1
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Bays DJ, Jenkins EN, Lyman M, Chiller T, Strong N, Ostrosky-Zeichner L, Hoenigl M, Pappas PG, Thompson III GR. Epidemiology of Invasive Candidiasis. Clin Epidemiol 2024; 16:549-566. [PMID: 39219747 PMCID: PMC11366240 DOI: 10.2147/clep.s459600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/15/2024] [Indexed: 09/04/2024] Open
Abstract
Invasive candidiasis (IC) is an increasingly prevalent, costly, and potentially fatal infection brought on by the opportunistic yeast, Candida. Previously, IC has predominantly been caused by C. albicans which is often drug susceptible. There has been a global trend towards decreasing rates of infection secondary to C. albicans and a rise in non-albicans species with a corresponding increase in drug resistance creating treatment challenges. With advances in management of malignancies, there has also been an increase in the population at risk from IC along with a corresponding increase in incidence of breakthrough IC infections. Additionally, the emergence of C. auris creates many challenges in management and prevention due to drug resistance and the organism's ability to transmit rapidly in the healthcare setting. While the development of novel antifungals is encouraging for future management, understanding the changing epidemiology of IC is a vital step in future management and prevention.
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Affiliation(s)
- Derek J Bays
- Department of Internal Medicine, Division of Infectious Diseases, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Emily N Jenkins
- ASRT, Inc, Atlanta, GA, USA
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Meghan Lyman
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tom Chiller
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nora Strong
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Clinical and Translational Fungal Working Group, University of California San Diego, La Jolla, CA, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George R Thompson III
- Department of Internal Medicine, Division of Infectious Diseases, School of Medicine, University of California Davis, Sacramento, CA, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, CA, USA
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2
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Franconi I, Rizzato C, Ghelardi E, Lupetti A. Hospital distribution, seasonality, time trends and antifungal susceptibility profiles of all Aspergillus species isolated from clinical samples from 2015 to 2022 in a tertiary care hospital. BMC Microbiol 2024; 24:111. [PMID: 38570761 PMCID: PMC10988875 DOI: 10.1186/s12866-024-03267-8] [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: 04/27/2023] [Accepted: 03/19/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Aspergillus species cause a variety of serious clinical conditions with increasing trend in antifungal resistance. The present study aimed at evaluating hospital epidemiology and antifungal susceptibility of all isolates recorded in our clinical database since its implementation. METHODS Data on date of isolation, biological samples, patients' age and sex, clinical settings, and antifungal susceptibility tests for all Aspergillus spp. isolated from 2015 to 2022 were extracted from the clinical database. Score test for trend of odds, non-parametric Mann Kendall trend test and logistic regression analysis were used to analyze prevalence, incidence, and seasonality of Aspergillus spp. isolates. RESULTS A total of 1126 Aspergillus spp. isolates were evaluated. A. fumigatus was the most prevalent (44.1%) followed by A. niger (22.3%), A. flavus (17.7%) and A. terreus (10.6%). A. niger prevalence increased over time in intensive care units (p-trend = 0.0051). Overall, 16 (1.5%) were not susceptible to one azole compound, and 108 (10.9%) to amphotericin B, with A. niger showing the highest percentage (21.9%). The risk of detecting A. fumigatus was higher in June, (OR = 2.14, 95% CI [1.16; 3.98] p = 0.016) and reduced during September (OR = 0.48, 95% CI [0.27; 0.87] p = 0.015) and October as compared to January (OR = 0.39, 95% CI [0.21; 0.70] p = 0.002. A. niger showed a reduced risk of isolation from all clinical samples in the month of June as compared to January (OR = 0.34, 95% CI [0.14; 0.79] p = 0.012). Seasonal trend for A. flavus showed a higher risk of detection in September (OR = 2.7, 95% CI [1.18; 6.18] p = 0.019), October (OR = 2.32, 95% CI [1.01; 5.35] p = 0.048) and November (OR = 2.42, 95% CI [1.01; 5.79] p = 0.047) as compared to January. CONCLUSIONS This is the first study to analyze, at once, data regarding prevalence, time trends, seasonality, species distribution and antifungal susceptibility profiles of all Aspergillus spp. isolates over a 8-year period in a tertiary care center. Surprisingly no increase in azole resistance was observed over time.
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Affiliation(s)
- Iacopo Franconi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via San Zeno 37-39, 56127, Pisa, Italy
- Mycology Unit, Pisa University Hospital, Pisa, Italy
| | | | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via San Zeno 37-39, 56127, Pisa, Italy
- Mycology Unit, Pisa University Hospital, Pisa, Italy
| | - Antonella Lupetti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via San Zeno 37-39, 56127, Pisa, Italy.
- Mycology Unit, Pisa University Hospital, Pisa, Italy.
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3
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Uehara S, Takahashi Y, Iwakoshi K, Nishino Y, Wada K, Ono A, Hagiwara D, Chiba T, Yokoyama K, Sadamasu K. Isolation of azole-resistant Aspergillus spp. from food products. Med Mycol 2024; 62:myae026. [PMID: 38490745 DOI: 10.1093/mmy/myae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/01/2024] [Accepted: 03/15/2024] [Indexed: 03/17/2024] Open
Abstract
The prevalence of azole-resistant Aspergillus fumigatus is increasing worldwide and is speculated to be related to the use of azole pesticides. Aspergillus spp., the causative agent of aspergillosis, could be brought into domestic dwellings through food. However, studies on azole-resistant Aspergillus spp. in food products are limited. Therefore, we aimed to isolate Aspergillus spp. from processed foods and commercial agricultural products and performed drug susceptibility tests for azoles. Among 692 food samples, we isolated 99 strains of Aspergillus spp. from 50 food samples, including vegetables (22.9%), citrus fruits (26.3%), cereals (25.5%), and processed foods (1.8%). The isolates belonged to 18 species across eight sections: Aspergillus, Candidi, Clavati, Flavi, Fumigati, Nidulantes, Nigri, and Terrei. The most frequently isolated section was Fumigati with 39 strains, followed by Nigri with 28 strains. Aspergillus fumigatus and A. welwitschiae were the predominant species. Ten A. fumigatus and four cryptic strains, four A. niger cryptic strains, two A. flavus, and four A. terreus strains exceeded epidemiological cutoff values for azoles. Aspergillus tubingensis, A. pseudoviridinutans, A. lentulus, A. terreus, and N. hiratsukae showed low susceptibility to multi-azoles. Foods containing agricultural products were found to be contaminated with Aspergillus spp., with 65.3% of isolates having minimal inhibitory concentrations below epidemiological cutoff values. Additionally, some samples harbored azole-resistant strains of Aspergillus spp. Our study serves as a basis for elucidating the relationship between food, environment, and clinically important Aspergillus spp.
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Affiliation(s)
- Satomi Uehara
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Yumi Takahashi
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Keiko Iwakoshi
- Department of Food Safety, Tokyo Metropolitan Institute of Public Health, Japan
| | - Yukari Nishino
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Kotono Wada
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Asuka Ono
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Daisuke Hagiwara
- Faculty of Life and Environmental Sciences, University of Tsukuba MiCS, University of Tsukuba, Japan
| | - Takashi Chiba
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Keiko Yokoyama
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
| | - Kenji Sadamasu
- Department of Microbiology, Tokyo Metropolitan Insitute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku,Tokyo, Japan
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4
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Pfaller MA, Carvalhaes CG, Rhomberg PR, Desphande LM, Castanheira M. Trends in the activity of mold-active azole agents against Aspergillus fumigatus clinical isolates with and without cyp51 alterations from Europe and North America (2017-2021). J Clin Microbiol 2024; 62:e0114123. [PMID: 38193696 PMCID: PMC10865804 DOI: 10.1128/jcm.01141-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/03/2023] [Indexed: 01/10/2024] Open
Abstract
Azole resistance in Aspergillus fumigatus (AFM) is increasing and often associated with cyp51 alterations. We evaluated the activity of isavuconazole and other mold-active azoles against 731 AFM isolates causing invasive aspergillosis collected in Europe (EU; n = 449) and North America (NA; n = 282). Isolates were submitted to CLSI susceptibility testing and epidemiological cutoff value (ECV) criteria. A posaconazole ECV of 0.5 mg/L was used as no CLSI ECV was determined. Azole non-wild-type (NWT) isolates were submitted for cyp51 sequencing by whole genome sequencing. Overall, isavuconazole activity (92.7%/94.0% WT in EU/NA) was comparable to other azoles (WT rate range, 90.9%-96.4%/91.8%-98.6%, respectively), regardless of the region. A total of 79 (10.8%) azole NWT isolates were detected, and similar rates of these isolates were noted in EU (10.7%) and NA (11.0%). Although most AFM were WT to azoles, increasing azole NWT rates were observed in NA (from 6.0% in 2017 to 29.3% in 2021). Azole NWT rates varied from 4.9% (2019) to 20.6% (2018) in EU without an observed trend. cyp51 alterations occurred in 56.3%/54.8% of azole NWT from EU/NA, respectively. The cyp51A TR34/L98H alteration was observed only in EU isolates (72.0% of EU isolates), while cyp51A I242V occurred only in NA isolates (58.3%). Isavuconazole remained active (MIC, ≤1 mg/L) against 18.5/47.1% of azole NWT AFM exhibiting cyp51 alterations in EU/NA, along with voriconazole (29.6/82.4%; MIC, ≤1 mg/L) and posaconazole (48.1/88.2%; MIC, ≤0.5 mg/L). Fourteen different cyp51 alterations were detected in 44 of 79 NWT isolates. The in vitro activity of the azoles varied in AFM that displayed cyp51 alterations. IMPORTANCE A few microbiology laboratories perform antifungal susceptibility testing locally for systemically active antifungal agents. The identification of emerging azole-resistant Aspergillus fumigatus is worrisome. As such, there is a critical role for antifungal surveillance in tracking emerging resistance among both common and uncommon opportunistic fungi. Differences in the regional prevalence and antifungal resistance of these fungi render local epidemiological knowledge essential for the care of patients with a suspected invasive fungal infection.
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Affiliation(s)
- M. A. Pfaller
- JMI Laboratories, North Liberty, Iowa, USA
- University of Iowa, Iowa City, Iowa, USA
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5
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Lass-Flörl C, Steixner S. The changing epidemiology of fungal infections. Mol Aspects Med 2023; 94:101215. [PMID: 37804792 DOI: 10.1016/j.mam.2023.101215] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/19/2023] [Accepted: 09/21/2023] [Indexed: 10/09/2023]
Abstract
Invasive fungal diseases are common complications in critically ill patients and in those with significant underlying imbalanced immune systems. Fungal co-, and/or super-infections are emerging and have become a rising concern within the last few years. In Europe, cases of candidiasis and aspergillosis dominate, followed by mucormycosis in India. Epidemiological studies show an increasing trend in the incidence of all three entities. Parallel to this, a shift within the underlying fungal pathogens is observed. More non-albicans Candida infections and aspergillosis with cryptic species are on the rise; cryptic species may cover intrinsic resistance to azoles and other antifungal drugs. The recent COVID-19 pandemic led to a significantly increasing incidence of invasive fungal diseases among hospitalized patients.
