Delivering on Antimicrobial Resistance Agenda Not Possible without Improving Fungal Diagnostic Capabilities

WHO global research priorities for antimicrobial resistance in human health

The WHO research agenda for antimicrobial resistance (AMR) in human health has identified 40 research priorities to be addressed by the year 2030. These priorities focus on bacterial and fungal pathogens of crucial importance in addressing AMR, including drug-resistant pathogens causing tuberculosis. These research priorities encompass the entire people-centred journey, covering prevention, diagnosis, and treatment of antimicrobial-resistant infections, in addition to addressing the overarching knowledge gaps in AMR epidemiology, burden and drivers, policies and regulations, and awareness and education. The research priorities were identified through a multistage process, starting with a comprehensive scoping review of knowledge gaps, with expert inputs gathered through a survey and open call. The priority setting involved a rigorous modified Child Health and Nutrition Research Initiative approach, ensuring global representation and applicability of the findings. The ultimate goal of this research agenda is to encourage research and investment in the generation of evidence to better understand AMR dynamics and facilitate policy translation for reducing the burden and consequences of AMR.

Mycology laboratory diagnostic capacity for invasive fungal diseases in public hospitals in Vietnam

This was a cross-sectional study on the availability of laboratory infrastructure and capacity for the diagnosis of invasive fungal diseases in 24 public hospitals in Vietnam in 2023. Among the hospitals surveyed, 66.7% (14/21) had specialized personnel assigned for mycology testing, and 95.8% (23/24) had a separate microbiology laboratory space. Microscopy and culture methods are available in nearly all laboratories for isolate identification. Antifungal susceptibility testing is only performed for yeasts in 16/24 (66.7%) laboratories. Non-culture methods are hardly used in laboratories. Strengthening local laboratory capacities is essential to meeting health needs in these endemic regions.

Universal digital high-resolution melting for the detection of pulmonary mold infections

Invasive mold infections (IMIs) are associated with high morbidity, particularly in immunocompromised patients, with mortality rates between 40% and 80%. Early initiation of appropriate antifungal therapy can substantially improve outcomes, yet early diagnosis remains difficult to establish and often requires multidisciplinary teams evaluating clinical and radiological findings plus supportive mycological findings. Universal digital high-resolution melting (U-dHRM) analysis may enable rapid and robust diagnoses of IMI. A universal fungal assay was developed for U-dHRM and used to generate a database of melt curve signatures for 19 clinically relevant fungal pathogens. A machine learning algorithm (ML) was trained to automatically classify these pathogen curves and detect novel melt curves. Performance was assessed on 73 clinical bronchoalveolar lavage samples from patients suspected of IMI. Novel curves were identified by micropipetting U-dHRM reactions and Sanger sequencing amplicons. U-dHRM achieved 97% overall fungal organism identification accuracy and a turnaround time of ~4 hrs. U-dHRM detected pathogenic molds (Aspergillus, Mucorales, Lomentospora, and Fusarium) in 73% of 30 samples classified as IMI, including mixed infections. Specificity was optimized by requiring the number of pathogenic mold curves detected in a sample to be >8 and a sample volume to be 1 mL, which resulted in 100% specificity in 21 at-risk patients without IMI. U-dHRM showed promise as a separate or combination diagnostic approach to standard mycological tests. U-dHRM's speed, ability to simultaneously identify and quantify clinically relevant mold pathogens in polymicrobial samples, and detect emerging opportunistic pathogens may aid treatment decisions, improving patient outcomes.

IMPORTANCE

Improvements in diagnostics for invasive mold infections are urgently needed. This work presents a new molecular detection approach that addresses technical and workflow challenges to provide fast pathogen detection, identification, and quantification that could inform treatment to improve patient outcomes.

Identifying the risk factors of ICU-acquired fungal infections: clinical evidence from using machine learning

Background

Fungal infections are associated with high morbidity and mortality in the intensive care unit (ICU), but their diagnosis is difficult. In this study, machine learning was applied to design and define the predictive model of ICU-acquired fungi (ICU-AF) in the early stage of fungal infections using Random Forest.

Objectives

This study aimed to provide evidence for the early warning and management of fungal infections.

