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Liu F, Zeng M, Zhou X, Huang F, Song Z. Aspergillus fumigatus escape mechanisms from its harsh survival environments. Appl Microbiol Biotechnol 2024; 108:53. [PMID: 38175242 DOI: 10.1007/s00253-023-12952-z] [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: 08/15/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 01/05/2024]
Abstract
Aspergillus fumigatus is a ubiquitous pathogenic mold and causes several diseases, including mycotoxicosis, allergic reactions, and systemic diseases (invasive aspergillosis), with high mortality rates. In its ecological niche, the fungus has evolved and mastered many reply strategies to resist and survive against negative threats, including harsh environmental stress and deficiency of essential nutrients from natural environments, immunity responses and drug treatments in host, and competition from symbiotic microorganisms. Hence, treating A. fumigatus infection is a growing challenge. In this review, we summarized A. fumigatus reply strategies and escape mechanisms and clarified the main competitive or symbiotic relationships between A. fumigatus, viruses, bacteria, or fungi in host microecology. Additionally, we discussed the contemporary drug repertoire used to treat A. fumigatus and the latest evidence of potential resistance mechanisms. This review provides valuable knowledge which will stimulate further investigations and clinical applications for treating and preventing A. fumigatus infections. KEY POINTS: • Harsh living environment was a great challenge for A. fumigatus survival. • A. fumigatus has evolved multiple strategies to escape host immune responses. • A. fumigatus withstands antifungal drugs via intrinsic escape mechanisms.
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Affiliation(s)
- Fangyan Liu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, People's Republic of China
| | - Meng Zeng
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, People's Republic of China
- Department of Clinical Laboratory, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, People's Republic of China
| | - Xue Zhou
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, People's Republic of China
| | - Fujiao Huang
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, People's Republic of China
| | - Zhangyong Song
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, 646000, People's Republic of China.
- Molecular Biotechnology Platform, Public Center of Experimental Technology, Southwest Medical University, Luzhou, 646000, People's Republic of China.
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2
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Ror S, Stamnes MA, Moye-Rowley WS. Gene-specific transcriptional activation by the Aspergillus fumigatus AtrR factor requires a conserved C-terminal domain. mSphere 2024:e0042524. [PMID: 38975761 DOI: 10.1128/msphere.00425-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
Treatment of fungal infections associated with the filamentous fungus Aspergillus fumigatus is becoming more problematic as this organism is developing resistance to the main chemotherapeutic drug at an increasing rate. Azole drugs represent the current standard-of-care in the treatment of aspergillosis with this drug class acting by inhibiting a key step in the biosynthesis of the fungal sterol ergosterol. Azole compounds block the activity of the lanosterol α-14 demethylase, encoded by the cyp51A gene. A common route of azole resistance involves an increase in transcription of cyp51A. This transcriptional increase requires the function of a Zn2Cys6 DNA-binding domain-containing transcription activator protein called AtrR. AtrR was identified through its action as a positive regulator of expression of an ATP-binding cassette transporter (abcC/cdr1B here called abcG1). Using both deletion and alanine scanning mutagenesis, we demonstrate that a conserved C-terminal domain in A. fumigatus is required for the expression of abcG1 but dispensable for cyp51A transcription. This domain is also found in several other fungal pathogen AtrR homologs consistent with a conserved gene-selective function of this protein segment being conserved. Using RNA sequencing (RNA-seq), we find that this gene-specific transcriptional defect extends to several other membrane transporter-encoding genes including a second ABC transporter locus. Our data reveal that AtrR uses at least two distinct mechanisms to induce gene expression and that normal susceptibility to azole drugs cannot be provided by maintenance of wild-type expression of the ergosterol biosynthetic pathway when ABC transporter expression is reduced. IMPORTANCE Aspergillus fumigatus is the primary human filamentous fungal pathogen. The principal chemotherapeutic drug used to control infections associated with A. fumigatus is the azole compound. These drugs are well-tolerated and effective, but resistance is emerging at an alarming rate. Most resistance is associated with mutations that lead to overexpression of the azole target enzyme, lanosterol α-14 demethylase, encoded by the cyp51A gene. A key regulator of cyp51A gene expression is the transcription factor AtrR. Very little is known of the molecular mechanisms underlying the effect of AtrR on gene expression. Here, we use deletion and clustered amino acid substitution mutagenesis to map a region of AtrR that confers gene-specific activation on target genes of this transcription factor. This region is highly conserved across AtrR homologs from other pathogenic species arguing that its importance in transcriptional regulation is maintained across evolution.
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Affiliation(s)
- Shivani Ror
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Mark A Stamnes
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - W Scott Moye-Rowley
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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3
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Debergh H, Castelain P, Goens K, Lefevere P, Claessens J, De Vits E, Vissers M, Blindeman L, Bataille C, Saegerman C, Packeu A. Detection of pan-azole resistant Aspergillus fumigatus in horticulture and a composting facility in Belgium. Med Mycol 2024; 62:myae055. [PMID: 38769604 PMCID: PMC11223581 DOI: 10.1093/mmy/myae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/04/2024] [Accepted: 05/16/2024] [Indexed: 05/22/2024] Open
Abstract
Azole resistance in Aspergillus fumigatus (ARAf) is becoming a worldwide health threat due to increasing occurrence in the environment. However, environmental surveillance programs are not commonly in place and are lacking in Belgium. Since no data on the occurrence of ARAf and the presence of hotspots for the selection of azole resistance is available in Belgium, a first study on the prevalence of ARAf in the environment was conducted. A total of 232 air and compost or soil samples were taken from two composting facilities, and from horticultural and agricultural crops. The azole susceptibility pattern was determined using the EUCAST method (E. Def. 9.4), and the cyp51A gene and its promotor region were sequenced in A. fumigatus isolates with phenotypic azole resistance. Six pan-azole-resistant A. fumigatus isolates were identified, originating from compost and horticultural crops. Four isolates carried the TR34/L98H mutation, and one isolate carried the TR46/Y121F/T289A mutation. However, we did not observe any ARAf isolates from agricultural crops. In conclusion, this study reported the first TR34/L98H and TR46/Y121F/T289A mutation isolated from a composting facility and horticulture in Belgium. The implementation of standardization in environmental surveillance of A. fumigatus on a European level would be beneficial in order to identify hotspots.
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Affiliation(s)
- Hanne Debergh
- Mycology and Aerobiology, Sciensano, 1050 Brussels, Belgium
- Fundamental and Applied Research for Animal and Health (FARAH) Center, University of Liège, 4000 Liège, Belgium
| | | | - Karine Goens
- Mycology and Aerobiology, Sciensano, 1050 Brussels, Belgium
| | | | | | - Elien De Vits
- Mycology and Aerobiology, Sciensano, 1050 Brussels, Belgium
| | - Marc Vissers
- Ornamental Plant Research, PCS, 9070 Destelbergen, Belgium
| | | | | | - Claude Saegerman
- Fundamental and Applied Research for Animal and Health (FARAH) Center, University of Liège, 4000 Liège, Belgium
| | - Ann Packeu
- Mycology and Aerobiology, Sciensano, 1050 Brussels, Belgium
- BCCM/IHEM, Mycology and Aerobiology, Sciensano, 1050 Brussels, Belgium
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4
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Morrissey CO, Kim HY, Duong TMN, Moran E, Alastruey-Izquierdo A, Denning DW, Perfect JR, Nucci M, Chakrabarti A, Rickerts V, Chiller TM, Wahyuningsih R, Hamers RL, Cassini A, Gigante V, Sati H, Alffenaar JW, Beardsley J. Aspergillus fumigatus-a systematic review to inform the World Health Organization priority list of fungal pathogens. Med Mycol 2024; 62:myad129. [PMID: 38935907 PMCID: PMC11210617 DOI: 10.1093/mmy/myad129] [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: 09/16/2023] [Revised: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 06/29/2024] Open
Abstract
Recognizing the growing global burden of fungal infections, the World Health Organization established a process to develop a priority list of fungal pathogens (FPPL). In this systematic review, we aimed to evaluate the epidemiology and impact of invasive infections caused by Aspergillus fumigatus to inform the first FPPL. The pre-specified criteria of mortality, inpatient care, complications and sequelae, antifungal susceptibility, risk factors, preventability, annual incidence, global distribution, and emergence were used to search for relevant articles between 1 January 2016 and 10 June 2021. Overall, 49 studies were eligible for inclusion. Azole antifungal susceptibility varied according to geographical regions. Voriconazole susceptibility rates of 22.2% were reported from the Netherlands, whereas in Brazil, Korea, India, China, and the UK, voriconazole susceptibility rates were 76%, 94.7%, 96.9%, 98.6%, and 99.7%, respectively. Cross-resistance was common with 85%, 92.8%, and 100% of voriconazole-resistant A. fumigatus isolates also resistant to itraconazole, posaconazole, and isavuconazole, respectively. The incidence of invasive aspergillosis (IA) in patients with acute leukemia was estimated at 5.84/100 patients. Six-week mortality rates in IA cases ranged from 31% to 36%. Azole resistance and hematological malignancy were poor prognostic factors. Twelve-week mortality rates were significantly higher in voriconazole-resistant than in voriconazole-susceptible IA cases (12/22 [54.5%] vs. 27/88 [30.7%]; P = .035), and hematology patients with IA had significantly higher mortality rates compared with solid-malignancy cases who had IA (65/217 [30%] vs. 14/78 [18%]; P = .04). Carefully designed surveillance studies linking laboratory and clinical data are required to better inform future FPPL.
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Affiliation(s)
- C Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Hannah Y Kim
- The University of Sydney Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Tra-My N Duong
- The University of Sydney Infectious Diseases Institute (Sydney ID), New South Wales, Australia
| | - Eric Moran
- Sinclair Dermatology, East Melbourne, Victoria, Australia
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - David W Denning
- Global Action for Fungal Infections, Geneva, Switzerland
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro and Grupo Oncoclinicas, Rio de Janeiro, RJ, Brazil
| | | | - Volker Rickerts
- Robert Koch Institute Berlin, FG16, Seestrasse 10, 13353 Berlin, Germany
| | - Tom M Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Retno Wahyuningsih
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Parasitology, Faculty of Medicine, Universitas Kristen, Jakarta, Indonesia
| | - Raph L Hamers
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Alessandro Cassini
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
- Public Health Department, Canton of Vaud, Lausanne, Switzerland
| | - Valeria Gigante
- AMR Division, World Health Organization, Geneva, Switzerland
| | - Hatim Sati
- AMR Division, World Health Organization, Geneva, Switzerland
| | - Jan-Willem Alffenaar
- The University of Sydney Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Justin Beardsley
- The University of Sydney Infectious Diseases Institute (Sydney ID), New South Wales, Australia
- Westmead Institute for Medical Research, Westmead, New South Wales, Australia
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5
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Kelty MT, Miron-Ocampo A, Beattie SR. A series of pyrimidine-based antifungals with anti-mold activity disrupt ER function in Aspergillus fumigatus. Microbiol Spectr 2024:e0104524. [PMID: 38916314 DOI: 10.1128/spectrum.01045-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/23/2024] [Indexed: 06/26/2024] Open
Abstract
Fungal infections are a major contributor to morbidity and mortality among immunocompromised populations. Moreover, fungal disease caused by molds are difficult to treat and are associated with particularly high mortality. To address the need for new mold-active antifungal drugs, we performed a high-throughput screen with Aspergillus fumigatus, the most common pathogenic mold. We identified a novel, pyrimidine-based chemical scaffold with broad-spectrum antifungal activity including activity against several difficult-to-treat molds. A chemical genetics screen of Saccharomyces cerevisiae suggested that this compound may target the endoplasmic reticulum (ER) and perturb ER function and/or homeostasis. Consistent with this model, this compound induces the unfolded protein response and inhibits secretion of A. fumigatus collagenases. Initial cytotoxicity and pharmacokinetic studies show favorable features including limited mammalian cell toxicity and bioavailability in vivo. Together, these data support the further medicinal chemistry and pre-clinical development of this pyrimidine scaffold toward more effective treatments for life-threatening invasive mold infections.IMPORTANCEInvasive fungal diseases are life-threatening infections caused by fungi in immunocompromised individuals. Currently, there are only three major classes of antifungal drugs available to treat fungal infections; however, these options are becoming even more limited with the global emergence of antifungal drug resistance. To address the need for new antifungal therapies, we performed a screen of chemical compounds and identified a novel molecule with antifungal activity. Initial characterization of this compound shows drug-like features and broad-spectrum activity against medically important fungi. Together, our results support the continued development of this compound as a potential future therapy for these devastating fungal infections.
