1
|
Thompson GR, Chen SCA, Alfouzan WA, Izumikawa K, Colombo AL, Maertens J. A global perspective of the changing epidemiology of invasive fungal disease and real-world experience with the use of isavuconazole. Med Mycol 2024; 62:myae083. [PMID: 39138063 PMCID: PMC11382804 DOI: 10.1093/mmy/myae083] [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: 05/13/2024] [Revised: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
Global epidemiological data show that the incidence of invasive fungal disease (IFD) has increased in recent decades, with the rising frequency of infections caused by Aspergillus and Mucorales order species. The number and variety of patients at risk of IFD has also expanded, owing in part to advances in the treatment of hematologic malignancies and other serious diseases, including hematopoietic stem cell transplantation (HCT) and other therapies causing immune suppression. Isavuconazonium sulfate (active moiety: isavuconazole) is an advanced-generation triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis that has demonstrated activity against a variety of yeasts, moulds, and dimorphic fungi. While real-world clinical experience with isavuconazole is sparse in some geographic regions, it has been shown to be effective and well tolerated in diverse patient populations, including those with multiple comorbidities who may have failed to respond to prior triazole antifungal therapy. Isavuconazole may be suitable for patients with IFD receiving concurrent QTc-prolonging therapy, as well as those on venetoclax or ruxolitinib. Data from clinical trials are not available to support the use of isavuconazole prophylactically for the prevention of IFD or for the treatment of endemic IFD, such as those caused by Histoplasma spp., but real-world evidence from case studies suggests that it has clinical utility in these settings. Isavuconazole is an option for patients at risk of IFD, particularly when the use of alternative antifungal therapies is not possible because of toxicities, pharmacokinetics, or drug interactions.
Collapse
Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Disease, UC Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California, Davis, California, USA
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology, and the Department of Infectious Diseases, Westmead Hospital, School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Wadha Ahmed Alfouzan
- Department of Laboratories, Farwaniya Hospital, Farwaniya, Kuwait
- Department of Microbiology, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Arnaldo L Colombo
- Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
- Antimicrobial Resistance Institute of São Paulo, São Paulo, Brazil
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven and Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Monzo-Gallo P, Alastruey-Izquierdo A, Chumbita M, Aiello TF, Gallardo-Pizarro A, Peyrony O, Teijon-Lumbreras C, Alcazar-Fuoli L, Espasa M, Soriano A, Marco F, Garcia-Vidal C. Report of three azole-resistant Aspergillus fumigatus cases with TR34/L98H mutation in hematological patients in Barcelona, Spain. Infection 2024:10.1007/s15010-024-02236-7. [PMID: 38801514 DOI: 10.1007/s15010-024-02236-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/12/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES We aimed to report the emergence of azole-resistant invasive aspergillosis in hematologic patients admitted to a tertiary hospital in Spain during the last 4 months. METHODS Prospective, descriptive study was performed to describe and follow all consecutive proven and probable invasive aspergillosis resistant to azoles from hematological cohort during the last 4 months. All patients had fungal cultures and antifungal susceptibility or real-time PCR detection for Aspergillus species and real-time PCR detection for azole-resistant mutation. RESULTS Four cases of invasive aspergillosis were diagnosed in 4 months. Three of them had azole-resistant aspergillosis. Microbiological diagnosis was achieved in three cases by means of fungal culture isolation and subsequent antifungal susceptibility whereas one case was diagnosed by PCR-based aspergillus and azole resistance detection. All the azole-resistant aspergillosis presented TR34/L98H mutation. Patients with azole-resistant aspergillosis had different hematologic diseases: multiple myeloma, lymphoblastic acute leukemia, and angioimmunoblastic T lymphoma. Regarding risk factors, one had prolonged neutropenia, two had corticosteroids, and two had viral co-infection. Two of the patients developed aspergillosis under treatment with azoles. CONCLUSION We have observed a heightened risk of azole-resistant aspergillosis caused by A. fumigatus harboring the TR34/L98H mutation in patients with hematologic malignancies. The emergence of azole-resistant aspergillosis raises concerns for the community, highlighting the urgent need for increased surveillance and the importance of susceptibility testing and new drugs development.
Collapse
Affiliation(s)
- Patricia Monzo-Gallo
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
| | - Ana Alastruey-Izquierdo
- ISCIII, Instituto de Salud Carlos III, Madrid, Spain
- CIBERINFECT, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid, Spain
| | - Mariana Chumbita
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
| | - Tommaso Francesco Aiello
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
| | - Antonio Gallardo-Pizarro
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christian Teijon-Lumbreras
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - Laura Alcazar-Fuoli
- ISCIII, Instituto de Salud Carlos III, Madrid, Spain
- CIBERINFECT, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid, Spain
| | - Mateu Espasa
- Department of Microbiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
- CIBERINFECT, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
| | - Francesc Marco
- Department of Microbiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.
- CIBERINFECT, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid, Spain.
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
| |
Collapse
|
3
|
Wang C, Miller N, Vines D, Severns PM, Momany M, Brewer MT. Azole resistance mechanisms and population structure of the human pathogen Aspergillus fumigatus on retail plant products. Appl Environ Microbiol 2024; 90:e0205623. [PMID: 38651929 PMCID: PMC11107156 DOI: 10.1128/aem.02056-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/30/2024] [Indexed: 04/25/2024] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprotroph and human-pathogenic fungus that is life-threatening to the immunocompromised. Triazole-resistant A. fumigatus was found in patients without prior treatment with azoles, leading researchers to conclude that resistance had developed in agricultural environments where azoles are used against plant pathogens. Previous studies have documented azole-resistant A. fumigatus across agricultural environments, but few have looked at retail plant products. Our objectives were to determine if azole-resistant A. fumigatus is prevalent in retail plant products produced in the United States (U.S.), as well as to identify the resistance mechanism(s) and population genetic structure of these isolates. Five hundred twenty-five isolates were collected from retail plant products and screened for azole resistance. Twenty-four isolates collected from compost, soil, flower bulbs, and raw peanuts were pan-azole resistant. These isolates had the TR34/L98H, TR46/Y121F/T289A, G448S, and H147Y cyp51A alleles, all known to underly pan-azole resistance, as well as WT alleles, suggesting that non-cyp51A mechanisms contribute to pan-azole resistance in these isolates. Minimum spanning networks showed two lineages containing isolates with TR alleles or the F46Y/M172V/E427K allele, and discriminant analysis of principle components identified three primary clusters. This is consistent with previous studies detecting three clades of A. fumigatus and identifying pan-azole-resistant isolates with TR alleles in a single clade. We found pan-azole resistance in U.S. retail plant products, particularly compost and flower bulbs, which indicates a risk of exposure to these products for susceptible populations and that highly resistant isolates are likely distributed worldwide on these products.IMPORTANCEAspergillus fumigatus has recently been designated as a critical fungal pathogen by the World Health Organization. It is most deadly to people with compromised immune systems, and with the emergence of antifungal resistance to multiple azole drugs, this disease carries a nearly 100% fatality rate without treatment or if isolates are resistant to the drugs used to treat the disease. It is important to determine the relatedness and origins of resistant A. fumigatus isolates in the environment, including plant-based retail products, so that factors promoting the development and propagation of resistant isolates can be identified.
Collapse
Affiliation(s)
- Caroline Wang
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Natalie Miller
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Douglas Vines
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Paul M. Severns
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| | - Michelle Momany
- Fungal Biology Group, Plant Biology Department, University of Georgia, Athens, Georgia, USA
| | - Marin T. Brewer
- Fungal Biology Group, Plant Pathology Department, University of Georgia, Athens, Georgia, USA
| |
Collapse
|
4
|
Celia-Sanchez BN, Mangum B, Gómez Londoño LF, Wang C, Shuman B, Brewer MT, Momany M. Pan-azole- and multi-fungicide-resistant Aspergillus fumigatus is widespread in the United States. Appl Environ Microbiol 2024; 90:e0178223. [PMID: 38557086 PMCID: PMC11022549 DOI: 10.1128/aem.01782-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
Aspergillus fumigatus is an important global fungal pathogen of humans. Azole drugs are among the most effective treatments for A. fumigatus infection. Azoles are also widely used in agriculture as fungicides against fungal pathogens of crops. Azole-resistant A. fumigatus has been increasing in Europe and Asia for two decades where clinical resistance is thought to be driven by agricultural use of azole fungicides. The most prevalent mechanisms of azole resistance in A. fumigatus are tandem repeats (TR) in the cyp51A promoter coupled with mutations in the coding region which result in resistance to multiple azole drugs (pan-azole resistance). Azole-resistant A. fumigatus has been isolated from patients in the United States (U.S.), but little is known about its environmental distribution. To better understand the distribution of azole-resistant A. fumigatus in the U.S., we collected isolates from agricultural sites in eight states and tested 202 isolates for sensitivity to azoles. We found azole-resistant A. fumigatus in agricultural environments in seven states showing that it is widespread in the U.S. We sequenced environmental isolates representing the range of U.S. sample sites and compared them with publicly available environmental worldwide isolates in phylogenetic, principal component, and ADMIXTURE analyses. We found worldwide isolates fell into three clades, and TR-based pan-azole resistance was largely in a single clade that was strongly associated with resistance to multiple agricultural fungicides. We also found high levels of gene flow indicating recombination between clades highlighting the potential for azole-resistance to continue spreading in the U.S.IMPORTANCEAspergillus fumigatus is a fungal pathogen of humans that causes over 250,000 invasive infections each year. It is found in soils, plant debris, and compost. Azoles are the first line of defense antifungal drugs against A. fumigatus. Azoles are also used as agricultural fungicides to combat other fungi that attack plants. Azole-resistant A. fumigatus has been a problem in Europe and Asia for 20 years and has recently been reported in patients in the United States (U.S.). Until this study, we did not know much about azole-resistant A. fumigatus in agricultural settings in the U.S. In this study, we isolated azole-resistant A. fumigatus from multiple states and compared it to isolates from around the world. We show that A. fumigatus which is resistant to azoles and to other strictly agricultural fungicides is widespread in the U.S.
Collapse
Affiliation(s)
| | - B. Mangum
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | | | - C. Wang
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | - B. Shuman
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
| | - M. T. Brewer
- Department of Plant Pathology, University of Georgia, Athens, Georgia, USA
| | - M. Momany
- Department of Plant Biology, University of Georgia, Athens, Georgia, USA
| |
Collapse
|
5
|
M. Jimenez Madrid A, Paul RA, Rotondo F, Deblais L, Rajashekara G, Miller SA, Ivey MLL. Triazole resistance in Aspergillus fumigatus isolated from a tomato production environment exposed to propiconazole. Appl Environ Microbiol 2024; 90:e0001724. [PMID: 38534143 PMCID: PMC11022574 DOI: 10.1128/aem.00017-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
The emergence of azole-resistant Aspergillus fumigatus (ARAf) across the world is an important public health concern. We sought to determine if propiconazole, a demethylase inhibitor (DMI) fungicide, exerted a selective pressure for ARAf in a tomato production environment following multiple exposures to the fungicide. A tomato field trial was established in 2019 and propiconazole was applied weekly until harvest. Soil, leaf, and fruit (when present) samples were collected at baseline and after each propiconazole application. A. fumigatus isolates (n, 178) were recovered and 173 were tested for susceptibility to itraconazole, posaconazole, voriconazole, and propiconazole in accordance with CLSI M38 guidelines. All the isolates were susceptible to medical triazoles and the propiconazole MIC ranged from 0.25 to 8 mg/L. A linear regression model was fitted that showed no longitudinal increment in the log2-fold azole MIC of the isolates collected after each propiconazole exposure compared to the baseline isolates. AsperGenius real-time multiplex assay ruled out TR34/L98H and TR46/Y121F/T289A cyp51A resistance markers in these isolates. Sequencing of a subset of isolates (n, 46) demonstrated widespread presence of F46Y/M172V/E427K and F46Y/M172V/N248T/D255E/E427K cyp51A mutations previously associated with reduced susceptibility to triazoles. IMPORTANCE The agricultural use of azole fungicides to control plant diseases has been implicated as a major contributor to ARAf infections in humans. Our study did not reveal imposition of selection pressure for ARAf in a vegetable production system. However, more surveillance studies for ARAf in food crop production and other environments are warranted in understanding this public and One Health issue.