Methods

We analyzed the data of patients with culture-positive fungi during their admission to seven ICUs of the First Affiliated Hospital of Chongqing Medical University from January 1, 2015, to December 31, 2019. Patients whose first culture was positive for fungi longer than 48 h after ICU admission were included in the ICU-AF cohort. A predictive model of ICU-AF was obtained using the Least Absolute Shrinkage and Selection Operator and machine learning, and the relationship between the features within the model and the disease severity and mortality of patients was analyzed. Finally, the relationships between the ICU-AF model, antifungal therapy and empirical antifungal therapy were analyzed.

Results

A total of 1,434 cases were included finally. We used lasso dimensionality reduction for all features and selected six features with importance ≥0.05 in the optimal model, namely, times of arterial catheter, enteral nutrition, corticosteroids, broadspectrum antibiotics, urinary catheter, and invasive mechanical ventilation. The area under the curve of the model for predicting ICU-AF was 0.981 in the test set, with a sensitivity of 0.960 and specificity of 0.990. The times of arterial catheter (p = 0.011, OR = 1.057, 95% CI = 1.053-1.104) and invasive mechanical ventilation (p = 0.007, OR = 1.056, 95%CI = 1.015-1.098) were independent risk factors for antifungal therapy in ICU-AF. The times of arterial catheter (p = 0.004, OR = 1.098, 95%CI = 0.855-0.970) were an independent risk factor for empirical antifungal therapy.

Conclusion

The most important risk factors for ICU-AF are the six time-related features of clinical parameters (arterial catheter, enteral nutrition, corticosteroids, broadspectrum antibiotics, urinary catheter, and invasive mechanical ventilation), which provide early warning for the occurrence of fungal infection. Furthermore, this model can help ICU physicians to assess whether empiric antifungal therapy should be administered to ICU patients who are susceptible to fungal infections.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and in vitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy in vitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Universal Digital High Resolution Melt for the detection of pulmonary mold infections

Background

Invasive mold infections (IMIs) such as aspergillosis, mucormycosis, fusariosis, and lomentosporiosis are associated with high morbidity and mortality, particularly in immunocompromised patients, with mortality rates as high as 40% to 80%. Outcomes could be substantially improved with early initiation of appropriate antifungal therapy, yet early diagnosis remains difficult to establish and often requires multidisciplinary teams evaluating clinical and radiological findings plus supportive mycological findings. Universal digital high resolution melting analysis (U-dHRM) may enable rapid and robust diagnosis of IMI. This technology aims to accomplish timely pathogen detection at the single genome level by conducting broad-based amplification of microbial barcoding genes in a digital polymerase chain reaction (dPCR) format, followed by high-resolution melting of the DNA amplicons in each digital reaction to generate organism-specific melt curve signatures that are identified by machine learning.

Methods

A universal fungal assay was developed for U-dHRM and used to generate a database of melt curve signatures for 19 clinically relevant fungal pathogens. A machine learning algorithm (ML) was trained to automatically classify these 19 fungal melt curves and detect novel melt curves. Performance was assessed on 73 clinical bronchoalveolar lavage (BAL) samples from patients suspected of IMI. Novel curves were identified by micropipetting U-dHRM reactions and Sanger sequencing amplicons.

Results

U-dHRM achieved an average of 97% fungal organism identification accuracy and a turn-around-time of 4hrs. Pathogenic molds (Aspergillus, Mucorales, Lomentospora and Fusarium) were detected by U-dHRM in 73% of BALF samples suspected of IMI. Mixtures of pathogenic molds were detected in 19%. U-dHRM demonstrated good sensitivity for IMI, as defined by current diagnostic criteria, when clinical findings were also considered.

Conclusions

U-dHRM showed promising performance as a separate or combination diagnostic approach to standard mycological tests. The speed of U-dHRM and its ability to simultaneously identify and quantify clinically relevant mold pathogens in polymicrobial samples as well as detect emerging opportunistic pathogens may provide information that could aid in treatment decisions and improve patient outcomes.

Diagnostic capacity for cutaneous fungal diseases in the African continent

BACKGROUND

Cutaneous fungal infections are very common, especially in poorer communities and with intercurrent HIV infection. Determining the fungal pathogen in skin-related fungal neglected tropical diseases (NTDs) determines optimal therapy. We undertook a country survey across many African countries to determine the diagnostic capacity for skin fungal diseases.