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Affiliation(s)
- Martin T Kelty
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Aracely Miron-Ocampo
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Sarah R Beattie
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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6
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van Dijk MAM, Buil JB, Tehupeiory-Kooreman M, Broekhuizen MJ, Broens EM, Wagenaar JA, Verweij PE. Azole Resistance in Veterinary Clinical Aspergillus fumigatus Isolates in the Netherlands. Mycopathologia 2024; 189:50. [PMID: 38864903 PMCID: PMC11169034 DOI: 10.1007/s11046-024-00850-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/14/2024] [Indexed: 06/13/2024]
Abstract
Aspergillus fumigatus is a saprophytic fungal pathogen that causes opportunistic infections in animals and humans. Azole resistance has been reported globally in human A. fumigatus isolates, but the prevalence of resistance in isolates from animals is largely unknown. A retrospective resistance surveillance study was performed using a collection of clinical A. fumigatus isolates from various animal species collected between 2015 and 2020. Agar-based azole resistance screening of all isolates was followed by in vitro antifungal susceptibility testing and cyp51A gene sequencing of the azole-resistant isolates. Over the 5 year period 16 (11.3%) of 142 A. fumigatus culture-positive animals harbored an azole-resistant isolate. Resistant isolates were found in birds (15%; 2/13), cats (21%; 6/28), dogs (8%; 6/75) and free-ranging harbor porpoise (33%; 2/6). Azole-resistance was cyp51A mediated in all isolates: 81.3% (T-67G/)TR34/L98H, 12.5% TR46/Y121F/T289A. In one azole-resistant A. fumigatus isolate a combination of C(-70)T/F46Y/C(intron7)T/C(intron66)T/M172V/E427K single-nucleotide polymorphisms in the cyp51A gene was found. Of the animals with an azole-resistant isolate and known azole exposure status 71.4% (10/14) were azole naive. Azole resistance in A. fumigatus isolates from animals in the Netherlands is present and predominantly cyp51A TR-mediated, supporting an environmental route of resistance selection. Our data supports the need to include veterinary isolates in resistance surveillance programs. Veterinarians should consider azole resistance as a reason for therapy failure when treating aspergillosis and consider resistance testing of relevant isolates.
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Affiliation(s)
- Marloes A M van Dijk
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands.
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marlou Tehupeiory-Kooreman
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Marian J Broekhuizen
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Els M Broens
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Jaap A Wagenaar
- Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
- Wageningen Bioveterinary Research, 8221 RA, Lelystad, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, 6525 GA, Nijmegen, The Netherlands
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Ghorbel D, Amouri I, Khemekhem N, Neji S, Trabelsi H, Elloumi M, Sellami H, Makni F, Ayadi A, Hadrich I. Investigation of Azole Resistance Involving cyp51A and cyp51B Genes in Clinical Aspergillus flavus Isolates. Pol J Microbiol 2024; 73:131-142. [PMID: 38700908 PMCID: PMC11192525 DOI: 10.33073/pjm-2024-001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/03/2023] [Indexed: 06/22/2024] Open
Abstract
This study aimed to investigate azole resistance mechanisms in Aspergillus flavus, which involve cyp51A and cyp51B genes. Real-time Reverse Transcriptase qPCR method was applied to determine the overexpression of cyp51A and cyp51B genes for 34 A. flavus isolates. PCR sequencing of these two genes was used to detect the presence of gene mutations. Susceptibility test found sensitivity to voriconazole (VOR) in all strains. 14.7% and 8.8% of isolates were resistant to itraconazole (IT) and posaconazole (POS), respectively, with a cross-resistance in 5.8%. For the double resistant isolates (IT/POS), the expression of cyp51A was up to 17-fold higher. PCR sequencing showed the presence of 2 mutations in cyp51A: a synonymous point mutation (P61P) in eight isolates, which did not affect the structure of CYP51A protein, and another non synonymous mutation (G206L) for only the TN-33 strain (cross IT/POS resistance) causing an amino acid change in the protein sequence. However, we noted in cyp51B the presence of the only non-synonymous mutation (L177G) causing a change in amino acids in the protein sequence for the TN-31 strain, which exhibits IT/POS cross-resistance. A short single intron of 67 bp was identified in the cyp51A gene, whereas three short introns of 54, 53, and 160 bp were identified in the cyp51B gene. According to the models provided by PatchDock software, the presence of non-synonymous mutations did not affect the interaction of CYP51A and CYP51B proteins with antifungals. In our study, the overexpression of the cyp51A and cyp51B genes is the primary mechanism responsible for resistance in A. flavus collection. Nevertheless, other resistance mechanisms can be involved.
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Affiliation(s)
- Dhoha Ghorbel
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Imen Amouri
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Nahed Khemekhem
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Sourour Neji
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Houaida Trabelsi
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Moez Elloumi
- Haematology Department, UH Hedi Chaker, Sfax, Tunisia
| | - Hayet Sellami
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Fattouma Makni
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Ali Ayadi
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
| | - Ines Hadrich
- Fungi and Parasitic Molecular Biology Laboratory, School of Medicine, University of Sfax, Sfax, Tunisia
- Faculty of Science, University of Gabes, Gabes, Tunisia
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Ror S, Stamnes MA, Moye-Rowley WS. Loss of a conserved C-terminal region of the Aspergillus fumigatus AtrR transcriptional regulator leads to a gene-specific defect in target gene expression. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.22.595332. [PMID: 38826412 PMCID: PMC11142210 DOI: 10.1101/2024.05.22.595332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Treatment of fungal infections associated with the filamentous fungus Aspergillus fumigatus is becoming more problematic as this organism is developing resistance to the main chemotherapeutic drug at an increasing rate. Azole drugs represent the current standard-of-care in treatment of aspergillosis with this drug class acting by inhibiting a key step in biosynthesis of the fungal sterol ergosterol. Azole compounds block the activity of the lanosterol α-14 demethylase, encoded by the cyp51A gene. A common route of azole resistance involves an increase in transcription of cyp51A. This transcriptional increase requires the function of a Zn2Cys6 DNA-binding domain-containing transcription activator protein called AtrR. AtrR was identified through its action as a positive regulator of expression of an ATP-binding cassette transporter (abcC/cdr1B here called abcG1). Using both deletion and alanine scanning mutagenesis, we demonstrate that a conserved C-terminal domain in A. fumigatus is required for expression of abcG1 but dispensable for cyp51A transcription. This domain is also found in several other fungal pathogen AtrR homologues consistent with a conserved gene-selective function of this protein segment being conserved. Using RNA-seq, we find that this gene-specific transcriptional defect extends to several other membrane transporter-encoding genes including a second ABC transporter locus. Our data reveal that AtrR uses at least two distinct mechanisms to induce gene expression and that normal susceptibility to azole drugs cannot be provided by maintenance of wild-type expression of the ergosterol biosynthetic pathway when ABC transporter expression is reduced.
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Affiliation(s)
- Shivani Ror
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Mark A Stamnes
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - W Scott Moye-Rowley
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
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9
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Atamna A, Yeshurun M, Shargian L, Raanani P, Kramer M, Ben Zvi H, Ben Ami R, Marr KA, Bishara J. Fatal invasive pulmonary and cerebral aspergillosis due to triazole-resistant Aspergillus fumigatus with multiple CYP51A mutations. J Antimicrob Chemother 2024; 79:1191-1192. [PMID: 38334380 DOI: 10.1093/jac/dkae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Affiliation(s)
- Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Moshe Yeshurun
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Bone Marrow Transplantation Unit, Institute of Hematology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Liat Shargian
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Bone Marrow Transplantation Unit, Institute of Hematology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Institute of Hematology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Mordechai Kramer
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Haim Ben Zvi
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Clinical Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Ronen Ben Ami
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- National Reference Laboratory for Clinical Mycology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Kieren A Marr
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Tel Aviv Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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10
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Wei L, Shi H, Chen B, Li X, Chen W, Wu C, Gai Y, Chen C. Functional Plasticity, Redundancy, and Specificity of Lanosterol 14α-Demethylase in Regulating the Sensitivity to DMIs in Calonectria ilicicola. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2024; 72:8444-8459. [PMID: 38574108 DOI: 10.1021/acs.jafc.4c01948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Cytochrome P450 sterol 14α-demethylase (CYP51) is a key enzyme involved in the sterol biosynthesis pathway and serves as a target for sterol demethylation inhibitors (DMIs). In this study, the 3D structures of three CPY51 paralogues from Calonectria ilicicola (C. ilicicola) were first modeled by AlphaFold2, and molecular docking results showed that CiCYP51A, CiCYP51B, or CiCYP51C proteins individually possessed two active pockets that interacted with DMIs. Our results showed that the three paralogues play important roles in development, pathogenicity, and sensitivity to DMI fungicides. Specifically, CiCYP51A primarily contributed to cell wall integrity maintenance and tolerance to abiotic stresses, and CiCYP51B was implicated in sexual reproduction and virulence, while CiCYP51C exerted negative regulatory effects on sterol 14α-demethylase activity within the ergosterol biosynthetic pathway, revealing its genus-specific function in C. ilicicola. These findings provide valuable insights into developing rational strategies for controlling soybean red crown rot caused by C. ilicicola.
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Affiliation(s)
- Lingling Wei
- College of Plant Protection, Nanjing Agricultural University, Nanjing, Jiangsu 210095, China
| | - Haiping Shi
- College of Plant Protection, Nanjing Agricultural University, Nanjing, Jiangsu 210095, China
| | - Bin Chen
- College of Plant Protection, Nanjing Agricultural University, Nanjing, Jiangsu 210095, China
| | - Xiujuan Li
- College of Plant Protection, Nanjing Agricultural University, Nanjing, Jiangsu 210095, China
| | - Wenchan Chen
- Institute of Plant Protection, Jiangsu Academy of Agricultural Sciences, Nanjing, Jiangsu 210095, China
| | - Chengdong Wu
- Pukou District Modern Agricultural Development Service Center of Nanjing City, Nanjing, Jiangsu 211800, China
| | - Yunpeng Gai
- School of Grassland Science, Beijing Forestry University, Beijing 100083, China
| | - Changjun Chen
- College of Plant Protection, Nanjing Agricultural University, Nanjing, Jiangsu 210095, China
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11
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Chen S, Zhu G, Lin H, Guo J, Deng S, Wu W, Goldman GH, Lu L, Zhang Y. Variability in competitive fitness among environmental and clinical azole-resistant Aspergillus fumigatus isolates. mBio 2024; 15:e0026324. [PMID: 38407058 PMCID: PMC11005360 DOI: 10.1128/mbio.00263-24] [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: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/27/2024] Open
Abstract
Azoles are the primary antifungal drugs used to treat infections caused by Aspergillus fumigatus. However, the emergence of azole resistance in A. fumigatus has become a global health concern despite the low proportion of resistant isolates in natural populations. In bacteria, antibiotic resistance incurs a fitness cost that renders strains less competitive in the absence of antibiotics. Consequently, fitness cost is a key determinant of the spread of resistant mutations. However, the cost of azole resistance and its underlying causes in A. fumigatus remain poorly understood. In this observation, we revealed that the 10 out of 15 screened azole-resistant isolates, which possessed the most common azole-targeted cyp51A mutations, particularly the presence of tandem repeats in the promoter region, exhibit fitness cost when competing with the susceptible isolates in azole-free environments. These results suggest that fitness cost may significantly influence the dynamics of azole resistance, which ultimately contributes to the low prevalence of azole-resistant A. fumigatus isolates in the environment and clinic. By constructing in situ cyp51A mutations in a parental azole-susceptible strain and reintroducing the wild-type cyp51A gene into the azole-resistant strains, we demonstrated that fitness cost is not directly dependent on cyp51A mutations but is instead associated with the evolution of variable mutations related to conidial germination or other unknown development-related processes. Importantly, our observations unexpectedly revealed that some azole-resistant isolates showed no detectable fitness cost, and some even exhibited significantly increased competitive fitness in azole-free environments, highlighting the potential risk associated with the prevalence of these isolates. IMPORTANCE Azole resistance in the human fungal pathogen Aspergillus fumigatus presents a global public health challenge. Understanding the epidemic trends and evolutionary patterns of azole resistance is critical to prevent and control the spread of azole-resistant isolates. The primary cause is the mutation of the drug target 14α-sterol-demethylase Cyp51A, yet its impact on competitive ability remains uncertain. Our competition assays revealed a diverse range of fitness outcomes for environmental and clinical cyp51A-mutated isolates. We have shown that this fitness cost is not reliant on cyp51A mutations but might be linked to unknown mutations induced by stress conditions. Among these isolates, the majority displayed fitness costs, while a few displayed enhanced competitive ability, which may have a potential risk of spread and the need to closely monitor these isolates. Our observation reveals the variation in fitness costs among azole-resistant isolates of A. fumigatus, highlighting the significant role of fitness cost in the spread of resistant strains.