Collapse
Affiliation(s)
- Alejandra M. Jimenez Madrid
- Department of Plant Pathology, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Raees A. Paul
- Department of Plant Pathology, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Francesca Rotondo
- Department of Plant Pathology, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Loic Deblais
- Department of Animal Sciences, Center for Food Animal Health, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Gireesh Rajashekara
- Department of Animal Sciences, Center for Food Animal Health, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Sally A. Miller
- Department of Plant Pathology, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| | - Melanie L. Lewis Ivey
- Department of Plant Pathology, The Ohio State University College of Food, Agricultural and Environmental Sciences-Wooster, Wooster, Ohio, USA
| |
Collapse
|
6
|
Pontes L, Arai T, Gualtieri Beraquet CA, Giordano ALPL, Reichert-Lima F, da Luz EA, Fernanda de Sá C, Ortolan Levy L, Tararam CA, Watanabe A, Moretti ML, Zaninelli Schreiber A. Uncovering a Novel cyp51A Mutation and Antifungal Resistance in Aspergillus fumigatus through Culture Collection Screening. J Fungi (Basel) 2024; 10:122. [PMID: 38392794 PMCID: PMC10890095 DOI: 10.3390/jof10020122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Aspergillus fumigatus is an important concern for immunocompromised individuals, often resulting in severe infections. With the emergence of resistance to azoles, which has been the therapeutic choice for Aspergillus infections, monitoring the resistance of these microorganisms becomes important, including the search for mutations in the cyp51A gene, which is the gene responsible for the mechanism of action of azoles. We conducted a retrospective analysis covering 478 A. fumigatus isolates. METHODS This comprehensive dataset comprised 415 clinical isolates and 63 isolates from hospital environmental sources. For clinical isolates, they were evaluated in two different periods, from 1998 to 2004 and 2014 to 2021; for environmental strains, one strain was isolated in 1998, and 62 isolates were evaluated in 2015. Our primary objectives were to assess the epidemiological antifungal susceptibility profile; trace the evolution of resistance to azoles, Amphotericin B (AMB), and echinocandins; and monitor cyp51A mutations in resistant strains. We utilized the broth microdilution assay for susceptibility testing, coupled with cyp51A gene sequencing and microsatellite genotyping to evaluate genetic variability among resistant strains. RESULTS Our findings reveal a progressive increase in Minimum Inhibitory Concentrations (MICs) for azoles and AMB over time. Notably, a discernible trend in cyp51A gene mutations emerged in clinical isolates starting in 2014. Moreover, our study marks a significant discovery as we detected, for the first time, an A. fumigatus isolate carrying the recently identified TR46/F495I mutation within a sample obtained from a hospital environment. The observed cyp51A mutations underscore the ongoing necessity for surveillance, particularly as MICs for various antifungal classes continue to rise. CONCLUSIONS By conducting resistance surveillance within our institution's culture collection, we successfully identified a novel TR46/F495I mutation in an isolate retrieved from the hospital environment which had been preserved since 1998. Moreover, clinical isolates were found to exhibit TR34/L98H/S297T/F495I mutations. In addition, we observed an increase in MIC patterns for Amphotericin B and azoles, signaling a change in the resistance pattern, emphasizing the urgent need for the development of new antifungal drugs. Our study highlights the importance of continued monitoring and research in understanding the evolving challenges in managing A. fumigatus infections.
Collapse
Affiliation(s)
- Laís Pontes
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
| | - Teppei Arai
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba 260-8670, Japan
| | | | | | - Franqueline Reichert-Lima
- Department of Medicine, School of Medical Sciences in São José dos Campos-Humanitas, São José dos Campos 12220-061, São Paulo, Brazil
| | - Edson Aparecido da Luz
- Division of Clinical Pathology, Microbiology Laboratory, University of Campinas Clinical Hospital, Campinas 13083-888, São Paulo, Brazil
| | - Camila Fernanda de Sá
- Division of Clinical Pathology, Microbiology Laboratory, University of Campinas Clinical Hospital, Campinas 13083-888, São Paulo, Brazil
| | - Larissa Ortolan Levy
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
| | | | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba 260-8670, Japan
| | - Maria Luiza Moretti
- School of Medical Sciences, University of Campinas, Campinas 13083-970, São Paulo, Brazil
| | | |
Collapse
|
7
|
Thakur R, Shishodia SK, Sharma A, Chauhan A, Kaur S, Shankar J. Accelerating the understanding of Aspergillus terreus: Epidemiology, physiology, immunology and advances. CURRENT RESEARCH IN MICROBIAL SCIENCES 2024; 6:100220. [PMID: 38303967 PMCID: PMC10831165 DOI: 10.1016/j.crmicr.2024.100220] [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] [Indexed: 02/03/2024] Open
Abstract
Aspergillus species encompass a variety of infections, ranging from invasive aspergillosis to allergic conditions, contingent upon the immune status of the host. In this spectrum, Aspergillus terreus stands out due to its emergence as a notable pathogen and its intrinsic resistance to amphotericin-B. The significance of Aspergillus-associated infections has witnessed a marked increase in the past few decades, particularly with the increasing number of immunocompromised individuals. The exploration of epidemiology, morphological transitions, immunopathology, and novel treatment approaches such as new antifungal drugs (PC945, olorofim) and combinational therapy using antifungal drugs and phytochemicals (Phytochemicals: quercetin, shikonin, artemisinin), also using immunotherapies to modulate immune response has resulted in better outcomes. Furthermore, in the context COVID-19 era and its aftermath, fungal infections have emerged as a substantial challenge for both immunocompromised and immunocompetent individuals. This is attributed to the use of immune-suppressing therapies during COVID-19 infections and the increase in transplant cases. Consequently, this review aims to provide an updated overview encompassing the epidemiology, germination events, immunopathology, and novel drug treatment strategies against Aspergillus terreus-associated infections.
Collapse
Affiliation(s)
- Raman Thakur
- Department of Medical Laboratory Science, Lovely Professional University, Jalandhar, Punjab, India
| | | | - Ananya Sharma
- Genomic Laboratory, Department of Biotechnology and Bioinformatics, Jaypee University of Information Technology, Waknaghat Solan, Himachal Pradesh, India
| | - Arjun Chauhan
- Department of Biotechnology, Institute of Applied Sciences and Humanities, GLA University, Mathura, Uttar Pradesh, India
| | - Sumanpreet Kaur
- Department of Medical Laboratory Science, Lovely Professional University, Jalandhar, Punjab, India
| | - Jata Shankar
- Genomic Laboratory, Department of Biotechnology and Bioinformatics, Jaypee University of Information Technology, Waknaghat Solan, Himachal Pradesh, India
| |
Collapse
|
8
|
Pfaller MA, Carvalhaes CG, Castanheira M. Susceptibility patterns of amphotericin B, itraconazole, posaconazole, voriconazole and caspofungin for isolates causing invasive mould infections from the SENTRY Antifungal Surveillance Program (2018-2021) and application of single-site epidemiological cutoff values to evaluate amphotericin B activity. Mycoses 2023; 66:854-868. [PMID: 37431241 DOI: 10.1111/myc.13620] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 07/12/2023]
Abstract
We evaluated the activity of amphotericin B, itraconazole, posaconazole, voriconazole and caspofungin against 1468 invasive moulds collected worldwide from 2018 to 2021. Most (>92%) of the Aspergillus spp. isolates were wildtype (WT) to amphotericin B, caspofungin and the azoles. Azole-non-wildtype A. fumigatus rates were higher in Europe (9.5%) and North America (9.1%) than Latin America (0.0%; only 12 isolates) and the Asia-Pacific region (5.3%). Amphotericin B and caspofungin were active against azole-non-wildtype A. fumigatus isolates. Posaconazole and amphotericin B were the most active agents against the Mucorales. Among the less common moulds, several expressed a pan-azole-resistant phenotype; many of these species also showed elevated MIC values (MIC, >2 mg/L) for amphotericin B and caspofungin. Although most isolates of Aspergillus spp. remain WT to the azoles, azole resistance is increasing in both North America and Europe. Amphotericin B and caspofungin exhibit potentially useful activity against azole-resistant A. fumigatus.
Collapse
Affiliation(s)
- Michael A Pfaller
- JMI Laboratories, North Liberty, Iowa, USA
- University of Iowa College of Medicine, Iowa City, Iowa, USA
| | | | | |
Collapse
|
9
|
Zhang T, Zeng Q, Ji F, Wu H, Ledesma-Amaro R, Wei Q, Yang H, Xia X, Ren Y, Mu K, He Q, Kang Z, Deng R. Precise in-field molecular diagnostics of crop diseases by smartphone-based mutation-resolved pathogenic RNA analysis. Nat Commun 2023; 14:4327. [PMID: 37468480 PMCID: PMC10356797 DOI: 10.1038/s41467-023-39952-x] [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: 07/21/2022] [Accepted: 07/05/2023] [Indexed: 07/21/2023] Open
Abstract
Molecular diagnostics for crop diseases can guide the precise application of pesticides, thereby reducing pesticide usage while improving crop yield, but tools are lacking. Here, we report an in-field molecular diagnostic tool that uses a cheap colorimetric paper and a smartphone, allowing multiplexed, low-cost, rapid detection of crop pathogens. Rapid nucleic acid amplification-free detection of pathogenic RNA is achieved by combining toehold-mediated strand displacement with a metal ion-mediated urease catalysis reaction. We demonstrate multiplexed detection of six wheat pathogenic fungi and an early detection of wheat stripe rust. When coupled with a microneedle for rapid nucleic acid extraction and a smartphone app for results analysis, the sample-to-result test can be completed in ~10 min in the field. Importantly, by detecting fungal RNA and mutations, the approach allows to distinguish viable and dead pathogens and to sensitively identify mutation-carrying fungicide-resistant isolates, providing fundamental information for precision crop disease management.
Collapse
Affiliation(s)
- Ting Zhang
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China
| | - Qingdong Zeng
- State Key Laboratory of Crop Stress Biology for Arid Areas, Northwest A&F University, Yangling, 712100, China
| | - Fan Ji
- State Key Laboratory of Crop Stress Biology for Arid Areas, Northwest A&F University, Yangling, 712100, China
| | - Honghong Wu
- MOA Key Laboratory of Crop Ecophysiology and Farming System in the Middle Reaches of the Yangtze River, College of Plant Science & Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Rodrigo Ledesma-Amaro
- Department of Bioengineering, Imperial College Centre for Synthetic Biology, Imperial College London, London, SW7 2AZ, UK
| | - Qingshan Wei
- Department of Chemical and Biomolecular Engineering, Emerging Plant Disease and Global Food Security Cluster, North Carolina State University, Raleigh, NC, 27696, USA
| | - Hao Yang
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China
| | - Xuhan Xia
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China
| | - Yao Ren
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China
| | - Keqing Mu
- State Key Laboratory of Crop Stress Biology for Arid Areas, Northwest A&F University, Yangling, 712100, China
| | - Qiang He
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China
| | - Zhensheng Kang
- State Key Laboratory of Crop Stress Biology for Arid Areas, Northwest A&F University, Yangling, 712100, China
| | - Ruijie Deng
- College of Biomass Science and Engineering, Healthy Food Evaluation Research Center, Sichuan University, Chengdu, 610065, China.
| |
Collapse
|
10
|
Bosetti D, Neofytos D. Invasive Aspergillosis and the Impact of Azole-resistance. CURRENT FUNGAL INFECTION REPORTS 2023; 17:1-10. [PMID: 37360857 PMCID: PMC10024029 DOI: 10.1007/s12281-023-00459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review IA (invasive aspergillosis) caused by azole-resistant strains has been associated with higher clinical burden and mortality rates. We review the current epidemiology, diagnostic, and therapeutic strategies of this clinical entity, with a special focus on patients with hematologic malignancies. Recent Findings There is an increase of azole resistance in Aspergillus spp. worldwide, probably due to environmental pressure and the increase of long-term azole prophylaxis and treatment in immunocompromised patients (e.g., in hematopoietic stem cell transplant recipients). The therapeutic approaches are challenging, due to multidrug-resistant strains, drug interactions, side effects, and patient-related conditions. Summary Rapid recognition of resistant Aspergillus spp. strains is fundamental to initiate an appropriate antifungal regimen, above all for allogeneic hematopoietic cell transplantation recipients. Clearly, more studies are needed in order to better understand the resistance mechanisms and optimize the diagnostic methods to identify Aspergillus spp. resistance to the existing antifungal agents/classes. More data on the susceptibility profile of Aspergillus spp. against the new classes of antifungal agents may allow for better treatment options and improved clinical outcomes in the coming years. In the meantime, continuous surveillance studies to monitor the prevalence of environmental and patient prevalence of azole resistance among Aspergillus spp. is absolutely crucial.
