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Serrano-Lobo J, Reigadas E, Muñoz P, Escribano P, Guinea J. Azole resistance screening in Aspergillus fumigatus sensu stricto using the azole-containing agar method (EUCAST E.Def 10.2): conidial suspension filtration and inoculum adjustment before inoculum preparation may not be needed. J Clin Microbiol 2024; 62:e0036924. [PMID: 38819167 PMCID: PMC11250424 DOI: 10.1128/jcm.00369-24] [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: 03/01/2024] [Accepted: 04/26/2024] [Indexed: 06/01/2024] Open
Abstract
Azole resistance screening in Aspergillus fumigatus sensu stricto can be routinely carried out by using azole-containing agar plates (E.Def 10.2 procedure); however, conidial suspension filtering and inoculum adjustment before inoculum preparation are time-consuming. We evaluated whether skipping the filtration and inoculum adjustment steps negatively influenced the performance of the E.Def 10.2 procedure. A. fumigatus sensu stricto isolates (n = 98), previously classified as azole susceptible or azole resistant (E.Def 9.4 method), were studied. Azole-resistant isolates had either the wild-type cyp51A gene sequence (n = 1) or the following cyp51A gene substitutions: TR34-L98H (n = 41), G54R (n = 5), TR46-Y121F-T289A (n = 1), or G448S (n = 1). In-house azole-containing agar plates were prepared according to the EUCAST E.Def 10.2 procedure. Conidial suspensions obtained by adding distilled water (Tween 20 0.1%) were either filtered and the inocula adjusted to 0.5 McFarland or left unfiltered and unadjusted. Agreements between the agar screening methods using inocula prepared by each procedure were high for itraconazole (99%), voriconazole (100%), and posaconazole (94.9%). Sensitivity and specificity (considering the susceptibility category as per the microdilution E.Def 9.4 method as the gold standard) of E.Def 10.2 were 100% to rule in or rule out resistance when unfiltered and unadjusted suspensions were used; the resistance phenotype of isolates harboring the TR34-L98H, G54R, or TR46-Y121F-T289A substitutions was correctly detected. Unfiltered and unadjusted conidial suspensions do not negatively influence the performance of the E.Def 10.2 method when screening for azole resistance in A. fumigatus sensu stricto. IMPORTANCE Azole resistance screening in Aspergillus fumigatus sensu stricto can be routinely carried out by using azole-containing plates (E.Def 10.2 procedure); however, conidial suspension filtering and inoculum adjustment before inoculation of plates are time-consuming. We, here, showed that unfiltered and unadjusted conidial suspensions do not negatively influence the performance of the E.Def 10.2 method when screening for azole resistance in A. fumigatus sensu stricto.
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Affiliation(s)
- Julia Serrano-Lobo
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Elena Reigadas
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Faculty of Health Sciences, HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Faculty of Health Sciences, HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
| | - on behalf of the ASPEIN Study GroupRomeraWaldo Sánchez-YebraSánchez-GómezJuan AntonioLozanoInmaculada GuerreroTejero-GarcíaRocíoMartínezFernando CoboViñuelaLaurade LunaFrancisco Franco-ÁlvarezOyaAna LaraMoreno-TorresIsabel CasanovasRuizMaría Pilar BermúdezBarrenecheaAna Isabel SuárezMéndezCarmen Castrode PipaónMaite Ruiz PérezCondadoHéctor CondadoSánchezRocío CebolladaGómezConcepción LópezRomeroEmilio David ValverdePérezHenar VillarTempranoMarta AriasMartínezAlba GuiuPeláezTeresaCastello-AbietarCristianGinerCarmen ColladoCruixentEva AlcocebaEscobarCarla IglesiasLafuenteAna Patricia Martínezde TorrellaAna GualLópez-SoriaLeyreJiménezOlga BelloBarañanoMiren Josebe UnzagaRamosIris Sharon PérezAlbizuMiren Nekane AzkueFernández-TorresMarinaLuengoRaúl GilarranzMartínezIsabel de MiguelMartínezÁngeles SampereGutiérrezSilvia Rosa CamposMesonesMaría Pía RoizSerraJulia LozanoSerranoCristina ColmenarejoCaseroQuilez MaloZuritaMaría Elena RodríguezBarrenaRosa JiménezEsguevaMarta FernándezSantosOscar FraileSánchezBeatriz PascualEcheverríaCristina LabayruDe FreitasLisbeth GonçalvesGayLaura MilianFernándezRaquel CallejaFonsecaAlicia BarrealesPuertasAlmudena Silvia TinajasLópez-RamosIreneBravoMoisés GarcíaBellidoJuan Luis MuñozAndrésNoelia ArenalYánezCristina VeintimillaRealSusana HernandoPérezM. Rosario IbáñezAparicioFederico Miguel BecerraLópezJesús MartínezSoriaPilarMansillaCarmen AldeaVidalBelén LorenzoVelascoIrene MerinoGilMercedes MartínGómezMaría Antonia MiguelMestanzaCristina LópezCornejoJaime MartínCalleMaría Luz AsensioTorresAdrián AntuoriBurgosEva CuchíSánchez-ReusFerranLópez-QuerolCristinaParaJaume JuanolaRevertéFrancesc MarcoEspasaMateuArditeJosefina AyatsOlmosRobertoRamosDavid SanchezGómezMaría Teresa MartínPalauMontserrat ColomerSánchezIván PratsBajadorIsabel PujolPernasAntonio CasabellaBertomeuFrederic Francesc GómezGranellSergio PardoPlanaEster PicóTorresMaría Dolores GuerreroMorenoMaría Mar Olga PérezRodríguezEva del CorralOlivaresMiguel FajardoPachecoCarmen PazosRodríguez-MayoMaría DoloresLageSusana MéndezDomínguezJavier AlbaFernándezYolanda VilaMaseday Susana OrolLamaAna CidReyAna María RodríguezGonzálezMaría de los Ángeles PallarésCarballo-FernándezRaquelPenaRocío TrastoyMartínez-LamasLucíaBlancoLuis Miguel SoriaPérez-AyalaAnade la PedrosaElia Gómez GarcíaSánchez-RomeroIsabelFernándezSarela García-MasedoGuineaJesusEscribanoPilarNúñezAna GómezLeivaJosé GonzálezPalomaresLaura PérezLiaudansdanskyteAsta KastanauskaiteRodríguezNatalia DíazPérezSarah MonteroSerrano-LoboJuliaReigadasElenade ParedesPatricia Muñoz GarcíaMeleroInmaculada QuilesClementePaloma GarcíaDurán-ValleMaría TeresaGadeaIgnacioGarcíaMarta MartínZuritaNellyGutiérrezAinhoaCuétaraMaría SoledadAmadorPaloma Merinode la TorreIrene DíazFernández-AlonsoMirianMontoroIrene ArcoGarcía-FigueresEugenioHellínVictoria SánchezRosMaría Isabel GascónBorjaSalvador RagaMartínAmparo ValentínGaitánAlba RuizRodríguezJavier ColominaOleaBeatrizClariMaría de los Ángeles
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Faculty of Health Sciences, HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
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Arendrup MC, Guinea J, Meletiadis J. Twenty Years in EUCAST Anti-Fungal Susceptibility Testing: Progress & Remaining Challenges. Mycopathologia 2024; 189:64. [PMID: 38990395 DOI: 10.1007/s11046-024-00861-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/15/2024] [Indexed: 07/12/2024]
Abstract
Since its inception in 2002, the EUCAST Antifungal Susceptibility Testing Subcommittee (AFST) has developed and refined susceptibility testing methods for yeast, moulds and dermatophytes, and established epidemiological cut-off values and breakpoints for antifungals. For yeast, three challenges have been addressed. Interpretation of trailing growth in fluconazole susceptibility testing, which has been proven without impact on efficacy if below the 50% endpoint. Variability in rezafungin MIC testing due to laboratory conditions, which has been solved by the addition of Tween 20 to the growth medium in E.Def 7.4. And third, interpretation of MICs for rare yeast with no breakpoints, where recommendations have been established for MIC-based clinical advice. For moulds, refinements include the validation of spectrophotometer reading for A. fumigatus to facilitate objective MIC determination, and for dermatophytes the establishment of a microdilution method with automated reading and a selective medium to minimise the risk of contaminations. Recent initiatives involve development and validation of agar-based screening assays for detection of potential azole and echinocandin resistance in A. fumigatus and Aspergillus species, respectively, and of terbinafine resistance in Trichophyton species. Moreover, the development of a EUCAST guidance document for molecular resistance testing represents an advancement, particularly for identifying target gene alterations associated with resistance. In summary, EUCAST AFST continues to play a pivotal role in standardizing AFST and facilitating accurate interpretation of susceptibility data for clinical decision-making. Adoption of EUCAST breakpoints for commercial test methods, however, requires thorough validation to ensure concordance with EUCAST reference testing species-specific MIC distributions.