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Affiliation(s)
- Shu Chen
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Guoxing Zhu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Huiping Lin
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Guo
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shuwen Deng
- The People’s Hospital of SND (Suzhou New District), Suzhou, China
| | - Wenjuan Wu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Ling Lu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Yuanwei Zhang
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
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12
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Kang Y, Li Q, Yao Y, Xu C, Qiu Z, Jia W, Li G, Wang P. Epidemiology and Azole Resistance of Clinical Isolates of Aspergillus fumigatus from a Large Tertiary Hospital in Ningxia, China. Infect Drug Resist 2024; 17:427-439. [PMID: 38328338 PMCID: PMC10849152 DOI: 10.2147/idr.s440363] [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: 10/06/2023] [Accepted: 01/18/2024] [Indexed: 02/09/2024] Open
Abstract
Purpose The objective of this study was to determine the clinical distribution, in vitro antifungal susceptibility and underlying resistance mechanisms of Aspergillus fumigatus (A. fumigatus) isolates from the General Hospital of Ningxia Medical University between November 2021 and May 2023. Methods Antifungal susceptibility testing was performed using the Sensititre YeastOne YO10, and isolates with high minimal inhibitory concentrations (MICs) were further confirmed using the standard broth microdilution assays established by the Clinical and Laboratory Standards Institute (CLSI) M38-third edition. Whole-Genome Resequencing and RT-qPCR in azole-resistant A. fumigatus strains were performed to investigate the underlying resistance mechanisms. Results Overall, a total of 276 A. fumigatus isolates were identified from various clinical departments, showing an increasing trend in the number of isolates over the past 3 years. Two azole-resistant A. fumigatus strains (0.72%) were observed, one of which showed overexpression of cyp51A, cyp51B, cdr1B, MDR1/2, artR, srbA, erg24A, and erg4B, but no cyp51A mutation. However, the other strain harbored two alterations in the cyp51A sequences (L98H/S297T). Therefore, we first described two azole-resistant clinical A. fumigatus strains in Ningxia, China, and reported one azole-resistant strain that has the L98H/S297T mutations in the cyp51A gene without any tandem repeat (TR) sequences in the promoter region. Conclusions This study emphasizes the importance of enhancing attention and surveillance of azole-resistant A. fumigatus, particularly those with non-TR point mutations of cyp51A or non-cyp51A mutations, in order to gain a better understanding of their prevalence and spread in the region.
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Affiliation(s)
- Yuting Kang
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Qiujie Li
- College of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Yao Yao
- Center of Medical Laboratory, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Chao Xu
- College of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Zhuoran Qiu
- College of Clinical Medicine, Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Wei Jia
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
- Center of Medical Laboratory, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Gang Li
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
- Center of Medical Laboratory, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
| | - Pengtao Wang
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, People’s Republic of China
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13
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Verweij PE, Song Y, Buil JB, Zhang J, Melchers WJG. Antifungal Resistance in Pulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:32-40. [PMID: 38196063 DOI: 10.1055/s-0043-1776997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Aspergilli may cause various pulmonary diseases in humans, including allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA), and acute invasive pulmonary aspergillosis (IPA). In addition, chronic colonization may occur in cystic fibrosis (CF). Aspergillus fumigatus represents the main pathogen, which may employ different morphotypes, for example, conidia, hyphal growth, and asexual sporulation, in the various Aspergillus diseases. These morphotypes determine the ease by which A. fumigatus can adapt to stress by antifungal drug exposure, usually resulting in one or more resistance mutations. Key factors that enable the emergence of resistance include genetic variation and selection. The ability to create genetic variation depends on the reproduction mode, including, sexual, parasexual, and asexual, and the population size. These reproduction cycles may take place in the host and/or in the environment, usually when specific conditions are present. Environmental resistance is commonly characterized by tandem repeat (TR)-mediated mutations, while in-host resistance selection results in single-resistance mutations. Reported cases from the literature indicate that environmental resistance mutations are almost exclusively present in patients with IA indicating that the risk for in-host resistance selection is very low. In aspergilloma, single-point mutations are the dominant resistance genotype, while in other chronic Aspergillus diseases, for example, ABPA, CPA, and CF, both TR-mediated and single-resistance mutations are reported. Insights into the pathogenesis of resistance selection in various Aspergillus diseases may help to improve diagnostic and therapeutic strategies.
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Affiliation(s)
- Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Yinggai Song
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Dermatology and Venerology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, China
- National Clinical Research Center For Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
| | - Jianhua Zhang
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
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14
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Lockhart SR, Chowdhary A, Gold JAW. The rapid emergence of antifungal-resistant human-pathogenic fungi. Nat Rev Microbiol 2023; 21:818-832. [PMID: 37648790 DOI: 10.1038/s41579-023-00960-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
During recent decades, the emergence of pathogenic fungi has posed an increasing public health threat, particularly given the limited number of antifungal drugs available to treat invasive infections. In this Review, we discuss the global emergence and spread of three emerging antifungal-resistant fungi: Candida auris, driven by global health-care transmission and possibly facilitated by climate change; azole-resistant Aspergillus fumigatus, driven by the selection facilitated by azole fungicide use in agricultural and other settings; and Trichophyton indotineae, driven by the under-regulated use of over-the-counter high-potency corticosteroid-containing antifungal creams. The diversity of the fungi themselves and the drivers of their emergence make it clear that we cannot predict what might emerge next. Therefore, vigilance is critical to monitoring fungal emergence, as well as the rise in overall antifungal resistance.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Medical Mycology Unit, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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15
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Schürch S, Gindro K, Schnee S, Dubuis PH, Codina JM, Wilhelm M, Riat A, Lamoth F, Sanglard D. Occurrence of Aspergillus fumigatus azole resistance in soils from Switzerland. Med Mycol 2023; 61:myad110. [PMID: 37930839 PMCID: PMC10653585 DOI: 10.1093/mmy/myad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
Aspergillus fumigatus is a fungal species causing diverse diseases in humans. The use of azoles for treatments of A. fumigatus diseases has resulted in azole resistance. Azoles are also widely used in the environment for crop protection, which resulted in azole resistance. Resistance is primarily due to mutations in cyp51A, which encodes the target protein for azoles. Here we addressed the occurrence of azole resistance in soils from a vast part of Switzerland. We aimed to associate the use of azoles in the environment with the occurrence of azole resistance. We targeted sample sites from different agricultural environments as well as sites with no agricultural practice (natural sites and urban sites). Starting from 327 sites, 113 A. fumigatus isolates were recovered (2019-2021), among which 19 were azole-resistant (15 with TR34/L98H and four with TR46/Y121F/T289A resistance mutations in cyp51A). Our results show that azole resistance was not associated with a specific agricultural practice. Azoles could be chemically detected in investigated soils, however, their presence was not associated with the occurrence of azole-resistant isolates. Interestingly, genetic markers of resistance to other fungicides were detected but only in azole-resistant isolates, thus reinforcing the notion that A. fumigatus cross-resistance to fungicides has an environmental origin. In conclusion, this study reveals the spreading of azole resistance in A. fumigatus from the environment in Switzerland. The proximity of agricultural areas to urban centers may facilitate the transmission of resistant strains to at-risk populations. Thus, vigilant surveillance is required to maintain effective treatment options for aspergillosis.
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Affiliation(s)
- Stéphanie Schürch
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Katia Gindro
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Sylvain Schnee
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Pierre-Henri Dubuis
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Josep Massana Codina
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Matthieu Wilhelm
- Plant Protection Research Division, Mycology Group, Agroscope, 1260 Nyon, Switzerland
| | - Arnaud Riat
- Service of Infectious Diseases and Service of Laboratory Medicine, Geneva University Hospitals and Geneva University, 1205 Geneva, Switzerland
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Dominique Sanglard
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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16
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Álvarez-Pérez S, García ME, Martínez-Nevado E, Blanco JL. Presence of Aspergillus fumigatus with the TR 34/L98H Cyp51A mutation and other azole-resistant aspergilli in the air of a zoological park. Res Vet Sci 2023; 164:104993. [PMID: 37657393 DOI: 10.1016/j.rvsc.2023.104993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/03/2023] [Accepted: 08/23/2023] [Indexed: 09/03/2023]
Abstract
Antifungal-resistant fungi, including Aspergillus fumigatus and other Aspergillus species, pose an urgent threat to human and animal health. Furthermore, the environmental route of azole resistance selection due to the widespread use of azole fungicides in crop protection and other applications is a major public health issue. Although environmental surveillance of fungi is frequently performed in many zoological parks and wildlife rehabilitation centers, the antifungal susceptibility of recovered isolates is only rarely analyzed, which precludes a clear assessment of the threat posed by these fungi to captive animals. In this study, we assessed the presence of airborne azole-resistant Aspergillus spp., including the so-called 'cryptic species' (i.e., species which are phenotypically similar to more well-known aspergilli but clearly constitute different phylogenetic lineages) in a zoological park located in the city of Madrid, Spain. In general, our results revealed a low prevalence A. fumigatus and cryptic aspergilli with decreased susceptibility to azoles. However, we detected an A. fumigatus isolate with the TR34/L98H mutation in the gene encoding the lanosterol 14α-demethylase (Cyp51A), consisting of a tandem repeat of 34 base pairs in the promoter region and a lysine to histidine substitution at codon 98. Notably, this TR34/L98H mutation has been linked to the environmental route of azole resistance selection, thus highlighting the 'One Health' dimension of the emerging problem of antifungal resistance. In this context, continuous environmental surveillance of azole-resistant aspergilli in zoological parks and other similar animal facilities is recommended.
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Affiliation(s)
- Sergio Álvarez-Pérez
- Department of Animal Health, Faculty of Veterinary Medicine, Complutense University of Madrid, Avenida Puerta de Hierro s/n, Madrid 28040, Spain.
| | - Marta E García
- Department of Animal Health, Faculty of Veterinary Medicine, Complutense University of Madrid, Avenida Puerta de Hierro s/n, Madrid 28040, Spain
| | | | - José L Blanco
- Department of Animal Health, Faculty of Veterinary Medicine, Complutense University of Madrid, Avenida Puerta de Hierro s/n, Madrid 28040, Spain
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17
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Shi N, Qiu D, Chen F, Yang YQ, Du Y. Analysis of the Difenoconazole-Resistance Risk and Its Molecular Basis in Colletotrichum truncatum from Soybean. PLANT DISEASE 2023; 107:3123-3130. [PMID: 37172974 DOI: 10.1094/pdis-12-22-2983-re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Anthracnose disease, caused by Colletotrichum truncatum, is a destructive fungal disease in soybean worldwide, and some demethylation inhibitor fungicides are used to manage it. In this study, the sensitivity of C. truncatum to difenoconazole was determined, and the risk for resistance development of C. truncatum to difenoconazole was also assessed. The results showed that the mean EC50 value was 0.9313 μg/ml, and the frequency of sensitivity formed a unimodal distribution. Six stable mutants with a mutation frequency of 8.33 × 10-5 were generated, and resistance factors ranged from 3.00 to 5.81 after 10 successive culture transfers. All mutants exhibited fitness penalties in reduced mycelial growth rate, sporulation, and pathogenicity, except for the Ct2-3-5 mutant. Positive cross-resistance was observed between difenoconazole and propiconazole but not between difenoconazole and prochloraz, pyraclostrobin, or fluazinam. One point mutation I463V in CYP51A was found in five resistant mutants. Surprisingly, the homologous I463V mutation has not been observed in other plant pathogens. CYP51A and CYP51B expression increased slightly in the resistant mutants as compared to wild-types when exposed to difenoconazole but not in the CtR61-2-3f and CtR61-2-4a mutants. In general, a new point mutation, I463V in CYP51A, could be associated with low resistance to difenoconazole in C. truncatum. In the greenhouse assay, control efficacy of difenoconazole on both parental isolates and the mutants increased in a dose-dependent manner. Collectively, the resistance risk of C. truncatum to difenoconazole is regarded to be low to moderate, suggesting that difenoconazole can still be reasonably used to control soybean anthracnose.