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Affiliation(s)
- Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, A-6020, Innsbruck, Austria.
| | - Stephan Steixner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, A-6020, Innsbruck, Austria
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6
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Sen P, Gupta L, Vijay M, Vermani Sarin M, Shankar J, Hameed S, Vijayaraghavan P. 4-Allyl-2-methoxyphenol modulates the expression of genes involved in efflux pump, biofilm formation and sterol biosynthesis in azole resistant Aspergillus fumigatus. Front Cell Infect Microbiol 2023; 13:1103957. [PMID: 36816579 PMCID: PMC9929553 DOI: 10.3389/fcimb.2023.1103957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/06/2023] [Indexed: 02/04/2023] Open
Abstract
Introduction Antifungal therapy for aspergillosis is becoming problematic because of the toxicity of currently available drugs, biofilm formation on host surface, and increasing prevalence of azole resistance in Aspergillus fumigatus. Plants are rich source of bioactive molecules and antimicrobial activity of aromatic bioactive compounds draws attention because of its promising biological properties. The present study elucidated the antibiofilm activity of 4-allyl-2-methoxyphenol (eugenol) against azole-resistant environmental A. fumigatus isolates. Methods Soil samples were collected from agricultural fields across India; azole-resistant A. fumigatus (ARAF) were isolated followed by their molecular identification. Antibiofilm activity of eugenol was calculated via tetrazolium based-MTT assay. The expression of the multidrug efflux pumps genes MDR1, MDR4, transporters of the MFS gene, erg11A gene encoding 14α demethylase, and transcription regulatory genes, MedA, SomA and SrbA, involved in biofilm formation of A. fumigatus were calculated by quantitative real time PCR. Results Out of 89 A. fumigatus isolates, 10 were identified as azole resistant. Eugenol exhibited antibiofilm activity against ARAF isolates, ranging from 312 to 500 µg/mL. Confocal laser scanning microscopy analysis revealed absence of extracellular matrix of ARAF biofilm after eugenol treatment. The gene expression indicated significantly low expression of efflux pumps genes MDR1, MDR4, erg11A and MedA in eugenol treated ARAF isolates when compared with untreated isolates. Conclusions Our results demonstrate that eugenol effects the expression of efflux pump and biofilm associated genes as well as inhibits biofilm formation in azole resistant isolates of A. fumigatus.
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Affiliation(s)
- Pooja Sen
- Anti-mycotic Drug Susceptibility Laboratory, Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India
| | - Lovely Gupta
- Anti-mycotic Drug Susceptibility Laboratory, Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India
| | - Mukund Vijay
- Anti-mycotic Drug Susceptibility Laboratory, Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India
| | - Maansi Vermani Sarin
- Anti-mycotic Drug Susceptibility Laboratory, Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India
| | - Jata Shankar
- Department of Biotechnology and Bioinformatics, Jaypee University of Information Technology, Solan, India
| | - Saif Hameed
- Amity Institute of Biotechnology, Amity University Haryana, Gurugram (Manesar), India
| | - Pooja Vijayaraghavan
- Anti-mycotic Drug Susceptibility Laboratory, Amity Institute of Biotechnology, Amity University Uttar Pradesh, Noida, India,*Correspondence: Pooja Vijayaraghavan,
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7
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Species Distribution and Antifungal Susceptibilities of
Aspergillus
Section
Fumigati
Isolates in Clinical Samples from the United States. J Clin Microbiol 2022; 60:e0028022. [DOI: 10.1128/jcm.00280-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aspergillus
species are capable of causing both invasive disease and chronic infections in immunocompromised patients or those with preexisting lung conditions.
Aspergillus fumigatus
is the most commonly cultured species, and there is increasing concern regarding resistance to the azoles, which are the mainstays of antifungal therapy against aspergillosis. We evaluated the species distribution and susceptibility profiles of isolates within
Aspergillus
section
Fumigati
in the United States over a 52-month period.
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8
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Ahmed J, Singh G, Mohan A, Agarwal R, Sachdev J, Khullar S, Bhusan Xess A, Mathur P, Das B, Xess I. Invasive pulmonary aspergillosis infection in severely ill COPD patients in pulmonary ward and ICU. Indian J Med Microbiol 2022; 40:223-227. [DOI: 10.1016/j.ijmmb.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/03/2022] [Accepted: 02/23/2022] [Indexed: 11/05/2022]
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9
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Antifungal susceptibilities of opportunistic filamentous fungal pathogens from the Asia and Western Pacific Region: data from the SENTRY Antifungal Surveillance Program (2011-2019). J Antibiot (Tokyo) 2021; 74:519-527. [PMID: 34188199 PMCID: PMC8241534 DOI: 10.1038/s41429-021-00431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 02/06/2023]
Abstract
Antifungal surveillance is an important tool to monitor the prevalence of uncommon fungal species and increasing antifungal resistance throughout the world, but data comparing results across several different Asian countries are scarce. In this study, 372 invasive molds collected in the Asia-Western Pacific region in 2011-2019 were susceptibility tested for mold-active triazoles (isavuconazole, posaconazole, voriconazole, and itraconazole). The collection includes 318 Aspergillus spp. isolates and 53 non-Aspergillus molds. The MIC values using CLSI methods for isavuconazole versus Aspergillus fumigatus ranged from 0.25 to 2 mg l-1. Isavuconazole, itraconazole, posaconazole, and voriconazole acted similarly against A. fumigatus. The mold-active triazoles exhibited a wildtype phenotype to most of the Aspergillus spp. isolates tested (>94%), but poor activity against Fusarium solani species complex and Lomentospora prolificans. Voriconazole was most active against the Scedosporium spp. and posaconazole was most active against the Mucorales. In summary, isavuconazole displayed excellent activity against most species of Aspergillus and was comparable to other mold-active triazoles against non-Aspergillus molds.
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10
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Yang X, Chen W, Liang T, Tan J, Liu W, Sun Y, Wang Q, Xu H, Li L, Zhou Y, Wang Q, Wan Z, Song Y, Li R, Liu W. A 20-Year Antifungal Susceptibility Surveillance (From 1999 to 2019) for Aspergillus spp. and Proposed Epidemiological Cutoff Values for Aspergillus fumigatus and Aspergillus flavus: A Study in a Tertiary Hospital in China. Front Microbiol 2021; 12:680884. [PMID: 34367087 PMCID: PMC8339419 DOI: 10.3389/fmicb.2021.680884] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
The emergence of resistant Aspergillus spp. is increasing worldwide. Long-term susceptibility surveillance for clinically isolated Aspergillus spp. strains is warranted for understanding the dynamic change in susceptibility and monitoring the emergence of resistance. Additionally, neither clinical breakpoints (CBPs) nor epidemiological cutoff values (ECVs) for Aspergillus spp. in China have been established. In this study, we performed a 20-year antifungal susceptibility surveillance for 706 isolates of Aspergillus spp. in a clinical laboratory at Peking University First Hospital from 1999 to 2019; and in vitro antifungal susceptibility to triazoles, caspofungin, and amphotericin B was determined by the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method. It was observed that Aspergillus fumigatus was the most common species, followed by Aspergillus flavus and Aspergillus terreus. Forty isolates (5.7%), including A. fumigatus, A. flavus, A. terreus, Aspergillus niger, and Aspergillus nidulans, were classified as non-wild type (non-WT). Importantly, multidrug resistance was observed among A. flavus, A. terreus, and A. niger isolates. Cyp51A mutations were characterized for 19 non-WT A. fumigatus isolates, and TR34/L98H/S297T/F495I was the most prevalent mutation during the 20-year surveillance period. The overall resistance trend of A. fumigatus increased over 20 years in China. Furthermore, based on ECV establishment principles, proposed ECVs for A. fumigatus and A. flavus were established using gathered minimum inhibitory concentration (MIC)/minimum effective concentration (MEC) data. Consequently, all the proposed ECVs were identical to the CLSI ECVs, with the exception of itraconazole against A. flavus, resulting in a decrease in the non-WT rate from 6.0 to 0.6%.
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Affiliation(s)
- Xinyu Yang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Wei Chen
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Tianyu Liang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - JingWen Tan
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Weixia Liu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yi Sun
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Qian Wang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Hui Xu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Lijuan Li
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yabin Zhou
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Qiqi Wang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Zhe Wan
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yinggai Song
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Ruoyu Li
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Wei Liu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
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11
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In vitro activity of posaconazole and comparators versus opportunistic filamentous fungal pathogens globally collected during 8 years. Diagn Microbiol Infect Dis 2021; 101:115473. [PMID: 34352433 DOI: 10.1016/j.diagmicrobio.2021.115473] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/21/2022]
Abstract
The epidemiology of invasive filamentous fungal diseases requires monitoring due to changes in susceptibility patterns of new and established antifungal agents that may affect clinical practices. We evaluated the activity of posaconazole against 2,157 invasive moulds collected worldwide from 2010-2017. The isolates included 1,775 Aspergillus spp. and 382 non-Aspergillus moulds, including 81 Fusarium spp., 62 Mucorales group, and 57 Scedosporium spp. Isolates were tested using the CLSI reference broth microdilution method. Posaconazole showed similar activity to itraconazole and voriconazole against A. fumigatus. Applying published ECV, 98.0% of the A. fumigatus and 97.7% to 100.0% of other common Aspergillus species were wildtype to posaconazole. Categorical agreement between posaconazole and the other azoles tested against A. fumigatus was 98.7%. Notably, most of the Aspergillus spp. isolates recovered from this large collection were wildtype to echinocandins and all azoles. Posaconazole non-wildtype rates of A. fumigatus varied across the different geographic regions, with 2.1% in Europe, 2.2% in North America, 1.8% in Latin America, and 0.7% in the Asia-Pacific region. The frequency of azole non-wildtype A. fumigatus isolates from Europe increased steadily from 2010-2017 for all 3 triazoles (0.0%-5.0%). The azole non-wildtype A. fumigatus rates from the other geographic areas were stable over time. Fusarium and/or Scedosporium spp. isolates were highly resistant to azoles and echinocandins. Posaconazole and amphotericin B were the most active agents against the Mucorales. Posaconazole was very active against most species of Aspergillus and was comparable to itraconazole and voriconazole against the less common moulds. Posaconazole should provide a useful addition to the anti-mould grouping of antifungal agents.