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Affiliation(s)
- Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Building 45/112, Artillerivej 5, 2300, Copenhagen, Denmark.
- Department Clinical Microbiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.
| | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007, Madrid, Spain
- Faculty of Health Sciences-HM Hospitals, Universidad Camilo José Cela, Madrid, Spain
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Jeong GJ, Khan F, Tabassum N, Cho KJ, Kim YM. Strategies for controlling polymicrobial biofilms: A focus on antibiofilm agents. Int J Antimicrob Agents 2024; 64:107243. [PMID: 38908533 DOI: 10.1016/j.ijantimicag.2024.107243] [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: 03/13/2024] [Revised: 04/29/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024]
Abstract
Polymicrobial biofilms are among the leading causes of antimicrobial treatment failure. In these biofilms, bacterial and fungal pathogens interact synergistically at the interspecies, intraspecies, and interkingdom levels. Consequently, combating polymicrobial biofilms is substantially more difficult compared to single-species biofilms due to their distinct properties and the resulting potential variation in antimicrobial drug efficiency. In recent years, there has been an increased focus on developing alternative strategies for controlling polymicrobial biofilms formed by bacterial and fungal pathogens. Current approaches for controlling polymicrobial biofilms include monotherapy (using either natural or synthetic compounds), combination treatments, and nanomaterials. Here, a comprehensive review of different types of polymicrobial interactions between pathogenic bacterial species or bacteria and fungi is provided along with a discussion of their relevance. The mechanisms of action of individual compounds, combination treatments, and nanomaterials against polymicrobial biofilms are thoroughly explored. This review provides various future perspectives that can advance the strategies used to control polymicrobial biofilms and their likely modes of action. Since the majority of research on combating polymicrobial biofilms has been conducted in vitro, it would be an essential step in performing in vivo tests to determine the clinical effectiveness of different treatments against polymicrobial biofilms.
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Affiliation(s)
- Geum-Jae Jeong
- Department of Food Science and Technology, Pukyong National University, Busan, 48513, Republic of Korea; Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, 48513, Republic of Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan, 48513, Republic of Korea
| | - Fazlurrahman Khan
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, 48513, Republic of Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan, 48513, Republic of Korea; Institute of Fisheries Science, Pukyong National University, Busan, 48513, Republic of Korea; International Graduate Program of Fisheries Science, Pukyong National University, Busan, 48513, Republic of Korea.
| | - Nazia Tabassum
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, 48513, Republic of Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan, 48513, Republic of Korea
| | - Kyung-Jin Cho
- Department of Food Science and Technology, Pukyong National University, Busan, 48513, Republic of Korea; Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, 48513, Republic of Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan, 48513, Republic of Korea
| | - Young-Mog Kim
- Department of Food Science and Technology, Pukyong National University, Busan, 48513, Republic of Korea; Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan, 48513, Republic of Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan, 48513, Republic of Korea.
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van Dijk MAM, Buil JB, Tehupeiory-Kooreman M, Broekhuizen MJ, Broens EM, Wagenaar JA, Verweij PE. Azole Resistance in Veterinary Clinical Aspergillus fumigatus Isolates in the Netherlands. Mycopathologia 2024; 189:50. [PMID: 38864903 PMCID: PMC11169034 DOI: 10.1007/s11046-024-00850-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/14/2024] [Indexed: 06/13/2024]
Abstract
Aspergillus fumigatus is a saprophytic fungal pathogen that causes opportunistic infections in animals and humans. Azole resistance has been reported globally in human A. fumigatus isolates, but the prevalence of resistance in isolates from animals is largely unknown. A retrospective resistance surveillance study was performed using a collection of clinical A. fumigatus isolates from various animal species collected between 2015 and 2020. Agar-based azole resistance screening of all isolates was followed by in vitro antifungal susceptibility testing and cyp51A gene sequencing of the azole-resistant isolates. Over the 5 year period 16 (11.3%) of 142 A. fumigatus culture-positive animals harbored an azole-resistant isolate. Resistant isolates were found in birds (15%; 2/13), cats (21%; 6/28), dogs (8%; 6/75) and free-ranging harbor porpoise (33%; 2/6). Azole-resistance was cyp51A mediated in all isolates: 81.3% (T-67G/)TR34/L98H, 12.5% TR46/Y121F/T289A. In one azole-resistant A. fumigatus isolate a combination of C(-70)T/F46Y/C(intron7)T/C(intron66)T/M172V/E427K single-nucleotide polymorphisms in the cyp51A gene was found. Of the animals with an azole-resistant isolate and known azole exposure status 71.4% (10/14) were azole naive. Azole resistance in A. fumigatus isolates from animals in the Netherlands is present and predominantly cyp51A TR-mediated, supporting an environmental route of resistance selection. Our data supports the need to include veterinary isolates in resistance surveillance programs. Veterinarians should consider azole resistance as a reason for therapy failure when treating aspergillosis and consider resistance testing of relevant isolates.
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Affiliation(s)
- Marloes A M van Dijk
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands.
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marlou Tehupeiory-Kooreman
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marian J Broekhuizen
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Els M Broens
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Jaap A Wagenaar
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
- Wageningen Bioveterinary Research, 8221 RA, Lelystad, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, 6525 GA, Nijmegen, The Netherlands
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Lucio J, Alcazar-Fuoli L, Gil H, Cano-Pascual S, Hernandez-Egido S, Cuetara MS, Mellado E. Distribution of Aspergillus species and prevalence of azole resistance in clinical and environmental samples from a Spanish hospital during a three-year study period. Mycoses 2024; 67:e13719. [PMID: 38551063 DOI: 10.1111/myc.13719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Surveillance studies are crucial for updating trends in Aspergillus species and antifungal susceptibility information. OBJECTIVES Determine the Aspergillus species distribution and azole resistance prevalence during this 3-year prospective surveillance study in a Spanish hospital. MATERIALS AND METHODS Three hundred thirty-five Aspergillus spp. clinical and environmental isolates were collected during a 3-year study. All isolates were screened for azole resistance using an agar-based screening method and resistance was confirmed by EUCAST antifungal susceptibility testing. The azole resistance mechanism was confirmed by sequencing the cyp51A gene and its promoter. All Aspergillus fumigatus strains were genotyped using TRESPERG analysis. RESULTS Aspergillus fumigatus was the predominant species recovered with a total of 174 strains (51.94%). The rest of Aspergillus spp. were less frequent: Aspergillus niger (14.93%), Aspergillus terreus (9.55%), Aspergillus flavus (8.36%), Aspergillus nidulans (5.37%) and Aspergillus lentulus (3.28%), among other Aspergillus species (6.57%). TRESPERG analysis showed 99 different genotypes, with 72.73% of the strains being represented as a single genotype. Some genotypes were common among clinical and environmental A. fumigatus azole-susceptible strains, even when isolated months apart. We describe the occurrence of two azole-resistant A. fumigatus strains, one clinical and another environmental, that were genotypically different and did not share genotypes with any of the azole-susceptible strains. CONCLUSIONS Aspergillus fumigatus strains showed a very diverse population although several genotypes were shared among clinical and environmental strains. The isolation of azole-resistant strains from both settings suggest that an efficient analysis of clinical and environmental sources must be done to detect azole resistance in A. fumigatus.