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Affiliation(s)
- Niuniu Shi
- Institute of Plant Protection, Fujian Academy of Agricultural Sciences, Fuzhou, Fujian 350013, China
- Fujian Key Laboratory for Monitoring and Integrated Management of Crop Pests, Fuzhou, Fujian 350013, China
| | - Dezhu Qiu
- Institute of Plant Protection, Fujian Academy of Agricultural Sciences, Fuzhou, Fujian 350013, China
| | - Furu Chen
- Institute of Plant Protection, Fujian Academy of Agricultural Sciences, Fuzhou, Fujian 350013, China
- Fujian Key Laboratory for Monitoring and Integrated Management of Crop Pests, Fuzhou, Fujian 350013, China
| | - Ying-Qing Yang
- Institute of Plant Protection, Jiangxi Academy of Agricultural Sciences, Nanchang, Jiangxi 330000, China
| | - Yixin Du
- Institute of Plant Protection, Fujian Academy of Agricultural Sciences, Fuzhou, Fujian 350013, China
- Fujian Key Laboratory for Monitoring and Integrated Management of Crop Pests, Fuzhou, Fujian 350013, China
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18
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Paul S, Stamnes MA, Moye-Rowley WS. Interactions between the transcription factors FfmA and AtrR are required to properly regulate gene expression in the fungus Aspergillus fumigatus. G3 (BETHESDA, MD.) 2023; 13:jkad173. [PMID: 37523774 PMCID: PMC10542180 DOI: 10.1093/g3journal/jkad173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
Transcriptional regulation of azole resistance in the filamentous fungus Aspergillus fumigatus is a key step in development of this problematic clinical phenotype. We and others have previously described a C2H2-containing transcription factor called FfmA that is required for normal levels of voriconazole susceptibility. Null alleles of ffmA exhibit a strongly compromised growth rate even in the absence of any external stress. Here, we employ an acutely repressible doxycycline-off form of ffmA to rapidly deplete FfmA protein from the cell. Using this approach, we carried out RNA-seq analyses to probe the transcriptome cells acutely deprived of FfmA. A total of 2,000 genes were differentially expressed upon acute depletion of FfmA, illustrating the broad transcriptomic effect of this factor. Interestingly, the transcriptome changes observed upon this acute depletion of FfmA expression only shared limited overlap with those found in an ffmAΔ null strain analyzed by others. Chromatin immunoprecipitation coupled with high throughput DNA sequencing analysis (ChIP-seq) identified 530 genes that were bound by FfmA. More than 300 of these genes were also bound by AtrR, a transcription factor important in azole drug resistance, demonstrating striking regulatory overlap with FfmA. However, while AtrR is an upstream activation protein with known specificity, our data suggest that FfmA is a chromatin-associated factor that binds DNA in a manner dependent on other factors. We provide evidence that AtrR and FfmA interact in the cell and show reciprocal expression modulation. Interaction of AtrR and FfmA is required for normal gene expression in A. fumigatus.
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Affiliation(s)
- Sanjoy Paul
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Mark A Stamnes
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - W Scott Moye-Rowley
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
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19
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Lin H, Guo J, Li Y, Xiao C, Hu L, Chen H, Lu X, Wu W. In vitro antifungal susceptibility profile and genotypic characterization of clinical Aspergillus isolates in Eastern China on behalf of Eastern China Invasive Fungi Infection Group. Med Mycol 2023; 61:myad082. [PMID: 37580143 DOI: 10.1093/mmy/myad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/27/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023] Open
Abstract
Aspergillus species is a widespread environmental mould that can cause aspergillosis. The purpose of this study was to investigate the antifungal susceptibility profile and genotypic characterization of clinical Aspergillus isolates from different provinces in Eastern China. The data included the antifungal susceptibility distributions with eight common antifungal drugs, cyp51A gene mutations of triazole-resistant Aspergillus fumigatus sensu stricto, and the genotypic relationships among the A. fumigatus sensu stricto isolates based on microsatellite typing. A. fumigatus sensu lato was the most common clinical Aspergillus species (n = 252), followed by A. flavus (n = 169), A. terreus (n = 37), A. niger (n = 29), and A. nidulans (n = 4). The modal minimum effective concentration values of micafungin and anidulafungin were lower than those of caspofungin for all Aspergillus species. The in vitro efficacy of isavuconazole was similar to that of voriconazole against most Aspergillus species. Sequencing revealed cyp51A gene mutations TR34/L98H, TR34/L98H/S297T/F495I, and TR46/Y121F/T289A in four triazole-resistant A. fumigatus sensu stricto. Phylogenetic analyses using microsatellite markers of A. fumigatus sensu stricto revealed that 211 unique genotypes clustered into two clades. The data demonstrate the diversity of clinically relevant Aspergillus species in Eastern China. Routine antifungal susceptibility testing should be performed to monitor the antifungal resistance and guide clinical therapy.
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Affiliation(s)
- Huiping Lin
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Jian Guo
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Yueting Li
- Department of Laboratory Medicine, Jiangxi provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Chenlu Xiao
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Liang Hu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Hui Chen
- Department of Laboratory Medicine, Jiangxi provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Xiuhai Lu
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, 250000, China
| | - Wenjuan Wu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
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20
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Li Y, Dai M, Lu L, Zhang Y. The C 2H 2-Type Transcription Factor ZfpA, Coordinately with CrzA, Affects Azole Susceptibility by Regulating the Multidrug Transporter Gene atrF in Aspergillus fumigatus. Microbiol Spectr 2023; 11:e0032523. [PMID: 37318356 PMCID: PMC10434176 DOI: 10.1128/spectrum.00325-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023] Open
Abstract
The incidence of invasive aspergillosis caused by Aspergillus fumigatus has risen steadily over the past few decades due to the limited effective treatment options and the emergence of antifungal-resistant isolates. In clinic-isolated A. fumigatus, the azole resistance mechanism is primarily caused by mutations of the drug target and/or overexpression of drug efflux pumps. However, knowledge about how drug efflux pumps are transcriptionally regulated is limited. In this study, we found that loss of a C2H2 transcription factor ZfpA (zinc finger protein) results in the marked upregulation of a series of drug efflux pump-encoding genes, especially atrF, which contributes to azole drug resistance in A. fumigatus. CrzA is a previously identified positive transcription factor for genes of drug efflux pumps, and ZfpA transcriptionally inhibits expressions of drug efflux pumps in a CrzA-dependent way. Under the treatment of azoles, both ZfpA and CrzA transfer to nuclei and coregulate the expression of multidrug transporters and then keep normal drug susceptibility in fungal cells. Findings in this study demonstrated that ZfpA is not only involved in fungal growth and virulence potential but also negatively regulates antifungal drug susceptibility. IMPORTANCE Conserved across all kingdoms of life, ABC transporters comprise one of the largest protein families. They are associated with multidrug resistance, affecting aspects such as resistance to antimicrobials or anticancer drugs. Despite the importance of ABC transporters in multidrug resistance, the understanding of their regulatory network is still limited in A. fumigatus. Here, we found that the loss of the transcription factor ZfpA induces the expression of the ABC transporter gene atrF, altering azole susceptibility in A. fumigatus. ZfpA, coordinately with CrzA, affects the azole susceptibility by regulating the expression of the ABC transporter gene atrF. These findings reveal the regulatory mechanism of the ABC transporter gene atrF in A. fumigatus.
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Affiliation(s)
- Yeqi Li
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Mengyao Dai
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Ling Lu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
| | - Yuanwei Zhang
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Centre for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
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21
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Shelton JMG, Rhodes J, Uzzell CB, Hemmings S, Brackin AP, Sewell TR, Alghamdi A, Dyer PS, Fraser M, Borman AM, Johnson EM, Piel FB, Singer AC, Fisher MC. Citizen science reveals landscape-scale exposures to multiazole-resistant Aspergillus fumigatus bioaerosols. SCIENCE ADVANCES 2023; 9:eadh8839. [PMID: 37478175 PMCID: PMC10361594 DOI: 10.1126/sciadv.adh8839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/20/2023] [Indexed: 07/23/2023]
Abstract
Using a citizen science approach, we identify a country-wide exposure to aerosolized spores of a human fungal pathogen, Aspergillus fumigatus, that has acquired resistance to the agricultural fungicide tebuconazole and first-line azole clinical antifungal drugs. Genomic analysis shows no distinction between resistant genotypes found in the environment and in patients, indicating that at least 40% of azole-resistant A. fumigatus infections are acquired from environmental exposures. Hotspots and coldspots of aerosolized azole-resistant spores were not stable between seasonal sampling periods. This suggests a high degree of atmospheric mixing resulting in an estimated per capita cumulative annual exposure of 21 days (±2.6). Because of the ubiquity of this measured exposure, it is imperative that we determine sources of azole-resistant A. fumigatus to reduce treatment failure in patients with aspergillosis.
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Affiliation(s)
- Jennifer M. G. Shelton
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- UK Centre for Ecology & Hydrology, Wallingford, Oxfordshire, UK
| | - Johanna Rhodes
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Christopher B. Uzzell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Samuel Hemmings
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Amelie P. Brackin
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Thomas R. Sewell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Asmaa Alghamdi
- School of Life Sciences, University of Nottingham, Nottingham, UK
- Faculty of Science, Department of Biology, Al-Baha University, Al-Baha, Saudi Arabia
| | - Paul S. Dyer
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Mark Fraser
- UK National Mycology Reference Laboratory, National Infections Service, Public Health England, Science Quarter, Southmead Hospital, Bristol, UK
| | - Andrew M. Borman
- UK National Mycology Reference Laboratory, National Infections Service, Public Health England, Science Quarter, Southmead Hospital, Bristol, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Elizabeth M. Johnson
- UK National Mycology Reference Laboratory, National Infections Service, Public Health England, Science Quarter, Southmead Hospital, Bristol, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Frédéric B. Piel
- NIHR HPRU in Environmental Exposures and Health, Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | | | - Matthew C. Fisher
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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22
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Paul S, Stamnes MA, Moye-Rowley WS. Transcription factor FfmA interacts both physically and genetically with AtrR to properly regulate gene expression in the fungus Aspergillus fumigatus. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.06.543935. [PMID: 37333080 PMCID: PMC10274792 DOI: 10.1101/2023.06.06.543935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Transcriptional regulation of azole resistance in the filamentous fungus Aspergillus fumigatus is a key step in development of this problematic clinical phenotype. We and others have previously described a C2H2-containing transcription factor called FfmA that is required for normal levels of voriconazole susceptibility and expression of an ATP-binding cassette transporter gene called abcG1 . Null alleles of ffmA exhibit a strongly compromised growth rate even in the absence of any external stress. Here we employ an acutely repressible doxycycline-off form of ffmA to rapidly deplete FfmA protein from the cell. Using this approach, we carried out RNA-seq analyses to probe the transcriptome of A. fumigatus cells that have been deprived of normal FfmA levels. We found that 2000 genes were differentially expressed upon depletion of FfmA, consistent with the wide-ranging effect of this factor on gene regulation. Chromatin immunoprecipitation coupled with high throughput DNA sequencing analysis (ChIP-seq) identified 530 genes that were bound by FfmA using two different antibodies for immunoprecipitation. More than 300 of these genes were also bound by AtrR demonstrating the striking regulatory overlap with FfmA. However, while AtrR is clearly an upstream activation protein with clear sequence specificity, our data suggest that FfmA is a chromatin-associated factor that may bind to DNA in a manner dependent on other factors. We provide evidence that AtrR and FfmA interact in the cell and can influence one another's expression. This interaction of AtrR and FfmA is required for normal azole resistance in A. fumigatus .
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Affiliation(s)
- Sanjoy Paul
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA. 52242 USA
| | - Mark A. Stamnes
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA. 52242 USA
| | - W. Scott Moye-Rowley
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA. 52242 USA
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23
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Kanaujia R, Singh S, Rudramurthy SM. Aspergillosis: an Update on Clinical Spectrum, Diagnostic Schemes, and Management. CURRENT FUNGAL INFECTION REPORTS 2023; 17:1-12. [PMID: 37360858 PMCID: PMC10157594 DOI: 10.1007/s12281-023-00461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review gives an overview of the diseases caused by Aspergillus, including a description of the species involved and the infected clinical systems. We provide insight into the various diagnostic methods available for diagnosing aspergillosis, particularly invasive aspergillosis (IA), including the role of radiology, bronchoscopy, culture, and non-culture-based microbiological methods. We also discuss the available diagnostic algorithms for the different disease conditions. This review also summarizes the main aspects of managing infections due to Aspergillus spp., such as antifungal resistance, choice of antifungals, therapeutic drug monitoring, and new antifungal alternatives. Recent Findings The risk factors for this infection continue to evolve with the development of many biological agents that target the immune system and the increase of viral illnesses such as coronavirus disease. Due to the limitations of present mycological test methods, establishing a fast diagnosis is frequently difficult, and reports of developing antifungal resistance further complicate the management of aspergillosis. Many commercial assays, like AsperGenius®, MycAssay Aspergillus®, and MycoGENIE®, have the advantage of better species-level identification and concomitant resistance-associated mutations. Fosmanogepix, ibrexafungerp, rezafungin, and olorofim are newer antifungal agents in the pipeline exhibiting remarkable activity against Aspergillus spp. Summary The fungus Aspergillus is found ubiquitously around the world and can cause various infections, from harmless saprophytic colonization to severe IA. Understanding the diagnostic criteria to be used in different patient groups and the local epidemiological data and antifungal susceptibility profile is critical for optimal patient management.