Collapse
Affiliation(s)
- Davide Bosetti
- Division of Infectious Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| |
Collapse
|
11
|
Abstract
Isavuconazole is the newest of the clinically available advanced generation triazole antifungals and is active against a variety of yeasts, molds, and dimorphic fungi. Its current FDA-approved indications include the management of invasive aspergillosis as well as mucormycosis, though the latter indication is supported by limited clinical data. Isavuconazole did not achieve noninferiority to caspofungin for the treatment of invasive candidiasis and therefore lacks an FDA-approved indication for this invasive disease. Significant advantages of isavuconazole, primarily over voriconazole but in some circumstances posaconazole as well, make it an appealing option for the management of complex patients with invasive fungal infections. These potential advantages include lack of QTc interval prolongation, more predictable pharmacokinetics, a less complicated drug interaction profile, and improved tolerability, particularly when compared to voriconazole. This review discusses these topics in addition to addressing the in vitro activity of the compound against a variety of fungi and provides insight into other distinguishing factors among isavuconazole, voriconazole, and posaconazole. The review concludes with an opinion section in which the authors provide the reader with a framework for the current role of isavuconazole in the antifungal armamentarium and where further data are required.
Collapse
|
12
|
Yang G, Cui S, Ma N, Song Y, Ma J, Huang W, Zhang Y, Xu J. Genetic Structure and Triazole Antifungal Susceptibilities of Alternaria alternata from Greenhouses in Kunming, China. Microbiol Spectr 2022; 10:e0038222. [PMID: 35546576 PMCID: PMC9241833 DOI: 10.1128/spectrum.00382-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/22/2022] [Indexed: 11/20/2022] Open
Abstract
Alternaria alternata is an opportunistic human fungal pathogen and a ubiquitous phytopathogen capable of causing diseases to >100 agricultural crops and ornamental plants. To control plant diseases caused by A. alternata, triazole fungicides have been widely used both in open crop and vegetable fields and in indoor growth facilities such as greenhouses. At present, the effect of fungicide use on triazole resistance development in A. alternata populations is not known. Here, we isolated 237 A. alternata strains from nine greenhouses around metropolitan Kunming in Yunnan, southwest China, determined their genotypes using 10 short tandem repeat markers, and quantified their susceptibility to four triazoles (difenoconazole, tebuconazole, itraconazole, and voriconazole). Abundant allelic and genotypic diversities were detected among these A. alternata strains. Significantly, over 17% of the strains were resistant to difenoconazole, and both known and new drug-resistance mutations were found in the triazole target gene cyp51. Our findings of high-level genetic variation of A. alternata in greenhouses coupled with high-frequency fungicide resistance call for greater attention to continued monitoring and to developing alternative plant fungal disease management strategies in greenhouses. IMPORTANCE Alternaria alternata is among the most common fungi in our environments, such as indoor facilities, the soil, and outdoor air. It can cause diseases in >100 crop and ornamental plants. Furthermore, it can cause human infections. However, our understanding of its genetic diversity and antifungal susceptibility is very limited. Indeed, the critical threshold values for resistance have not been defined for most antifungal drugs in this species. Greenhouses are known to have heavy applications of agricultural fungicides. In this study, we analyzed strains of A. alternata from nine greenhouses near metropolitan Kunming in southwestern China. Our study revealed very high genetic diversity and identified strains with high MIC values against two agricultural and two medical triazole antifungals within each of the nine greenhouses. Our study calls for greater attention to this emerging threat to food security and human health.
Collapse
Affiliation(s)
- Guangzhu Yang
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Key Laboratory for Southwest Microbial Diversity of the Ministry of Education, Yunnan University, Kunming, People’s Republic of China
- School of Life Science, Yunnan University, Kunming, People’s Republic of China
- Horticultural Research Institute, Yunnan Academy of Agricultural Sciences, Kunming, People’s Republic of China
| | - Sai Cui
- School of Life Science, Yunnan University, Kunming, People’s Republic of China
| | - Nan Ma
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Key Laboratory for Southwest Microbial Diversity of the Ministry of Education, Yunnan University, Kunming, People’s Republic of China
| | - Yuansha Song
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Key Laboratory for Southwest Microbial Diversity of the Ministry of Education, Yunnan University, Kunming, People’s Republic of China
| | - Jun Ma
- Horticultural Research Institute, Yunnan Academy of Agricultural Sciences, Kunming, People’s Republic of China
| | - Wenjing Huang
- Horticultural Research Institute, Yunnan Academy of Agricultural Sciences, Kunming, People’s Republic of China
| | - Ying Zhang
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Key Laboratory for Southwest Microbial Diversity of the Ministry of Education, Yunnan University, Kunming, People’s Republic of China
| | - Jianping Xu
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Key Laboratory for Southwest Microbial Diversity of the Ministry of Education, Yunnan University, Kunming, People’s Republic of China
- Department of Biology, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
13
|
Abstract
Aspergillus fumigatus is the primary mold pathogen in humans. It can cause a wide range of diseases in humans, with high mortality rates in immunocompromised patients. The first-line treatments for invasive A. fumigatus infections are the triazole antifungals that inhibit Cyp51 lanosterol demethylase activity, blocking ergosterol biosynthesis. However, triazole-resistant strains of A. fumigatus are increasingly encountered, leading to increased mortality. The most common triazole resistance mechanisms in A. fumigatus are alterations in the cyp51A gene or promoter. We tested the hypothesis that A. fumigatus can acquire triazole resistance by horizontal gene transfer (HGT) of resistance-conferring gene cyp51A. HGT has not been experimentally analyzed in filamentous fungi. Therefore, we developed an HGT assay containing donor A. fumigatus strains carrying resistance-conferring mutated cyp51A, either in its chromosomal locus or in a self-replicating plasmid, and recipient strains that were hygromycin resistant and triazole sensitive. Donor and recipient A. fumigatus strains were cocultured and transferred to selective conditions, and the recipient strain tested for transferred triazole resistance. We found that chromosomal transfer of triazole resistance required selection under both voriconazole and hygromycin, resulting in diploid formation. Notably, plasmid-mediated transfer was also activated by voriconazole or hypoxic stress alone, suggesting a possible route to HGT of antifungal resistance in A. fumigatus, both in the environment and during host infection. This study provides, for the first time, preliminary experimental evidence for HGT mediating antifungal resistance in a pathogenic fungus. IMPORTANCE It is well known that bacteria can transfer antibiotic resistance from one strain to another by horizontal gene transfer (HGT), leading to the current worldwide crisis of rapidly emerging antibiotic-resistant bacteria. However, in fungi, HGT events have only been indirectly documented by whole-genome sequencing. This study directly examined fungal HGT of antibiotic resistance in a laboratory setting. We show that HGT of antifungal triazole resistance occurs in the important human fungal pathogen Aspergillus fumigatus. Importantly, we show a plasmid-mediated transfer of triazole resistance occurs under conditions likely to prevail in the environment and in infected patients. This study provides an experimental foundation for future work identifying the drivers and mechanistic underpinnings of HGT in fungi.
Collapse
|
14
|
McCarty TP, Luethy PM, Baddley JW, Pappas PG. Clinical utility of antifungal susceptibility testing. JAC Antimicrob Resist 2022; 4:dlac067. [PMID: 35774069 PMCID: PMC9237445 DOI: 10.1093/jacamr/dlac067] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Invasive fungal diseases cause significant morbidity and mortality, in particular affecting immunocompromised patients. Resistant organisms are of increasing importance, yet there are many notable differences in the ability to both perform and interpret antifungal susceptibility testing compared with bacteria. In this review, we will highlight the strengths and limitations of resistance data of pathogenic yeasts and moulds that may be used to guide treatment and predict clinical outcomes.
Collapse
Affiliation(s)
- Todd P McCarty
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
- Birmingham VA Medical Center , Birmingham, AL , USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland , Baltimore, MD , USA
| | - John W Baddley
- Department of Medicine, University of Maryland , Baltimore, MD , USA
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
| |
Collapse
|
15
|
Population genomics confirms acquisition of drug-resistant Aspergillus fumigatus infection by humans from the environment. Nat Microbiol 2022; 7:663-674. [PMID: 35469019 PMCID: PMC9064804 DOI: 10.1038/s41564-022-01091-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 02/23/2022] [Indexed: 02/07/2023]
Abstract
Infections caused by the fungal pathogen Aspergillus fumigatus are increasingly resistant to first-line azole antifungal drugs. However, despite its clinical importance, little is known about how susceptible patients acquire infection from drug-resistant genotypes in the environment. Here, we present a population genomic analysis of 218 A. fumigatus isolates from across the UK and Ireland (comprising 153 clinical isolates from 143 patients and 65 environmental isolates). First, phylogenomic analysis shows strong genetic structuring into two clades (A and B) with little interclade recombination and the majority of environmental azole resistance found within clade A. Second, we show occurrences where azole-resistant isolates of near-identical genotypes were obtained from both environmental and clinical sources, indicating with high confidence the infection of patients with resistant isolates transmitted from the environment. Third, genome-wide scans identified selective sweeps across multiple regions indicating a polygenic basis to the trait in some genetic backgrounds. These signatures of positive selection are seen for loci containing the canonical genes encoding fungicide resistance in the ergosterol biosynthetic pathway, while other regions under selection have no defined function. Lastly, pan-genome analysis identified genes linked to azole resistance and previously unknown resistance mechanisms. Understanding the environmental drivers and genetic basis of evolving fungal drug resistance needs urgent attention, especially in light of increasing numbers of patients with severe viral respiratory tract infections who are susceptible to opportunistic fungal superinfections.
Collapse
|
16
|
Wang Y, Zhang L, Zhou L, Zhang M, Xu Y. Epidemiology, Drug Susceptibility, and Clinical Risk Factors in Patients With Invasive Aspergillosis. Front Public Health 2022; 10:835092. [PMID: 35493371 PMCID: PMC9051236 DOI: 10.3389/fpubh.2022.835092] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThis study aimed to investigate the Aspergillus species distribution, antifungal sensitivities, clinical characteristics, and risk factors of patients with invasive aspergillosis (IA) in a tertiary teaching hospital in Anhui Province.MethodsIn the present study, 156 Aspergillus isolates were collected from patients admitted to a 2,800-bed comprehensive hospital between January 2019 and April 2021. The epidemiology of Aspergillus species was well-examined, and its antifungal susceptibility was specifically measured by the microbroth dilution method. The risk factors of patients with IA were documented and analyzed intensively. In addition, gene sequencing was employed to determine gene mutations of cytochrome P450 14-α sterol demethylase-Aspergillus (cyp51A) associated with azole resistance among Aspergillus fumigatus.ResultsThe Aspergillus species distribution was dominated by A. fumigatus (56.41%), Aspergillus flavus (20.51%), and Aspergillus niger (15.38%) locally. In particular, all Aspergillus species showed very low minimum inhibitory concentrations (MICs, ≤ 0.5 μg/ml) for azoles and echinocandins, slightly high MICs (1.66–2.91 μg/ml) for amphotericin B, and exceptionally high MICs (>64 μg/ml) for flucytosine. Azole-resistant rate of Aspergillus species in this local region reached up to 5.79%. Correlation analyses of multiple antifungals indicate a significant MIC relevance between isavuconazole and voriconazole (Pearson correlation coefficient was 0.81, P < 0.0001). The clinical risk factors for patients with IA were found primarily to be pulmonary diseases (P = 0.007) and patients' age (P < 0.001). Notably, three mutant loci (TR46/Y121F/T289A) of the cyp51A gene were identified in azole-resistant A. fumigatus.ConclusionsThe Aspergillus species emerged increasingly, of which A. fumigatus and A. flavus remained the main pathogens for invasive Aspergillus infections in the local region. The vast majority of Aspergillus species exhibited good susceptibility to all the antifungals, except flucytosine. The local occurrence of azole-resistant Aspergillus species grew gradually and needed monitoring in time. Pulmonary diseases and age were likely considered as highly associated risk factors for IA. To our knowledge, the clinically isolated azole-resistant A. fumigatus with TR46/Y121F/T289A mutations identified here were rarely reported in the area of China.