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Affiliation(s)
- Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Laura Alcazar-Fuoli
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
| | - Horacio Gil
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Samuel Cano-Pascual
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
| | - Sara Hernandez-Egido
- Microbiology Department, University Hospital Severo Ochoa, Leganés, Madrid, Spain
| | | | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
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Pontes L, Arai T, Gualtieri Beraquet CA, Giordano ALPL, Reichert-Lima F, da Luz EA, Fernanda de Sá C, Ortolan Levy L, Tararam CA, Watanabe A, Moretti ML, Zaninelli Schreiber A. Uncovering a Novel cyp51A Mutation and Antifungal Resistance in Aspergillus fumigatus through Culture Collection Screening. J Fungi (Basel) 2024; 10:122. [PMID: 38392794 PMCID: PMC10890095 DOI: 10.3390/jof10020122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Aspergillus fumigatus is an important concern for immunocompromised individuals, often resulting in severe infections. With the emergence of resistance to azoles, which has been the therapeutic choice for Aspergillus infections, monitoring the resistance of these microorganisms becomes important, including the search for mutations in the cyp51A gene, which is the gene responsible for the mechanism of action of azoles. We conducted a retrospective analysis covering 478 A. fumigatus isolates. METHODS This comprehensive dataset comprised 415 clinical isolates and 63 isolates from hospital environmental sources. For clinical isolates, they were evaluated in two different periods, from 1998 to 2004 and 2014 to 2021; for environmental strains, one strain was isolated in 1998, and 62 isolates were evaluated in 2015. Our primary objectives were to assess the epidemiological antifungal susceptibility profile; trace the evolution of resistance to azoles, Amphotericin B (AMB), and echinocandins; and monitor cyp51A mutations in resistant strains. We utilized the broth microdilution assay for susceptibility testing, coupled with cyp51A gene sequencing and microsatellite genotyping to evaluate genetic variability among resistant strains. RESULTS Our findings reveal a progressive increase in Minimum Inhibitory Concentrations (MICs) for azoles and AMB over time. Notably, a discernible trend in cyp51A gene mutations emerged in clinical isolates starting in 2014. Moreover, our study marks a significant discovery as we detected, for the first time, an A. fumigatus isolate carrying the recently identified TR46/F495I mutation within a sample obtained from a hospital environment. The observed cyp51A mutations underscore the ongoing necessity for surveillance, particularly as MICs for various antifungal classes continue to rise. CONCLUSIONS By conducting resistance surveillance within our institution's culture collection, we successfully identified a novel TR46/F495I mutation in an isolate retrieved from the hospital environment which had been preserved since 1998. Moreover, clinical isolates were found to exhibit TR34/L98H/S297T/F495I mutations. In addition, we observed an increase in MIC patterns for Amphotericin B and azoles, signaling a change in the resistance pattern, emphasizing the urgent need for the development of new antifungal drugs. Our study highlights the importance of continued monitoring and research in understanding the evolving challenges in managing A. fumigatus infections.
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Affiliation(s)
- Laís Pontes
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
| | - Teppei Arai
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba 260-8670, Japan
| | | | | | - Franqueline Reichert-Lima
- Department of Medicine, School of Medical Sciences in São José dos Campos-Humanitas, São José dos Campos 12220-061, São Paulo, Brazil
| | - Edson Aparecido da Luz
- Division of Clinical Pathology, Microbiology Laboratory, University of Campinas Clinical Hospital, Campinas 13083-888, São Paulo, Brazil
| | - Camila Fernanda de Sá
- Division of Clinical Pathology, Microbiology Laboratory, University of Campinas Clinical Hospital, Campinas 13083-888, São Paulo, Brazil
| | - Larissa Ortolan Levy
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
| | | | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba 260-8670, Japan
| | - Maria Luiza Moretti
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
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Simmons BC, Rhodes J, Rogers TR, Verweij PE, Abdolrasouli A, Schelenz S, Hemmings SJ, Talento AF, Griffin A, Mansfield M, Sheehan D, Bosch T, Fisher MC. Genomic Epidemiology Identifies Azole Resistance Due to TR 34/L98H in European Aspergillus fumigatus Causing COVID-19-Associated Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:1104. [PMID: 37998909 PMCID: PMC10672581 DOI: 10.3390/jof9111104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Aspergillus fumigatus has been found to coinfect patients with severe SARS-CoV-2 virus infection, leading to COVID-19-associated pulmonary aspergillosis (CAPA). The CAPA all-cause mortality rate is approximately 50% and may be complicated by azole resistance. Genomic epidemiology can help shed light on the genetics of A. fumigatus causing CAPA, including the prevalence of resistance-associated alleles. We present a population genomic analysis of 21 CAPA isolates from four European countries with these isolates compared against 240 non-CAPA A. fumigatus isolates from a wider population. Bioinformatic analysis and antifungal susceptibility testing were performed to quantify resistance and identify possible genetically encoded azole-resistant mechanisms. The phylogenetic analysis of the 21 CAPA isolates showed that they were representative of the wider A. fumigatus population with no obvious clustering. The prevalence of phenotypic azole resistance in CAPA was 14.3% (n = 3/21); all three CAPA isolates contained a known resistance-associated cyp51A polymorphism. The relatively high prevalence of azole resistance alleles that we document poses a probable threat to treatment success rates, warranting the enhanced surveillance of A. fumigatus genotypes in these patients. Furthermore, potential changes to antifungal first-line treatment guidelines may be needed to improve patient outcomes when CAPA is suspected.
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Affiliation(s)
- Benjamin C. Simmons
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- UK Health Security Agency, London EP14 4PU, UK
| | - Johanna Rhodes
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
| | - Thomas R. Rogers
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
- Radboudumc-CWZ Center of Expertise for Mycology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Alireza Abdolrasouli
- Department of Infectious Diseases, Imperial College London, London W2 1NY, UK;
- Department of Infectious Diseases, King’s College Hospital, London SE5 9RS, UK
| | - Silke Schelenz
- Infection Sciences, King’s College Hospital, London SE5 9RS, UK;
- School of Immunology & Microbial Sciences, King’s College London, London WC2R 2LS, UK
| | - Samuel J. Hemmings
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
| | - Alida Fe Talento
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
- Department of Microbiology, Our Lady of Lourdes Hospital, A92 VW28 Drogheda, Ireland
- Department of Microbiology, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Auveen Griffin
- Department of Microbiology, St. James’ Hospital, D08 NHY1 Dublin, Ireland;
| | - Mary Mansfield
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - David Sheehan
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Thijs Bosch
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Matthew C. Fisher
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
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8
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Salehi Z, Sharifynia S, Jamzivar F, Shams-Ghahfarokhi M, Poorabdollah M, Abtahian Z, Nasiri N, Marjani M, Moniri A, Salehi M, Tabarsi P, Razzaghi-Abyaneh M. Clinical epidemiology of pulmonary aspergillosis in hospitalized patients and contribution of Cyp51A, Yap1, and Cdr1B mutations to voriconazole resistance in etiologic Aspergillus species. Eur J Clin Microbiol Infect Dis 2023:10.1007/s10096-023-04608-7. [PMID: 37142789 DOI: 10.1007/s10096-023-04608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 04/19/2023] [Indexed: 05/06/2023]
Abstract
Pulmonary aspergillosis is a life-threatening fungal infection with worldwide distribution. In the present study, clinical epidemiology of pulmonary aspergillosis and antifungal susceptibility of etiologic Aspergillus species were evaluated in one-hundred fifty patients with special focus on the frequency of voriconazole resistance. All the cases were confirmed by the clinical pictures, laboratory findings, and isolation of etiologic Aspergillus species which belonged to two major species, i.e., A. flavus and A. fumigatus. Seventeen isolates displayed voriconazole MIC greater than or equal to the epidemiological cutoff value. Expression of cyp51A, Cdr1B, and Yap1 genes was analyzed in voriconazole-intermediate/resistant isolates. In A. flavus, Cyp51A protein sequencing showed the substitutions T335A and D282E. In the Yap1 gene, A78C replacement led to Q26H amino acid substitution that was not reported previously in A. flavus resistant to voriconazole. No mutations associated with voriconazole resistance were found in the three genes of A. fumigatus. The expression of Yap1 was higher than that of two other genes in both A. flavus and A. fumigatus. Overall, voriconazole-resistant strains of both A. fumigatus and A. flavus demonstrated overexpression of Cdr1B, Cyp51A, and Yap1 genes compared to voriconazole-susceptible strains. Although there are still ambiguous points about the mechanisms of azole resistance, our results showed that mutations were not present in majority of resistant and intermediate isolates, while all of these isolates showed overexpression in all three genes studied. As a conclusion, it seems that the main reason of the emergence of mutation in voriconazole-resistant isolates of A. flavus and A. fumigatus is previous or prolonged exposure to azoles.