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Affiliation(s)
- Rimjhim Kanaujia
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
| | - Shreya Singh
- Department of Microbiology, Dr B R Ambedkar State Institute of Medical Sciences (AIMS), Mohali, Punjab India
| | - Shivaprakash M. Rudramurthy
- Mycology Division, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
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24
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Stewart AG, Isler B, Simos P, Farquhar D, George N, Golmayo M, Heney C. Aspergillus Species Causing Invasive Fungal Disease in Queensland, Australia. Mycopathologia 2023:10.1007/s11046-023-00713-5. [PMID: 37067664 DOI: 10.1007/s11046-023-00713-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/05/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Aspergillus species are important causes of invasive fungal disease, particularly among those with an impaired immune system. Increasing reports have revealed a rising incidence of antifungal drug resistance among Aspergillus spp., particularly among cryptic species. Understanding local antifungal susceptibility patterns is paramount to delivering optimal clinical care. METHODS Aspergillus spp. recovered from clinical specimens between 2000 and 2021 from Pathology Queensland were collected. Aspergillus spp. were identified routinely morphologically, and where there was ambiguity or a lack of sporulation, by sequencing of the internal transcribed spacer (ITS) region. All Aspergillus spp. that underwent antifungal susceptibility testing according to the CLSI M38-A3 method and were recorded and included in the study. Amphotericin B, voriconazole, posaconazole, isavuconazole, micafungin, caspofungin, and anidulafungin were tested. Pathology Queensland services all public healthcare facilities in Queensland, Australia. RESULTS 236 Aspergillus spp. were identified from clinical specimens during the study period. The most frequent species identified were Aspergillus section Fumigati (n = 119), Aspergillus section Flavi (n = 35), Aspergillus terreus (n = 32) and Aspergillus niger (n = 29). Overall, MIC50/90 values for voriconazole, posaconazole, itraconazole, and isavuconazole were 0.25/1, 0.25/0.5, 0.25/0.5, and 0.5/2 mg/L respectively. Echinocandins demonstrated low MIC values overall with micafungin and anidulafungin both having an MIC50/90 of 0.015/0.03 mg/L. A total of 15 cryptic species were identified; high triazole MIC values were observed with a voriconazole MIC50/90 of 2/8 mg/L. From 2017 to 2021 we observed an increase in incidence of isolates with high voriconazole MIC values. There was no difference in voriconazole MIC values between Aspergillus spp. acquired in North Queensland when compared to Southeast Queensland, Australia. CONCLUSION Increasing reports of antifungal resistance among Aspergillus spp. is concerning and warrants further investigation both locally and worldwide. Active surveillance of both the emergence of different Aspergillus spp. and changes in antifungal susceptibility patterns over time is crucial to informing clinicians and treatment guidelines.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia.
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Central Microbiology, Pathology Queensland, Brisbane, Australia.
| | - Burcu Isler
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Peter Simos
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Drew Farquhar
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Narelle George
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Mila Golmayo
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Claire Heney
- Central Microbiology, Pathology Queensland, Brisbane, Australia
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25
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Magoye E, Nägeli L, Bühlmann A, Hilber-Bodmer M, Keller P, Mühlethaler K, Riat A, Schrenzel J, Freimoser FM. Clinical Aureobasidium Isolates Are More Fungicide Sensitive than Many Agricultural Isolates. Microbiol Spectr 2023; 11:e0529922. [PMID: 36943135 PMCID: PMC10100788 DOI: 10.1128/spectrum.05299-22] [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: 12/27/2022] [Accepted: 02/24/2023] [Indexed: 03/23/2023] Open
Abstract
Fungicide applications in agriculture and medicine can promote the evolution of resistant, pathogenic fungi, which is a growing problem for disease management in both settings. Nonpathogenic mycobiota are also exposed to fungicides, may become tolerant, and could turn into agricultural or medical problems, for example, due to climate change or in immunocompromised individuals. However, quantitative data about fungicide sensitivity of environmental fungi is mostly lacking. Aureobasidium species are widely distributed and frequently isolated yeast-like fungi. One species, A. pullulans, is used as a biocontrol agent, but is also encountered in clinical samples, regularly. Here, we compared 16 clinical and 30 agricultural Aureobasidium isolates based on whole-genome data and by sensitivity testing with the 3 fungicides captan, cyprodinil, and difenoconazole. Our phylogenetic analyses determined that 7 of the 16 clinical isolates did not belong to the species A. pullulans. These isolates clustered with other Aureobasidium species, including A. melanogenum, a recently separated species that expresses virulence traits that are mostly lacking in A. pullulans. Interestingly, the clinical Aureobasidium isolates were significantly more fungicide sensitive than many isolates from agricultural samples, which implies selection for fungicide tolerance of non-target fungi in agricultural ecosystems. IMPORTANCE Environmental microbiota are regularly found in clinical samples and can cause disease, in particular, in immunocompromised individuals. Organisms of the genus Aureobasidium belonging to this group are highly abundant, and some species are even described as pathogens. Many A. pullulans isolates from agricultural samples are tolerant to different fungicides, and it seems inevitable that such strains will eventually appear in the clinics. Selection for fungicide tolerance would be particularly worrisome for species A. melanogenum, which is also found in the environment and exhibits virulence traits. Based on our observation and the strains tested here, clinical Aureobasidium isolates are still fungicide sensitive. We, therefore, suggest monitoring fungicide sensitivity in species, such as A. pullulans and A. melanogenum, and to consider the development of fungicide tolerance in the evaluation process of fungicides.
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Affiliation(s)
- Electine Magoye
- Agroscope, Research Division Plant Protection, Nyon, Switzerland
| | - Lukas Nägeli
- Agroscope, Research Division Plant Protection, Nyon, Switzerland
| | - Andreas Bühlmann
- Agroscope, Research Division Food Microbial Systems, Wädenswil, Switzerland
| | | | - Peter Keller
- University of Bern, Institute for Infectious Diseases, Bern, Switzerland
| | - Konrad Mühlethaler
- University of Bern, Institute for Infectious Diseases, Bern, Switzerland
| | - Arnaud Riat
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland
| | - Jacques Schrenzel
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland
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26
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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.
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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
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27
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Xu S, Shen J, Lang H, Zhang L, Fang H, Yu Y. Triazole resistance in Aspergillus fumigatus exposed to new chiral fungicide mefentrifluconazole. PEST MANAGEMENT SCIENCE 2023; 79:560-568. [PMID: 36205310 DOI: 10.1002/ps.7224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Triazole resistance in the human fungal pathogen Aspergillus fumigatus has been a growing challenge in clinic treatment with triazole drugs such as itraconazole. The fast evolvement of triazole resistance in A. fumigatus in the ecosystem has drawn great attention, and there has been a possible link between the application of triazole fungicides in agriculture and triazole resistance in A. fumigatus. The change in susceptibility of A. fumigatus exposed to the new chiral triazole fungicide mefentrifluconazole was investigated in this study. RESULTS The results indicated that triazole resistance in A. fumigatus was acquired with exposure to mefentrifluconazole at a level of greater than or equal to 2 mg L-1 in liquid medium and soil (not at 0.4 nor 1 mg L-1 ). Interestingly, stereoselectivity was found in the acquisition of triazole resistance in A. fumigatus when exposed to mefentrifluconazole. R-mefentrifluconazole, which is very active on plant pathogens, exhibited stronger possibility in the development of the resistance in A. fumigatus than its antipode. Overexpression of cyp51A, AtrF, AfuMDR1 and AfuMDR4 were associated with the acquired resistance in A. fumigatus with hereditary stability. CONCLUSION The results suggest that triazole resistance in A. fumigatus could be resulted from the selection of mefentrifluconazole at concentrations larger than 2 mg L-1 . Mefentrifluconazole should be applied within the dosage recommended by good agricultural practice to avoid the resistance in A. fumigatus in soil. This also may be applicable to other triazole fungicides. © 2022 Society of Chemical Industry.
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Affiliation(s)
- Shiji Xu
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
| | - Jiatao Shen
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
| | - Hongbin Lang
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
| | - Luqing Zhang
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
| | - Hua Fang
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
| | - Yunlong Yu
- Institute of Pesticide and Environmental Toxicology, the Key Laboratory of Molecular Biology of Crop Pathogens and Insects, the Key Laboratory of Biology of Crop Pathogens and Insects of Zhejiang Province, College of Agriculture and Biotechnology, Zhejiang University, Hangzhou, China
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28
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Alastruey-Izquierdo A, Martín-Galiano AJ. The challenges of the genome-based identification of antifungal resistance in the clinical routine. Front Microbiol 2023; 14:1134755. [PMID: 37152754 PMCID: PMC10157239 DOI: 10.3389/fmicb.2023.1134755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/05/2023] [Indexed: 05/09/2023] Open
Abstract
The increasing number of chronic and life-threatening infections caused by antimicrobial resistant fungal isolates is of critical concern. Low DNA sequencing cost may facilitate the identification of the genomic profile leading to resistance, the resistome, to rationally optimize the design of antifungal therapies. However, compared to bacteria, initiatives for resistome detection in eukaryotic pathogens are underdeveloped. Firstly, reported mutations in antifungal targets leading to reduced susceptibility must be extensively collected from the literature to generate comprehensive databases. This information should be complemented with specific laboratory screenings to detect the highest number possible of relevant genetic changes in primary targets and associations between resistance and other genomic markers. Strikingly, some drug resistant strains experience high-level genetic changes such as ploidy variation as much as duplications and reorganizations of specific chromosomes. Such variations involve allelic dominance, gene dosage increments and target expression regime effects that should be explicitly parameterized in antifungal resistome prediction algorithms. Clinical data indicate that predictors need to consider the precise pathogen species and drug levels of detail, instead of just genus and drug class. The concomitant needs for mutation accuracy and assembly quality assurance suggest hybrid sequencing approaches involving third-generation methods will be utilized. Moreover, fatal fast infections, like fungemia and meningitis, will further require both sequencing and analysis facilities are available in-house. Altogether, the complex nature of antifungal resistance demands extensive sequencing, data acquisition and processing, bioinformatic analysis pipelines, and standard protocols to be accomplished prior to genome-based protocols are applied in the clinical setting.
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Affiliation(s)
- Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC-CB21/13/00105), Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Ana Alastruey-Izquierdo,
| | - Antonio J. Martín-Galiano
- Core Scientific and Technical Units, Instituto de Salud Carlos III, Madrid, Spain
- Antonio J. Martín-Galiano,
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29
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Zhai P, Ma Y, Du W, Lu L. The metal chaperone protein MtmA plays important roles in antifungal drug susceptibility in Aspergillus fumigatus. Front Microbiol 2022; 13:1062282. [DOI: 10.3389/fmicb.2022.1062282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/21/2022] [Indexed: 12/04/2022] Open
Abstract
Drug-resistant fungal infections are emerging as an important clinical problem. In general, antifungal resistance results from increased target expression or mutations within the target protein sequence. However, the molecular mechanisms of non-drug target mutations of antifungal resistance in fungal pathogens remain to be explored. Previous studies indicated that the metal chaperone protein Mtm1 is required for mitochondrial Sod2 activation and responses to oxidative stress in yeast and in the fungal pathogen Aspergillus fumigatus, but there is no report of MtmA-related antifungal resistance. In this study, we found that repressed expression of MtmA (only 10% expression) using a conditional promoter resulted in significantly enhanced itraconazole resistance, which was not the result of highly expressed drug targets Erg11A and Erg11B. Furthermore, we demonstrated that repressed expression of MtmA results in upregulation of a series of multidrug resistance-associated transport genes, which may cause multidrug resistance. Further mechanistic studies revealed that inhibition of MtmA expression led to abnormal activation of the calcium signaling system and prompted persistent nucleation of the calcium signaling transcription factor CrzA. Our findings suggest that the metal chaperone protein MtmA is able to negatively regulate fungal resistance via affecting calcium signaling pathway.
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30
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Celia-Sanchez BN, Mangum B, Brewer M, Momany M. Analysis of Cyp51 protein sequences shows 4 major Cyp51 gene family groups across fungi. G3 (BETHESDA, MD.) 2022; 12:jkac249. [PMID: 36130263 PMCID: PMC9635630 DOI: 10.1093/g3journal/jkac249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/07/2022] [Indexed: 06/15/2023]
Abstract
Azole drugs target fungal sterol biosynthesis and are used to treat millions of human fungal infections each year. Resistance to azole drugs has emerged in multiple fungal pathogens including Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum, and Aspergillus fumigatus. The most well-studied resistance mechanism in A. fumigatus arises from missense mutations in the coding sequence combined with a tandem repeat in the promoter of cyp51A, which encodes a cytochrome P450 enzyme in the fungal sterol biosynthesis pathway. Filamentous members of Ascomycota such as A. fumigatus have either 1 or 2 of 3 Cyp51 paralogs (Cyp51A, Cyp51B, and Cyp51C). Most previous research in A. fumigatus has focused on Cyp51A due to its role in azole resistance. We used the A. fumigatus Cyp51A protein sequence as the query in database searches to identify Cyp51 proteins across fungi. We found 435 Cyp51 proteins in 295 species spanning from early-diverging fungi (Blastocladiomycota, Chytridiomycota, Zoopagomycota, and Mucormycota) to late-diverging fungi (Ascomycota and Basidiomycota). We found these sequences formed 4 major Cyp51 groups: Cyp51, Cyp51A, Cyp51B, and Cyp51C. Surprisingly, we found all filamentous Ascomycota had a Cyp51B paralog, while only 50% had a Cyp51A paralog. We created maximum likelihood trees to investigate the evolution of Cyp51 in fungi. Our results suggest Cyp51 is present in all fungi with 3 paralogs emerging in Pezizomycotina, including Cyp51C which appears to have diverged from the progenitor of the Cyp51A and Cyp51B groups.