Collapse
|
17
|
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.
Collapse
|
18
|
Kang SE, Sumabat LG, Melie T, Mangum B, Momany M, Brewer MT. Evidence for the agricultural origin of resistance to multiple antimicrobials in Aspergillus fumigatus, a fungal pathogen of humans. G3 (BETHESDA, MD.) 2022; 12:jkab427. [PMID: 34897421 PMCID: PMC9210323 DOI: 10.1093/g3journal/jkab427] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/03/2021] [Indexed: 11/12/2022]
Abstract
Pathogen resistance to clinical antimicrobial agents is an urgent problem. The fungus Aspergillus fumigatus causes 300,000 life-threatening infections in susceptible humans annually. Azoles, which are widely used in both clinical and agricultural settings, are currently the most effective treatment, but resistance to clinical azoles is emerging worldwide. Here, we report the isolation and analysis of azole-sensitive and azole-resistant A. fumigatus from agricultural environments in the southeastern United States (USA) and show that the USA pan-azole-resistant isolates form a clade with pan-azole-resistant isolates from the United Kingdom, the Netherlands, and India. We show that several pan-azole-resistant isolates from agricultural settings in the USA and India also carry alleles with mutations conferring resistance to agricultural fungicides from the benzimidazole (MBC) and quinone outside inhibitor (QoI) classes. We further show that pan-azole-resistant A. fumigatus isolates from patients in clinical settings in the USA, India, and the Netherlands also carry alleles conferring resistance to MBC and QoI agricultural fungicides. The presence of markers for resistance to agricultural-use fungicides in clinical A. fumigatus isolates is strong evidence for an agricultural origin of pan-azole resistance in patients. The presence of multiple fungicide-resistance alleles in agricultural and clinical isolates further suggests that the unique genetics of the pan-azole-resistant clade enables the evolution and/or persistence of antimicrobial resistance mutations leading to the establishment of multifungicide-resistant isolates.
Collapse
Affiliation(s)
- S Earl Kang
- Fungal Biology Group and Plant Biology Department, University of Georgia, Athens, GA 30602, USA
| | - Leilani G Sumabat
- Fungal Biology Group and Plant Pathology Department, University of Georgia, Athens, GA 30602, USA
| | - Tina Melie
- Fungal Biology Group and Plant Pathology Department, University of Georgia, Athens, GA 30602, USA
| | - Brandon Mangum
- Fungal Biology Group and Plant Biology Department, University of Georgia, Athens, GA 30602, USA
- Fungal Biology Group and Plant Pathology Department, University of Georgia, Athens, GA 30602, USA
| | - Michelle Momany
- Fungal Biology Group and Plant Biology Department, University of Georgia, Athens, GA 30602, USA
| | - Marin T Brewer
- Fungal Biology Group and Plant Pathology Department, University of Georgia, Athens, GA 30602, USA
| |
Collapse
|
19
|
Bastos RW, Rossato L, Goldman GH, Santos DA. Fungicide effects on human fungal pathogens: Cross-resistance to medical drugs and beyond. PLoS Pathog 2021; 17:e1010073. [PMID: 34882756 PMCID: PMC8659312 DOI: 10.1371/journal.ppat.1010073] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fungal infections are underestimated threats that affect over 1 billion people, and Candida spp., Cryptococcus spp., and Aspergillus spp. are the 3 most fatal fungi. The treatment of these infections is performed with a limited arsenal of antifungal drugs, and the class of the azoles is the most used. Although these drugs present low toxicity for the host, there is an emergence of therapeutic failure due to azole resistance. Drug resistance normally develops in patients undergoing azole long-term therapy, when the fungus in contact with the drug can adapt and survive. Conversely, several reports have been showing that resistant isolates are also recovered from patients with no prior history of azole therapy, suggesting that other routes might be driving antifungal resistance. Intriguingly, antifungal resistance also happens in the environment since resistant strains have been isolated from plant materials, soil, decomposing matter, and compost, where important human fungal pathogens live. As the resistant fungi can be isolated from the environment, in places where agrochemicals are extensively used in agriculture and wood industry, the hypothesis that fungicides could be driving and selecting resistance mechanism in nature, before the contact of the fungus with the host, has gained more attention. The effects of fungicide exposure on fungal resistance have been extensively studied in Aspergillus fumigatus and less investigated in other human fungal pathogens. Here, we discuss not only classic and recent studies showing that environmental azole exposure selects cross-resistance to medical azoles in A. fumigatus, but also how this phenomenon affects Candida and Cryptococcus, other 2 important human fungal pathogens found in the environment. We also examine data showing that fungicide exposure can select relevant changes in the morphophysiology and virulence of those pathogens, suggesting that its effect goes beyond the cross-resistance.
Collapse
Affiliation(s)
- Rafael W. Bastos
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto-SP, Brazil
| | - Luana Rossato
- Federal University of Grande Dourados, Dourados-MS, Brazil
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto-SP, Brazil
| | - Daniel A. Santos
- Laboratory of Mycology, Federal University of Minas Gerais, Belo Horizonte-MG, Brazil
| |
Collapse
|
20
|
Doughty KJ, Sierotzki H, Semar M, Goertz A. Selection and Amplification of Fungicide Resistance in Aspergillus fumigatus in Relation to DMI Fungicide Use in Agronomic Settings: Hotspots versus Coldspots. Microorganisms 2021; 9:2439. [PMID: 34946041 PMCID: PMC8704312 DOI: 10.3390/microorganisms9122439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 12/18/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprophytic fungus. Inhalation of A. fumigatus spores can lead to Invasive Aspergillosis (IA) in people with weakened immune systems. The use of triazole antifungals with the demethylation inhibitor (DMI) mode of action to treat IA is being hampered by the spread of DMI-resistant "ARAf" (azole-resistant Aspergillus fumigatus) genotypes. DMIs are also used in the environment, for example, as fungicides to protect yield and quality in agronomic settings, which may lead to exposure of A. fumigatus to DMI residues. An agronomic setting can be a "hotspot" for ARAf if it provides a suitable substrate and favourable conditions for the growth of A. fumigatus in the presence of DMI fungicides at concentrations capable of selecting ARAf genotypes at the expense of the susceptible wild-type, followed by the release of predominantly resistant spores. Agronomic settings that do not provide these conditions are considered "coldspots". Identifying and mitigating hotspots will be key to securing the agronomic use of DMIs without compromising their use in medicine. We provide a review of studies of the prevalence of ARAf in various agronomic settings and discuss the mitigation options for confirmed hotspots, particularly those relating to the management of crop waste.
Collapse
Affiliation(s)
- Kevin J. Doughty
- Bayer AG, Alfred Nobel Strasse 50, 40789 Monheim-am-Rhein, Germany;
| | - Helge Sierotzki
- Syngenta Crop Protection, Schaffhauserstrasse 101, 4332 Stein, Switzerland;
| | - Martin Semar
- BASF SE, Speyerer Strasse 2, 67117 Limburgerhof, Germany;
| | - Andreas Goertz
- Bayer AG, Alfred Nobel Strasse 50, 40789 Monheim-am-Rhein, Germany;
| |
Collapse
|
21
|
Fraaije BA, Atkins SL, Santos RF, Hanley SJ, West JS, Lucas JA. Epidemiological Studies of Pan-Azole Resistant Aspergillus fumigatus Populations Sampled during Tulip Cultivation Show Clonal Expansion with Acquisition of Multi-Fungicide Resistance as Potential Driver. Microorganisms 2021; 9:2379. [PMID: 34835504 PMCID: PMC8618125 DOI: 10.3390/microorganisms9112379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/13/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022] Open
Abstract
Pan-azole resistant isolates are found in clinical and environmental Aspergillus fumigatus (Af) populations. Azole resistance can evolve in both settings, with Af directly targeted by antifungals in patients and, in the environment, Af unintendedly exposed to fungicides used for material preservation and plant disease control. Resistance to non-azole fungicides, including methyl benzimidazole carbamates (MBCs), quinone outside inhibitors (QoIs) and succinate dehydrogenase inhibitors (SDHIs), has recently been reported. These fungicide groups are not used in medicine but can play an important role in the further spread of pan-azole resistant genotypes. We investigated the multi-fungicide resistance status and the genetic diversity of Af populations sampled from tulip field soils, tulip peel waste and flower compost heaps using fungicide sensitivity testing and a range of genotyping tools, including STRAf typing and sequencing of fungicide resistant alleles. Two major clones were present in the tulip bulb population. Comparisons with clinical isolates and literature data revealed that several common clonal lineages of TR34/L98H and TR46/Y121F/T289A strains that have expanded successfully in the environment have also acquired resistance to MBC, QoI and/or SDHI fungicides. Strains carrying multiple fungicide resistant alleles have a competitive advantage in environments where residues of multiple fungicides belonging to different modes of action are present.
Collapse
Affiliation(s)
- Bart A. Fraaije
- NIAB, Cambridge CB3 0LE, UK;
- Rothamsted Research, Harpenden AL5 2Q, UK; (S.J.H.); (J.S.W.); (J.A.L.)
| | | | - Ricardo F. Santos
- Luiz de Queiroz College of Agriculture, University of São Paulo, Piracicaba 13418-900, SP, Brazil;
| | - Steven J. Hanley
- Rothamsted Research, Harpenden AL5 2Q, UK; (S.J.H.); (J.S.W.); (J.A.L.)
| | - Jonathan S. West
- Rothamsted Research, Harpenden AL5 2Q, UK; (S.J.H.); (J.S.W.); (J.A.L.)
| | - John A. Lucas
- Rothamsted Research, Harpenden AL5 2Q, UK; (S.J.H.); (J.S.W.); (J.A.L.)
| |
Collapse
|
22
|
Long Terminal Repeat Retrotransposon Afut4 Promotes Azole Resistance of Aspergillus fumigatus by Enhancing the Expression of sac1 Gene. Antimicrob Agents Chemother 2021; 65:e0029121. [PMID: 34516252 DOI: 10.1128/aac.00291-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aspergillus fumigatus causes a series of invasive diseases, including the high-mortality invasive aspergillosis, and has been a serious global health threat because of its increased resistance to the first-line clinical triazoles. We analyzed the whole-genome sequence of 15 A. fumigatus strains from China and found that long terminal repeat retrotransposons (LTR-RTs), including Afut1, Afut2, Afut3, and Afut4, are most common and have the largest total nucleotide length among all transposable elements in A. fumigatus. Deleting one of the most enriched Afut4977-sac1 in azole-resistant strains decreased azole resistance and downregulated its nearby gene, sac1, but it did not significantly affect the expression of genes of the ergosterol synthesis pathway. We then discovered that 5'LTR of Afut4977-sac1 had promoter activity and enhanced the adjacent sac1 gene expression. We found that sac1 is important to A. fumigatus, and the upregulated sac1 caused elevated resistance of A. fumigatus to azoles. Finally, we showed that Afut4977-sac1 has an evolution pattern similar to that of the whole genome of azole-resistant strains due to azoles; phylogenetic analysis of both the whole genome and Afut4977-sac1 suggests that the insertion of Afut4977-sac1 might have preceded the emergence of azole-resistant strains. Taking these data together, we found that the Afut4977-sac1 LTR-RT might be involved in the regulation of azole resistance of A. fumigatus by upregulating its nearby sac1 gene.
Collapse
|
23
|
Wiederhold NP. Antifungal Susceptibility Testing: A Primer for Clinicians. Open Forum Infect Dis 2021; 8:ofab444. [PMID: 34778489 PMCID: PMC8579947 DOI: 10.1093/ofid/ofab444] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Clinicians treating patients with fungal infections may turn to susceptibility testing to obtain information regarding the activity of different antifungals against a specific fungus that has been cultured. These results may then be used to make decisions regarding a patient's therapy. However, for many fungal species that are capable of causing invasive infections, clinical breakpoints have not been established. Thus, interpretations of susceptible or resistant cannot be provided by clinical laboratories, and this is especially true for many molds capable of causing severe mycoses. The purpose of this review is to provide an overview of susceptibility testing for clinicians, including the methods used to perform these assays, their limitations, how clinical breakpoints are established, and how the results may be put into context in the absence of interpretive criteria. Examples of when susceptibility testing is not warranted are also provided.