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Affiliation(s)
- Zahra Salehi
- Department of Mycology, Pasteur Institute of Iran, Tehran, 1316943551, Iran
| | - Somayeh Sharifynia
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Mihan Poorabdollah
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Abtahian
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naser Nasiri
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Majid Marjani
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afshin Moniri
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Salehi
- Research Center for Antibiotic Stewardship & Antimicrobial Resistance, Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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9
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Serrano-Lobo J, Gómez A, Reigadas E, Muñoz P, Escribano P, Guinea J. Screening of azole resistance in Aspergillus fumigatus using the EUCAST E.Def 10.2 azole-containing agar method: a single study suggests that filtration of conidial suspensions prior to inoculum preparation may not be needed. Mycoses 2022; 65:1045-1049. [PMID: 35796747 DOI: 10.1111/myc.13492] [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: 03/14/2022] [Accepted: 07/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Azole resistance screening in A. fumigatus isolates can be routinely carried out by using azole-containing plates (E.Def 10.2 method), that requires filtering conidial suspensions prior inoculum adjustment. OBJECTIVES We evaluated whether skipping the filtration step of conidial suspensions negatively influences the performance of the E.Def 10.2. Patients/Methods A. fumigatus sensu stricto isolates (n=92), classified as azole-susceptible or azole-resistant according to the EUCAST microdilution E.Def 9.4 method, were studied. Azole-resistant isolates had either wild type cyp51A gene sequence (n = 3) or the TR34 -L98H (n = 26), G54R (n = 5), TR46 -Y121F-T289A (n = 1), F46Y-M172V-N248T-D255E-E427K (n = 1), F165L (n=1), or G448S (n=1) cyp51A gene substitutions. In-house azole-containing agar plates were prepared according to the EUCAST E.Def 10.2 procedure. Conidial suspensions were obtained by adding distilled water (Tween 20 0.1%). Subsequently, the suspensions were either filtered or left unfiltered prior to inoculum adjustment to 0.5 McFarland. Using microdilution as the gold standard, agreement, sensitivity, and specificity of the agar plates inoculated with two inoculums were assessed. RESULTS Agreements for the agar screening method with either unfiltered or filtered conidial suspensions were high for itraconazole (100%), voriconazole (100%), and posaconazole (97.8%). Sensitivity (100%) and specificity (98.2%) of the procedure to rule in or out resistance when unfiltered suspensions were used were also high. Isolates harbouring the TR34 -L98H, G54R, and TR46 -Y121F-T289A substitutions were detected with the modified method. CONCLUSIONS Unfiltered conidial suspensions does not negatively influence the performance of the E.Def 10.2 method when screening for A. fumigatus sensu stricto.
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Affiliation(s)
- Julia Serrano-Lobo
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Gómez
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Elena Reigadas
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
- Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
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10
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Koehler P, von Stillfried S, Garcia Borrega J, Fuchs F, Salmanton-García J, Pult F, Böll B, Eichenauer DA, Shimabukuro-Vornhagen A, Kurzai O, Boor P, Kochanek M, Cornely OA. Aspergillus tracheobronchitis in COVID-19 ARDS patients - a cohort study. Eur Respir J 2022; 59:13993003.03142-2021. [PMID: 35144992 PMCID: PMC9068972 DOI: 10.1183/13993003.03142-2021] [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: 12/12/2021] [Accepted: 02/02/2022] [Indexed: 11/15/2022]
Abstract
Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2 showed a profoundly altered immune system and received immune-modulating therapeutic interventions. This enhanced the susceptibility for fungal superinfections [1, 2]. With the first reports of COVID-19-associated pulmonary aspergillosis (CAPA) the 2020 European Confederation of Medical Mycology (ECMM)/International Society for Human and Animal Mycology (ISHAM) consensus criteria were proposed [3, 4] and Aspergillus tracheobronchitis (ATB) was distinguished as a sub-entity in CAPA [4–6]. During bronchoscopy, ATB presents as ulcerations, pseudomembranes, plaques and eschars, possibly combined with tracheal stenosis [5]. Facing the risk of transmission and SARS-CoV-2 infection of examiners during bronchoscopy, blind suctioning of upper airway samples has been implemented with tracheal aspirates (TA) and non-bronchoscopic lavages. These techniques preclude inspection of the airways, so that ATB cannot be diagnosed beyond the level of suspicion. To study ATB in CAPA patients, we performed a retrospective, single-centre cohort study. Comprehensive work-up is needed for COVID-19 ARDS patients, especially when suspecting invasive fungal infections. Aspergillus tracheobronchitis has a substantial prevalence in patients with CAPA accounting for an overall mortality of 75% in this study.https://bit.ly/3uF3FZU
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Affiliation(s)
- Philipp Koehler
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | | | - Jorge Garcia Borrega
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Frieder Fuchs
- University of Cologne, Medical Faculty and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
| | - Jon Salmanton-García
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Fabian Pult
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Boris Böll
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | | | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Wuerzburg, Wuerzburg, Germany.,National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Jena, Germany
| | - Peter Boor
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany.,Department of Nephrology and Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne, ZKS Köln, Cologne, Germany.,University of Cologne, Medical Faculty and University Hospital Cologne, German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,MK and OAC share last authorship
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11
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Buil JB, Oliver JD, Law D, Baltussen T, Zoll J, Hokken MWJ, Tehupeiory-Kooreman M, Melchers WJG, Birch M, Verweij PE. Resistance profiling of Aspergillus fumigatus to olorofim indicates absence of intrinsic resistance and unveils the molecular mechanisms of acquired olorofim resistance. Emerg Microbes Infect 2022; 11:703-714. [PMID: 35109772 PMCID: PMC8890541 DOI: 10.1080/22221751.2022.2034485] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Olorofim (F901318) is a new antifungal currently under clinical development that shows both in vitro and in vivo activity against a number of filamentous fungi including Aspergillus fumigatus. In this study, we screened A. fumigatus isolates for intrinsic olorofim-resistant A. fumigatus and evaluated the ability of A. fumigatus to acquire an olorofim-resistant phenotype. No intrinsic resistance was found in 975 clinical A. fumigatus isolates. However, we found that isolates with increased olorofim MICs (> 8 mg/L) could be selected using a high number of conidia and olorofim exposure under laboratory conditions. Assessment of the frequency of acquired olorofim resistance development of A. fumigatus was shown to be higher than for voriconazole but lower than for itraconazole. Sequencing the PyrE gene of isogenic isolates with olorofim MICs of >8 mg/L identified various amino acid substitutions with a hotspot at locus G119. Olorofim was shown to have reduced affinity to mutated target protein dihydroorotate dehydrogenase (DHODH) and the effect of these mutations was proven by introducing the mutations directly in A. fumigatus. We then investigated whether G119 mutations were associated with a fitness cost in A. fumigatus. These experiments showed a small but significant reduction in growth rate for strains with a G119V substitution, while strains with a G119C substitution did not exhibit a reduction in growth rate. These in vitro findings were confirmed in an in vivo pathogenicity model.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, The Netherlands
| | | | - Derek Law
- F2G Ltd, Lankro Way, Manchester, United Kingdom
| | - Tim Baltussen
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Zoll
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, The Netherlands
| | - Margriet W J Hokken
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlou Tehupeiory-Kooreman
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, The Netherlands
| | - Mike Birch
- F2G Ltd, Lankro Way, Manchester, United Kingdom
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, The Netherlands
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12
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Lucio J, Gonzalez-Jimenez I, Garcia-Rubio R, Cuetara MS, Mellado E. An expanded agar-based screening method for azole-resistant Aspergillus fumigatus. Mycoses 2021; 65:178-185. [PMID: 34806786 DOI: 10.1111/myc.13400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022]
Abstract
Antifungal susceptibility testing is an essential tool for guiding antifungal therapy. Reference methods are complex and usually only available in specialised laboratories. We have designed an expanded agar-based screening method for the detection of azole-resistant Aspergillus fumigatus isolates. Normally, identification of resistance mechanisms is obtained only after sequencing the cyp51A gene and promoter. However, our screening method provides azole resistance detection and presumptive resistance mechanisms identification. A previous agar-based method consisting of four wells containing voriconazole, itraconazole, posaconazole and a growth control, detected azole resistance to clinical azoles. Here, we have modified the concentrations of voriconazole and posaconazole to adapt to the updated EUCAST breakpoints against A. fumigatus. We have also expanded the method to include environmental azoles to assess azole resistance and the azole resistance mechanism involved. We used a collection of A. fumigatus including 54 azole-resistant isolates with Cyp51A modifications (G54, M220, G448S, TR53 , TR34 /L98H, TR46 /Y121F/T289A, TR34 /L98H/S297T/F495I), and 50 azole susceptible isolates with wild-type Cyp51A. The screening method detects azole-resistant A. fumigatus isolates when there is growth in any of the azole-containing wells after 48h. The growth pattern in the seven azoles tested helps determine the underlying azole resistance mechanism. This approach is designed for surveillance screening of A. fumigatus azole-resistant isolates and can be useful for the clinical management of patients prior to antifungal susceptibility testing confirmation.