METHODS

A detailed questionnaire was delivered to country contacts to collect data on availability, frequency, and location of testing for key diagnostic procedures and followed up with 2 rounds of validation by video call and by confirmation of individual country data confirmation by email.

RESULTS

Of 47 countries with data, seven (15%) and 21 (45%) do not offer skin biopsy in the public or private sector, respectively, but 22 (46%) countries do it regularly, mostly in university hospitals. Direct microscopy is often performed in 20 of 48 (42%) countries in the public sector and not done in 10 (21%). Fungal cultures are often performed in 21 of 48 (44%) countries in the public sector but not done in nine (20%) or 21 (44%) in either public or private facilities. Histopathological examination of tissue is frequently used in 19 of 48 (40%) countries but not in nine (20%) countries in the public sector. The cost of diagnostics to patients was a major limiting factor in usage.

CONCLUSION

Major improvements in the availability and use of diagnostic tests for skin, hair, and nail fungal disease are urgently needed across Africa.

Nanotechnology-Based Strategies to Combat Multidrug-Resistant Candida auris Infections

An emerging multidrug-resistant pathogenic yeast called Candida auris has a high potential to spread quickly among hospitalized patients and immunodeficient patients causing nosocomial outbreaks. It has the potential to cause pandemic outbreaks in about 45 nations with high mortality rates. Additionally, the fungus has become resistant to decontamination techniques and can survive for weeks in a hospital environment. Nanoparticles might be a good substitute to treat illnesses brought on by this newly discovered pathogen. Nanoparticles have become a trend and hot topic in recent years to combat this fatal fungus. This review gives a general insight into the epidemiology of C. auris and infection. It discusses the current conventional therapy and mechanism of resistance development. Furthermore, it focuses on nanoparticles, their different types, and up-to-date trials to evaluate the promising efficacy of nanoparticles with respect to C. auris.

Fungal cell barriers and organelles are disrupted by polyhexamethylene biguanide (PHMB)

The similarities between fungal and mammalian cells pose inherent challenges for the development of treatments for fungal infections, due to drug crossover recognition of host drug targets by antifungal agents. Thus, there are a limited number of drug classes available for treatment. Treatment is further limited by the acquisition and dissemination of antifungal resistance which contributes to the urgent need of new therapies. Polyhexamethylene biguanide (PHMB) is a cationic antimicrobial polymer with bactericidal, parasiticidal and fungicidal activities. The antifungal mechanism of action appears to involve preferential mechanical disruption of microbial cell structures, offering an alternative to conventional antifungals. However, the antifungal mechanisms have been little studied. The aim of this study was to characterise PHMB's activities on selected yeast (Saccharomyces cerevisiae, Candida albicans) and filamentous fungal species (Fusarium oxysporum, Penicillium glabrum). Fungal membrane disruption, cell entry and intracellular localisation activities of PHMB were evaluated using viability probe entry and polymer localisation studies. We observed that PHMB initially permeabilises fungal cell membranes and then accumulates within the cytosol. Once in the cytosol, it disrupts the nuclear membrane, leading to DNA binding and fragmentation. The electrostatic interaction of PHMB with membranes suggests other intracellular organelles could be potential targets of its action. Overall, the results indicate multiple antifungal mechanisms, which may help to explain its broad-spectrum efficacy. A better understanding of PHMB's mechanism(s) of action may aid the development of improved antifungal treatment strategies.

Antifungal Activity of Mycogenic Silver Nanoparticles on Clinical Yeasts and Phytopathogens