Collapse
Affiliation(s)
- Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| |
Collapse
|
24
|
Arastehfar A, Carvalho A, Houbraken J, Lombardi L, Garcia-Rubio R, Jenks J, Rivero-Menendez O, Aljohani R, Jacobsen I, Berman J, Osherov N, Hedayati M, Ilkit M, Armstrong-James D, Gabaldón T, Meletiadis J, Kostrzewa M, Pan W, Lass-Flörl C, Perlin D, Hoenigl M. Aspergillus fumigatus and aspergillosis: From basics to clinics. Stud Mycol 2021; 100:100115. [PMID: 34035866 PMCID: PMC8131930 DOI: 10.1016/j.simyco.2021.100115] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The airborne fungus Aspergillus fumigatus poses a serious health threat to humans by causing numerous invasive infections and a notable mortality in humans, especially in immunocompromised patients. Mould-active azoles are the frontline therapeutics employed to treat aspergillosis. The global emergence of azole-resistant A. fumigatus isolates in clinic and environment, however, notoriously limits the therapeutic options of mould-active antifungals and potentially can be attributed to a mortality rate reaching up to 100 %. Although specific mutations in CYP 51A are the main cause of azole resistance, there is a new wave of azole-resistant isolates with wild-type CYP 51A genotype challenging the efficacy of the current diagnostic tools. Therefore, applications of whole-genome sequencing are increasingly gaining popularity to overcome such challenges. Prominent echinocandin tolerance, as well as liver and kidney toxicity posed by amphotericin B, necessitate a continuous quest for novel antifungal drugs to combat emerging azole-resistant A. fumigatus isolates. Animal models and the tools used for genetic engineering require further refinement to facilitate a better understanding about the resistance mechanisms, virulence, and immune reactions orchestrated against A. fumigatus. This review paper comprehensively discusses the current clinical challenges caused by A. fumigatus and provides insights on how to address them.
Collapse
Affiliation(s)
- A. Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - A. Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J. Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - L. Lombardi
- UCD Conway Institute and School of Medicine, University College Dublin, Dublin 4, Ireland
| | - R. Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - J.D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA, 92093, USA
| | - O. Rivero-Menendez
- Medical Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, 28222, Spain
| | - R. Aljohani
- Department of Infectious Diseases, Imperial College London, London, UK
| | - I.D. Jacobsen
- Department of Microbial Pathogenicity Mechanisms, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - J. Berman
- Research Group Microbial Immunology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
| | - N. Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, 69978, Israel
| | - M.T. Hedayati
- Invasive Fungi Research Center/Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M. Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Çukurova University, 01330, Adana, Turkey
| | | | - T. Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, Barcelona, 08034, Spain
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluís Companys 23, 08010, Barcelona, Spain
| | - J. Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - W. Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - C. Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - D.S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - M. Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| |
Collapse
|
25
|
Etienne KA, Berkow EL, Gade L, Nunnally N, Lockhart SR, Beer K, Jordan IK, Rishishwar L, Litvintseva AP. Genomic Diversity of Azole-Resistant Aspergillus fumigatus in the United States. mBio 2021; 12:e0180321. [PMID: 34372699 PMCID: PMC8406307 DOI: 10.1128/mbio.01803-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022] Open
Abstract
Azole resistance in pathogenic Aspergillus fumigatus has become a global public health issue threatening the use of medical azoles. The environmentally occurring resistance mutations, TR34/L98H (TR34) and TR46/Y121F/T289A (TR46), are widespread across multiple continents and emerging in the United States. We used whole-genome single nucleotide polymorphism (SNP) analysis on 179 nationally represented clinical and environmental A. fumigatus genomes from the United States along with 18 non-U.S. genomes to evaluate the genetic diversity and foundation of the emergence of azole resistance in the United States. We demonstrated the presence of clades of A. fumigatus isolates: clade A (17%) comprised a global collection of clinical and environmental azole-resistant strains, including all strains with the TR34/L98H allele from India, The Netherlands, the United Kingdom, and the United States, and clade B (83%) consisted of isolates without this marker mainly from the United States. The TR34/L98H polymorphism was shared among azole-resistant A. fumigatus strains from India, The Netherlands, the United Kingdom, and the United States, suggesting the common origin of this resistance mechanism. Six percent of azole-resistant A. fumigatus isolates from the United States with the TR34 resistance marker had a mixture of clade A and clade B alleles, suggestive of recombination. Additionally, the presence of equal proportions of both mating types further suggests the ongoing presence of recombination. This study demonstrates the genetic background for the emergence of azole resistance in the United States, supporting a single introduction and subsequent propagation, possibly through recombination of environmentally driven resistance mutations. IMPORTANCE Aspergillus fumigatus is one of the most common causes of invasive mold infections in patients with immune deficiencies and has also been reported in patients with severe influenza and severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2). Triazole drugs are the first line of therapy for this infection; however, their efficacy has been compromised by the emergence of azole resistance in A. fumigatus, which was proposed to be selected for by exposure to azole fungicides in the environment [P. E. Verweij, E. Snelders, G. H. J. Kema, E. Mellado, et al., Lancet Infect Dis 9:789-795, 2009, https://doi.org/10.1016/S1473-3099(09)70265-8]. Isolates with environmentally driven resistance mutations, TR34/L98H (TR34) and TR46/Y121F/T289A (TR46), have been reported worldwide. Here, we used genomic analysis of a large sample of resistant and susceptible A. fumigatus isolates to demonstrate a single introduction of TR34 in the United States and suggest its ability to spread into the susceptible population is through recombination between resistant and susceptible isolates.
Collapse
Affiliation(s)
- Kizee A. Etienne
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Elizabeth L. Berkow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| | - Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| | - Natalie Nunnally
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| | - Shawn R. Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| | - Karlyn Beer
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| | - I. King Jordan
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Lavanya Rishishwar
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Anastasia P. Litvintseva
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia, USA
| |
Collapse
|
26
|
Trabasso P, Matsuzawa T, Arai T, Hagiwara D, Mikami Y, Moretti ML, Watanabe A. Development and validation of LAMP primer sets for rapid identification of Aspergillus fumigatus carrying the cyp51A TR 46 azole resistance gene. Sci Rep 2021; 11:17087. [PMID: 34429488 PMCID: PMC8384855 DOI: 10.1038/s41598-021-96651-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/09/2021] [Indexed: 11/09/2022] Open
Abstract
Infections due to triazole-resistant Aspergillus fumigatus are increasingly reported worldwide and are associated with treatment failure and mortality. The principal class of azole-resistant isolates is characterized by tandem repeats of 34 bp or 46 bp within the promoter region of the cyp51A gene. Loop-mediated isothermal amplification (LAMP) is a widely used nucleic acid amplification system that is fast and specific. Here we describe a LAMP assay method to detect the 46 bp tandem repeat insertion in the cyp51A gene promoter region based on novel LAMP primer sets. It also differentiated strains with TR46 tandem repeats from those with TR34 tandem repeats. These results showed this TR46-LAMP method is specific, rapid, and provides crucial insights to develop novel antifungal therapeutic strategies against severe fungal infections due to A. fumigatus with TR46 tandem repeats.
Collapse
Affiliation(s)
- Plinio Trabasso
- School of Medical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil.
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Rua Tessalia Vieira de Camargo, Campinas, Sao Paulo, 126, Brazil.
| | | | - Teppei Arai
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Daisuke Hagiwara
- Medical Mycology Research Center, Chiba University, Chiba, Japan
- Faculty of Life and Environmental Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Microbiology Research Center for Sustainability, University of Tsukuba, Ibaraki, Japan
| | - Yuzuru Mikami
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Maria Luiza Moretti
- School of Medical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Akira Watanabe
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| |
Collapse
|
27
|
van Rhijn N, Denning DW. Is an azole-resistant Aspergillus hotspot emerging in South-East Asia? Environ Microbiol 2021; 23:7275-7277. [PMID: 34425631 DOI: 10.1111/1462-2920.15710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/04/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Norman van Rhijn
- Manchester Fungal Infection Group, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David W Denning
- Manchester Fungal Infection Group, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
28
|
Souza ACO, Martin-Vicente A, Nywening AV, Ge W, Lowes DJ, Peters BM, Fortwendel JR. Loss of Septation Initiation Network (SIN) kinases blocks tissue invasion and unlocks echinocandin cidal activity against Aspergillus fumigatus. PLoS Pathog 2021; 17:e1009806. [PMID: 34370772 PMCID: PMC8376064 DOI: 10.1371/journal.ppat.1009806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/19/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022] Open
Abstract
Although considered effective treatment for many yeast fungi, the therapeutic efficacy of the echinocandin class of antifungals for invasive aspergillosis (IA) is limited. Recent studies suggest intense kinase- and phosphatase-mediated echinocandin adaptation in A. fumigatus. To identify A. fumigatus protein kinases required for survival under echinocandin stress, we employed CRISPR/Cas9-mediated gene targeting to generate a protein kinase disruption mutant library in a wild type genetic background. Cell wall and echinocandin stress screening of the 118 disruption mutants comprising the library identified only five protein kinase disruption mutants displaying greater than 4-fold decreased echinocandin minimum effective concentrations (MEC) compared to the parental strain. Two of these mutated genes, the previously uncharacterized A. fumigatus sepL and sidB genes, were predicted to encode protein kinases functioning as core components of the Septation Initiation Network (SIN), a tripartite kinase cascade that is necessary for septation in fungi. As the A. fumigatus SIN is completely uncharacterized, we sought to explore these network components as effectors of echinocandin stress survival. Our data show that mutation of any single SIN kinase gene caused complete loss of hyphal septation and increased susceptibility to cell wall stress, as well as widespread hyphal damage and loss of viability in response to echinocandin stress. Strikingly, mutation of each SIN kinase gene also resulted in a profound loss of virulence characterized by lack of tissue invasive growth. Through the deletion of multiple novel regulators of hyphal septation, we show that the non-invasive growth phenotype is not SIN-kinase dependent, but likely due to hyphal septation deficiency. Finally, we also find that echinocandin therapy is highly effective at eliminating residual tissue burden in mice infected with an aseptate strain of A. fumigatus. Together, our findings suggest that inhibitors of septation could enhance echinocandin-mediated killing while simultaneously limiting the invasive potential of A. fumigatus hyphae.
Collapse
Affiliation(s)
- Ana Camila Oliveira Souza
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Adela Martin-Vicente
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Ashley V. Nywening
- Integrated Program in Biomedical Sciences, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Wenbo Ge
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - David J. Lowes
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Brian M. Peters
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Microbiology, Immunology, and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Jarrod R. Fortwendel
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- Department of Microbiology, Immunology, and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
- * E-mail:
| |
Collapse
|
29
|
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.
Collapse
|
30
|
Combined high dose caspofungin and liposomal amphotericin B for the treatment of azole-resistant cerebral aspergillosis. Antimicrob Agents Chemother 2021; 65:e0047421. [PMID: 34252300 DOI: 10.1128/aac.00474-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The prevalence of azole-resistant aspergillosis is increasing and represents a public health issue in some countries, with an excess mortality of 25% (1).….