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Affiliation(s)
- Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain
| | - Irene Gonzalez-Jimenez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain
| | - Rocio Garcia-Rubio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain
| | | | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), ISCIII, Majadahonda, Spain
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13
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Heuer C, Bahnemann J, Scheper T, Segal E. Paving the Way to Overcome Antifungal Drug Resistance: Current Practices and Novel Developments for Rapid and Reliable Antifungal Susceptibility Testing. SMALL METHODS 2021; 5:e2100713. [PMID: 34927979 DOI: 10.1002/smtd.202100713] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/05/2021] [Indexed: 06/14/2023]
Abstract
The past year has established the link between the COVID-19 pandemic and the global spread of severe fungal infections; thus, underscoring the critical need for rapid and realizable fungal disease diagnostics. While in recent years, health authorities, such as the Centers for Disease Control and Prevention, have reported the alarming emergence and spread of drug-resistant pathogenic fungi and warned against the devastating consequences, progress in the diagnosis and treatment of fungal infections is limited. Early diagnosis and patient-tailored therapy are established to be key in reducing morbidity and mortality associated with fungal (and cofungal) infections. As such, antifungal susceptibility testing (AFST) is crucial in revealing susceptibility or resistance of these pathogens and initiating correct antifungal therapy. Today, gold standard AFST methods require several days for completion, and thus this much delayed time for answer limits their clinical application. This review focuses on the advancements made in developing novel AFST techniques and discusses their implications in the context of the practiced clinical workflow. The aim of this work is to highlight the advantages and drawbacks of currently available methods and identify the main gaps hindering their progress toward clinical application.
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Affiliation(s)
- Christopher Heuer
- Institute of Technical Chemistry, Leibniz University Hannover, 30167, Hannover, Germany
- Department of Biotechnology and Food Engineering, Technion-Israel Institute of Technology, Haifa, 320003, Israel
| | - Janina Bahnemann
- Institute of Technical Chemistry, Leibniz University Hannover, 30167, Hannover, Germany
| | - Thomas Scheper
- Institute of Technical Chemistry, Leibniz University Hannover, 30167, Hannover, Germany
| | - Ester Segal
- Department of Biotechnology and Food Engineering, Technion-Israel Institute of Technology, Haifa, 320003, Israel
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14
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Durand C, Maubon D, Cornet M, Wang Y, Aldebert D, Garnaud C. Can We Improve Antifungal Susceptibility Testing? Front Cell Infect Microbiol 2021; 11:720609. [PMID: 34568095 PMCID: PMC8461061 DOI: 10.3389/fcimb.2021.720609] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Systemic antifungal agents are increasingly used for prevention or treatment of invasive fungal infections, whose prognosis remains poor. At the same time, emergence of resistant or even multi-resistant strains is of concern as the antifungal arsenal is limited. Antifungal susceptibility testing (AFST) is therefore of key importance for patient management and antifungal stewardship. Current AFST methods, including reference and commercial types, are based on growth inhibition in the presence of an antifungal, in liquid or solid media. They usually enable Minimal Inhibitory Concentrations (MIC) to be determined with direct clinical application. However, they are limited by a high turnaround time (TAT). Several innovative methods are currently under development to improve AFST. Techniques based on MALDI-TOF are promising with short TAT, but still need extensive clinical validation. Flow cytometry and computed imaging techniques detecting cellular responses to antifungal stress other than growth inhibition are also of interest. Finally, molecular detection of mutations associated with antifungal resistance is an intriguing alternative to standard AFST, already used in routine microbiology labs for detection of azole resistance in Aspergillus and even directly from samples. It is still restricted to known mutations. The development of Next Generation Sequencing (NGS) and whole-genome approaches may overcome this limitation in the near future. While promising approaches are under development, they are not perfect and the ideal AFST technique (user-friendly, reproducible, low-cost, fast and accurate) still needs to be set up routinely in clinical laboratories.
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Affiliation(s)
| | - Danièle Maubon
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
| | - Muriel Cornet
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
| | | | | | - Cécile Garnaud
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
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15
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Arastehfar A, Carvalho A, Houbraken J, Lombardi L, Garcia-Rubio R, Jenks J, Rivero-Menendez O, Aljohani R, Jacobsen I, Berman J, Osherov N, Hedayati M, Ilkit M, Armstrong-James D, Gabaldón T, Meletiadis J, Kostrzewa M, Pan W, Lass-Flörl C, Perlin D, Hoenigl M. Aspergillus fumigatus and aspergillosis: From basics to clinics. Stud Mycol 2021; 100:100115. [PMID: 34035866 PMCID: PMC8131930 DOI: 10.1016/j.simyco.2021.100115] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The airborne fungus Aspergillus fumigatus poses a serious health threat to humans by causing numerous invasive infections and a notable mortality in humans, especially in immunocompromised patients. Mould-active azoles are the frontline therapeutics employed to treat aspergillosis. The global emergence of azole-resistant A. fumigatus isolates in clinic and environment, however, notoriously limits the therapeutic options of mould-active antifungals and potentially can be attributed to a mortality rate reaching up to 100 %. Although specific mutations in CYP 51A are the main cause of azole resistance, there is a new wave of azole-resistant isolates with wild-type CYP 51A genotype challenging the efficacy of the current diagnostic tools. Therefore, applications of whole-genome sequencing are increasingly gaining popularity to overcome such challenges. Prominent echinocandin tolerance, as well as liver and kidney toxicity posed by amphotericin B, necessitate a continuous quest for novel antifungal drugs to combat emerging azole-resistant A. fumigatus isolates. Animal models and the tools used for genetic engineering require further refinement to facilitate a better understanding about the resistance mechanisms, virulence, and immune reactions orchestrated against A. fumigatus. This review paper comprehensively discusses the current clinical challenges caused by A. fumigatus and provides insights on how to address them.
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Affiliation(s)
- A. Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - A. Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J. Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - L. Lombardi
- UCD Conway Institute and School of Medicine, University College Dublin, Dublin 4, Ireland
| | - R. Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - J.D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA, 92093, USA
| | - O. Rivero-Menendez
- Medical Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, 28222, Spain
| | - R. Aljohani
- Department of Infectious Diseases, Imperial College London, London, UK
| | - I.D. Jacobsen
- Department of Microbial Pathogenicity Mechanisms, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - J. Berman
- Research Group Microbial Immunology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
| | - N. Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, 69978, Israel
| | - M.T. Hedayati
- Invasive Fungi Research Center/Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M. Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Çukurova University, 01330, Adana, Turkey
| | | | - T. Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, Barcelona, 08034, Spain
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluís Companys 23, 08010, Barcelona, Spain
| | - J. Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - W. Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - C. Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - D.S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - M. Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
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16
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Azole-Resistant Aspergillus fumigatus Clinical Isolate Screening in Azole-Containing Agar Plates (EUCAST E.Def 10.1): Low Impact of Plastic Trays Used and Poor Performance in Cryptic Species. Antimicrob Agents Chemother 2021; 65:e0048221. [PMID: 34252311 DOI: 10.1128/aac.00482-21] [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: 12/11/2022] Open
Abstract
Azole-containing agar is used in routine Aspergillus fumigatus azole resistance screening. We evaluated the impact of the type of plastic used to prepare in-house agar plates on the procedure's performance against A. fumigatus sensu stricto and cryptic species. A. fumigatus sensu stricto (n = 91) and cryptic species (n = 52) were classified as susceptible or resistant (EUCAST E.Def 9.3.2; clinical breakpoints v10). In-house azole-containing agar plates were prepared following EUCAST E.Def 10.1 on three types of multidish plates. We assessed the sensitivity, specificity, and agreement values of the agar plates to screen for azole resistance. Overall, sensitivity and specificity values of the agar screening method were 100% and 93.3%, respectively. The type of tray used did not affect these values. All isolates harboring TR34-L98H substitutions were classified as resistant to itraconazole and voriconazole by the agar method; however, false susceptibility (very major error) to posaconazole was not uncommon and happened in isolates with posaconazole MICs of 0.25 mg/liter. Isolates harboring G54R and TR46-Y121F-T289A substitutions were correctly classified by the agar method as itraconazole/posaconazole resistant and voriconazole resistant, respectively. False resistance (major error) occurred in isolates showing tiny fungal growth. Finally, agreements between both procedures against cryptic species were much lower. Azole-containing agar plates are a convenient and reliable tool to screen for resistance in A. fumigatus sensu stricto; the type of plastic tray used minimally affects the method. On the contrary, the performance against cryptic species is rather poor.