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12
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In vitro activity of isavuconazole versus opportunistic filamentous fungal pathogens from the SENTRY Antifungal Surveillance Program, 2017–2018. Diagn Microbiol Infect Dis 2020; 97:115007. [DOI: 10.1016/j.diagmicrobio.2020.115007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
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13
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Rudramurthy SM, Paul RA, Chakrabarti A, Mouton JW, Meis JF. Invasive Aspergillosis by Aspergillus flavus: Epidemiology, Diagnosis, Antifungal Resistance, and Management. J Fungi (Basel) 2019; 5:jof5030055. [PMID: 31266196 PMCID: PMC6787648 DOI: 10.3390/jof5030055] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 12/12/2022] Open
Abstract
Aspergillus flavus is the second most common etiological agent of invasive aspergillosis (IA) after A. fumigatus. However, most literature describes IA in relation to A. fumigatus or together with other Aspergillus species. Certain differences exist in IA caused by A. flavus and A. fumigatus and studies on A. flavus infections are increasing. Hence, we performed a comprehensive updated review on IA due to A. flavus. A. flavus is the cause of a broad spectrum of human diseases predominantly in Asia, the Middle East, and Africa possibly due to its ability to survive better in hot and arid climatic conditions compared to other Aspergillus spp. Worldwide, ~10% of cases of bronchopulmonary aspergillosis are caused by A. flavus. Outbreaks have usually been associated with construction activities as invasive pulmonary aspergillosis in immunocompromised patients and cutaneous, subcutaneous, and mucosal forms in immunocompetent individuals. Multilocus microsatellite typing is well standardized to differentiate A. flavus isolates into different clades. A. flavus is intrinsically resistant to polyenes. In contrast to A. fumigatus, triazole resistance infrequently occurs in A. flavus and is associated with mutations in the cyp51C gene. Overexpression of efflux pumps in non-wildtype strains lacking mutations in the cyp51 gene can also lead to high voriconazole minimum inhibitory concentrations. Voriconazole remains the drug of choice for treatment, and amphotericin B should be avoided. Primary therapy with echinocandins is not the first choice but the combination with voriconazole or as monotherapy may be used when the azoles and amphotericin B are contraindicated.
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Affiliation(s)
- Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India.
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, 3015GD Rotterdam, The Netherlands.
| | - Raees A Paul
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, 3015GD Rotterdam, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ) and Center of Expertise, 6532SZ Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, 6532SZ Nijmegen, The Netherlands
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14
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Romero M, Messina F, Marin E, Arechavala A, Depardo R, Walker L, Negroni R, Santiso G. Antifungal Resistance in Clinical Isolates of Aspergillus spp.: When Local Epidemiology Breaks the Norm. J Fungi (Basel) 2019; 5:E41. [PMID: 31117260 PMCID: PMC6617206 DOI: 10.3390/jof5020041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
Aspergillosis is a set of very frequent and widely distributed opportunistic diseases. Azoles are the first choice for most clinical forms. However, the distribution of azole-resistant strains is not well known around the world, especially in developing countries. The aim of our study was to determine the proportion of non-wild type strains among the clinical isolates of Aspergillus spp. To this end, the minimum inhibitory concentration of three azoles and amphotericin B (used occasionally in severe forms) was studied by broth microdilution. Unexpectedly, it was found that 8.1% of the isolates studied have a diminished susceptibility to itraconazole. This value turned out to be similar to the highest azole resistance rate reported in different countries across the world.
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Affiliation(s)
- Mercedes Romero
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Fernando Messina
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Emmanuel Marin
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Alicia Arechavala
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Roxana Depardo
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Laura Walker
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Ricardo Negroni
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
| | - Gabriela Santiso
- Mycology Unit of the Infectious Diseases Hospital F.J. Muñiz, Reference Center of Mycology of Buenos Aires City, Buenos Aires C1282A, Argentina.
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15
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Zhang J, Snelders EE, Zwaan BJ, Schoustra SE, Kuijper EJ, Arendrup MC, Melchers WJG, Verweij PE, Debets AJM. Relevance of heterokaryosis for adaptation and azole-resistance development in Aspergillus fumigatus. Proc Biol Sci 2019; 286:20182886. [PMID: 30963936 PMCID: PMC6408600 DOI: 10.1098/rspb.2018.2886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/21/2019] [Indexed: 12/27/2022] Open
Abstract
Aspergillus fumigatus causes a range of diseases in humans, some of which are characterized by fungal persistence. Aspergillus fumigatus, being a generalist saprotroph, may initially establish lung colonization due to its physiological versatility and subsequently adapt through genetic changes to the human lung environment and antifungal treatments. Human lung-adapted genotypes can arise by spontaneous mutation and/or recombination and subsequent selection of the fittest genotypes. Sexual and asexual spores are considered crucial contributors to the genetic diversity and adaptive potential of aspergilli by recombination and mutation supply, respectively. However, in certain Aspergillus diseases, such as cystic fibrosis and chronic pulmonary aspergillosis, A. fumigatus may not sporulate but persist as a network of fungal mycelium. During azole therapy, such mycelia may develop patient-acquired resistance and become heterokaryotic by mutations in one of the nuclei. We investigated the relevance of heterokaryosis for azole-resistance development in A. fumigatus. We found evidence for heterokaryosis of A. fumigatus in patients with chronic Aspergillus diseases. Mycelium from patient-tissue biopsies segregated different homokaryons, from which heterokaryons could be reconstructed. Whereas all variant homokaryons recovered from the same patient were capable of forming a heterokaryon, those from different patients were heterokaryon-incompatible. We furthermore compared heterokaryons and heterozygous diploids constructed from environmental isolates with different levels of azole resistance. When exposed to azole, the heterokaryons revealed remarkable shifts in their nuclear ratio, and the resistance level of heterokaryons exceeded that of the corresponding heterozygous diploids.
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Affiliation(s)
- Jianhua Zhang
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Eveline E. Snelders
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Bas J. Zwaan
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Sijmen E. Schoustra
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Ed J. Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maiken C. Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Willem J. G. Melchers
- Department of Medical Microbiology and Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology and Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
| | - Alfons J. M. Debets
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
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16
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Trovato L, Scalia G, Domina M, Oliveri S. Environmental Isolates of Multi-Azole-Resistant Aspergillus spp. in Southern Italy. J Fungi (Basel) 2018; 4:jof4040131. [PMID: 30563198 PMCID: PMC6308927 DOI: 10.3390/jof4040131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/21/2018] [Accepted: 12/04/2018] [Indexed: 11/16/2022] Open
Abstract
Azole resistance in Aspergillus spp. has been increasingly reported worldwide. Acquired azole resistance is probably linked to environmental exposure to fungicides used in agriculture. We collected a total of 84 soil and leaf samples from eight farms in Southern Italy. Aspergillus isolates were tested for resistance to itraconazole, posaconazole, and voriconazole by the EUCAST method. Five out of 84 samples yielded A. fumigatus isolates: four of them were itraconazole-resistant and were identified as A. fumigatus sensu stricto, three of them were posaconazole-resistant, and two were also voriconazole-resistant. All three isolates harbored the TR34/L98H resistance mechanism, which was detected by DNA sequencing of the cyp51A gene. Fifteen out of 84 samples yielded Aspergillus spp. isolates and included 11 itraconazole-resistant isolates: Aspergillus section Nigri (9) and Aspergillus section Flavi (2). Our study reports for the first time the isolation of azole-resistant A. fumigatus harboring TR34/L98H mutation from the environment of Southern Italy. The present work provides a better understanding of the magnitude of the environmental spread of azole resistance in the context of a necessary effective surveillance program to improve the management of Aspergillus-related disease.
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Affiliation(s)
- Laura Trovato
- U.O.C. Laboratory Analysis Unit, A.O.U. "Policlinico-Vittorio Emanuele", 95123 Catania, Italy.
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy.
| | - Guido Scalia
- U.O.C. Laboratory Analysis Unit, A.O.U. "Policlinico-Vittorio Emanuele", 95123 Catania, Italy.
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy.
| | - Maria Domina
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy.
| | - Salvatore Oliveri
- U.O.C. Laboratory Analysis Unit, A.O.U. "Policlinico-Vittorio Emanuele", 95123 Catania, Italy.
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy.
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17
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Viegas C, Moreira R, Faria T, Caetano LA, Carolino E, Gomes AQ, Viegas S. Aspergillus prevalence in air conditioning filters from vehicles: Taxis for patient transportation, forklifts, and personal vehicles. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2018; 74:341-349. [PMID: 29727587 DOI: 10.1080/19338244.2018.1472545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/24/2018] [Accepted: 04/30/2018] [Indexed: 06/08/2023]
Abstract
The frequency and importance of Aspergillus infections is increasing worldwide. This study aimed to assess the occupational exposure of forklifts and taxi drivers to Aspergillus spp. Nineteen filters from air conditioning system of taxis, 17 from forklifts and 37 from personal vehicles were assessed. Filters extract were streaked onto MEA, DG18 and in azole-supplemented media. Real-time quantitative PCR amplification of selected Aspergillus species-complex was also performed. Forklifts filter samples presented higher median values. Aspergillus section Nigri was the most observed in forklifts filters in MEA (28.2%) and in azole-supplemented media. DNA from Aspergillus sections Fumigati and Versicolores was successfully amplified by qPCR. This study enlightens the added value of using filters from the air conditioning system to assess Aspergillus spp. occupational exposure. Aspergillus azole resistance screening should be included in future occupational exposure assessments.