In this study, seven different silver nanoparticles (AgNPs) were obtained using the fungi species from the phylum Ascomycota, Aspergillus tubingensis, Aspergillus spp., Cladosporium pini-ponderosae, Fusarium proliferatum, Epicoccum nigrum, Exserohilum rostratum, and Bionectria ochroleuca, isolated from the Brazilian biodiversity, particularly from the mangrove and Caatinga biomes. The nanoparticles were coded as AgNP-AT, AgNP-Asp, AgNP-CPP, AgNP-FP, AgNP-EN, AgNP-ER, and AgNP-BO and characterized using spectrophotometry (UV-Vis), dynamic light scattering (DLS), zeta potential, transmission electron microcopy (TEM), and Fourier-transform infrared (FTIR) spectroscopy. All the AgNPs presented homogeneous size in the range from 43.4 to 120.6 nm (DLS) and from 21.8 to 35.8 nm (TEM), pH from 4.5 to 7.5, negative charge, and presence of protein coating on their surface. The antifungal activity of the AgNPs was evaluated on clinical strains of Candida albicans, and on the non-albicans species, Candida krusei, Candida glabrata, Candida parapsilosis, Candida tropicalis, and Candida guilliermondii, common in hospital infections, and against the phytopathogens Fusarium oxysporum, Fusarium phaseoli, Fusarium sacchari, Fusarium subglutinans, Fusarium verticillioides, and Curvularia lunata, which are species responsible for serious damage to agriculture production. The AgNPs were effective against the yeasts with MICs ranging from 1.25 to 40 µM and on the phytopathogens with MICs from 4 to 250 µM, indicating the promising possibility of application of these AgNPs as antifungal agents. The results indicated that the physicochemical parameters of the AgNPs, including the functional groups present on their surface, interfered with their antifungal activity. Overall, the results indicate that there is no specificity of the AgNPs for the yeasts or for the phytopathogens, which can be an advantage, increasing the possibility of application in different areas.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital

Background

There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital.

Methods

We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time.

Results

Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016–1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96).

Conclusions

In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01114-x.

Biogenic silver nanoparticles as antifungal agents

In recent years, an increase in multidrug-resistant fungal strains has been observed, which, together with the limited number of clinically available antifungal agents, highlights the need for the development of new antifungal agents. Due to the proven antifungal activity of silver nanoparticles (AgNPs), there is a growing interest in their use in the treatment of fungal infections. Nanoparticles are usually synthesised through a variety of physical and chemical processes that are costly and pollute the environment. For this reason, biogenic synthesis is emerging as an environmentally friendly technology and new strategies are increasingly based on the use of biogenic AgNPs as antifungal agents for clinical use. The aim of this review is to compare the antifungal activity of different biogenic AgNPs and to summarise the current knowledge on the mechanisms of action and resistance of fungi to AgNPs. Finally, a general analysis of the toxicity of biogenic AgNPs in human and veterinary medicine is performed.

Antifungal drug resistance: an update

The number of antifungal classes is small, and resistance is becoming a much more frequent problem. Much greater emphasis needs to be placed on susceptibility testing and antifungal stewardship. Such efforts demonstrably improve survival and overall clinical outcomes. Positively diagnosing a fungal infection with laboratory markers often allows antibacterial therapy to be stopped (ie, anti-tuberculous therapy in chronic pulmonary aspergillosis or antibiotics other than cotrimoxazole in Pneumocystis pneumonia), contributing to antimicrobial resistance control generally. Non-culture based diagnostics for fungal disease are transformational in terms of sensitivity and speed, but only occasionally identify antifungal resistance.

Antifungal Polymeric Materials and Nanocomposites

Rising global populations due to medicinal advancements increases the patient population susceptible to superficial and severe fungal infections. Fungi often implicated in these diseases includes the dermatophytes (Microsporum spp., Epidermophtyon spp., Trichophyton spp.) as well as species of the Candida spp., Aspergillosis spp. and Cryptococcus spp. genera. In addition, increasing global populations leads to increasing agricultural demands. Thus, fungal infections of preharvested crops and stored food by plant pathogens such as Magnaporthe oryzae and Fusarium oxysporum can have detrimental socioeconomic effects due to food insecurity. Current antifungal strategies are based mainly on small molecule antifungal drugs. However, these drugs are limited by poor solubility and bioavailability. Furthermore, antifungal resistance against these drugs are on the rise. Thus, antimicrobial polymers offer an alternative antifungal strategy. Antifungal polymers are characterised by cationic and hydrophobic regions where the cationic regions have been shown to interact with microbial phospholipids and membranes. These polymers can be synthetic or natural and demonstrate distinct antifungal mechanisms ranging from fungal cell membrane permeabilisation, cell membrane depolarisation or cell entry. Although the relative importance of such mechanisms is difficult to decipher. Due to the chemical properties of these polymers, they can be combined with other antimicrobial compounds including existing antifungal drugs, charcoals, lipids and metal ions to elicit synergistic effects. In some cases, antifungal polymers and nanocomposites show better antifungal effects or reduced toxicity compared to the widely used small molecule antifungal drugs. This review provides an overview of antimicrobial polymers and nanocomposites with antifungal activity and the current understanding of their antifungal mechanisms.