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17
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Antifungal Susceptibility and Mutations in the Squalene Epoxidase Gene in Dermatophytes of the Trichophyton mentagrophytes Species Complex. Antimicrob Agents Chemother 2021; 65:e0005621. [PMID: 33972254 PMCID: PMC8284460 DOI: 10.1128/aac.00056-21] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
During the past decade, a prolonged and serious outbreak of dermatophytosis due to a terbinafine-resistant novel species in the Trichophyton mentagrophytes-T. interdigitale complex has been ongoing in India, and it has spread to several European countries. The objective of this study was to investigate the molecular background of the squalene epoxidase (SQLE) gene in order to understand the risk of emergence and spread of multiresistance in dermatophytes. Antifungal susceptibility to fluconazole, griseofulvin, itraconazole, ketoconazole, miconazole, naftifine, sertaconazole, and terbinafine was tested in 135 isolates from India, China, Australia, Germany, and The Netherlands. Based on the latest taxonomic insights, strains were identified as three species: T. mentagrophytessensu stricto (n = 35), T. indotineae (n = 64, representing the Indian clone), and T. interdigitalesensu stricto (n = 36). High MICs of terbinafine (>16 mg/liter) were found in 34 (53%) T. indotineae isolates. These isolates showed an amino acid substitution in the 397th position of the SQLE gene. Elevated MICs of terbinafine (0.5 mg/liter) were noted in 2 (3%) T. indotineae isolates; these isolates lead to Phe415Val and Leu393Ser of the SQLE gene. The stability of the effect of the mutations was proven by serial transfer on drug-free medium. Lys276Asn and Leu419Phe substitutions were found in susceptible T. mentagrophytes strains. The Phe377Leu/Ala448Thr double mutant showed higher MIC values for triazoles. High MICs of terbinafine are as yet limited to T. indotineae and are unlikely to be distributed throughout the T. mentagrophytes species complex by genetic exchange.
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18
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Kidd SE, Crawford LC, Halliday CL. Antifungal Susceptibility Testing and Identification. Infect Dis Clin North Am 2021; 35:313-339. [PMID: 34016280 DOI: 10.1016/j.idc.2021.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The requirement for antifungal susceptibility testing is increasing given the availability of new drugs, increasing populations of individuals at risk for fungal infection, and emerging multiresistant fungi. Rapid and accurate fungal identification remains at the forefront of laboratory efforts to guide empiric therapy. Antifungal susceptibility testing methods have greatly improved, but are subject to variation in results between methods. Careful standardization, validation, and extensive training of users is essential to ensure susceptibility results are clinically useful and interpreted appropriately. Interpretive criteria for many drugs and species are still lacking, but this will continue to evolve.
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Affiliation(s)
- Sarah E Kidd
- National Mycology Reference Centre, Microbiology & Infectious Diseases, SA Pathology, SA Pathology (Frome Campus), PO Box 14, Rundle Mall, Adelaide, South Australia 5000, Australia; School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia.
| | - Lucy C Crawford
- Microbiology & Infectious Diseases, SA Pathology, PO Box 14, Rundle Mall, Adelaide, South Australia 5000, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Catriona L Halliday
- Clinical Mycology Reference Laboratory, Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, The University of Sydney, Level 3 ICPMR, Darcy Road, Westmead, New South Wales 2145, Australia
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19
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Brackin AP, Shelton JMG, Abdolrasouli A, Fisher MC, Sewell TR. A Low-Cost Tebuconazole-Based Screening Test for Azole-Resistant Aspergillus fumigatus. ACTA ACUST UNITED AC 2021; 58:e112. [PMID: 32857921 DOI: 10.1002/cpmc.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The global emergence of azole resistance in Aspergillus fumigatus is resulting in health and food security concerns. Rapid diagnostics and environmental surveillance methods are key to understanding the distribution and prevalence of azole resistance. However, such methods are often associated with high costs and are not always applicable to laboratories based in the least-developed countries. Here, we present and validate a low-cost screening protocol that can be used to differentiate between azole-susceptible "wild-type" and azole-resistant A. fumigatus isolates. © 2020 The Authors. Basic Protocol 1: Preparation of Tebucheck multi-well plates Basic Protocol 2: Inoculation of Tebucheck multi-well plates.
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Affiliation(s)
- Amelie P Brackin
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Jennifer M G Shelton
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Alireza Abdolrasouli
- Diagnostic Mycology Service, Department of Medical Microbiology, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Matthew C Fisher
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Thomas R Sewell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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20
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Resendiz-Sharpe A, Dewaele K, Merckx R, Bustamante B, Vega-Gomez MC, Rolon M, Jacobs J, Verweij PE, Maertens J, Lagrou K. Triazole-Resistance in Environmental Aspergillus fumigatus in Latin American and African Countries. J Fungi (Basel) 2021; 7:jof7040292. [PMID: 33921497 PMCID: PMC8070258 DOI: 10.3390/jof7040292] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 01/10/2023] Open
Abstract
Triazole-resistance has been reported increasingly in Aspergillus fumigatus. An international expert team proposed to avoid triazole monotherapy for the initial treatment of invasive aspergillosis in regions with >10% environmental-resistance, but this prevalence is largely unknown for most American and African countries. Here, we screened 584 environmental samples (soil) from urban and rural locations in Mexico, Paraguay, and Peru in Latin America and Benin and Nigeria in Africa for triazole-resistant A. fumigatus. Samples were screened using triazole-containing agars and confirmed as triazole-resistant by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth dilution reference method. Isolates were further characterized by cyp51A sequencing and short-tandem repeat typing. Fungicide presence in samples was likewise determined. Among A. fumigatus positive samples, triazole-resistance was detected in 6.9% (7/102) of samples in Mexico, 8.3% (3/36) in Paraguay, 9.8% (6/61) in Peru, 2.2% (1/46) in Nigeria, and none in Benin. Cyp51A gene mutations were present in most of the triazole-resistant isolates (88%; 15/17). The environmentally-associated mutations TR34/L98H and TR46/Y121F/T289A were prevalent in Mexico and Peru, and isolates harboring these mutations were closely related. For the first time, triazole-resistant A. fumigatus was found in environmental samples in Mexico, Paraguay, Peru, and Nigeria with a prevalence of 7-10% in the Latin American countries. Our findings emphasize the need to establish triazole-resistance surveillance programs in these countries.
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Affiliation(s)
- Agustin Resendiz-Sharpe
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Klaas Dewaele
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Rita Merckx
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Beatriz Bustamante
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
| | - Maria Celeste Vega-Gomez
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Miriam Rolon
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Jan Jacobs
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerpen, Belgium
| | - Paul E. Verweij
- Radboud University Medical Center, Department of Medical Microbiology, 6500 HB Nijmegen, The Netherlands;
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
- Correspondence: ; Tel.: +32-016-34-70-98
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21
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Proven Fatal Invasive Aspergillosis in a Patient with COVID-19 and Staphylococcus aureus Pneumonia. J Fungi (Basel) 2021; 7:jof7030230. [PMID: 33808931 PMCID: PMC8003593 DOI: 10.3390/jof7030230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
There is increasing attention for opportunistic pathogens such as Aspergillus fumigatus complicating SARS-CoV-2 infections in the critically ill. For invasive fungal disease, establishing a clear diagnosis can be challenging due to the invasiveness of diagnostic procedures required for a proven case. Here we present one of the first proven cases of COVID-19-associated pulmonary aspergillosis by positive culture of post-mortem lung biopsy.
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22
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Effects of Agricultural Fungicide Use on Aspergillus fumigatus Abundance, Antifungal Susceptibility, and Population Structure. mBio 2020; 11:mBio.02213-20. [PMID: 33234685 PMCID: PMC7701986 DOI: 10.1128/mbio.02213-20] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Antibiotic resistance is an increasing threat to human health. In the case of Aspergillus fumigatus, which is both an environmental saprobe and an opportunistic human fungal pathogen, resistance is suggested to arise from fungicide use in agriculture, as the azoles used for plant protection share the same molecular target as the frontline antifungals used clinically. However, limiting azole fungicide use on crop fields to preserve their activity for clinical use could threaten the global food supply via a reduction in yield. In this study, we clarify the link between azole fungicide use on crop fields and resistance in a prototypical human pathogen through systematic soil sampling on farms in Germany and surveying fields before and after fungicide application. We observed a reduction in the abundance of A. fumigatus on fields following fungicide treatment in 2017, a finding that was not observed on an organic control field with only natural plant protection agents applied. However, this finding was less pronounced during our 2018 sampling, indicating that the impact of fungicides on A. fumigatus population size is variable and influenced by additional factors. The overall resistance frequency among agricultural isolates is low, with only 1 to 3% of isolates from 2016 to 2018 displaying resistance to medical azoles. Isolates collected after the growing season and azole exposure show a subtle but consistent decrease in susceptibility to medical and agricultural azoles. Whole-genome sequencing indicates that, despite the alterations in antifungal susceptibility, fungicide application does not significantly affect the population structure and genetic diversity of A. fumigatus in fields. Given the low observed resistance rate among agricultural isolates as well the lack of genomic impact following azole application, we do not find evidence that azole use on crops is significantly driving resistance in A. fumigatus in this context.IMPORTANCE Antibiotic resistance is an increasing threat to human health. In the case of Aspergillus fumigatus, which is an environmental fungus that also causes life-threatening infections in humans, antimicrobial resistance is suggested to arise from fungicide use in agriculture, as the chemicals used for plant protection are almost identical to the antifungals used clinically. However, removing azole fungicides from crop fields threatens the global food supply via a reduction in yield. In this study, we survey crop fields before and after fungicide application. We find a low overall azole resistance rate among agricultural isolates, as well as a lack of genomic and population impact following fungicide application, leading us to conclude azole use on crops does not significantly contribute to resistance in A. fumigatus.