Collapse
|
31
|
Siopi M, Rivero-Menendez O, Gkotsis G, Panara A, Thomaidis NS, Alastruey-Izquierdo A, Pournaras S, Meletiadis J. Nationwide surveillance of azole-resistant Aspergillus fumigatus environmental isolates in Greece: detection of pan-azole resistance associated with the TR46/Y121F/T289A cyp51A mutation. J Antimicrob Chemother 2021; 75:3181-3188. [PMID: 32814940 DOI: 10.1093/jac/dkaa316] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/15/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Acquired azole resistance (AR) in Aspergillus fumigatus emphasizes the importance of the One Health multisectorial approach. The prevalence of azole-resistant A. fumigatus in the environment of Greece is unknown. METHODS Between October 2016 and September 2017, a total of 716 soil samples were collected from 23 provinces and screened for AR using azole-containing agar plates. Recovered isolates were macro-/microscopically identified and colonies were counted. Azole susceptibility testing of A. fumigatus species complex (SC) isolates was performed (EUCAST E.DEF9.3.1). Azole-resistant A. fumigatus isolates were subjected to confirmatory molecular identification and sequencing of the cyp51A gene. RESULTS No yeasts were recovered, while multiple moulds grew on 695 (97%) samples. Overall, zygomycetes (most non-Mucor genera) grew on 432 (60%) samples, while Aspergillus spp. grew on 500 (70%) [410 (57%) Aspergillus niger SC; 120 (17%) Aspergillus terreus SC; 101 (14%) A. fumigatus SC; 34 (5%) Aspergillus flavus SC]. The mean ± SD soil load of Aspergillus spp. was 2.23 ± 0.41 log10 cfu/g (no differences among species). No azole-resistant non-A. fumigatus spp. isolate was detected. Itraconazole, voriconazole, isavuconazole and posaconazole MIC50/MIC90 (MIC range) of A. fumigatus SC strains were 0.25/0.5 (0.25 to >8), 0.5/1 (0.25 to >8), 1/1 (0.125 to >8) and 0.06/0.125 (0.06-1) mg/L, respectively. Overall, 1/500 (0.2%) of Aspergillus isolates, and 1/101 (1%) of A. fumigatus SC isolates, was pan-azole-resistant (itraconazole, voriconazole, isavuconazole and posaconazole MIC >8, >8, >8 and 1 mg/L, respectively). The resistant isolate was recovered from organically grown raisin grapes treated with homemade compost and it was an A. fumigatus sensu stricto isolate harbouring the TR46/Y121F/T289A mutation. The soil's load was higher compared with azole-susceptible strains (3.74 versus 2.09 log10 cfu/g). CONCLUSIONS This is the first known report of environmental pan-azole-resistant A. fumigatus in Greece. Since data on Greek clinical isolates are lacking, this finding must alarm the systematic local surveillance of AR in medical settings.
Collapse
Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Olga Rivero-Menendez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Georgios Gkotsis
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Anthi Panara
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos S Thomaidis
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
32
|
Parent-Michaud M, Dufresne PJ, Fournier E, Folch B, Martineau C, Moreira S, Doucet N, De Repentigny L, Dufresne SF. Prevalence and mechanisms of azole resistance in clinical isolates of Aspergillus section Fumigati species in a Canadian tertiary care centre, 2000 to 2013. J Antimicrob Chemother 2021; 75:849-858. [PMID: 31891387 DOI: 10.1093/jac/dkz534] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/14/2019] [Accepted: 12/01/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Azole resistance among Aspergillus fumigatus isolates is a growing concern worldwide. Induction of mutations during azole therapy, environment-acquired mutations caused by azole fungicides and intrinsic resistance of cryptic Fumigati species all contribute to the burden of resistance. However, there is a lack of data in Canada on this emerging threat. METHODS To gain insights into the magnitude and mechanisms of resistance, a 14 year collection of Aspergillus section Fumigati comprising 999 isolates from 807 patients at a Montreal hospital was screened for azole resistance, and resistance mechanisms were investigated with the combined use of genome sequencing, 3D modelling and phenotypic efflux pump assays. RESULTS Overall azole resistance was low (4/807 patients; 0.5%). A single azole-resistant A. fumigatus sensu stricto strain, isolated from a patient with pulmonary aspergillosis, displayed efflux-pump-mediated resistance. Three patients were colonized or infected with azole-resistant cryptic Fumigati species (one Aspergillus thermomutatus, one Aspergillus lentulus and one Aspergillus turcosus). Evidence is presented that azole resistance is efflux-pump-mediated in the A. turcosus isolate, but not in the A. lentulus and A. thermomutatus isolates. CONCLUSIONS Azole resistance is rare in our geographic area and currently driven by cryptic Fumigati species. Continued surveillance of emergence of resistance is warranted.
Collapse
Affiliation(s)
- Maxime Parent-Michaud
- Department of Microbiology, Infectious Diseases and Immunology, University of Montreal, Montreal, Quebec, Canada
| | - Philippe J Dufresne
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Eric Fournier
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Benjamin Folch
- INRS-Institut Armand Frappier, University of Quebec, Laval, Quebec, Canada
| | - Christine Martineau
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Sandrine Moreira
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Nicolas Doucet
- INRS-Institut Armand Frappier, University of Quebec, Laval, Quebec, Canada
| | - Louis De Repentigny
- Department of Microbiology, Infectious Diseases and Immunology, University of Montreal, Montreal, Quebec, Canada
| | - Simon F Dufresne
- Department of Microbiology, Infectious Diseases and Immunology, University of Montreal, Montreal, Quebec, Canada.,Division of Infectious Diseases and Clinical Microbiology, Department of Medicine, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| |
Collapse
|
33
|
Pasula S, Chandrasekar PH. Azole resistance in Aspergillus species: promising therapeutic options. Expert Opin Pharmacother 2021; 22:2071-2078. [PMID: 34129410 DOI: 10.1080/14656566.2021.1940134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Azoles are the first-line antifungal agents used for the treatment of Aspergillus infection. There is an increasing concern for azole resistance all over the world mainly from agricultural fungicide use. Choosing safe and effective antifungal regimens has become a challenge. AREAS COVERED Here, the authors review the epidemiology, mechanisms, and detection of azole resistance along with management options for azole-resistant Aspergillus infection, including new antifungal agents under development. EXPERT OPINION Routine global epidemiological surveillance is required to understand azole resistance prevalence. Azole-resistant Aspergillus infections are associated with high mortality. No good therapeutic options are currently available. High index of suspicion of resistance is required if a patient is not responding to 4-7 days of azole therapy, particularly in the areas of resistance. Susceptibility testing for Aspergillus is not routinely available in many parts of the world, which makes it difficult to diagnose azole resistance in Aspergillus infection. There are several new antifungal classes with novel mechanisms of action; clinical trials are ongoing.
Collapse
Affiliation(s)
- Shirisha Pasula
- Department of Internal medicine, Division of Infectious diseases, Detroit Medical Center/Wayne State University, Detroit, MI, USA
| | | |
Collapse
|
34
|
James JE, Lamping E, Santhanam J, Cannon RD. PDR Transporter ABC1 Is Involved in the Innate Azole Resistance of the Human Fungal Pathogen Fusarium keratoplasticum. Front Microbiol 2021; 12:673206. [PMID: 34149660 PMCID: PMC8211738 DOI: 10.3389/fmicb.2021.673206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/22/2021] [Indexed: 12/30/2022] Open
Abstract
Fusarium keratoplasticum is arguably the most common Fusarium solani species complex (FSSC) species associated with human infections. Invasive fusariosis is a life-threatening fungal infection that is difficult to treat with conventional azole antifungals. Azole drug resistance is often caused by the increased expression of pleiotropic drug resistance (PDR) ATP-binding cassette (ABC) transporters of the ABCG sub-family. Most investigations of Fusarium ABC transporters associated with azole antifungal drug resistance are limited to plant pathogens. Through the manual curation of the entire ABCG protein family of four FSSC species including the fully annotated genome of the plant pathogen Nectria haematococca we identified PDR transporters ABC1 and ABC2 as the efflux pump candidates most likely to be associated with the innate azole resistance phenotype of Fusarium keratoplasticum. An initial investigation of the transcriptional response of logarithmic phase F. keratoplasticum cells to 16 mg/L voriconazole confirmed strong upregulation (372-fold) of ABC1 while ABC2 mRNA levels were unaffected by voriconazole exposure over a 4 h time-period. Overexpression of F. keratoplasticum ABC1 and ABC2 in the genetically modified Saccharomyces cerevisiae host ADΔΔ caused up to ∼1,024-fold increased resistance to a number of xenobiotics, including azole antifungals. Although ABC1 and ABC2 were only moderately (20% and 10%, respectively) expressed compared to the Candida albicans multidrug efflux pump CDR1, overexpression of F. keratoplasticum ABC1 caused even higher resistance levels to certain xenobiotics (e.g., rhodamine 6G and nigericin) than CDR1. Our investigations suggest an important role for ABC1 orthologues in the innate azole resistance phenotype of FSSC species.
Collapse
Affiliation(s)
- Jasper Elvin James
- Biomedical Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Erwin Lamping
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Jacinta Santhanam
- Biomedical Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Richard David Cannon
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| |
Collapse
|
35
|
Emergence of Triazole Resistance in Aspergillus spp. in Latin America. CURRENT FUNGAL INFECTION REPORTS 2021; 15:93-103. [PMID: 34025901 PMCID: PMC8132279 DOI: 10.1007/s12281-021-00418-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review Azole resistance in Aspergillus spp. is becoming a public health problem worldwide. However, data about this subject is lacking in Latin American countries. This review focuses in the epidemiology and molecular mechanisms of azole resistance in Aspergillus spp. emphasizing in Latin America. Data on Aspergillus fumigatus stands out because it is the most prevalent Aspergillus spp. pathogen. Recent Findings Azole resistance in Aspergillus spp. emergence was linked with intensive use of these antifungals both in the clinical setting and in the environment (as pesticides). Reports on azole-resistant A. fumigatus strains are being constantly published in different countries. Molecular mechanisms of resistance mainly involve substitution in the azole target (CYP51A) and/or overexpression of this gene. However, several other non-CYP51A-related mechanisms were described. Moreover, intrinsically resistant cryptic Aspergillus species are starting to be reported as human pathogens. Summary After a comprehensive literature review, it is clear that azole resistance in Aspergillus spp. is emerging in Latin America and perhaps it is underestimated. All the main molecular mechanisms of azole resistance were described in patients and/or environmental samples. Moreover, one of the molecular mechanisms was described only in South America. Cryptic intrinsic azole-resistant species are also described.
Collapse
|
36
|
Toda M, Beer KD, Kuivila KM, Chiller TM, Jackson BR. Trends in Agricultural Triazole Fungicide Use in the United States, 1992-2016 and Possible Implications for Antifungal-Resistant Fungi in Human Disease. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:55001. [PMID: 33949891 PMCID: PMC8098123 DOI: 10.1289/ehp7484] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 02/28/2021] [Accepted: 03/16/2021] [Indexed: 05/18/2023]
Abstract
BACKGROUND The fungus Aspergillus fumigatus (A. fumigatus) is the leading cause of invasive mold infections, which cause severe disease and death in immunocompromised people. Use of triazole antifungal medications in recent decades has improved patient survival; however, triazole-resistant infections have become common in parts of Europe and are emerging in the United States. Triazoles are also a class of fungicides used in plant agriculture, and certain triazole-resistant A. fumigatus strains found causing disease in humans have been linked to environmental fungicide use. OBJECTIVES We examined U.S. temporal and geographic trends in the use of triazole fungicides using U.S. Geological Survey agricultural pesticide use estimates. DISCUSSION Based on our analysis, overall tonnage of triazole fungicide use nationwide was relatively constant during 1992-2005 but increased >4-fold during 2006-2016 to 2.9 million kg in 2016. During 1992-2005, triazole fungicide use occurred mostly in orchards and grapes, wheat, and other crops, but recent increases in use have occurred primarily in wheat, corn, soybeans, and other crops, particularly in Midwest and Southeast states. We conclude that, given the chemical similarities between triazole fungicides and triazole antifungal drugs used in human medicine, increased monitoring for environmental and clinical triazole resistance in A. fumigatus would improve overall understanding of these interactions, as well as help identify strategies to mitigate development and spread of resistance. https://doi.org/10.1289/EHP7484.
Collapse
Affiliation(s)
- Mitsuru Toda
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karlyn D. Beer
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kathryn M. Kuivila
- U.S. Geological Survey Oregon Water Science Center, Portland, Oregon, USA
| | - Tom M. Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan R. Jackson
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
37
|
Resendiz-Sharpe A, Dewaele K, Merckx R, Bustamante B, Vega-Gomez MC, Rolon M, Jacobs J, Verweij PE, Maertens J, Lagrou K. Triazole-Resistance in Environmental Aspergillus fumigatus in Latin American and African Countries. J Fungi (Basel) 2021; 7:jof7040292. [PMID: 33921497 PMCID: PMC8070258 DOI: 10.3390/jof7040292] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 01/10/2023] Open
Abstract
Triazole-resistance has been reported increasingly in Aspergillus fumigatus. An international expert team proposed to avoid triazole monotherapy for the initial treatment of invasive aspergillosis in regions with >10% environmental-resistance, but this prevalence is largely unknown for most American and African countries. Here, we screened 584 environmental samples (soil) from urban and rural locations in Mexico, Paraguay, and Peru in Latin America and Benin and Nigeria in Africa for triazole-resistant A. fumigatus. Samples were screened using triazole-containing agars and confirmed as triazole-resistant by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth dilution reference method. Isolates were further characterized by cyp51A sequencing and short-tandem repeat typing. Fungicide presence in samples was likewise determined. Among A. fumigatus positive samples, triazole-resistance was detected in 6.9% (7/102) of samples in Mexico, 8.3% (3/36) in Paraguay, 9.8% (6/61) in Peru, 2.2% (1/46) in Nigeria, and none in Benin. Cyp51A gene mutations were present in most of the triazole-resistant isolates (88%; 15/17). The environmentally-associated mutations TR34/L98H and TR46/Y121F/T289A were prevalent in Mexico and Peru, and isolates harboring these mutations were closely related. For the first time, triazole-resistant A. fumigatus was found in environmental samples in Mexico, Paraguay, Peru, and Nigeria with a prevalence of 7-10% in the Latin American countries. Our findings emphasize the need to establish triazole-resistance surveillance programs in these countries.