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Affiliation(s)
- Carla Viegas
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa
| | - Ricardo Moreira
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Tiago Faria
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
- Centro de Ciências e Tecnologias Nucleares, Instituto Superior Técnico, Universidade de Lisboa, Portugal
| | - Liliana Aranha Caetano
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Elisabete Carolino
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Anita Quintal Gomes
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
- University of Lisbon Institute of Molecular Medicine, Faculty of Medicine, Lisbon, Portugal
| | - Susana Viegas
- H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa
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18
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Elad D, Segal E. Diagnostic Aspects of Veterinary and Human Aspergillosis. Front Microbiol 2018; 9:1303. [PMID: 29977229 PMCID: PMC6022203 DOI: 10.3389/fmicb.2018.01303] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022] Open
Abstract
The genus Aspergillus is composed of more than 300 species, a fraction of which are involved in animal or human infections mostly following environmental exposure. Various risk factors (i.e., immunosuppression, tuberculosis) have been recognized for human whereas for veterinary infections, unhygienic management, trauma, anatomical conformation of the skull, or suspected immunological deficiencies have been suggested. In animals, aspergillosis is mostly sporadic but in some circumstance such as infections on poultry farms may involve the whole flock. Since the high prevalence of immunosuppression in human patients has not been mirrored in veterinary medicine, and although to the best of our knowledge, no comprehensive data on the prevalence of aspergillosis in animals has been published, their epidemiology has not changed during the last decades. The impact of these infections may be economic or if they are incurable, sentimental. The objective of the first part is to describe the diagnosis of the main clinical entities caused by Aspergillus spp. in animals. It includes disseminated canine aspergillosis, canine and feline sino-nasal and sino-orbital aspergillosis, guttural pouch mycosis in horses, mycotic abortion in cattle, mycotic keratitis in horses, and avian aspergillosis. When pathogenesis and clinical aspects are relevant for diagnosis—they will be addressed as well. The second part deals with human aspergillosis, which is a multifaceted disease, manifested in a spectrum of clinical entities affecting one or more organs. Diagnosis is based on the clinical manifestation, supported and confirmed by laboratory means, involving the classical approach of demonstrating the etiological agent in the clinical specimens and in culture. Noncultural methods, such as antigen detection and/or molecular assays to detect fungal nucleic acids or protein profiles, are used as well. The isolation and identification of the fungus allows the determination of its susceptibility to antifungal drugs. Thus, antifungal susceptibility testing maybe considered as part of the diagnostic process, which is of relevance for management of the infection. In this review article, the part dealing with diagnostic aspects of aspergillosis in humans concentrates on susceptibility testing of Aspergillus spp. to antifungal drugs and drug combinations. The technologies and methods of susceptibility testing are described and evaluated.
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Affiliation(s)
- Daniel Elad
- Department of Clinical Bacteriology and Mycology, Kimron Veterinary Institute, Bet Dagan, Israel
| | - Esther Segal
- Department of Clinical Microbiology and Immunology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Sato K, Oinuma KI, Niki M, Yamagoe S, Miyazaki Y, Asai K, Yamada K, Hirata K, Kaneko Y, Kakeya H. Identification of a Novel Rhizopus-specific Antigen by Screening with a Signal Sequence Trap and Evaluation as a Possible Diagnostic Marker of Mucormycosis. Med Mycol 2018; 55:713-719. [PMID: 28199672 DOI: 10.1093/mmy/myw146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023] Open
Abstract
Mucormycosis is the second most common mould infection, often indistinguishable from other invasive mould infections such as aspergillosis. Although an appropriate antifungal therapy is effective at an early stage of the infection, there is no reliable diagnostic method for decision making. Thus, it is necessary to develop an efficient method that can detect mucormycosis rapidly and accurately. We searched for secreted or membrane-bound proteins of Rhizopus oryzae, which is the most common pathogen of mucormycosis, using the method of a signal sequence trap by retrovirus-mediated expression (SST-REX). Among the identified proteins, a Rhizopus-specific antigen was selected as a candidate, and efficacy of this specific antigen was evaluated using R. oryzae-infected mice. Of 302 clones obtained from the SST-REX library, a hypothetical protein (23 kDa, named "protein RSA") was selected as a candidate because of its highest prevalence of clones. Protein RSA was detected at significantly higher concentrations in serum and in lung homogenates of the infected mice as compared to those of uninfected mice. Our study indicates that protein RSA may be a promising biomarker of R. oryzae infection. SST-REX may be useful for comprehensive screening of prospective eukaryotic biomarkers of intractable mould infections.
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Affiliation(s)
- Kanako Sato
- Department of Bacteriology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ken-Ichi Oinuma
- Department of Bacteriology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Research Center for Infectious Disease Sciences
| | - Mamiko Niki
- Department of Bacteriology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Research Center for Infectious Disease Sciences
| | - Satoshi Yamagoe
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshitsugu Miyazaki
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Yamada
- Research Center for Infectious Disease Sciences.,Department of Infection Control Science, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazuto Hirata
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yukihiro Kaneko
- Department of Bacteriology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Research Center for Infectious Disease Sciences
| | - Hiroshi Kakeya
- Research Center for Infectious Disease Sciences.,Department of Infection Control Science, Osaka City University Graduate School of Medicine, Osaka, Japan
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20
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Idelevich EA, Groß U, Becker K, Bader O. Comparative evaluation of different gradient diffusion tests for detection of azole resistance in Aspergillus fumigatus. Diagn Microbiol Infect Dis 2018; 91:52-54. [PMID: 29422272 DOI: 10.1016/j.diagmicrobio.2018.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/01/2018] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
Gradient diffusion assays Etest and MIC Test Strip for itraconazole, posaconazole and voriconazole as well as isavuconazole (MIC Test Strip) were evaluated for Aspergillus fumigatus against EUCAST broth microdilution. Both assays demonstrated generally good performance; however, posaconazole MIC Test Strip showed low agreement with broth microdilution due to MIC overestimation.
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Affiliation(s)
- Evgeny A Idelevich
- Institute of Medical Microbiology, University Hospital Münster, Domagkstraße 10, 48149 Münster, Germany
| | - Uwe Groß
- Institute for Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital Münster, Domagkstraße 10, 48149 Münster, Germany.
| | - Oliver Bader
- Institute for Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany
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21
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Deng S, Zhang L, Ji Y, Verweij PE, Tsui KM, Hagen F, Houbraken J, Meis JF, Abliz P, Wang X, Zhao J, Liao W. Triazole phenotypes and genotypic characterization of clinical Aspergillus fumigatus isolates in China. Emerg Microbes Infect 2017; 6:e109. [PMID: 29209054 PMCID: PMC5750463 DOI: 10.1038/emi.2017.97] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/09/2023]
Abstract
This study investigated the triazole phenotype and genotypic of clinical Aspergillus fumigatus isolates from China. We determined the triazole susceptibility profiles of 159 A. fumigatus isolates collected between 2011 and 2015 from four different areas in China tested against 10 antifungal drugs using the Clinical Laboratory Standard Institute M38-A2 method. For the seven itraconazole-resistant A. fumigatus isolates identified in the study, the cyp51A gene, including its promoter region, was sequenced and the mutation patterns were characterized. The resistant isolates were genotyped by microsatellite typing to determine the genetic relatedness to isolates from China and other countries. The frequency of itraconazole resistance in A. fumigatus isolates in our study was 4.4% (7/159). Six of the seven triazole-resistant isolates were recovered from the east and southeast of China, and one from was recovered from the west of China. No resistant isolates were found in the north. Three triazole-resistant isolates exhibited the TR34/L98H mutation, two carried the TR34/L98H/S297T/F495I mutation and one harbored a G54V mutation in the cyp51A gene. Analysis of the microsatellite markers from seven non-wild-type isolates indicated the presence of five unique genotypes, which clustered into two major genetic groups. The cyp51A gene mutations TR34/L98H and TR34/L98H/S297T were the most frequently found mutations, and the G54V mutation was reported for the first time in China. The geographic origin of the triazole-resistant isolates appeared to concentrate in eastern and south-eastern areas, which suggests that routine antifungal susceptibility testing in these areas should be performed for all clinically relevant A. fumigatus isolates to guide antifungal therapy and for epidemiological purposes.
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Affiliation(s)
- Shuwen Deng
- Department of Medical Microbiology, People's Hospital of Suzhou National New & Hi-Tech Industrial Development Zone, Jiangsu 215219, China
| | - Lili Zhang
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Yanfeng Ji
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen 6500HB, The Netherlands
| | - Kin Ming Tsui
- Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver V6H3Z6, Canada
| | - Ferry Hagen
- Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen 6500GS, The Netherlands.,Centre of Expertise in Mycology Radboud University Medical Centre/CWZ, Nijmegen 6500HB, The Netherlands
| | - Jos Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht 3584CT, The Netherlands
| | - Jacque F Meis
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen 6500HB, The Netherlands.,Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen 6500GS, The Netherlands.,Centre of Expertise in Mycology Radboud University Medical Centre/CWZ, Nijmegen 6500HB, The Netherlands
| | - Parida Abliz
- First Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Xiaodong Wang
- First Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Jingjun Zhao
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Wanqing Liao
- Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
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22
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Ashu EE, Kim GY, Roy-Gayos P, Dong K, Forsythe A, Giglio V, Korfanty G, Yamamura D, Xu J. Limited evidence of fungicide-driven triazole-resistant Aspergillus fumigatus in Hamilton, Canada. Can J Microbiol 2017; 64:119-130. [PMID: 29156151 DOI: 10.1139/cjm-2017-0410] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aspergillus fumigatus is a ubiquitous opportunistic fungal pathogen that can cause aspergillosis in humans. Over the last decade there have been increasing global reports of treatment failure due to triazole resistance. An emerging hypothesis states that agricultural triazole fungicide use causes clinical triazole resistance. Here we test this hypothesis in Hamilton, Ontario, Canada, by examining a total of 195 agricultural, urban, and clinical isolates using 9 highly polymorphic microsatellite markers. For each isolate, the in vitro susceptibilities to itraconazole and voriconazole, 2 triazole drugs commonly used in the management of patients, were also determined. Our analyses suggested frequent gene flow among the agricultural, urban environmental, and clinical populations of A. fumigatus and found evidence for widespread sexual recombination within and among the different populations. Interestingly, all 195 isolates analyzed in this study were susceptible to both triazoles tested. However, compared with the urban population, agricultural and clinical populations showed significantly reduced susceptibility to itraconazole and voriconazole, consistent with ecological niche-specific selective pressures on A. fumigatus populations in Hamilton. Frequent gene flow and genetic recombination among these populations suggest greater attention should be paid to monitor A. fumigatus populations in Hamilton and other similar jurisdictions.