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23
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Biomimicry of microbial polysaccharide hydrogels for tissue engineering and regenerative medicine – A review. Carbohydr Polym 2020; 241:116345. [DOI: 10.1016/j.carbpol.2020.116345] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 12/17/2022]
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24
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Ghelfenstein-Ferreira T, Saade A, Alanio A, Bretagne S, Araujo de Castro R, Hamane S, Azoulay E, Bredin S, Dellière S. Recovery of a triazole-resistant Aspergillus fumigatus in respiratory specimen of COVID-19 patient in ICU - A case report. Med Mycol Case Rep 2020; 31:15-18. [PMID: 32837880 PMCID: PMC7331532 DOI: 10.1016/j.mmcr.2020.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022] Open
Abstract
Although invasive pulmonary aspergillosis (IPA) is typically described in immunocompromised host, patient with severe influenzae can develop IPA. Similarly, patients with severe COVID-19 complicated with IPA are increasingly reported. Here, we describe a case of invasive aspergillosis with triazole-resistant A. fumigatus (TR34/L98H mutation) in a 56-year-old patient with COVID-19 in intensive care unit. This report highlights the need to define the available tools for diagnosis of invasive aspergillosis in severe COVID-19 patients. Association between COVID-19 and invasive aspergillosis. Early screening for aspergillosis should be performed in respiratory specimen. This case emphasizes the need to screen isolates for pan-azole resistance.
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Affiliation(s)
| | - Anastasia Saade
- Médecine Intensive et Réanimation, Hôpital Saint-Louis (AP-HP), Université de Paris, France
| | - Alexandre Alanio
- Laboratoire de Parasitologie - Mycologie, Hôpital Saint-Louis (AP-HP), Université de Paris, France.,Unité de Mycologie Moléculaire, Institut Pasteur, CNRS URA 3012, Centre National de Référence des Mycoses Invasives et des Antifongiques, URA, 3012, Paris, France
| | - Stéphane Bretagne
- Laboratoire de Parasitologie - Mycologie, Hôpital Saint-Louis (AP-HP), Université de Paris, France.,Unité de Mycologie Moléculaire, Institut Pasteur, CNRS URA 3012, Centre National de Référence des Mycoses Invasives et des Antifongiques, URA, 3012, Paris, France
| | - Raffael Araujo de Castro
- Unité de Mycologie Moléculaire, Institut Pasteur, CNRS URA 3012, Centre National de Référence des Mycoses Invasives et des Antifongiques, URA, 3012, Paris, France
| | - Samia Hamane
- Laboratoire de Parasitologie - Mycologie, Hôpital Saint-Louis (AP-HP), Université de Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis (AP-HP), Université de Paris, France
| | - Swann Bredin
- Médecine Intensive et Réanimation, Hôpital Saint-Louis (AP-HP), Université de Paris, France
| | - Sarah Dellière
- Laboratoire de Parasitologie - Mycologie, Hôpital Saint-Louis (AP-HP), Université de Paris, France
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25
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Lestrade PP, Bentvelsen RG, Schauwvlieghe AFAD, Schalekamp S, van der Velden WJFM, Kuiper EJ, van Paassen J, van der Hoven B, van der Lee HA, Melchers WJG, de Haan AF, van der Hoeven HL, Rijnders BJA, van der Beek MT, Verweij PE. Voriconazole Resistance and Mortality in Invasive Aspergillosis: A Multicenter Retrospective Cohort Study. Clin Infect Dis 2020; 68:1463-1471. [PMID: 30307492 DOI: 10.1093/cid/ciy859] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 10/04/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Triazole resistance is an increasing problem in invasive aspergillosis (IA). Small case series show mortality rates of 50%-100% in patients infected with a triazole-resistant Aspergillus fumigatus, but a direct comparison with triazole-susceptible IA is lacking. METHODS A 5-year retrospective cohort study (2011-2015) was conducted to compare mortality in patients with voriconazole-susceptible and voriconazole-resistant IA. Aspergillus fumigatus culture-positive patients were investigated to identify patients with proven, probable, and putative IA. Clinical characteristics, day 42 and day 90 mortality, triazole-resistance profiles, and antifungal treatments were investigated. RESULTS Of 196 patients with IA, 37 (19%) harbored a voriconazole-resistant infection. Hematological malignancy was the underlying disease in 103 (53%) patients, and 154 (79%) patients were started on voriconazole. Compared with voriconazole-susceptible cases, voriconazole resistance was associated with an increase in overall mortality of 21% on day 42 (49% vs 28%; P = .017) and 25% on day 90 (62% vs 37%; P = .0038). In non-intensive care unit patients, a 19% lower survival rate was observed in voriconazole-resistant cases at day 42 (P = .045). The mortality in patients who received appropriate initial voriconazole therapy was 24% compared with 47% in those who received inappropriate therapy (P = .016), despite switching to appropriate antifungal therapy after a median of 10 days. CONCLUSIONS Voriconazole resistance was associated with an excess overall mortality of 21% at day 42 and 25% at day 90 in patients with IA. A delay in the initiation of appropriate antifungal therapy was associated with increased overall mortality.
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Affiliation(s)
- Pieter P Lestrade
- Department of Medical Microbiology, Radboud University Medical Center
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
| | | | | | - Steven Schalekamp
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen
| | - Walter J F M van der Velden
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
- Department of Hematology, Radboud University Medical Center, Nijmegen
| | - Ed J Kuiper
- Department of Medical Microbiology, Leiden University Medical Center
| | | | | | - Henrich A van der Lee
- Department of Medical Microbiology, Radboud University Medical Center
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
| | - Anton F de Haan
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hans L van der Hoeven
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bart J A Rijnders
- Department of Medical Microbiology and Infectious Disease, Erasmus Medical Center, Rotterdam
| | | | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center
- Center of Expertise in Mycology Radboud University Medical Center/CWZ, Nijmegen
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26
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Koehler P, Cornely OA, Böttiger BW, Dusse F, Eichenauer DA, Fuchs F, Hallek M, Jung N, Klein F, Persigehl T, Rybniker J, Kochanek M, Böll B, Shimabukuro-Vornhagen A. COVID-19 associated pulmonary aspergillosis. Mycoses 2020; 63:528-534. [PMID: 32339350 PMCID: PMC7267243 DOI: 10.1111/myc.13096] [Citation(s) in RCA: 374] [Impact Index Per Article: 93.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Patients with acute respiratory distress syndrome (ARDS) due to viral infection are at risk for secondary complications like invasive aspergillosis. Our study evaluates coronavirus disease 19 (COVID-19) associated invasive aspergillosis at a single centre in Cologne, Germany. METHODS A retrospective chart review of all patients with COVID-19 associated ARDS admitted to the medical or surgical intensive care unit at the University Hospital of Cologne, Cologne, Germany. RESULTS COVID-19 associated invasive pulmonary aspergillosis was found in five of 19 consecutive critically ill patients with moderate to severe ARDS. CONCLUSION Clinicians caring for patients with ARDS due to COVID-19 should consider invasive pulmonary aspergillosis and subject respiratory samples to comprehensive analysis to detect co-infection.