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Affiliation(s)
| | - Brandon Mangum
- Department of Plant Biology, University of Georgia, Athens, GA 30606, USA
| | - Marin Brewer
- Department of Plant Pathology, University of Georgia, Athens, GA 30606, USA
| | - Michelle Momany
- Department of Plant Biology, University of Georgia, Athens, GA 30606, USA
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Gow NAR, Johnson C, Berman J, Coste AT, Cuomo CA, Perlin DS, Bicanic T, Harrison TS, Wiederhold N, Bromley M, Chiller T, Edgar K. The importance of antimicrobial resistance in medical mycology. Nat Commun 2022; 13:5352. [PMID: 36097014 PMCID: PMC9466305 DOI: 10.1038/s41467-022-32249-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/22/2022] [Indexed: 01/08/2023] Open
Abstract
Prior to the SARS-CoV-2 pandemic, antibiotic resistance was listed as the major global health care priority. Some analyses, including the O'Neill report, have predicted that deaths due to drug-resistant bacterial infections may eclipse the total number of cancer deaths by 2050. Although fungal infections remain in the shadow of public awareness, total attributable annual deaths are similar to, or exceeds, global mortalities due to malaria, tuberculosis or HIV. The impact of fungal infections has been exacerbated by the steady rise of antifungal drug resistant strains and species which reflects the widespread use of antifungals for prophylaxis and therapy, and in the case of azole resistance in Aspergillus, has been linked to the widespread agricultural use of antifungals. This review, based on a workshop hosted by the Medical Research Council and the University of Exeter, illuminates the problem of antifungal resistance and suggests how this growing threat might be mitigated.
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Affiliation(s)
- Neil A R Gow
- MRC Centre for Medical Mycology, School of Biosciences, University of Exeter, Geoffrey Pope Building, Exeter, EX4 4QD, UK.
| | - Carolyn Johnson
- Medical Research Council, Polaris House, Swindon, SN2 1FL, UK.
| | - Judith Berman
- Shmunis School of Biomedical and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, 418 Britannia Building, Ramat Aviv, 69978, Israel
| | - Alix T Coste
- Microbiology Institute, University Hospital Lausanne, rue du Bugnon 48, 1011, Lausanne, Switzerland
| | - Christina A Cuomo
- (CAC) Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - David S Perlin
- Center for Discovery and Innovation, Hackensack Meridian health, Nutley, NJ, 07110, USA
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, SW17 0RE, UK
- Clinical Academic Group in Infection, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Thomas S Harrison
- MRC Centre for Medical Mycology, School of Biosciences, University of Exeter, Geoffrey Pope Building, Exeter, EX4 4QD, UK
- Institute of Infection and Immunity, St George's University of London, London, SW17 0RE, UK
- Clinical Academic Group in Infection, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Nathan Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Mike Bromley
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, CTF Building, 46 Grafton Street, Manchester, M13 9NT, UK
| | - Tom Chiller
- Center for Disease Control and Prevention Mycotic Disease Branch 1600 Clifton Rd, MSC-09, Atlanta, 30333, GA, USA
| | - Keegan Edgar
- Center for Disease Control and Prevention Mycotic Disease Branch 1600 Clifton Rd, MSC-09, Atlanta, 30333, GA, USA
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Frenkel M, Serhan H, Blum SE, Fleker M, Sionov E, Amit S, Gazit Z, Gefen-Halevi S, Segal E. What Is Hiding in the Israeli Mediterranean Seawater and Beach Sand. J Fungi (Basel) 2022; 8:jof8090950. [PMID: 36135675 PMCID: PMC9505208 DOI: 10.3390/jof8090950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: In the present study, we aimed to investigate the presence of fungi that may affect human health in sand and water on Israeli Mediterranean Sea coast beaches. Methods: The study included screening of the sand and water of six urban beaches from north to south on the Israeli Mediterranean coast. Sand samples were extracted with water, and the water wash was cultured and quantitated. Water samples were quantitated as well. MALDI-TOF MS analysis and ITS sequencing identified the fungi. Results: The study considered several parameters: 1. Presence of fecal-contamination-related fungi; 2. Presence of dermal-infection-related fungi. 3. Presence of allergy-related fungi; 4. Presence of fungi posing risk for immunocompromised individuals. The screen revealed that about 80% of the isolates were molds and about 20% yeasts. The mold species included opportunistic pathogens and potential allergens: Aspergillus fumigatus and other Aspergillus species, Fusarium, Penicillium, and Mucorales species. Yeast isolates included Candida—including the human commensals Candida albicans and Candida tropicalis—Cryptococcus, and Rhodotorula species. Conclusions: The results suggest that beaches should be monitored for fungi for safer use, better management, and the benefit of public health.
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Affiliation(s)
- Michael Frenkel
- Department of Clinical Microbiology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 562000, Israel
| | - Hanan Serhan
- Department of Clinical Microbiology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 562000, Israel
| | - Shlomo E. Blum
- Department of Clinical Bacteriology and Mycology, The Kimron Veterinary Institute, Bet Dagan 50200, Israel
| | - Marcelo Fleker
- Department of Clinical Bacteriology and Mycology, The Kimron Veterinary Institute, Bet Dagan 50200, Israel
| | - Edward Sionov
- Institute for Post Harwest and Food Sciences, Agricultural Research Organization, The Volcani Center, Rishon LeZion 7528809, Israel
| | - Sharon Amit
- Microbiology Laboratory, Sheba Medical Center, Tel Hashomer 5262000, Israel
| | - Zeela Gazit
- Microbiology Laboratory, Sheba Medical Center, Tel Hashomer 5262000, Israel
| | | | - Esther Segal
- Department of Clinical Microbiology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 562000, Israel
- Correspondence:
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Blass BE, Puri S, Sharma R, Day BM. Antifungal properties of (2S, 4R)-Ketoconazole sulfonamide analogs. FRONTIERS IN DRUG DISCOVERY 2022; 2:1000827. [PMID: 37214226 PMCID: PMC10198183 DOI: 10.3389/fddsv.2022.1000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Invasive candidiasis remains a significant health concern, as it is associated with a high mortality risk. In addition, the risk of infection is significantly elevated in immunocompromised patients such as those with HIV, cancer, or those taking imcmunosuppressive drugs as a result of organ transplantation. The majority of these cases are caused by C. albicans, and C. glabrata is the second most common cause. These infections are typically treated using approved antifungal agents, but the rise of drug-resistant fungi is a serious concern. As part of our on-going effort to identify novel antifungal agents, we have studied the in vitro antifungal properties of a series of sulfonamide analogs of (2S, 4R)-Ketoconazole. Herein we report on the in vitro activity against the key fungal pathogens C. albicans, and C. glabrata.
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Affiliation(s)
- Benjamin E. Blass
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, United States
| | - Sumant Puri
- Oral Microbiome Research Laboratory, Kornberg School of Dentistry, Temple University, Philadelphia, PA, United Stated
| | - Rishabh Sharma
- Oral Microbiome Research Laboratory, Kornberg School of Dentistry, Temple University, Philadelphia, PA, United Stated
| | - Brian M. Day
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, United States
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Novel Treatment Approach for Aspergilloses by Targeting Germination. J Fungi (Basel) 2022; 8:jof8080758. [PMID: 35893126 PMCID: PMC9331470 DOI: 10.3390/jof8080758] [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] [Received: 06/09/2022] [Revised: 07/03/2022] [Accepted: 07/19/2022] [Indexed: 12/24/2022] Open
Abstract
Germination of conidia is an essential process within the Aspergillus life cycle and plays a major role during the infection of hosts. Conidia are able to avoid detection by the majority of leukocytes when dormant. Germination can cause severe health problems, specifically in immunocompromised people. Aspergillosis is most often caused by Aspergillus fumigatus (A. fumigatus) and affects neutropenic patients, as well as people with cystic fibrosis (CF). These patients are often unable to effectively detect and clear the conidia or hyphae and can develop chronic non-invasive and/or invasive infections or allergic inflammatory responses. Current treatments with (tri)azoles can be very effective to combat a variety of fungal infections. However, resistance against current azoles has emerged and has been increasing since 1998. As a consequence, patients infected with resistant A. fumigatus have a reported mortality rate of 88% to 100%. Especially with the growing number of patients that harbor azole-resistant Aspergilli, novel antifungals could provide an alternative. Aspergilloses differ in defining characteristics, but germination of conidia is one of the few common denominators. By specifically targeting conidial germination with novel antifungals, early intervention might be possible. In this review, we propose several morphotypes to disrupt conidial germination, as well as potential targets. Hopefully, new antifungals against such targets could contribute to disturbing the ability of Aspergilli to germinate and grow, resulting in a decreased fungal burden on patients.
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Badiee P, Boekhout T, Zarei Mahmoudabadi A, Mohammadi R, Ayatollahi Mousavi SA, Najafzadeh MJ, Soltani J, Hashemi J, Diba K, Ghadimi-Moghadam A, Salimi-Khorashad AR, Shokohi T, Amin Shahidi M, Ghasemi F, Jafarian H. Multicenter Study of Susceptibility of Aspergillus Species Isolated from Iranian University Hospitals to Seven Antifungal Agents. Microbiol Spectr 2022; 10:e0253921. [PMID: 35579442 PMCID: PMC9241793 DOI: 10.1128/spectrum.02539-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/17/2022] [Indexed: 12/24/2022] Open
Abstract
Aspergillus species are a major cause of life-threatening invasive infections and noninvasive diseases. This study seeks to investigate the frequency of Aspergillus species among Iranian patients and their susceptibility to seven antifungals. In a cross-sectional study, 233 Aspergillus isolates were collected from 11 university hospitals in Iran between 2018 and 2021. Aspergillus isolates were identified based on colony morphology, microscopic characteristics, PCR-restriction fragment length polymorphism (RFLP), and sequencing of the beta-tubulin gene. The CLSI M38-A2 reference methodology was used for antifungal susceptibility testing of amphotericin B, voriconazole, posaconazole, itraconazole, luliconazole, isavuconazole, and caspofungin. Members of Aspergillus section Flavi (117/233, 50.2%), Aspergillus section Nigri (77/233, 33.1%), Aspergillus section Fumigati (21/233, 9%), Aspergillus section Terrei (14/233, 6%), Aspergillus pseudodeflectus (2/233, 0.85%), and Aspergillus melleus (2/233, 0.85%) were isolated from the samples. The lowest 0.25 MIC90 values for all isolates tested were for luliconazole (0.016 μg/mL) and isavuconazole (0.250 μg/mL), and the highest value was observed for itraconazole (≥ 8μg/mL). The 90% minimum effective concentration (MEC90) value for caspofungin was 0.125 μg/mL. MIC90 values for voriconazole, amphotericin B, and posaconazole were 1, 2, and 2 μg/mL, respectively. The non-wild-type species were presented for amphotericin B (3%), voriconazole (1.3%), posaconazole (2.6%), luliconazole (1.3%), isavuconazole (1.7%), and caspofungin (4.7%). Positive correlations in the MIC values of azole antifungals were observed, and using one azole increases the MIC value rates of other ones. None of the species were pan-azole resistant. Species of Aspergillus section Flavi were the most common Aspergillus species isolated from Iranian samples. Luliconazole, caspofungin, and isavuconazole present the most effective antifungal agents for treatment of infection due to Aspergillus species. Susceptibility tests should be performed frequently in each region for the best management of patients. IMPORTANCE Aspergillus species are the leading cause of invasive aspergillosis in immunocompromised hosts. The susceptibility of Aspergillus species to antifungal agents might be different. Azole-resistant species have emerged worldwide. Performing susceptibility testing in each region can help in the best management of patients. Here, we show the epidemiology and distribution of Aspergillus species in Iran and their susceptibility patterns for seven antifungal agents. The significant points of the present study are that species of Aspergillus section Flavi are the most prevalent Aspergillus species isolated from 11 university hospitals. Luliconazole, caspofungin, and isavuconazole were effective antifungal agents against all Aspergillus species.