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Affiliation(s)
- Eta Ebasi Ashu
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Ga Young Kim
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Patrick Roy-Gayos
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Kelly Dong
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Adrian Forsythe
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Victoria Giglio
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Gregory Korfanty
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Deborah Yamamura
- b Department of Pathology and Molecular Medicine, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
| | - Jianping Xu
- a Department of Biology and the Institute of Infectious Diseases Research, McMaster University, 1280 Main Street W, Hamilton, ON L8S 4K1, Canada
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A Novel Environmental Azole Resistance Mutation in Aspergillus fumigatus and a Possible Role of Sexual Reproduction in Its Emergence. mBio 2017; 8:mBio.00791-17. [PMID: 28655821 PMCID: PMC5487732 DOI: 10.1128/mbio.00791-17] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study investigated the dynamics of Aspergillus fumigatus azole-resistant phenotypes in two compost heaps with contrasting azole exposures: azole free and azole exposed. After heat shock, to which sexual but not asexual spores are highly resistant, the azole-free compost yielded 98% (49/50) wild-type and 2% (1/50) azole-resistant isolates, whereas the azole-containing compost yielded 9% (4/45) wild-type and 91% (41/45) resistant isolates. From the latter compost, 80% (36/45) of the isolates contained the TR46/Y121F/T289A genotype, 2% (1/45) harbored the TR46/Y121F/M172I/T289A/G448S genotype, and 9% (4/45) had a novel pan-triazole-resistant mutation (TR463/Y121F/M172I/T289A/G448S) with a triple 46-bp promoter repeat. Subsequent screening of a representative set of clinical A. fumigatus isolates showed that the novel TR463 mutant was already present in samples from three Dutch medical centers collected since 2012. Furthermore, a second new resistance mutation was found in this set that harbored four TR46 repeats. Importantly, in the laboratory, we recovered the TR463 mutation from a sexual cross between two TR46 isolates from the same azole-containing compost, possibly through unequal crossing over between the double tandem repeats (TRs) during meiosis. This possible role of sexual reproduction in the emergence of the mutation was further implicated by the high level of genetic diversity of STR genotypes in the azole-containing compost. Our study confirms that azole resistance mutations continue to emerge in the environment and indicates compost containing azole residues as a possible hot spot. Better insight into the biology of environmental resistance selection is needed to retain the azole class for use in food production and treatment of Aspergillus diseases. Composting of organic matter containing azole residues might be important for resistance development and subsequent spread of resistance mutations in Aspergillus fumigatus. In this article, we show the dominance of azole-resistant A. fumigatus in azole-exposed compost and the discovery of a new resistance mutation with clinical relevance. Furthermore, our study indicates that current fungicide application is not sustainable as new resistance mutations continue to emerge, thereby threatening the use of triazoles in medicine. We provide evidence that the sexual part of the fungal life cycle may play a role in the emergence of resistance mutations because under laboratory conditions, we reconstructed the resistance mutation through sexual crossing of two azole-resistant A. fumigatus isolates derived from the same compost heap. Understanding the mechanisms of resistance selection in the environment is needed to design strategies against the accumulation of resistance mutations in order to retain the azole class for crop protection and treatment of Aspergillus diseases.
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Abstract
Aspergillus spp. are important fungi because of the high mortality associated with aspergillosis. However, we have only three classes of anti-aspergillus drugs available; and only two drugs, itraconazole (ITCZ) and voriconazole (VRCZ), are available as oral agents in Japan. If azole-resistant Aspergillus causes chronic aspergillosis, we cannot treat such patients with oral azoles on an outpatient basis. As is the case with foreign countries, we found the existence of azole-resistant Aspergillus fumigatus in clinical settings in Japan. Resistance was attributed to mutations of the target protein (CYP51A). Additionally, we also found that long-term itraconazole treatment induced G54 substitution in CYP51A, causing itraconazole-resistance. Although there are few resistant Aspergillus strains existing in Japan now, we have to continue to find such resistant isolates, which are spreading worldwide.
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Affiliation(s)
- Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences
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25
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Genetic Diversity and In Vitro Antifungal Susceptibility of 200 Clinical and Environmental Aspergillus flavus Isolates. Antimicrob Agents Chemother 2017; 61:AAC.00004-17. [PMID: 28264849 DOI: 10.1128/aac.00004-17] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/03/2017] [Indexed: 11/20/2022] Open
Abstract
Aspergillus flavus has been frequently reported as the leading cause of invasive aspergillosis in certain tropical and subtropical countries. Two hundred A. flavus strains originating from clinical and environmental sources and collected between 2008 and 2015 were phylogenetically identified at the species level by analyzing partial β-tubulin and calmodulin genes. In vitro antifungal susceptibility testing was performed against antifungals using the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth microdilution method. In addition, genotyping was performed using a short-tandem-repeat (STR) assay of a panel of six microsatellite markers (A. flavus 2A, 2B, 2C, 3A, 3B, and 3C), in order to determine the genetic variation and the potential relationship between clinical and environmental isolates. The geometric means of the minimum inhibitory concentrations/minimum effective concentrations (MICs/MECs) of the antifungals across all isolates were (in increasing order): posaconazole, 0.13 mg/liter; anidulafungin, 0.16 mg/liter; itraconazole, 0.29 mg/liter; caspofungin, 0.42 mg/liter; voriconazole, 0.64 mg/liter; isavuconazole, 1.10 mg/liter; amphotericin B, 3.35 mg/liter; and flucytosine, 62.97 mg/liter. All of the clinical isolates were genetically different. However, an identical microsatellite genotype was found between a clinical isolate and two environmental strains. In conclusion, posaconazole and anidulafungin showed the greatest in vitro activity among systemic azoles and echinocandins, respectively. However, the majority of the A. flavus isolates showed reduced susceptibility to amphotericin B. Antifungal susceptibility of A. flavus was not linked with the clinical or environmental source of isolation. Microsatellite genotyping may suggest an association between clinical and environmental strains, although this requires further investigation.
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26
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Pharmacodynamics of Voriconazole against Wild-Type and Azole-Resistant Aspergillus flavus Isolates in a Nonneutropenic Murine Model of Disseminated Aspergillosis. Antimicrob Agents Chemother 2016; 61:AAC.01491-16. [PMID: 27821453 DOI: 10.1128/aac.01491-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/01/2016] [Indexed: 11/20/2022] Open
Abstract
Invasive aspergillosis (IA) due to Aspergillus flavus is associated with high mortality. Although voriconazole (VRC) is widely recommended as the first-line treatment for IA, emergence of azole resistance in Aspergillus spp. is translating to treatment failure. We evaluated the efficacy of voriconazole in a nonneutropenic murine model of disseminated A. flavus infection using two voriconazole-resistant isolates (one harboring the Y319H substitution in the cyp51C gene) and two wild-type isolates without mutations. All isolates exhibited a dose-response relationship, and voriconazole treatment improved mouse survival in a dose-dependent manner. At 40 mg/kg of body weight, 100% efficacy was observed for 1 susceptible isolate and 1 resistant isolate (with mutation), whereas for another susceptible isolate and resistant isolate (without mutation), survival rates were 81% and 72%, respectively. The Hill equation with a variable slope fitted the relationship between the area under the concentration-time curve (AUC)/MIC ratio and 14-day survival well for each strain. An F test showed the 50% effective doses to be significantly different from each other (P = 0.0023). However, contrary to expectation, there was a significant difference in exposure-response relationships between strains, and it appeared that the susceptible strains required a relatively higher exposure than the resistant ones to result in the same treatment effect, the 50% effective pharmacokinetic/pharmacodynamic (PK/PD) index (EI50) required being negatively and log-linearly related to the MIC (P = 0.04). We conclude that the efficacy of voriconazole depended on drug exposure and the voriconazole MIC of the isolates, but lower exposures are required for strains with higher MICs. These findings may have profound significance in clinical practice with respect to dosing and drug choice.
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27
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Screening and Characterization of a Non-cyp51A Mutation in an Aspergillus fumigatus cox10 Strain Conferring Azole Resistance. Antimicrob Agents Chemother 2016; 61:AAC.02101-16. [PMID: 27799210 DOI: 10.1128/aac.02101-16] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/18/2016] [Indexed: 12/14/2022] Open
Abstract
The rapid and global emergence of azole resistance in the human pathogen Aspergillus fumigatus has drawn attention. Thus, a thorough understanding of its mechanisms of drug resistance requires extensive exploration. In this study, we found that the loss of the putative calcium-dependent protein-encoding gene algA causes an increased frequency of azole-resistant A. fumigatus isolates. In contrast to previously identified azole-resistant isolates related to cyp51A mutations, only one isolate carries a point mutation in cyp51A (F219L mutation) among 105 independent stable azole-resistant isolates. Through next-generation sequencing (NGS), we successfully identified a new mutation (R243Q substitution) conferring azole resistance in the putative A. fumigatus farnesyltransferase Cox10 (AfCox10) (AFUB_065450). High-performance liquid chromatography (HPLC) analysis verified that the decreased absorption of itraconazole in related Afcox10 mutants is the primary reason for itraconazole resistance. Moreover, a complementation experiment by reengineering the mutation in a parental wild-type background strain demonstrated that both the F219L and R243Q mutations contribute to itraconazole resistance in an algA-independent manner. These data collectively suggest that the loss of algA results in an increased frequency of azole-resistant isolates with a non-cyp51A mutation. Our findings indicate that there are many unexplored non-cyp51A mutations conferring azole resistance in A. fumigatus and that algA defects make it possible to isolate drug-resistant alleles. In addition, our study suggests that genome-wide sequencing combined with alignment comparison analysis is an efficient approach to identify the contribution of single nucleotide polymorphism (SNP) diversity to drug resistance.
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28
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Chowdhary A, Masih A, Sharma C. Azole Resistance in Moulds—Approach to Detection in a Clinical Laboratory. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0265-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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29
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1635] [Impact Index Per Article: 204.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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30
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Albataineh MT, Sutton DA, Fothergill AW, Wiederhold NP. Update from the Laboratory: Clinical Identification and Susceptibility Testing of Fungi and Trends in Antifungal Resistance. Infect Dis Clin North Am 2015; 30:13-35. [PMID: 26739605 DOI: 10.1016/j.idc.2015.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite the availability of new diagnostic assays and broad-spectrum antifungal agents, invasive fungal infections remain a significant challenge to clinicians and are associated with marked morbidity and mortality. In addition, the number of etiologic agents of invasive mycoses has increased accompanied by an expansion in the immunocompromised patient populations, and the use of molecular tools for fungal identification and characterization has resulted in the discovery of several cryptic species. This article reviews various methods used to identify fungi and perform antifungal susceptibility testing in the clinical laboratory. Recent developments in antifungal resistance are also discussed.