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Affiliation(s)
- Philipp Koehler
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,ZKS Köln, Clinical Trials Centre Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Fabian Dusse
- Department of Anesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Frieder Fuchs
- Faculty of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Florian Klein
- Institute of Virology, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thorsten Persigehl
- Department of Radiology, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Rybniker
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Boris Böll
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
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Abstract
Although not as ubiquitous as antibacterial susceptibility testing, antifungal susceptibility testing (AFST) is a tool of increasing importance in clinical microbiology laboratories. The goal of AFST is to reliably produce MIC values that may be used to guide patient therapy, inform epidemiological studies, and track rates of antifungal drug resistance. There are three methods that have been standardized by standards development organizations: broth dilution, disk diffusion, and azole agar screening for Aspergillus Other commonly used methods include gradient diffusion and the use of rapid automated instruments. Novel methodologies for susceptibility testing are in development. It is important for laboratories to consider not only the method of testing but also the interpretation (or lack thereof) of in vitro data.
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Chen YC, Kuo SF, Wang HC, Wu CJ, Lin YS, Li WS, Lee CH. Azole resistance in Aspergillus species in Southern Taiwan: An epidemiological surveillance study. Mycoses 2019; 62:1174-1181. [PMID: 31549427 DOI: 10.1111/myc.13008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/11/2019] [Accepted: 09/19/2019] [Indexed: 12/01/2022]
Abstract
Poor clinical outcomes for invasive aspergillosis are associated with antifungal resistance. Performing antifungal susceptibility tests on clinically relevant Aspergillus isolates from patients and environmental regions with known azole resistance is recommended. The aim of the study was to assess the presence of azole resistance in clinical Aspergillus spp. isolates and those from hospital environments and farmlands within a 40 km radius of the hospital. Clinical Aspergillus spp. isolates were cultured, as well as environmental Aspergillus spp. isolates obtained from air samples. Samples were subcultured in azole-containing agar plates. Isolates with a positive screening test were subjected to YeastOne methods to determine their minimum inhibitory concentrations of antifungals. Resistance mechanisms were investigated in the azole-resistant Aspergillus spp. isolates. No azole-resistant clinical or environmental A flavus, A oryaze, A niger or A terreus isolates were found in the present study. All A fumigatus clinical isolates were azole-susceptible. Seven A fumigatus environmental isolates were associated with cyp51A mutations, including two that harboured TR34 /L98H mutations with S297T/F495I substitutions, two with TR34 /L98H mutations and three with TR46 /Y121F/T289A mutations. One of these isolates was collected from farmland, one was from A ward and five were from B ward. The proportion of azole-resistant A fumigatus was 10.2% (6/59) and 3.2% (1/31) in the hospital environments and the farmlands near the hospital, respectively. The results showed that azole-resistant A fumigatus existed within hospital environments. This emphasises the importance of periodic surveillance in hospital environments and monitoring for the emergence of azole-resistant A fumigatus clinical isolates.
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Affiliation(s)
- Yi-Chun Chen
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shu-Fang Kuo
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Chen Wang
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan
| | - Chi-Jung Wu
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Shiou Lin
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Sin Li
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Chang Gung University College of Medicine, Kaohsiung, Taiwan
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30
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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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31
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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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32
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Triazole Antifungal Susceptibility Patterns among Aspergillus Species in Québec, Canada. J Clin Microbiol 2019; 57:JCM.00404-19. [PMID: 30918044 DOI: 10.1128/jcm.00404-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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33
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Sanguinetti M, Posteraro B. Susceptibility Testing of Fungi to Antifungal Drugs. J Fungi (Basel) 2018; 4:jof4030110. [PMID: 30223554 PMCID: PMC6162686 DOI: 10.3390/jof4030110] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 01/05/2023] Open
Abstract
Susceptibility testing of fungi against antifungal drugs commonly used for therapy is a key component of the care of patients with invasive fungal infections. Antifungal susceptibility testing (AFST) has progressed in recent decades to finally become standardized and available as both Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methods and in commercial manual/automated phenotypic methods. In clinical practice, the Sensititre YeastOne and Etest methods are widely used for AFST, particularly for sterile site isolates of Candida. Nevertheless, AFST is moving toward new phenotypic methods, such as matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), that are capable of providing rapid, and potentially more actionable, results for the treating clinician. Our objective is to summarize updated data on phenotypic methods for AFST of Candida and Aspergillus species and to assess their significance in view of opposing, but emerging, molecular genotypic methods.
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Affiliation(s)
- Maurizio Sanguinetti
- Insititute of Micorbiology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Brunella Posteraro
- Insitutue of Public Health (Section of Hygiene), Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
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34
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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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35
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High prevalence of triazole resistance in clinical Aspergillus fumigatus isolates in a specialist cardiothoracic centre. Int J Antimicrob Agents 2018; 52:637-642. [PMID: 30103005 DOI: 10.1016/j.ijantimicag.2018.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/10/2018] [Accepted: 08/04/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the prevalence of triazole-resistant Aspergillus fumigatus and common molecular cyp51A polymorphisms amongst clinical isolates in a specialised cardiothoracic centre in London, UK. METHODS All A. fumigatus isolates were prospectively analysed from April 2014 to March 2016. Isolates were screened with a four-well VIPcheck™ plate to assess triazole susceptibility. Resistance was confirmed with a standard microbroth dilution method according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. Triazole-resistant A. fumigatus isolates were subjected to a mixed-format real time polymerase chain reaction (RT-PCR) assay (AsperGenius®) to detect common cyp51A alterations. RESULTS We identified 167 clinical A. fumigatus isolates from 135 patients. Resistance to at least one azole antifungal drug was confirmed in 22/167 (13.2%) of isolates from 18/135 (13.3%) patients, including 12/74 (16.2%) patients with cystic fibrosis (CF). The highest detection rate of azole-resistant A. fumigatus was among the 11- to 20-y age group. All triazole-resistant isolates (n = 22) were resistant to itraconazole, 18 showed cross-resistance to posaconazole and 10 displayed reduced susceptibility to voriconazole. No pan-azole-resistant A. fumigatus was identified. TR34/L98H was identified in 6/22 (27.3%) of azole-resistant isolates and detectable in 5/12 (42%) patients with CF. CONCLUSIONS In our specialist cardiothoracic centre, the prevalence of triazole-resistant A. fumigatus is alarmingly high (13.2%). The majority of azole-resistant isolates were from patients with CF. We found a higher prevalence of the environmentally driven mutation TR34/L98H in our A. fumigatus isolates than in published UK data from other specialist respiratory centres, which may reflect differing patient populations managed at these institutions.
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36
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Tsitsopoulou A, Posso R, Vale L, Bebb S, Johnson E, White PL. Determination of the Prevalence of Triazole Resistance in Environmental Aspergillus fumigatus Strains Isolated in South Wales, UK. Front Microbiol 2018; 9:1395. [PMID: 29997605 PMCID: PMC6028733 DOI: 10.3389/fmicb.2018.01395] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background/Objectives: Azole resistance in Aspergillus fumigatus associated with the TR34/L98H mutations in the cyp51A gene have been increasingly reported. Determining the environmental resistance rate has been deemed important when considering front-line therapy for invasive aspergillosis. The aim of the study was to determine prevalence of azole resistance in environmental A. fumigatus isolates across South Wales. Methods: Over 5 months in 2015, 513 A. fumigatus isolates were cultured from 671 soil and 44 air samples and were screened for azole resistance using VIPcheck™ agar plates containing itraconazole, voriconazole and posaconazole. Resistance was confirmed by the CLSI M38-A2 methodology. The mechanism of resistance was investigated using the PathoNostics AsperGenius® Assay. Results: Screening by VIPcheck™ plate identified azole-resistance in 30 isolates, most of which (28/30) harbored the TR34/L98H mutation, generating a prevalence of 6.0%. Twenty-five isolates had a MIC of ≥2 mg/L with itraconazole, 23 isolates had a MIC of ≥2 mg/L with voriconazole and seven isolates had a MIC ≥0.25 mg/L with posaconazole. All isolates deemed resistant by VIPcheck™ plates were resistant to at least one azole by reference methodology. Conclusions: There is significant environmental azole resistance (6%) in South Wales, in close proximity to patients susceptible to aspergillosis. Given this environmental reservoir, azole resistance should be routinely screened for in clinical practice and environmental monitoring continued.
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Affiliation(s)
- Alexandra Tsitsopoulou
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, Cardiff, United Kingdom
| | - Raquel Posso
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, Cardiff, United Kingdom
| | - Lorna Vale
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, Cardiff, United Kingdom
| | - Scarlett Bebb
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, Cardiff, United Kingdom
| | - Elizabeth Johnson
- National Mycology Reference Laboratory, Public Health England, Bristol, United Kingdom
| | - P L White
- Regional Mycology Reference Laboratory, Public Health Wales, Microbiology Cardiff, Cardiff, United Kingdom
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37
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 823] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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38
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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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