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Affiliation(s)
- Parisa Badiee
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Teun Boekhout
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
- Institute for Biodiversity and Ecosystem Dynamics, IBED, University of Amsterdam, Amsterdam, The Netherlands
| | - Ali Zarei Mahmoudabadi
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology, School of Medicine, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyyed Amin Ayatollahi Mousavi
- Department of Medical Parasitology and Mycology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Javad Najafzadeh
- Department of Medical Parasitology and Mycology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jafar Soltani
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Jamal Hashemi
- Medical Mycology Department, School of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Kambiz Diba
- Cellular and Molecular Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Abdolkarim Ghadimi-Moghadam
- Department of Pediatrics Infectious Disease, Emmam Sajjad Hospital, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Ali Reza Salimi-Khorashad
- Department of Parasitology and Mycology, School of Medicine, Infectious Diseases and Tropical Medicine Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Tahereh Shokohi
- Department of Medical Mycology, School of Medicine, Invasive Fungi Research Centre (IFRC), Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maneli Amin Shahidi
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Ghasemi
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadis Jafarian
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Differential Functions of Individual Transcription Factor Binding Sites in the Tandem Repeats Found in Clinically Relevant cyp51A Promoters in Aspergillus fumigatus. mBio 2022; 13:e0070222. [PMID: 35467427 PMCID: PMC9239056 DOI: 10.1128/mbio.00702-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Aspergillus fumigatus is the major filamentous fungal pathogen in humans. The gold standard treatment of A. fumigatus is based on azole drug use, but the appearance of azole-resistant isolates is increasing at an alarming rate. The cyp51A gene encodes the enzymatic target of azole drugs, and azole-resistant alleles of cyp51A often have an unusual genetic structure containing a duplication of a 34- or 46-bp region in the promoter causing enhanced gene transcription. These tandem repeats are called TR34 and TR46 and produce duplicated binding sites for the SrbA and AtrR transcription factors. Using site-directed mutagenesis, we demonstrate that both the SrbA (sterol response element [SRE]) and AtrR binding sites (AtrR response element [ATRE]) are required for normal cyp51A gene expression. Loss of either the SRE or ATRE from the distal 34-bp repeat of the TR34 promoter (further 5′ from the transcription start site) caused loss of expression of cyp51A and decreased voriconazole resistance. Surprisingly, loss of these same binding sites from the proximal 34- or 46-bp repeat led to increased cyp51A expression and voriconazole resistance. These data indicate that these duplicated regions in the cyp51A promoter function differently. Our findings suggest that the proximal 34- or 46-bp repeat in cyp51A recruits a corepressor that requires multiple factors to act while the distal repeat is free of this repression and provides the elevated cyp51A expression caused by these promoter duplications.
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Cateau E, Leclerc A, Cartier N, Valsechi I, Bailly É, Senechal RL, Becerra M, Gallou BL, Lavergne RA, Chesnay A, Robin JP, Cray C, Goddard N, Thorel M, Guillot J, Mulot B, Desoubeaux G. pAspergillosis in a colony of Humboldt penguins (Spheniscus humboldti) under managed care: a clinical and environmental investigation in a French zoological park. Med Mycol 2022; 60:6609783. [PMID: 35713494 DOI: 10.1093/mmy/myac046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/27/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Aspergillosis is pervasive in bird populations, especially those under human care. Its management can be critically impacted by exposure to high levels of conidia and by resistance to azole drugs. The fungal contamination in the environment of a Humboldt penguin (Spheniscus humboldti) group, housed in a French zoological park next to numerous large crop fields, was assessed through three serial sessions of surface sampling in nests, in 2018-20: all isolates were counted and characterized by sequencing. When identified as A. fumigatus, they were systematically screened for resistance mutations in the cyp51A gene and tested for MICs determination. In the same time, the clinical incidence of aspergillosis was evaluated in the penguin population by the means of systematic necropsy and mycological investigations. A microsatellite-based analysis tracked the circulation of A. fumigatus strains. Environmental investigations highlighted substantial increase of the fungal load during the summer season (>12-fold vs. the other timepoints) and large overrepresentation of species belonging to the Aspergillus section Fumigati, ranging from 22.7 to 94.6% relative prevalence. Only one cryptic species was detected (A. nishimurae), and one isolate exhibited G138S resistance mutation with elevated MICs. The overall incidence of aspergillosis was measured at ∼3.4% case-years, and mostly in juveniles. The analysis of microsatellite polymorphism revealed a high level of genetic diversity among A. fumigatus clinical isolates. In contrast, one environmental strain appeared largely overrepresented during the summer sampling session. In all, the rural location of the zoo did not influence the emergence of resistant strains.
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Affiliation(s)
- Estelle Cateau
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France.,Parasitologie - Mycologie, Hôpital de la Milétrie, 86021 CHU Poitiers, France
| | - Antoine Leclerc
- ZooParc de Beauval & Beauval Nature, 41110 Saint-Aignan-sur-Cher, France
| | - Noémie Cartier
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France
| | - Isabel Valsechi
- Dynamyc - Université Paris-Est Créteil-Val de Marne (UPEC), Ecole nationale vétérinaire d'Alfort (EnvA), USC Anses, 94000 Créteil, France
| | - Éric Bailly
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France
| | - Ronan Le Senechal
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France
| | - Margaux Becerra
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France
| | - Brice Le Gallou
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France
| | - Rose-Anne Lavergne
- Parasitologie - Mycologie, Hôtel Dieu, 44093 CHU Nantes, France.,Institute de Recherche en Santé 2, EA1155-IICiMed, 44200 Université de Nantes Atlantique, France
| | - Adélaïde Chesnay
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France.,Centre d'Etude des Pathologies Respiratoires - Inserm U100, Faculté de médecine, 37032 Université de Tours, France
| | - Jean-Patrice Robin
- Institut pluridisciplinaire Hubert Curien, CNRS - UMR 7178, 67037 Université de Strasbourg, France
| | - Carolyn Cray
- Miami University, Comparative pathology, Miller school of medicien, 33136 Miami - Florida, U.S.A
| | - Nicolas Goddard
- ZooParc de Beauval & Beauval Nature, 41110 Saint-Aignan-sur-Cher, France
| | - Milan Thorel
- ZooParc de Beauval & Beauval Nature, 41110 Saint-Aignan-sur-Cher, France
| | - Jacques Guillot
- Dynamyc - Université Paris-Est Créteil-Val de Marne (UPEC), Ecole nationale vétérinaire d'Alfort (EnvA), USC Anses, 94000 Créteil, France.,Oniris, Ecole nationale vétérinaire de Nantes, 44307 Nantes, France
| | - Baptiste Mulot
- ZooParc de Beauval & Beauval Nature, 41110 Saint-Aignan-sur-Cher, France
| | - Guillaume Desoubeaux
- Parasitologie - Mycologie - Médecine tropicale, Hôpital Bretonneau, 37044 CHRU Tours, France.,Centre d'Etude des Pathologies Respiratoires - Inserm U100, Faculté de médecine, 37032 Université de Tours, France
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Viegas C, Almeida B, Aranha Caetano L, Afanou A, Straumfors A, Veríssimo C, Gonçalves P, Sabino R. Algorithm to assess the presence of Aspergillus fumigatus resistant strains: The case of Norwegian sawmills. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2022; 32:963-971. [PMID: 32814444 DOI: 10.1080/09603123.2020.1810210] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 08/11/2020] [Indexed: 05/24/2023]
Abstract
Association between selection pressure caused by the use of azole fungicides in sawmills and the development of fungal resistance has been described. The aim of this study was to implement an algorithm to assess the presence of Aspergillus section Fumigati resistant strains in sawmills.Eighty-six full-shift inhalable dust samples were collected from eleven industrial sawmills in Norway. Different culture media were used and molecular identification to species level in Aspergillus section Fumigati was done by calmodulin sequencing and TR34/L98H and TR46/Y121F/T289A mutations were screened by real-time PCR assay and confirmed by cyp51A sequencing. Six Fumigati isolates were identified as A. fumigatus sensu stricto and two of these grew on azole-supplemented media and were further analyzed by real-time PCR. One was confirmed to be a TR34/L98H mutant.The obtained results reinforce the need to assess the presence of A. fumigatus sensu stricto resistant isolates at other workplaces with fungicide pressure.
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Affiliation(s)
- Carla Viegas
- ESTeSL- Escola Superior De Tecnologia Da Saúde, Instituto Politécnico De Lisboa, Lisbon, Portugal
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA De Lisboa Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), Lisbon, Portugal
| | - Beatriz Almeida
- ESTeSL- Escola Superior De Tecnologia Da Saúde, Instituto Politécnico De Lisboa, Lisbon, Portugal
| | - Liliana Aranha Caetano
- ESTeSL- Escola Superior De Tecnologia Da Saúde, Instituto Politécnico De Lisboa, Lisbon, Portugal
- Research Institute for Medicines (Imed.ulisboa), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Anani Afanou
- Department of Chemical and Biological Work Environment, National Institute of Occupational Health (STAMI), Oslo, Norway
| | - Anne Straumfors
- Department of Chemical and Biological Work Environment, National Institute of Occupational Health (STAMI), Oslo, Norway
| | - Cristina Veríssimo
- Reference Unit for Parasitic and Fungal Infections, Infectious Diseases Department, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Paulo Gonçalves
- Reference Unit for Parasitic and Fungal Infections, Infectious Diseases Department, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
- European Centre for Disease Prevention and Control, European Programme for Public Health Microbiology Training (EUPHEM), Stockholm, Sweden
| | - Raquel Sabino
- Reference Unit for Parasitic and Fungal Infections, Infectious Diseases Department, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
- Faculdade De Medicina Da, Instituto De Saúde Ambiental, Universidade De Lisboa, Lisbon, Portugal
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Aspergillus fumigatus ffmA Encodes a C 2H 2-Containing Transcriptional Regulator That Modulates Azole Resistance and Is Required for Normal Growth. mSphere 2022; 7:e0093821. [PMID: 35138125 PMCID: PMC8826999 DOI: 10.1128/msphere.00938-21] [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: 11/20/2022] Open
Abstract
The production of a collection of deletion mutant strains corresponding to a large number of transcription factors from the filamentous fungal pathogen Aspergillus fumigatus has permitted rapid identification of transcriptional regulators involved in a range of different processes. Here, we characterize a gene designated ffmA (favors fermentative metabolism) as a C2H2-containing transcription factor that is required for azole drug resistance and normal growth. Loss of ffmA caused cells to exhibit significant defects in growth, either under untreated or azole-challenged conditions. Loss of FfmA caused a reduction in expression of the AbcG1 ATP-binding cassette transporter, previously shown to contribute to azole resistance. Strikingly, overproduction of the AtrR transcription factor gene restored a wild-type growth phenotype to an ffmAΔ strain. Overexpression of AtrR also suppressed the defect in AbcG1 expression caused by loss of FfmA. Replacement of the ffmA promoter with a doxycycline-repressible promoter restored nearly normal growth in the absence of doxycycline. Finally, chromatin immunoprecipitation experiments indicated that FfmA bound to its own promoter as well as to the abcG1 promoter. These data imply that FfmA and AtrR interact both with respect to abcG1 expression and also more broadly to regulate hyphal growth. IMPORTANCE Infections associated with azole-resistant forms of the primary human pathogen Aspergillus fumigatus are associated with poor outcomes in patient populations. This makes analysis of the mechanisms underlying azole resistance of A. fumigatus a high priority. In this work, we describe characterization of a gene designated ffmA that encodes a sequence-specific transcriptional regulator. We identified ffmA in a screen of a collection of gene deletion mutant strains made in A. fumigatus. Loss of ffmA caused sensitivity to azole drugs and also a large reduction in normal growth. We found that overproduction of the AtrR transcription factor could restore growth to ffmA null cells. We provide evidence that FfmA can recognize promoters of genes involved in azole resistance as well as the ffmA promoter itself. Our data indicate that FfmA and AtrR interact to support azole resistance and normal growth.
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40
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Selection of Aspergillus fumigatus isolates carrying the G448S substitution in CYP51A gene after long-term treatment with voriconazole in an immunocompromised patient. Med Mycol Case Rep 2022; 36:5-9. [PMID: 35242508 PMCID: PMC8881195 DOI: 10.1016/j.mmcr.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 01/08/2023] Open
Abstract
We present a case of a 55-year-old man with a heart transplant who acquired Invasive Aspergillosis by Aspergillus fumigatus with the focus in the kidney. During about two years of antifungal treatment, most of the time with voriconazole, it was possible to obtain nine isolates of A. fumigatus, with the same genotypic characteristics, but with an increase in MIC for several azoles. The two last isolates presented high MICs for Voriconazole (>8 μg/mL>). Sequencing of the CYP51A gene showed G448S amino acid substitution in the same two isolates. In long-term treatments with antifungals, it would be important to regularly evaluate the susceptibility of isolated strains, as resistance to azoles has been increasingly described around the world.
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Novel Clinical and Laboratorial Challenges in Aspergillosis. Microorganisms 2022; 10:microorganisms10020259. [PMID: 35208714 PMCID: PMC8877562 DOI: 10.3390/microorganisms10020259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/04/2023] Open
Abstract
In recent years, research in the areas of Aspergillus and aspergillosis has continued to advance rapidly, including advancements in genomics, immunological studies, clinical areas, and diagnostic areas. Recently, new risk groups for the development of aspergillosis have emerged—patients with influenza- or COVID-19-ssociated pulmonary aspergillosis. The rise and spread of antifungal resistances have also become a clinical concern in some geographic areas and have drawn the attention of clinicians due to difficulties in treating these infections. In this paper, a snapshot of these issues is presented, emphasizing these novel clinical and laboratorial challenges in the aspergillosis field and focusing on their actual relevance.
