Germany.
| | - Martina Furitsch
- Institute of Medical Microbiology and Hygiene, University Hospital of Ulm, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
| | - Verena Wais
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Donald Bunjes
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Grit Walther
- National Reference Centre for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena, Germany
| | - Oliver Kurzai
- National Reference Centre for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena, Germany.; Institute for Hygiene and Microbiology, Julius Maximilians University of Würzburg, Würzburg, Germany
| | - Andreas Essig
- Institute of Medical Microbiology and Hygiene, University Hospital of Ulm, Albert-Einstein-Allee 23, D-89081 Ulm, Germany
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Arendrup MC, Friberg N, Mares M, Kahlmeter G, Meletiadis J, Guinea J. How to interpret MICs of antifungal compounds according to the revised clinical breakpoints v. 10.0 European committee on antimicrobial susceptibility testing (EUCAST). Clin Microbiol Infect 2020; 26:1464-1472. [PMID: 32562861 DOI: 10.1016/j.cmi.2020.06.007] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND EUCAST has revised the definition of the susceptibility category I from 'Intermediate' to 'Susceptible, Increased exposure'. This implies that I can be used where the drug concentration at the site of infection is high, either because of dose escalation or through other means to ensure efficacy. Consequently, I is no longer used as a buffer zone to prevent technical factors from causing misclassifications and discrepancies in interpretations. Instead, an Area of Technical Uncertainty (ATU) has been introduced for MICs that cannot be categorized without additional information as a warning to the laboratory that decision on how to act has to be made. To implement these changes, the EUCAST-AFST (Subcommittee on Antifungal Susceptibility Testing) reviewed all, and revised some, clinical antifungal breakpoints. OBJECTIVES The aim was to present an overview of the current antifungal breakpoints and supporting evidence behind the changes. SOURCES This document is based on the ten recently updated EUCAST rationale documents, clinical breakpoint and breakpoint ECOFF documents. CONTENT The following breakpoints (in mg/L) have been revised or established for Candida species: micafungin against C. albicans (ATU = 0.03); amphotericin B (S ≤/> R = 1/1), fluconazole (S ≤/> R = 2/4), itraconazole (S ≤/> R = 0.06/0.06), posaconazole (S ≤/> R = 0.06/0.06) and voriconazole (S ≤/> R = 0.06/0.25) against C. dubliniensis; fluconazole against C. glabrata (S ≤/> R = 0.001/16); and anidulafungin (S ≤/> R = 4/4) and micafungin (S ≤/> R = 2/2) against C. parapsilosis. For Aspergillus, new or revised breakpoints include itraconazole (ATU = 2) and isavuconazole against A. flavus (S ≤/> R = 1/2, ATU = 2); amphotericin B (S ≤/> R = 1/1), isavuconazole (S ≤ /> R = 1/2, ATU = 2), itraconazole (S ≤/> R = 1/1, ATU = 2), posaconazole (ATU = 0.25) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. fumigatus; itraconazole (S ≤/> R = 1/1, ATU = 2) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. nidulans; amphotericin B against A. niger (S ≤/> R = 1/1); and itraconazole (S ≤/> R = 1/1, ATU = 2) and posaconazole (ATU = 0.25) against A. terreus. IMPLICATIONS EUCAST-AFST has released ten new documents summarizing existing and new breakpoints and MIC ranges for control strains. A failure to adopt the breakpoint changes may lead to misclassifications and suboptimal or inappropriate therapy of patients with fungal infections.
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Affiliation(s)
- M C Arendrup
- Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - N Friberg
- Division of Clinical Microbiology, Helsinki University Hospital, HUSLAB, Finland
| | - M Mares
- Laboratory of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, Iasi, Romania
| | - G Kahlmeter
- The EUCAST Development Laboratory, Clinical Microbiology, Växjö, Sweden
| | - J Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - J Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Implications of Evolving and Emerging Pharmacokinetic-Pharmacodynamic Research for Triazoles and Echinocandins. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00391-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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23
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Koehler P, Bassetti M, Kochanek M, Shimabukuro-Vornhagen A, Cornely O. Intensive care management of influenza-associated pulmonary aspergillosis. Clin Microbiol Infect 2019; 25:1501-1509. [DOI: 10.1016/j.cmi.2019.04.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/21/2019] [Accepted: 04/27/2019] [Indexed: 12/15/2022]
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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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