Accelerated antibacterial red-carbon dots with photodynamic therapy against multidrug-resistant Acinetobacter baumannii

The emergence of antibiotic resistance in bacteria is a major public-health issue. Synthesis of efficient antibiotic-free material is very important for fighting bacterial infection-related diseases. Herein, red-carbon dots (R-CDs) with a broad range of spectral absorption (350-700 nm) from organic bactericides or intermediates were synthesized through a solvothermal route. The prepared R-CDs not only had intrinsic antibacterial activities, but also could kill multidrug-resistant bacteria (multidrug-resistant Acinetobacter baumannii (MRAB) and multidrug-resistant Staphylococcus aureus (MRSA)) effectively by generating reactive oxygen species. Furthermore, R-CDs could eliminate and inhibit the formation of MRAB biofilms, while conferring few side effects on normal cells. A unique property of R-CDs was demonstrated upon in vivo treatment of antibiotic-sensitive MRAB-induced infected wounds. These data suggested that this novel R-CDs-based strategy might enable the design of next-generation agents to fight drug-resistant bacteria.

ELECTRONIC SUPPLEMENTARY MATERIAL

Supplementary material is available for this article at 10.1007/s40843-021-1770-0 and is accessible for authorized users.

Antibiotic resistance in microbes: History, mechanisms, therapeutic strategies and future prospects

Antibiotics have been used to cure bacterial infections for more than 70 years, and these low-molecular-weight bioactive agents have also been used for a variety of other medicinal applications. In the battle against microbes, antibiotics have certainly been a blessing to human civilization by saving millions of lives. Globally, infections caused by multidrug-resistant (MDR) bacteria are on the rise. Antibiotics are being used to combat diversified bacterial infections. Synthetic biology techniques, in combination with molecular, functional genomic, and metagenomic studies of bacteria, plants, and even marine invertebrates are aimed at unlocking the world's natural products faster than previous methods of antibiotic discovery. There are currently only few viable remedies, potential preventive techniques, and a limited number of antibiotics, thereby necessitating the discovery of innovative medicinal approaches and antimicrobial therapies. MDR is also facilitated by biofilms, which makes infection control more complex. In this review, we have spotlighted comprehensively various aspects of antibiotics viz. overview of antibiotics era, mode of actions of antibiotics, development and mechanisms of antibiotic resistance in bacteria, and future strategies to fight the emerging antimicrobial resistant threat.

Molecular Cloning, Functional and Biophysical Characterization of an Antimicrobial Peptide from Rhizosphere Soil

AIM

This study was designed to screen and identify an antimicrobial peptide from rhizosphere soil. The study was further focused towards overexpression, purification and characterization of this antimicrobial peptide, and to functionally validate its efficiency and efficacy as an antimicrobial agent. Yet the study was further aimed at corroborating structural and functional studies using biophysical tools.

BACKGROUND

Antimicrobial resistance is emerging as one of the top 10 global health crisis, it is multifaceted and is the second largest cause of mortality. According to the World Health Organization (WHO), around the world, an estimated 700,000 people die each year from infection caused by antibiotic-resistant microbes. Antimicrobial peptides offers best alternative to combat and overcome this crisis. In this manuscript, we report cloning, expression, purification and characterization of an antimicrobial peptide discovered from rhizosphere soil.

OBJECTIVE

Objectives of this study includes construction, screening and identification of antimicrobial peptide from metagenome followed by its expression, purification and functional and biophysical investigation. Yet another objective of the study was to determine antimicrobial efficacy and efficiency as an antimicrobial peptide towards MRSA strains.

METHODS

In this study, we used array of molecular biology tools that include genetic engineering, PCR amplification, construction of an expression construct and NI-NTA based purification of the recombinant peptide. We have also carried out antimicrobial activity assay to determine MIC and IC50 values of antimicrobial peptide. To establish structural and functional relationship, circular dichroism, and both extrinsic and intrinsic fluorescence spectroscopy studies were carried out.