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Affiliation(s)
- Mohammad T Albataineh
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Deanna A Sutton
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Annette W Fothergill
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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31
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Busca A, Tortorano AM, Pagano L. Reviewing the importance and evolution of fungal infections and potential antifungal resistance in haematological patients. J Glob Antimicrob Resist 2015; 3:237-241. [DOI: 10.1016/j.jgar.2015.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 12/11/2022] Open
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In Vitro Biochemical Study of CYP51-Mediated Azole Resistance in Aspergillus fumigatus. Antimicrob Agents Chemother 2015; 59:7771-8. [PMID: 26459890 DOI: 10.1128/aac.01806-15] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/01/2015] [Indexed: 01/03/2023] Open
Abstract
The incidence of triazole-resistant Aspergillus infections is increasing worldwide, often mediated through mutations in the CYP51A amino acid sequence. New classes of azole-based drugs are required to combat the increasing resistance to existing triazole therapeutics. In this study, a CYP51 reconstitution assay is described consisting of eburicol, purified recombinant Aspergillus fumigatus CPR1 (AfCPR1), and Escherichia coli membrane suspensions containing recombinant A. fumigatus CYP51 proteins, allowing in vitro screening of azole antifungals. Azole-CYP51 studies determining the 50% inhibitory concentration (IC50) showed that A. fumigatus CYP51B (Af51B IC50, 0.50 μM) was 34-fold more susceptible to inhibition by fluconazole than A. fumigatus CYP51A (Af51A IC50, 17 μM) and that Af51A and Af51B were equally susceptible to inhibition by voriconazole, itraconazole, and posaconazole (IC50s of 0.16 to 0.38 μM). Af51A-G54W and Af51A-M220K enzymes were 11- and 15-fold less susceptible to inhibition by itraconazole and 30- and 8-fold less susceptible to inhibition by posaconazole than wild-type Af51A, confirming the azole-resistant phenotype of these two Af51A mutations. Susceptibility to voriconazole of Af51A-G54W and Af51A-M220K was only marginally lower than that of wild-type Af51A. Susceptibility of Af51A-L98H to inhibition by voriconazole, itraconazole, and posaconazole was only marginally lower (less than 2-fold) than that of wild-type Af51A. However, Af51A-L98H retained 5 to 8% residual activity in the presence of 32 μM triazole, which could confer azole resistance in A. fumigatus strains that harbor the Af51A-L98H mutation. The AfCPR1/Af51 assay system demonstrated the biochemical basis for the increased azole resistance of A. fumigatus strains harboring G54W, L98H, and M220K Af51A point mutations.
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Paul RA, Rudramurthy SM, Meis JF, Mouton JW, Chakrabarti A. A Novel Y319H Substitution in CYP51C Associated with Azole Resistance in Aspergillus flavus. Antimicrob Agents Chemother 2015; 59:6615-9. [PMID: 26248359 PMCID: PMC4576050 DOI: 10.1128/aac.00637-15] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/10/2015] [Indexed: 11/20/2022] Open
Abstract
This study aimed to explore any mutation in the CYP51 gene conferring azole resistance in Aspergillus flavus. Two voriconazole-resistant and 45 voriconazole-susceptible isolates were included in the study. Sequence analysis demonstrated a T1025C nucleotide change in CYP51C, resulting in the Y319H amino acid substitution in one resistant isolate. However, the earlier described T788G mutation in CYP51C conferring voriconazole resistance in A. flavus isolates was present in all isolates, irrespective of their susceptibility status.
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Affiliation(s)
- R A Paul
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - J W Mouton
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kalkanci A, Elli M, Adil Fouad A, Yesilyurt E, Jabban Khalil I. Assessment of susceptibility of mould isolates towards biocides. J Mycol Med 2015; 25:280-6. [PMID: 26420602 DOI: 10.1016/j.mycmed.2015.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 07/24/2015] [Accepted: 08/08/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to determine the susceptibility of 77 mould strains: Aspergillus fumigatus (20), Aspergillus flavus (8), Aspergillus niger (4), Aspergillus ochraceus (2), Penicillium citrinum (15), Penicillium crysogenum (14), Penicillium aurantiogriseum (1), Penicillium roquefortii (4), Penicillium paneum (2), Rhizopus spp. (3), Tricoderma spp. (1) and Mucor spp. (3) to biocides. METHODS MIC determination was determined based on CLSI methodology. RESULTS For hospital acquired strains, MIC50 was 0.5mg/L, MIC90 was 1mg/L for chlorhexidine (CHX); MIC50 was 0.5mg/L, and MIC90 was 1mg/L for benzalkonium chloride (BZC); MIC50 was 1mg/L, and MIC90 was 2mg/L for triclosan (TRC); MIC50 was 1024mg/L, and MIC90 was 2048mg/L for sodium hypochloride (SHC). For feed and food isolates MIC50 was 2mg/L, MIC90 was 8mg/L for CHX, MIC50 was 2mg/L, and MIC90 was 4mg/L for BZC, MIC50 was 2mg/L, and MIC90 was 4mg/L for TRC, MIC50 was 256mg/L, and MIC90 was 512mg/L for SHC. CONCLUSION We can conclude that food isolates presented slightly higher MIC50 and MIC90 values for CHX, BNZ and TRC, but not for SHC.
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Affiliation(s)
- A Kalkanci
- Department of Medical Microbiology, Gazi University School of Medicine, Besevler, Ankara, 06500, Turkey.
| | - M Elli
- AAT-Advanced Analytical Technologies Srl, Piacenza, Italy
| | - A Adil Fouad
- Department of Medical Microbiology, Gazi University School of Medicine, Besevler, Ankara, 06500, Turkey
| | - E Yesilyurt
- Department of Medical Microbiology, Gazi University School of Medicine, Besevler, Ankara, 06500, Turkey
| | - I Jabban Khalil
- Department of Medical Microbiology, Gazi University School of Medicine, Besevler, Ankara, 06500, Turkey
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35
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Zhang J, Debets AJM, Verweij PE, Melchers WJG, Zwaan BJ, Schoustra SE. Asexual sporulation facilitates adaptation: The emergence of azole resistance in Aspergillus fumigatus. Evolution 2015; 69:2573-86. [PMID: 26315993 DOI: 10.1111/evo.12763] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 07/11/2015] [Accepted: 08/03/2015] [Indexed: 12/26/2022]
Abstract
Understanding the occurrence and spread of azole resistance in Aspergillus fumigatus is crucial for public health. It has been hypothesized that asexual sporulation, which is abundant in nature, is essential for phenotypic expression of azole resistance mutations in A. fumigatus facilitating subsequent spread through natural selection. Furthermore, the disease aspergilloma is associated with asexual sporulation within the lungs of patients and the emergence of azole resistance. This study assessed the evolutionary advantage of asexual sporulation by growing the fungus under pressure of one of five different azole fungicides over seven weeks and by comparing the rate of adaptation between scenarios of culturing with and without asexual sporulation. Results unequivocally show that asexual sporulation facilitates adaptation. This can be explained by the combination of more effective selection because of the transition from a multicellular to a unicellular stage, and by increased mutation supply due to the production of spores, which involves numerous mitotic divisions. Insights from this study are essential to unravel the resistance mechanisms of sporulating pathogens to chemical compounds and disease agents in general, and for designing strategies that prevent or overcome the emerging threat of azole resistance in particular.
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Affiliation(s)
- Jianhua Zhang
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708PB, Wageningen, The Netherlands.
| | - Alfons J M Debets
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708PB, Wageningen, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
| | - Bas J Zwaan
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708PB, Wageningen, The Netherlands
| | - Sijmen E Schoustra
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708PB, Wageningen, The Netherlands
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36
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Comparing Etest and Broth Microdilution for Antifungal Susceptibility Testing of the Most-Relevant Pathogenic Molds. J Clin Microbiol 2015. [PMID: 26202113 DOI: 10.1128/jcm.00925-15] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Invasive mold infections are life-threatening diseases for which appropriate antifungal therapy is crucial. Their epidemiology is evolving, with the emergence of triazole-resistant Aspergillus spp. and multidrug-resistant non-Aspergillus molds. Despite the lack of interpretive criteria, antifungal susceptibility testing of molds may be useful in guiding antifungal therapy. The standard broth microdilution method (BMD) is demanding and requires expertise. We assessed the performance of a commercialized gradient diffusion method (Etest method) as an alternative to BMD. The MICs or minimal effective concentrations (MECs) of amphotericin B, voriconazole, posaconazole, caspofungin, and micafungin were assessed for 290 clinical isolates of the most representative pathogenic molds (154 Aspergillus and 136 non-Aspergillus isolates) with the BMD and Etest methods. Essential agreements (EAs) within ±2 dilutions of ≥90% between the two methods were considered acceptable. EAs for amphotericin B and voriconazole were >90% for most potentially susceptible species. For posaconazole, the correlation was acceptable for Mucoromycotina but Etest MIC values were consistently lower for Aspergillus spp. (EAs of <90%). Excellent EAs were found for echinocandins with highly susceptible (MECs of <0.015 μg/ml) or intrinsically resistant (MECs of >16 μg/ml) strains. However, MEC determinations lacked consistency between methods for strains exhibiting mid-range MECs for echinocandins. We concluded that the Etest method is an appropriate alternative to BMD for antifungal susceptibility testing of molds under specific circumstances, including testing with amphotericin B or triazoles for non-Aspergillus molds (Mucoromycotina and Fusarium spp.). Additional study of molecularly characterized triazole-resistant Aspergillus isolates is required to confirm the ability of the Etest method to detect voriconazole and posaconazole resistance among Aspergillus spp.
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Chowdhary A, Sharma C, Kathuria S, Hagen F, Meis JF. Prevalence and mechanism of triazole resistance in Aspergillus fumigatus in a referral chest hospital in Delhi, India and an update of the situation in Asia. Front Microbiol 2015; 6:428. [PMID: 26005442 PMCID: PMC4424976 DOI: 10.3389/fmicb.2015.00428] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/22/2015] [Indexed: 01/23/2023] Open
Abstract
Aspergillus fumigatus causes varied clinical syndromes ranging from colonization to deep infections. The mainstay of therapy of Aspergillus diseases is triazoles but several studies globally highlighted variable prevalence of triazole resistance, which hampers the management of aspergillosis. We studied the prevalence of resistance in clinical A. fumigatus isolates during 4 years in a referral Chest Hospital in Delhi, India and reviewed the scenario in Asia and the Middle East. Aspergillus species (n = 2117) were screened with selective plates for azole resistance. The isolates included 45.4% A. flavus, followed by 32.4% A. fumigatus, 15.6% Aspergillus species and 6.6% A. terreus. Azole resistance was found in only 12 (1.7%) A. fumigatus isolates. These triazole resistant A. fumigatus (TRAF) isolates were subjected to (a) calmodulin and β tubulin gene sequencing (b) in vitro antifungal susceptibility testing against triazoles using CLSI M38-A2 (c) sequencing of cyp51A gene and real-time PCR assay for detection of mutations and (d) microsatellite typing of the resistant isolates. TRAF harbored TR34/L98H mutation in 10 (83.3%) isolates with a pan-azole resistant phenotype. Among the remaining two TRAF isolates, one had G54E and the other had three non-synonymous point mutations. The majority of patients were diagnosed as invasive aspergillosis followed by allergic bronchopulmonary aspergillosis and chronic pulmonary aspergillosis. The Indian TR34/L98H isolates had a unique genotype and were distinct from the Chinese, Middle East, and European TR34/L98H strains. This resistance mechanism has been linked to the use of fungicide azoles in agricultural practices in Europe as it has been mainly reported from azole naïve patients. Reports published from Asia demonstrate the same environmental resistance mechanism in A. fumigatus isolates from two highly populated countries in Asia, i.e., China and India and also from the neighboring Middle East.