Collapse
Affiliation(s)
- Agustin Resendiz-Sharpe
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Klaas Dewaele
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Rita Merckx
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Beatriz Bustamante
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
| | - Maria Celeste Vega-Gomez
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Miriam Rolon
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Jan Jacobs
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerpen, Belgium
| | - Paul E. Verweij
- Radboud University Medical Center, Department of Medical Microbiology, 6500 HB Nijmegen, The Netherlands;
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
- Correspondence: ; Tel.: +32-016-34-70-98
| |
Collapse
|
38
|
Chen Y, Dong F, Zhao J, Fan H, Qin C, Li R, Verweij PE, Zheng Y, Han L. High Azole Resistance in Aspergillus fumigatus Isolates from Strawberry Fields, China, 2018. Emerg Infect Dis 2021; 26:81-89. [PMID: 31855142 PMCID: PMC6924917 DOI: 10.3201/eid2601.190885] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In 2018, we conducted a cross-sectional study to investigate azole resistance in environmental Aspergillus fumigatus isolates obtained from different agricultural fields in China. Using 63 soil cores, we cultured for azole-resistant A. fumigatus and characterized isolates by their cyp51A gene type, short tandem repeat genotype, and mating type. Of 206 A. fumigatus isolates, 21 (10.2%) were azole resistant. Nineteen of 21 had mutations in their cyp51A gene (5 TR34/L98H, 8 TR34/L98H/S297T/F495I, 6 TR46/Y121F/T289A). Eighteen were cultured from soil samples acquired from strawberry fields, suggesting this soil type is a potential hotspot for azole resistance selection. Twenty resistant isolates were mating type MAT1-1, suggesting asexual sporulation contributed to their evolution. Prochloraz, difenoconazole, and tebuconazole were the most frequently detected fungicides in soil samples with azole-resistant fungus. Our study results suggest that managing the fungicides used in agriculture will help contain the problem of antifungal drug resistance in clinics.
Collapse
|
39
|
Extensive Genetic Diversity and Widespread Azole Resistance in Greenhouse Populations of Aspergillus fumigatus in Yunnan, China. mSphere 2021; 6:6/1/e00066-21. [PMID: 33568450 PMCID: PMC8544883 DOI: 10.1128/msphere.00066-21] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aspergillus fumigatus is the main cause of invasive aspergillosis (IA) with a high annual global incidence and mortality rate. Recent studies have indicated an increasing prevalence of azole-resistant A. fumigatus (ARAF) strains, with agricultural use of azole fungicides as a potential contributor. China has an extensive agricultural production system and uses a wide array of fungicides for crop production, including in modern growth facilities such as greenhouses. Soils in greenhouses are among the most intensively cultivated. However, little is known about the occurrence and distribution of ARAF in greenhouse soils. Here, we investigated genetic variation and triazole drug susceptibility in A. fumigatus from greenhouses around metropolitan Kunming in Yunnan, southwest China. Abundant allelic and genotypic variations were found among 233 A. fumigatus strains isolated from nine greenhouses in this region. Significantly, ∼80% of the strains were resistant to at least one medical triazole drug, with >30% showing cross-resistance to both itraconazole and voriconazole. Several previously reported mutations associated with triazole resistance in the triazole target gene cyp51A were also found in our strains, with a strong positive correlation between the frequency of mutations at the cyp51A promoter and that of voriconazole resistance. Phylogenetic analyses of cyp51A gene sequences showed evidence for multiple independent origins of azole-resistant genotypes of A. fumigatus in these greenhouses. Evidence for multiple origins of azole resistance and the widespread distributions of genetically very diverse triazole-resistant strains of A. fumigatus in greenhouses calls for significant attention from public health agencies. IMPORTANCE The origin and prevalence of azole-resistant Aspergillus fumigatus have been attracting increasing attention from biologists, clinicians, and public health agencies. Current evidence suggests agricultural fungicide use as a major cause. In southwest China, greenhouses are used to produce large amounts of fruits, flowers, and vegetables for consumers throughout China as well as those in other countries, primarily in southeast Asia. Here, we found a very high frequency (∼80%) of triazole-resistant A. fumigatus in our sample, the highest reported so far, with a significant proportion of these strains resistant to both tested agricultural fungicides and medical triazole drugs. In addition, we found novel allelic and genotypic diversities and evidence for multiple independent origins of azole-resistant genotypes of A. fumigatus in greenhouse populations in this region. Our study calls for a systematic evaluation of the effects of azole fungicide usage in greenhouses on human health.
Collapse
|
40
|
Hospital Environment as a Source of Azole-Resistant Aspergillus fumigatus Strains with TR34/L98H and G448S Cyp51A Mutations. J Fungi (Basel) 2021; 7:jof7010022. [PMID: 33401764 PMCID: PMC7824632 DOI: 10.3390/jof7010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/22/2023] Open
Abstract
Azole-resistant Aspergillus fumigatus is an emerging worldwide problem with increasing reports of therapy failure cases produced by resistant isolates. A case of azole-resistant A. fumigatus hospital colonization in a patient is reported here. Investigations of the hospital environment led to the recovery of A. fumigatus strains harboring the TR34/L98H and the G448S Cyp51A azole resistance mechanisms. Isolate genotyping showed that one strain from the environment was isogenic with the patient strains. These are the first environmental A. fumigatus azole resistant strains collected in a hospital in Spain; it supports the idea of the hospital environment as a source of dissemination and colonization/infection by azole resistant A. fumigatus in patients. The isolation of an azole-resistant strain from an azole-naïve patient is an interesting finding, suggesting that an effective analysis of clinical and environmental sources must be done to detect azole resistance in A. fumigatus. The emergence and spread of these resistance mechanisms in A. fumigatus is of major concern because it confers high resistance to voriconazole and is associated with treatment failure in patients with invasive aspergillosis.
Collapse
|
41
|
Fraaije B, Atkins S, Hanley S, Macdonald A, Lucas J. The Multi-Fungicide Resistance Status of Aspergillus fumigatus Populations in Arable Soils and the Wider European Environment. Front Microbiol 2020; 11:599233. [PMID: 33384673 PMCID: PMC7770239 DOI: 10.3389/fmicb.2020.599233] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022] Open
Abstract
The evolution and spread of pan-azole resistance alleles in clinical and environmental isolates of Aspergillus fumigatus is a global human health concern. The identification of hotspots for azole resistance development in the wider environment can inform optimal measures to counteract further spread by minimizing exposure to azole fungicides and reducing inoculum build-up and pathogen dispersal. We investigated the fungicide sensitivity status of soil populations sampled from arable crops and the wider environment and compared these with urban airborne populations. Low levels of azole resistance were observed for isolates carrying the CYP51A variant F46Y/M172V/E427K, all belonging to a cluster of related cell surface protein (CSP) types which included t07, t08, t13, t15, t19, and t02B, a new allele. High levels of resistance were found in soil isolates carrying CYP51A variants TR34/L98H and TR46/Y121F/T289A, all belonging to CSP types t01, t02, t04B, or t11. TR46/Y121F/M172V/T289A/G448S (CSP t01) and TR46/Y121F/T289A/S363P/I364V/G448S (CSP t01), a new haplotype associated with high levels of resistance, were isolated from Dutch urban air samples, indicating azole resistance evolution is ongoing. Based on low numbers of pan-azole resistant isolates and lack of new genotypes in soils of fungicide-treated commercial and experimental wheat crops, we consider arable crop production as a coldspot for azole resistance development, in contrast to previously reported flower bulb waste heaps. This study also shows that, in addition to azole resistance, several lineages of A. fumigatus carrying TR-based CYP51A variants have also developed acquired resistance to methyl benzimidazole carbamate, quinone outside inhibitor and succinate dehydrogenase (Sdh) inhibitor fungicides through target-site alterations in the corresponding fungicide target proteins; beta-tubulin (F200Y), cytochrome b (G143A), and Sdh subunit B (H270Y and H270R), respectively. Molecular typing showed that several multi-fungicide resistant strains found in agricultural soils in this study were clonal as identical isolates have been found earlier in the environment and/or in patients. Further research on the spread of different fungicide-resistant alleles from the wider environment to patients and vice versa can inform optimal practices to tackle the further spread of antifungal resistance in A. fumigatus populations and to safeguard the efficacy of azoles for future treatment of invasive aspergillosis.
Collapse
Affiliation(s)
- Bart Fraaije
- NIAB, Cambridge, United Kingdom.,Rothamsted Research, Harpenden, United Kingdom
| | | | | | | | - John Lucas
- Rothamsted Research, Harpenden, United Kingdom
| |
Collapse
|
42
|
Wang F, Yao S, Cao D, Ju C, Yu S, Xu S, Fang H, Yu Y. Increased triazole-resistance and cyp51A mutations in Aspergillus fumigatus after selection with a combination of the triazole fungicides difenoconazole and propiconazole. JOURNAL OF HAZARDOUS MATERIALS 2020; 400:123200. [PMID: 32593937 DOI: 10.1016/j.jhazmat.2020.123200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 06/11/2023]
Abstract
Triazole-resistance in Aspergillus fumigatus is widespread. We evaluated whether triazole-resistance in A. fumigatus and its related cyp51A mutations, induced by a combination of the triazole fungicides difenoconazole and propiconazole, differs from resistance induced by the individual fungicides. Both difenoconazole and propiconazole can induce triazole-resistance in A. fumigatus. Resistance is much easier induced by formulated fungicides or a combination of these two fungicides compared with standard fungicides or individual fungicides, respectively. Six different mutations (G138S, G138D, H147Y, I246M, M263I and D430N) were identified in the induced resistant strains. The H147Y, I246M and M263I mutations were associated with triazole-resistance. This implies that the application of a combination of difenoconazole and propiconazole may result in higher triazole-resistance in A. fumigatus and more mutations in the cyp51A gene.
Collapse
Affiliation(s)
- Feiyan Wang
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Shijie Yao
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Duantao Cao
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Chao Ju
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Sumei Yu
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Shiji Xu
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Hua Fang
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Yunlong Yu
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agricultural and Biotechnology, Zhejiang University, Hangzhou, 310058, China.
| |
Collapse
|
43
|
Nywening AV, Rybak JM, Rogers PD, Fortwendel JR. Mechanisms of triazole resistance in Aspergillus fumigatus. Environ Microbiol 2020; 22:4934-4952. [PMID: 33047482 PMCID: PMC7828461 DOI: 10.1111/1462-2920.15274] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022]
Abstract
The ubiquitous fungal pathogen Aspergillus fumigatus is the primary cause of opportunistic mould infections in humans. Aspergilli disseminate via asexual conidia passively travelling through air currents to germinate within a broad range of environs, wherever suitable nutrients are found. Though the average human inhales hundreds of conidia daily, A. fumigatus invasive infections primarily affect the immunocompromised. At-risk individuals can develop often fatal invasive disease for which therapeutic options are limited. Regrettably, the global insurgence of isolates resistant to the triazoles, the frontline antifungal class used in medicine and agriculture to control A. fumigatus, is complicating the treatment of patients. Triazole antifungal resistance in A. fumigatus has become recognized as a global, yet poorly comprehended, problem. Due to a multitude of factors, the magnitude of resistant infections and their contribution to treatment outcomes are likely underestimated. Current studies suggest that human drug-resistant infections can be either environmentally acquired or de novo host selected during patient therapy. While much concerning development of resistance is yet unknown, recent investigations have revealed assorted underlying mechanisms enabling triazole resistance within individual clinical and environmental isolates. This review will provide an overview of triazole resistance as it is currently understood, as well as highlight some of the prominent biological mechanisms associated with clinical and environmental resistance to triazoles in A. fumigatus.