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Citizen-science surveillance of triazole-resistant Aspergillus fumigatus in UK residential garden soils. Appl Environ Microbiol 2022; 88:e0206121. [PMID: 34986003 DOI: 10.1128/aem.02061-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Compost is an ecological niche for Aspergillus fumigatus due to its role as a decomposer of organic matter and its ability to survive the high temperatures associated with the composting process. Subsequently, composting facilities are associated with high levels of A. fumigatus spores that are aerosolised from compost and cause respiratory illness in workers. In the UK, gardening is an activity enjoyed by individuals of all ages and it is likely that they are being exposed to A. fumigatus spores when handling commercial compost or compost they have produced themselves. In this study, 246 citizen scientists collected 509 soil samples from locations in their garden in the UK, from which were cultured 5,174 A. fumigatus isolates. Of these isolates, 736 (14%) were resistant to tebuconazole: the third most-sprayed triazole fungicide in the UK, which confers cross-resistance to the medical triazoles used to treat A. fumigatus lung infections in humans. These isolates were found to contain the common resistance mechanisms in the A. fumigatus cyp51A gene TR34/L98H or TR46/Y121F/T289A, and less common resistance mechanisms TR34, TR53, TR46/Y121F/T289A/S363P/I364V/G448S and (TR46)2/Y121F/M172I/T289A/G448S. Regression analyses found that soil samples containing compost were significantly more likely to grow susceptible and tebuconazole-resistant A. fumigatus than those that did not, and that compost samples grew significantly higher numbers of A. fumigatus than other samples. Importance These findings highlight compost as a potential health hazard to individuals with pre-disposing factors to A. fumigatus lung infections, and a potential health hazard to immunocompetent individuals who could be exposed to sufficiently high numbers of spores to develop infection. Furthermore, this study found that 14% of A. fumigatus isolates in garden soils were resistant to an agricultural triazole, which confers cross-resistance to medical triazoles used to treat A. fumigatus lung infections. This raises the question of whether compost bags should carry additional health warnings regarding inhalation of A. fumigatus spores, whether individuals should be advised to wear facemasks whilst handling compost or whether commercial producers should be responsible for sterilising compost before shipping. The findings support increasing public awareness of the hazard posed by compost and investigating measures that can be taken to reduce the exposure risk.
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43
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Rogers TR, Verweij PE, Castanheira M, Dannaoui E, White PL, Arendrup MC. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2053-2073. [PMID: 35703391 PMCID: PMC9333407 DOI: 10.1093/jac/dkac161] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The increasing incidence and changing epidemiology of invasive fungal infections continue to present many challenges to their effective management. The repertoire of antifungal drugs available for treatment is still limited although there are new antifungals on the horizon. Successful treatment of invasive mycoses is dependent on a mix of pathogen-, host- and antifungal drug-related factors. Laboratories need to be adept at detection of fungal pathogens in clinical samples in order to effectively guide treatment by identifying isolates with acquired drug resistance. While there are international guidelines on how to conduct in vitro antifungal susceptibility testing, these are not performed as widely as for bacterial pathogens. Furthermore, fungi generally are recovered in cultures more slowly than bacteria, and often cannot be cultured in the laboratory. Therefore, non-culture-based methods, including molecular tests, to detect fungi in clinical specimens are increasingly important in patient management and are becoming more reliable as technology improves. Molecular methods can also be used for detection of target gene mutations or other mechanisms that predict antifungal drug resistance. This review addresses acquired antifungal drug resistance in the principal human fungal pathogens and describes known resistance mechanisms and what in-house and commercial tools are available for their detection. It is emphasized that this approach should be complementary to culture-based susceptibility testing, given the range of mutations, resistance mechanisms and target genes that may be present in clinical isolates, but may not be included in current molecular assays.
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Affiliation(s)
| | | | | | | | | | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kakeya H. Medical Mycology Seen Through a One Health Approach. Med Mycol J 2022; 63:11-15. [DOI: 10.3314/mmj.22.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hiroshi Kakeya
- Department of Infection Control Science, Osaka City University Graduate School of Medicine
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45
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van de Peppel RJ, van Grootveld R, Hendriks BJC, van Paassen J, Bernards S, Jolink H, Koopmans JG, von dem Borne PA, van der Beek MT, de Boer MGJ. Implementation of a clinical decision rule for selecting empiric treatment for invasive aspergillosis in a setting with high triazole resistance. Med Mycol 2021; 60:6433628. [PMID: 34878121 PMCID: PMC8653343 DOI: 10.1093/mmy/myab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/17/2021] [Indexed: 11/14/2022] Open
Abstract
World-wide, emerging triazole resistance increasingly complicates treatment of invasive aspergillosis (IA). In settings with substantial (>10%) prevalence of triazole resistance, empiric combination therapy with both a triazole and liposomal amphotericin B (LAmB) can be considered because of the low yields of susceptibility testing. To avoid toxicity while optimizing outcome, a strategy with monotherapy would be preferable. A newly designed treatment algorithm based on literature and expert consensus provided guidance for empiric monotherapy with either voriconazole or LAmB. Over a four and a half year period, all adult patients in our hospital treated for IA were included and patient data were collected. An independent committee reviewed the attributability of death to IA for each patient. Primary outcomes were 30- and 100-day crude mortality and attributable mortality. In total, 110 patients were treated according to the treatment algorithm. Fifty-six patients (51%) were initially treated with voriconazole and 54 patients (49%) with LAmB. Combined attributable and contributable mortality was 13% within 30 days and 20% within 100 days. Treatment switch to LAmB was made in 24/56 (43%) of patients who were initially treated with voriconazole. Combined contributable and attributable 100-day mortality in this subgroup was 21% and was not increased when compared with patients initially treated with LAmB (P = 0.38). By applying a comprehensive clinical decision algorithm, an antifungal-sparing regime was successfully introduced. Further research is warranted to explore antifungal treatment strategies that account for triazole-resistance. LAY SUMMARY Due to resistance of Aspergillus against triazoles, combination therapy with liposomal amphotericin B (LAmB) is applied more often as primary therapy against invasive aspergillosis. This study presents the results of a decision tool which differentiated between triazole or LAmB monotherapy.
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Affiliation(s)
- Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Rebecca van Grootveld
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Bart J C Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Sandra Bernards
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Hetty Jolink
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Julia G Koopmans
- Department of Pulmonology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Martha T van der Beek
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
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46
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Barber AE, Sae-Ong T, Kang K, Seelbinder B, Li J, Walther G, Panagiotou G, Kurzai O. Aspergillus fumigatus pan-genome analysis identifies genetic variants associated with human infection. Nat Microbiol 2021; 6:1526-1536. [PMID: 34819642 DOI: 10.1038/s41564-021-00993-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 10/08/2021] [Indexed: 12/25/2022]
Abstract
Aspergillus fumigatus is an environmental saprobe and opportunistic human fungal pathogen. Despite an estimated annual occurrence of more than 300,000 cases of invasive disease worldwide, a comprehensive survey of the genomic diversity present in A. fumigatus-including the relationship between clinical and environmental isolates and how this genetic diversity contributes to virulence and antifungal drug resistance-has been lacking. In this study we define the pan-genome of A. fumigatus using a collection of 300 globally sampled genomes (83 clinical and 217 environmental isolates). We found that 7,563 of the 10,907 unique orthogroups (69%) are core and present in all isolates and the remaining 3,344 show presence/absence of variation, representing 16-22% of the genome of each isolate. Using this large genomic dataset of environmental and clinical samples, we found an enrichment for clinical isolates in a genetic cluster whose genomes also contain more accessory genes, including genes coding for transmembrane transporters and proteins with iron-binding activity, and genes involved in both carbohydrate and amino-acid metabolism. Finally, we leverage the power of genome-wide association studies to identify genomic variation associated with clinical isolates and triazole resistance as well as characterize genetic variation in known virulence factors. This characterization of the genomic diversity of A. fumigatus allows us to move away from a single reference genome that does not necessarily represent the species as a whole and better understand its pathogenic versatility, ultimately leading to better management of these infections.
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Affiliation(s)
- Amelia E Barber
- Research Group Fungal Septomics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany.,Junior Research Group Fungal Informatics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Tongta Sae-Ong
- Research Group Systems Biology and Bioinformatics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Kang Kang
- Research Group Systems Biology and Bioinformatics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Bastian Seelbinder
- Research Group Systems Biology and Bioinformatics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Jun Li
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China.,School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Grit Walther
- National Reference Center for Invasive Fungal Infections (NRZMyk), Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
| | - Gianni Panagiotou
- Research Group Systems Biology and Bioinformatics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany. .,Department of Medicine and State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, China.
| | - Oliver Kurzai
- Research Group Fungal Septomics, Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany. .,National Reference Center for Invasive Fungal Infections (NRZMyk), Leibniz Institute of Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany. .,Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany.
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47
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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: 40] [Impact Index Per Article: 13.3] [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.
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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
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48
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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.
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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;
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49
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Castelo-Branco D, Lockhart SR, Chen YC, Santos DA, Hagen F, Hawkins NJ, Lavergne RA, Meis JF, Le Pape P, Rocha MFG, Sidrim JJC, Arendrup M, Morio F. Collateral consequences of agricultural fungicides on pathogenic yeasts: A One Health perspective to tackle azole resistance. Mycoses 2021; 65:303-311. [PMID: 34821412 DOI: 10.1111/myc.13404] [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] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 01/07/2023]
Abstract
Candida and Cryptococcus affect millions of people yearly, being responsible for a wide array of clinical presentations, including life-threatening diseases. Interestingly, most human pathogenic yeasts are not restricted to the clinical setting, as they are also ubiquitous in the environment. Recent studies raise concern regarding the potential impact of agricultural use of azoles on resistance to medical antifungals in yeasts, as previously outlined with Aspergillus fumigatus. Thus, we undertook a narrative review of the literature and provide lines of evidence suggesting that an alternative, environmental route of azole resistance, may develop in pathogenic yeasts, in addition to patient route. However, it warrants sound evidence to support that pathogenic yeasts cross border between plants, animals and humans and that environmental reservoirs may contribute to azole resistance in Candida or other yeasts for humans. As these possibilities could concern public health, we propose a road map for future studies under the One Health perspective.
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Affiliation(s)
- Débora Castelo-Branco
- Specialized Medical Mycology Center, Group of Applied Medical Microbiology, Federal University of Ceará, Fortaleza, Brazil
| | - Shawn R Lockhart
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, Georgia, USA
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
| | | | - Rose-Anne Lavergne
- Nantes University Hospital and EA1155 IICiMed, Nantes University, Nantes, France
| | - Jacques F Meis
- Center of Expertise in Mycology, Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Bioprocess Engineering and Biotechnology Graduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Patrice Le Pape
- Nantes University Hospital and EA1155 IICiMed, Nantes University, Nantes, France
| | - Marcos Fabio Gadelha Rocha
- Specialized Medical Mycology Center, Group of Applied Medical Microbiology, Federal University of Ceará, Fortaleza, Brazil
| | - José Julio Costa Sidrim
- Specialized Medical Mycology Center, Group of Applied Medical Microbiology, Federal University of Ceará, Fortaleza, Brazil
| | - Maiken Arendrup
- Copenhagen University Hospital, and Statens Serum Institut, Copenhagen, Denmark
| | - Florent Morio
- Nantes University Hospital and EA1155 IICiMed, Nantes University, Nantes, France
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50
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Prognostic Scores and Azole-Resistant Aspergillus fumigatus in Invasive Aspergillosis from an Indian Respiratory Medicine ICU (ICU Patients with IA Suspicion). J Fungi (Basel) 2021; 7:jof7110991. [PMID: 34829278 PMCID: PMC8625311 DOI: 10.3390/jof7110991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/03/2021] [Accepted: 11/13/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To assess the effectiveness of three general prognostic models (APACHE II, SAPS II, and SOFA) with serum galactomannan antigen in a clinically suspected invasive aspergillosis (IA) subpopulation admitted to a respiratory medicine ICU and to identify azole-resistant Aspergillus fumigatus (ARAF) cases. Methodology and Results: A total of 235 clinically suspected IA patients were prospectively enrolled and observed 30-day mortality was 29.7%. The three general models showed poor discrimination assessed by area under receiver operating characteristic (ROC) curves (AUCs, <0.7) and good calibration (p = 0.92, 0.14, and 0.13 for APACHE II, SAPS II, and SOFA, respectively), evaluated using Hosmer–Lemeshow goodness-of-fit tests. However, discrimination was significantly better with galactomannan values (AUC, 0.924). In-vitro antifungal testing revealed higher minimum inhibitory concentration (MIC) for 12/34 isolates (35.3%) whereas azole resistance was noted in 40% of Aspergillus fumigatus isolates (6/15) with two hotspot cyp51A mutations, G54R and P216L. Conclusions: Patients diagnosed with putative and probable IA (71.4% and 34.6%, respectively), had high mortality. The general prognostic model APACHE II seemed fairly accurate for this subpopulation. However, the use of local GM cut-offs calculated for mortality, may help the intensivists in prompt initiation or change of therapy for better outcome of patients. In addition, the high MICs highlight the need of antifungal surveillance to know the local resistance rate which might aid in patient treatment.
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