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi Delhi, India
| | - Cheshta Sharma
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi Delhi, India
| | - Shallu Kathuria
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi Delhi, India
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital Nijmegen, Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital Nijmegen, Netherlands ; Department of Medical Microbiology, Radboud University Medical Center Nijmegen, Netherlands
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Kathuria S, Sharma C, Singh PK, Agarwal P, Agarwal K, Hagen F, Meis JF, Chowdhary A. Molecular epidemiology and in-vitro antifungal susceptibility of Aspergillus terreus species complex isolates in Delhi, India: evidence of genetic diversity by amplified fragment length polymorphism and microsatellite typing. PLoS One 2015; 10:e0118997. [PMID: 25781896 PMCID: PMC4363790 DOI: 10.1371/journal.pone.0118997] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/08/2015] [Indexed: 11/19/2022] Open
Abstract
Aspergillus terreus is emerging as an etiologic agent of invasive aspergillosis in immunocompromised individuals in several medical centers in the world. Infections due to A. terreus are of concern due to its resistance to amphotericin B, in vivo and in vitro, resulting in poor response to antifungal therapy and high mortality. Herein we examined a large collection of molecularly characterized, geographically diverse A. terreus isolates (n = 140) from clinical and environmental sources in India for the occurrence of cryptic A. terreus species. The population structure of the Indian A. terreus isolates and their association with those outside India was determined using microsatellite based typing (STR) technique and Amplified Fragment Length Polymorphism analysis (AFLP). Additionally, in vitro antifungal susceptibility of A. terreus isolates was determined against 7 antifungals. Sequence analyses of the calmodulin locus identified the recently described cryptic species A. hortai, comprising 1.4% of Aspergillus section Terrei isolates cultured from cases of aspergilloma and probable invasive aspergillosis not reported previously. All the nine markers used for STR typing of A. terreus species complex proved to be highly polymorphic. The presence of high genetic diversity revealing 75 distinct genotypes among 101 Indian A. terreus isolates was similar to the marked heterogeneity noticed in the 47 global A. terreus population exhibiting 38 unique genotypes mainly among isolates from North America and Europe. Also, AFLP analysis showed distinct banding patterns for genotypically diverse A. terreus isolates. Furthermore, no correlation between a particular genotype and amphotericin B susceptibility was observed. Overall, 8% of the A. terreus isolates exhibited low MICs of amphotericin B. All the echinocandins and azoles (voriconazole, posaconazole and isavuconazole) demonstrated high potency against all the isolates. The study emphasizes the need of molecular characterization of A. terreus species complex isolates to better understand the ecology, acquisition and transmission of this species.
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Affiliation(s)
- Shallu Kathuria
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Cheshta Sharma
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pradeep Kumar Singh
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Puneet Agarwal
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Kshitij Agarwal
- Department of Pulmonary Medicine, Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jacques F. Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- * E-mail:
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The molecular mechanism of azole resistance in Aspergillus fumigatus: from bedside to bench and back. J Microbiol 2015; 53:91-9. [PMID: 25626363 DOI: 10.1007/s12275-015-5014-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Abstract
The growing use of immunosuppressive therapies has resulted in a dramatic increased incidence of invasive fungal infections (IFIs) caused by Aspergillus fumigatus, a common pathogen, and is also associated with a high mortality rate. Azoles are the primary guideline-recommended therapy agents for first-line treatment and prevention of IFIs. However, increased azole usage in medicinal and agricultural settings has caused azole-resistant isolates to repeatedly emerge in the environment, resulting in a significant threat to human health. In this review, we present and summarize current research on the resistance mechanisms of azoles in A. fumigatus as well as efficient susceptibility testing methods. Moreover, we analyze and discuss the putative clinical (bedside) indication of these findings from bench work.
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Kontoyiannis DP, Lewis RE. Treatment principles for the management of mold infections. Cold Spring Harb Perspect Med 2014; 5:cshperspect.a019737. [PMID: 25377139 DOI: 10.1101/cshperspect.a019737] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Survival rates among immunocompromised patients with invasive mold infections have markedly improved over the last decade with earlier diagnosis and new antifungal treatment options. Yet, increasing antifungal resistance, breakthrough infections with intrinsically resistant fungi, and potentially life-threatening adverse effects and drug interactions are becoming more problematic, especially with prolonged therapy. Evidence-based recommendations for treating invasive aspergillosis and mucormycosis provide excellent guidance on the initial workup and treatment of these molds, but they cannot address all of the key management issues. Herein, we discuss 10 general treatment principles in the management of invasive mold disease in immunocompromised patients and discuss how these principles can be integrated to develop an effective, individualized treatment plan.
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Affiliation(s)
| | - Russell E Lewis
- Department of Medical Sciences and Surgery, University of Bologna, 40138 Bologna, Italy
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Pastor FJ, Guarro J. Treatment of Aspergillus terreus infections: a clinical problem not yet resolved. Int J Antimicrob Agents 2014; 44:281-9. [PMID: 25190543 DOI: 10.1016/j.ijantimicag.2014.07.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 07/03/2014] [Accepted: 07/10/2014] [Indexed: 10/24/2022]
Abstract
Despite the use of recommended therapies, invasive infections by Aspergillus terreus show a poor response. For years, investigative studies on the failure of therapy of fungal infections have focused on in vitro susceptibility data. However, it is well known that low minimum inhibitory concentrations (MICs) are not always predictive of response to therapy despite a correct dosage schedule. Many experimental and clinical studies have tried to establish a relationship between MICs and outcome in serious fungal infections but have come to contradictory and even surprising conclusions. The success or failure of treatment is determined by many factors, including the in vitro susceptibility of the causative fungal isolate, the pharmacokinetics/pharmacodynamics of the drug used for treatment, pharmacokinetic variability in the population, and the underlying disease that patients suffer. To try to understand this poor response to treatment, available data on the in vitro susceptibility of A. terreus, the experimental and clinical response to amphotericin B, triazoles and echinocandins, and the pharmacokinetics/pharmacodynamics of these antifungals have been reviewed. Of special interest are the fungistatic activites of these drugs against A. terreus and the high interpatient variability of serum drug levels observed in therapy based on triazoles, which make monitoring of infected patients necessary.
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Affiliation(s)
- F Javier Pastor
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Sant Llorenç 21, 43201 Reus, Spain
| | - Josep Guarro
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Sant Llorenç 21, 43201 Reus, Spain.
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Ahmad S, Khan Z, Hagen F, Meis JF. Occurrence of triazole-resistant Aspergillus fumigatus with TR34/L98H mutations in outdoor and hospital environment in Kuwait. ENVIRONMENTAL RESEARCH 2014; 133:20-26. [PMID: 24906064 DOI: 10.1016/j.envres.2014.05.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Invasive aspergillosis due to triazole-resistant Aspergillus fumigatus, a common airborne fungal pathogen, has emerged in some European and Asian countries, likely due to exposure to azole fungicides in the environment. This study determined the occurrence of triazole-resistant A. fumigatus in outdoor and hospital environment in Kuwait, a semi-arid desert country in Arabian Peninsula. METHODS Outdoor/indoor air, water and cotton swab samples were cultured on malt extract agar and A. fumigatus colonies were identified by phenotypic and molecular methods. Drug susceptibility of A. fumigatus isolates to itraconazole, posaconazole and voriconazole was carried out by an Etest and a broth microdilution method. Resistance mechanisms involving cyp51A mutations were probed by mixed-format real-time (MF-rt)-PCR assays. Triazole-resistant isolates were typed by nine-locus microsatellite analysis. A multiplex allele-specific (MAS)-PCR assay was developed for detection of L98H mutation in cyp51A. RESULTS Of 115 A. fumigatus isolates obtained from 362 environmental samples from across Kuwait, 8 isolates were resistant to itraconazole, posaconazole and voriconazole. All itraconazole-resistant isolates contained a 34-bp tandem repeat (TR34) in the promoter region and a L98H mutation at codon 98 (TR34/L98H) in cyp51A. These mutations were absent in all itraconazole-susceptible isolates. MAS-PCR accurately detected L98H mutation in all triazole-resistant isolates. Three microsatellite patterns were observed among resistant isolates with one pattern clustering with Indian clinical and environmental isolates. CONCLUSIONS Triazole-resistant A. fumigatus with TR34/L98H mutations in cyp51A is prevalent in Kuwait. Although triazole-resistant A. fumigatus has not yet been isolated from clinical specimens, its presence in the environment suggests that the possibility of susceptible individuals getting infected with such strains exists and may pose therapeutic challenges in its management.
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Affiliation(s)
- Suhail Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, P. O. Box 24923, Safat 13110, Kuwait
| | - Ziauddin Khan
- Department of Microbiology, Faculty of Medicine, Kuwait University, P. O. Box 24923, Safat 13110, Kuwait.
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Seyedmousavi S, Mouton JW, Melchers WJG, Brüggemann RJM, Verweij PE. The role of azoles in the management of azole-resistant aspergillosis: from the bench to the bedside. Drug Resist Updat 2014; 17:37-50. [PMID: 25066814 DOI: 10.1016/j.drup.2014.06.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 06/21/2014] [Accepted: 06/29/2014] [Indexed: 10/25/2022]
Abstract
Azole resistance is an emerging problem in Aspergillus fumigatus and is associated with a high probability of treatment failure. An azole resistance mechanism typically decreases the activity of multiple azole compounds, depending on the mutation. As alternative treatment options are limited and in some isolates the minimum inhibitory concentration (MIC) increases by only a few two-fold dilutions steps, we investigated if voriconazole and posaconazole have a role in treating azole-resistant Aspergillus disease. The relation between resistance genotype and phenotype, pharmacokinetic and pharmacodynamic properties, and (pre)clinical treatment efficacy were reviewed. The results were used to estimate the exposure needed to achieve the pharmacodynamic target for each MIC. For posaconazole adequate exposure can be achieved only for wild type isolates as dose escalation does not allow PD target attainment. However, the new intravenous formulation might result in sufficient exposure to treat isolates with a MIC of 0.5 mg/L. For voriconazole our analysis indicated that the exposure needed to treat infection due to isolates with a MIC of 2 mg/L is feasible and maybe isolates with a MIC of 4 mg/L. However, extreme caution and strict monitoring of drug levels would be required, as the probability of toxicity will also increase.