Collapse
Affiliation(s)
- Ashley V Nywening
- Department of Clinical Pharmacy and Translational Sciences, The University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
- College of Graduate Health Sciences, Integrated Biomedical Sciences Program, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Jeffrey M Rybak
- Department of Clinical Pharmacy and Translational Sciences, The University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - Phillip David Rogers
- Department of Clinical Pharmacy and Translational Sciences, The University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - Jarrod R Fortwendel
- Department of Clinical Pharmacy and Translational Sciences, The University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| |
Collapse
|
44
|
Cao D, Wu R, Dong S, Wang F, Ju C, Yu S, Xu S, Fang H, Yu Y. Triazole resistance in Aspergillus fumigatus in crop plant soil after tebuconazole applications. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2020; 266:115124. [PMID: 32673931 DOI: 10.1016/j.envpol.2020.115124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/30/2020] [Accepted: 06/26/2020] [Indexed: 06/11/2023]
Abstract
Aspergillus fumigatus is the primary agent of invasive aspergillosis (IA) causing high morbidity and mortality in immunocompromised patients. Triazole resistance in A. fumigatus and its sources have gained wide attention. For several years, environmental fungicides use has been proposed as the major cause for triazole resistance in A. fumigatus. However, there are few studies on azole-resistant A. fumigatus (ARAF) selected by triazole fungicides in agricultural systems. We studied the possible emergence of ARAF in the field after exposure to triazole fungicide tebuconazole. Our results showed that exposure to tebuconazole in soil selects for resistance to triazoles in A. fumigatus. The probability of ARAF developing in soils depends upon the concentrations of tebuconazole after application. We suggest that tebuconazole applications should be minimized to reduce selective pressure for the generation of ARAFs.
Collapse
Affiliation(s)
- Duantao Cao
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Ruilin Wu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Suxia Dong
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Feiyan Wang
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Chao Ju
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Sumei Yu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Shiji Xu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Hua Fang
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China
| | - Yunlong Yu
- Institute of Pesticide and Environmental Toxicology, Key Laboratory of Molecular Biology of Crop Pathogens and Insects, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, 310058, China.
| |
Collapse
|
45
|
Jung IY, Lee YJ, Shim HS, Cho YS, Sohn YJ, Hyun JH, Baek YJ, Kim MH, Kim JH, Ahn JY, Jeong SJ, Ku NS, Park YS, Yeom JS, Kim YK, Kim HY, Choi JY. Identification of Fungal Species and Detection of Azole-Resistance Mutations in the Aspergillus fumigatus cyp51A Gene at a South Korean Hospital. Yonsei Med J 2020; 61:698-704. [PMID: 32734733 PMCID: PMC7393294 DOI: 10.3349/ymj.2020.61.8.698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/26/2020] [Accepted: 06/22/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE With changing fungal epidemiology and azole resistance in Aspergillus species, identifying fungal species and susceptibility patterns is crucial to the management of aspergillosis and mucormycosis. The objectives of this study were to evaluate performance of panfungal polymerase chain reaction (PCR) assays on formalin-fixed paraffin embedded (FFPE) samples in the identification of fungal species and in the detection of azole-resistance mutations in the Aspergillus fumigatus cyp51A gene at a South Korean hospital. MATERIALS AND METHODS A total of 75 FFPE specimens with a histopathological diagnosis of aspergillosis or mucormycosis were identified during the 10-year study period (2006-2015). After deparaffinization and DNA extraction, panfungal PCR assays were conducted on FFPE samples for fungal species identification. The identified fungal species were compared with histopathological diagnosis. On samples identified as A. fumigatus, sequencing to identify frequent mutations in the cyp51A gene [tandem repeat 46 (TR46), L98H, and M220 alterations] that confer azole resistance was performed. RESULTS Specific fungal DNA was identified in 31 (41.3%) FFPE samples, and of these, 16 samples of specific fungal DNA were in accord with a histopathological diagnosis of aspergillosis or mucormycosis; 15 samples had discordant histopathology and PCR results. No azole-mediating cyp51A gene mutation was noted among nine cases of aspergillosis. Moreover, no cyp51A mutations were identified among three cases with history of prior azole use. CONCLUSION Panfungal PCR assay with FFPE samples may provide additional information of use to fungal species identification. No azole-resistance mediating mutations in the A. fumigatus cyp51A gene were identified among FFPE samples during study period.
Collapse
Affiliation(s)
- In Young Jung
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Youn Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Sup Shim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Suk Cho
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yu Jin Sohn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hoon Hyun
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yae Jee Baek
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Hyun Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Soo Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Sup Yeom
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyo Youl Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
46
|
Rybak JM, Fortwendel JR, Rogers PD. Emerging threat of triazole-resistant Aspergillus fumigatus. J Antimicrob Chemother 2020; 74:835-842. [PMID: 30561652 DOI: 10.1093/jac/dky517] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Invasive aspergillosis is a leading cause of morbidity and mortality among immunocompromised populations and is predicted to cause more than 200 000 life-threatening infections each year. Aspergillus fumigatus is the most prevalent pathogen isolated from patients with invasive aspergillosis, accounting for more than 60% of all cases. Currently, the only antifungal agents available with consistent activity against A. fumigatus are the mould-active triazoles and amphotericin B, of which the triazoles commonly represent both front-line and salvage therapeutic options. Unfortunately, the treatment of infections caused by A. fumigatus has recently been further complicated by the global emergence of triazole resistance among both clinical and environmental isolates. Mutations in the A. fumigatus sterol-demethylase gene cyp51A, overexpression of cyp51A and overexpression of efflux pump genes are all known to contribute to resistance, yet much of the triazole resistance among A. fumigatus still remains unexplained. Also lacking is clinical experience with therapeutic options for the treatment of triazole-resistant A. fumigatus infections and mortality associated with these infections remains unacceptably high. Thus, further research is greatly needed to both better understand the emerging threat of triazole-resistant A. fumigatus and to develop novel therapeutic strategies to combat these resistant infections.
Collapse
Affiliation(s)
- Jeffrey M Rybak
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - Jarrod R Fortwendel
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - P David Rogers
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| |
Collapse
|
47
|
Bustamante B, Illescas LR, Posadas A, Campos PE. Azole resistance among clinical isolates of Aspergillus fumigatus in Lima-Peru. Med Mycol 2020; 58:54-60. [PMID: 31329931 DOI: 10.1093/mmy/myz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
Azole resistance among Aspergillus fumigatus isolates, which is mainly related to mutations in the cyp51A gene, is a concern because it is rising, worldwide disseminated, and associated with treatment failure and death. Data on azole resistance of aspergillus from Latin American countries is very scarce and do not exist for Peru. Two hundred and seven Aspergillus clinical isolates collected prospectively underwent mycology and molecular testing for specie identification, and 143 isolates were confirmed as A. fumigatus sensu stricto (AFSS). All AFSS were tested for in vitro azole susceptibility, and resistant isolates underwent PCR amplification and sequencing of the whole cyp51A gene and its promoter. The in vitro susceptibility showed a minimal inhibitory concentration (MIC) range, MIC50 and MIC90 of 0.125 to >16, 0.25, and 0.5 μg/ml for itraconazole; 0.25 to 2, 0.5, and 0.5 μg/ml for voriconazole; and 0.003 to 1, 0.06, and 0.125 μg/ml for posaconazole. Three isolates (2%) showed resistance to itraconazole and exhibited different mutations of the cyp51A gene. One isolate harbored the mutation M220K, while a second one exhibited the G54 mutation plus a modification in the cyp51A gene promoter. The third isolate, from an azole naive patient, presented an integration of a 34-bp tandem repeat (TR34) in the promoter region of the gene and a substitution of leucine 98 by histidine (L98H). The three source patients had a diagnosis or suspicion of chronic pulmonary aspergillosis.
Collapse
Affiliation(s)
- Beatriz Bustamante
- Nacional Cayetano Heredia, Lima, Perú, and Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Andrés Posadas
- Unidad de Epidemiología Molecular-Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
| | | |
Collapse
|
48
|
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]
|
49
|
Won EJ, Joo MY, Lee D, Kim MN, Park YJ, Kim SH, Shin MG, Shin JH. Antifungal Susceptibility Tests and the cyp51 Mutant Strains among Clinical Aspergillus fumigatus Isolates from Korean Multicenters. MYCOBIOLOGY 2020; 48:148-152. [PMID: 32363043 PMCID: PMC7178884 DOI: 10.1080/12298093.2020.1744955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 06/11/2023]
Abstract
We investigated the antifungal susceptibilities and the cyp51 mutant strains among Aspergillus fumigatus clinical isolates obtained from 10 university hospitals in Korea. Of the 84 isolates examined, two itraconazole-resistant isolates were found with no amino acid substitution in the cyp51A/cyp51B genes. However, 19 (23.2%) azole-susceptible isolates harbored amino acid substitutions: Nine isolates harbored one to five mutations in cyp51A with high polymorphism, and 11 isolates exhibited the same Q42L mutation in cyp51B. Overall, a low azole resistance rate and high frequency of cyp51A/cyp51B amino acid substitutions were observed in the azole-susceptible A. fumigatus isolates in Korea.
Collapse
Affiliation(s)
- Eun Jeong Won
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
- Department of Parasitology and Tropical Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Min Young Joo
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dain Lee
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
- Department of Microbiology, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
50
|
James JE, Lamping E, Santhanam J, Milne TJ, Abd Razak MF, Zakaria L, Cannon RD. A 23 bp cyp51A Promoter Deletion Associated With Voriconazole Resistance in Clinical and Environmental Isolates of Neocosmospora keratoplastica. Front Microbiol 2020; 11:272. [PMID: 32296397 PMCID: PMC7136401 DOI: 10.3389/fmicb.2020.00272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/06/2020] [Indexed: 12/21/2022] Open
Abstract
In the fungal pathogen Aspergillus fumigatus, resistance to azole antifungals is often linked to mutations in CYP51A, a gene that encodes the azole antifungal drug target lanosterol 14α-demethylase. The aim of this study was to investigate whether similar changes could be associated with azole resistance in a Malaysian Fusarium solani species complex (FSSC) isolate collection. Most (11 of 15) clinical FSSC isolates were Neocosmospora keratoplastica and the majority (6 of 10) of environmental isolates were Neocosmospora suttoniana strains. All 25 FSSC isolates had high minimum inhibitory concentrations (MICs) for itraconazole and posaconazole, low MICs for amphotericin B, and various (1 to >32 mg/l) voriconazole susceptibilities. There was a tight association between a 23 bp CYP51A promoter deletion and high (>32 mg/l) voriconazole MICs; of 19 FSSC strains sequenced, nine isolates had voriconazole MICs > 32 mg/l, and they all contained the 23 bp CYP51A promoter deletion, although it was absent in the ten remaining isolates with low (≤12 mg/l) voriconazole MICs. Surprisingly, this association between voriconazole resistance and the 23 bp CYP51A promoter deletion held true across species boundaries. It was randomly distributed within and across species boundaries and both types of FSSC isolates were found among environmental and clinical isolates. Three randomly selected N. keratoplastica isolates with low (≤8 mg/l) voriconazole MICs had significantly lower (1.3–7.5 times) CYP51A mRNA expression levels than three randomly selected N. keratoplastica isolates with high (>32 mg/l) voriconazole MICs. CYP51A expression levels, however, were equally strongly induced (~6,500-fold) by voriconazole in two representative strains reaching levels, after 80 min of induction, that were comparable to those of CYP51B. Our results suggest that FSSC isolates with high voriconazole MICs have a 23 bp CYP51A promoter deletion that provides a potentially useful marker for voriconazole resistance in FSSC isolates. Early detection of possible voriconazole resistance is critical for choosing the correct treatment option for patients with invasive fusariosis.
Collapse
Affiliation(s)
- Jasper Elvin James
- Biomedical Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Erwin Lamping
- Faculty of Dentistry, Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand
| | - Jacinta Santhanam
- Biomedical Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Trudy Jane Milne
- Faculty of Dentistry, Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand
| | - Mohd Fuat Abd Razak
- Bacteriology Unit, Institute for Medical Research, National Institute of Health, Setia Alam, Malaysia
| | - Latiffah Zakaria
- School of Biological Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Richard David Cannon
- Faculty of Dentistry, Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand
| |
Collapse
|