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Affiliation(s)
- Seyedmojtaba Seyedmousavi
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, The Netherlands
| | | | | | - Paul E Verweij
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands.
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Chowdhary A, Sharma C, Hagen F, Meis JF. Exploring azole antifungal drug resistance in Aspergillus fumigatus with special reference to resistance mechanisms. Future Microbiol 2014; 9:697-711. [DOI: 10.2217/fmb.14.27] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ABSTRACT: Aspergillus fumigatus, a ubiquitously distributed opportunistic pathogen, is the global leading cause of aspergillosis. Azole antifungals play an important role in the management of aspergillosis. However, over a decade, azole resistance in A. fumigatus isolates has been increasingly reported with variable prevalence worldwide and it is challenging the effective management of aspergillosis. The high mortality rates observed in patients with invasive aspergillosis caused by azole-resistant A. fumigatus (ARAF) isolates pose serious challenges to the clinical microbiologist for timely identification of resistance and appropriate therapeutic interventions. The majority of ARAF isolates contain alterations in the cyp51A gene; however, there have been increasing reports on non-cyp51A mutations contributing to azole resistant phenotypes. This review highlights the emergence and various mechanisms implicated in the development of azole resistance in A. fumigatus. We further present recent developments related to the environmental route in the emergence of ARAF isolates and discuss the therapeutic options available.
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Cheshta Sharma
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Ferry Hagen
- Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Simple, low-cost molecular assays for TR34/L98H mutations in the cyp51A gene for rapid detection of triazole-resistant Aspergillus fumigatus isolates. J Clin Microbiol 2014; 52:2223-7. [PMID: 24719446 DOI: 10.1128/jcm.00408-14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Simple, low-cost PCR/PCR-restriction fragment length polymorphism (RFLP) assays targeting cyp51A promoter and codon 98 regions were developed for the detection of triazole-resistant Aspergillus fumigatus strains carrying TR34/L98H mutations. The assays were evaluated using 40 itraconazole-susceptible isolates and 35 itraconazole-resistant isolates. The prevalence of TR34/L98H mutations in clinical/environmental A. fumigatus isolates may now be determined easily from resource-poor settings.
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Evaluation of Etest performed in Mueller-Hinton agar supplemented with glucose for antifungal susceptibility testing of clinical isolates of filamentous fungi. Mycopathologia 2014; 177:157-66. [PMID: 24570038 DOI: 10.1007/s11046-014-9730-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 01/30/2014] [Indexed: 12/23/2022]
Abstract
Although reference broth microdilution protocol is currently available for filamentous fungi antifungal susceptibility testing (AFST), simpler alternatives as Etest(®) tend to be favoured in clinical routine, making their validation of utmost importance. In this study, Etest(®) method using 2% glucose supplemented Muller-Hinton agar was compared to the Clinical and Laboratory Standards Institute (CLSI) M38-A2 protocol for filamentous fungi AFST. The echinocandins, caspofungin and anidulafungin, the azoles voriconazole and posaconazole, and the polyene amphotericin B were tested against 48 Aspergillus spp., seven Fusarium spp., one Beauveria bassiana and three Paecilomyces lilacinus isolates. The majority of the isolates were susceptible to the antifungals tested, and the overall level of agreement between the CLSI and Etest methods was 71.9% for one dilution and 99.7% when using two dilutions. Since interpretative breakpoints for filamentous fungi employing the CLSI or Etest methods are not available yet, the established epidemiological cut-off values for Aspergillus spp. were used to distinguish wild-type isolates from those with acquired resistance mechanisms. Forty-five Aspergillus strains did not evidence resistance mutations.
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Bowyer P, Denning DW. Environmental fungicides and triazole resistance in Aspergillus. PEST MANAGEMENT SCIENCE 2014; 70:173-178. [PMID: 23616354 DOI: 10.1002/ps.3567] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 04/10/2013] [Accepted: 04/24/2013] [Indexed: 06/02/2023]
Abstract
Fungal diseases are problematic in both human health and agriculture. Treatment options are limited and resistance may emerge. The relatively recent recognition of triazole resistance in Aspergillus fumigatus has prompted questioning of the origin of resistance. While multiple mechanisms are described in clinical isolates from triazole-treated patients, some de novo resistance is also recognised, especially attributable to TR34 /L98H. Such strains probably arose in the environment, and, indeed, multiple studies have now demonstrated TR(34) /L98H triazole resistance strains of A. fumigatus from soil. Docking and other in vitro studies are consistent with environmental resistance induction through exposure to certain triazole fungicides, notably difenoconazole, propiconazole, epoxiconazole, bromuconazole and tebuconazole. This article addresses the potential implications of this issue for both human health and food security.
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Affiliation(s)
- Paul Bowyer
- National Aspergillosis Centre, University Hospital of South Manchester; Institute of Inflammation and Repair, University of Manchester; Manchester Academic Health Science Centre, Manchester, UK
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Lalitha P, Sun CQ, Prajna NV, Karpagam R, Geetha M, O'Brien KS, Cevallos V, McLeod SD, Acharya NR, Lietman TM. In vitro susceptibility of filamentous fungal isolates from a corneal ulcer clinical trial. Am J Ophthalmol 2014; 157:318-26. [PMID: 24439440 DOI: 10.1016/j.ajo.2013.10.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To describe the minimum inhibitory concentration (MIC) of fungal isolates to natamycin and voriconazole, and to compare these MICs to previous ocular susceptibility studies. DESIGN Experimental laboratory study using isolates from a randomized clinical trial. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked, multicenter trial comparing topical natamycin and voriconazole for fungal keratitis treatment. Susceptibility testing to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute methods. The relationship between organism and MIC was assessed. A literature review was performed to compare results to previous ocular susceptibility studies. RESULTS Of the 323 patients enrolled in the trial, MICs were available for 221 (68%). Fusarium (n = 126) and Aspergillus species (n = 52) were the most commonly isolated organisms. MICs to natamycin and voriconazole were significantly different across all genera (P < .001). The MIC median (MIC50) and 90th percentile (MIC90) for natamycin were equal to or higher than voriconazole for all organisms except Curvularia species. Compared to other organisms, Fusarium species isolates had the highest MICs to voriconazole and Aspergillus flavus isolates had the highest MICs to natamycin. Our results were similar to previous reports except that the voriconazole MIC90 against Aspergillus species was 2-fold higher and the natamycin MIC90 against Aspergillus fumigatus was 4-fold higher in our study. CONCLUSION In this large susceptibility study, Fusarium isolates were least susceptible to voriconazole and A flavus isolates were least susceptible to natamycin when compared to other filamentous fungi. In the future, susceptibility testing may help guide therapy if performed in a timely manner.
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Gheith S, Saghrouni F, Bannour W, Ben Youssef Y, Khelif A, Normand AC, Piarroux R, Ben Said M, Njah M, Ranque S. In vitro susceptibility to amphotericin B, itraconazole, voriconazole, posaconazole and caspofungin of Aspergillus spp. isolated from patients with haematological malignancies in Tunisia. SPRINGERPLUS 2014; 3:19. [PMID: 26034655 PMCID: PMC4447766 DOI: 10.1186/2193-1801-3-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 01/07/2014] [Indexed: 12/22/2022]
Abstract
The resistance of Aspergillus species to antifungal is increasingly reported and the knowledge of the local epidemiology and antifungal susceptibility pattern is pivotal to define adequate treatment policies. Our study aimed to: 1) describe the in vitro antifungal susceptibility profile of the Aspergillus species isolated from patients with haematological malignancies in Tunisia; 2) compare the E-test and Sensititre Yeast-One assays for the detection of paradoxical growth and trailing effect, both phenotypes commonly exhibited by Aspergillus spp. upon exposure to caspofungin and 3) to evaluate the mortality rate in patients according to the causative Aspergillus species and the antifungal treatment. We tested amphotericin B, itraconazole, voriconazole, posaconazole and caspofungin against 48 Aspergillus isolates (17, A. niger; 18, A. flavus; 9, A. tubingensis; 1, A. westerdijkiae; and 1, A. ochraceus) with the E-test. Minimal inhibition concentrations were above the epidemiological cut-off values for amphotericin B in 67% of A. flavus strains; for caspofungin in 22% of A. flavus strains; and for itraconazole in 22% of A. tubingensis strains, voriconazole and posaconazole MICs were below the epidemiological cut-off values for all strains. When exposed to caspofungin, 42% of the strains exhibited trailing effect and 38% paradoxical growth. Trailing effect occurred in 61% of A. flavus strains and paradoxical growth in 62% of Aspergillus section Nigri strains. E-test and Sensititre Yeast-One assays were only fairly concordant for the detection of these phenotypes. Repeatability of both assays was high for trailing effect but poor for paradoxical growth. The relatively high frequency of amphotericin B resistant strains makes voriconazole best adapted as a first-line treatment of invasive aspergillosis from amphotericin B to voriconazole in this hospital.
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Affiliation(s)
- Soukeina Gheith
- Service d'Hygiène Hospitalière, CHU Farhat Hached, Sousse, 4000 Tunisie ; Unité de recherche UR 04SP24, Ministère de la Santé Publique, Tunis, Tunisie ; Laboratoire de Parasitologie -Mycologie, CHU Farhat Hached, Sousse, 4000 Tunisie
| | - Fatma Saghrouni
- Unité de recherche UR 04SP24, Ministère de la Santé Publique, Tunis, Tunisie
| | - Wadiaa Bannour
- Service d'Hygiène Hospitalière, CHU Farhat Hached, Sousse, 4000 Tunisie
| | | | | | - Anne-Cécile Normand
- Parasitology & Mycology, CHU Timone-Adultes, Assistance Publique-Hôpitaux de Marseille, Marseille, 13005 France ; Aix-Marseille Université, IP-TPT UMR MD3, Marseille, 13885 France
| | - Renaud Piarroux
- Parasitology & Mycology, CHU Timone-Adultes, Assistance Publique-Hôpitaux de Marseille, Marseille, 13005 France ; Aix-Marseille Université, IP-TPT UMR MD3, Marseille, 13885 France
| | - Moncef Ben Said
- Unité de recherche UR 04SP24, Ministère de la Santé Publique, Tunis, Tunisie
| | - Mansour Njah
- Service d'Hygiène Hospitalière, CHU Farhat Hached, Sousse, 4000 Tunisie ; Unité de recherche UR 04SP24, Ministère de la Santé Publique, Tunis, Tunisie
| | - Stéphane Ranque
- Parasitology & Mycology, CHU Timone-Adultes, Assistance Publique-Hôpitaux de Marseille, Marseille, 13005 France ; Aix-Marseille Université, IP-TPT UMR MD3, Marseille, 13885 France
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