RESULTS

Screening of metagenomic library resulted in identification of gene (~500bp) harbouring an open reading frame (ORF) consisting of 282 bp. Open reading frame identified in gene encodes an antimicrobial peptide which had shared ~95% sequence similarity with the antimicrobial peptide of Bacillus origin. Purification of recombinant protein using Ni-NTA column chromatography demonstrated a purified protein band of ~11 kDa on 14% SDS-PAGE which is well corroborated to theoretical deduced molecular weight of peptide from its amino acids sequence. Interestingly, the peptide exhibited antimicrobial activity in broad range of pH and temperature. MIC (minimum inhibitory concentration) determined against gram positive Bacillus sp. was found to be 0.015mg/ml, whereas in case of gram negative E. coli, it was calculated to be 0.062mg/ml. The peptide exhibited IC50 values corresponding to ~0.25mg/ml against Bacillus and ~0.5 mg/ml against E. coli. Antimicrobial susceptibility assay performed against methicillin resistant Staphylococcus aureus strain ATCC 3412 and standard strain of Staphylococcus aureus ATCC 9144 revealed its strong inhibitory activity against MRSA, whereby we observed a ~16mm clearance zone at higher peptide concentrations ~2mg/ml (~181.8µM). Biophysical investigation carried out using Trp fluorescence, ANS fluorescence and circular dichroism spectroscopy further revealed conformational stability in its secondary and tertiary structure at wide range of temperature and pH.

CONCLUSION

Altogether, the peptide discovered from rhizosphere metagenome hold potential in inhibiting the growth of both the gram positive and gram negative bacteria, and was equally effective in inhibiting the multidrug resistant pathogenic strains (MRSA).

Point of care tests for invasive fungal infections: a blueprint for increasing availability in Africa

Invasive fungal infections (IFIs) such as cryptococcosis, disseminated histoplasmosis, and chronic pulmonary aspergillosis are significant causes of morbidity and mortality in Africa. Lack of laboratory infrastructure and laboratory personnel trained in diagnostic mycology hamper prompt detection and management of IFIs on the continent. Point-of-care tests (POCT) obviate the need for complex infrastructure, skilled technicians, and stable electricity and have had major impacts on the diagnosis of bacterial, viral, and parasitic infections in low- and middle-income countries. Over the last 10 years, POCTs for IFIs have become increasingly available and they have the potential to revolutionize the management of these infections if scaled up in Africa. At the beginning of 2021, the World Health Organization (WHO) Essential Diagnostic List (EDL) included a cryptococcal antigen test for the diagnosis of cryptococcosis, Histoplasma antigen test for the diagnosis of disseminated histoplasmosis, and Aspergillus-specific test for the diagnosis of chronic pulmonary aspergillosis. All of these are available in formats that may be used as POCTs and it is hoped that this will improve the diagnosis of these life-threatening IFIs, especially in low- and middle-income countries. This perspective review discusses commercially available POCTs and outlines strategies of a blueprint to achieve their roll-out in Africa. The strategies include raising awareness, conducting research that uncovers the exact burden of IFIs, increasing advocacy, integrating diagnosis of IFIs into existing public health programs, adoption of the WHO EDL at country levels, and improving logistics and supply chains.

In vitro activity of posaconazole and comparators versus opportunistic filamentous fungal pathogens globally collected during 8 years

The epidemiology of invasive filamentous fungal diseases requires monitoring due to changes in susceptibility patterns of new and established antifungal agents that may affect clinical practices. We evaluated the activity of posaconazole against 2,157 invasive moulds collected worldwide from 2010-2017. The isolates included 1,775 Aspergillus spp. and 382 non-Aspergillus moulds, including 81 Fusarium spp., 62 Mucorales group, and 57 Scedosporium spp. Isolates were tested using the CLSI reference broth microdilution method. Posaconazole showed similar activity to itraconazole and voriconazole against A. fumigatus. Applying published ECV, 98.0% of the A. fumigatus and 97.7% to 100.0% of other common Aspergillus species were wildtype to posaconazole. Categorical agreement between posaconazole and the other azoles tested against A. fumigatus was 98.7%. Notably, most of the Aspergillus spp. isolates recovered from this large collection were wildtype to echinocandins and all azoles. Posaconazole non-wildtype rates of A. fumigatus varied across the different geographic regions, with 2.1% in Europe, 2.2% in North America, 1.8% in Latin America, and 0.7% in the Asia-Pacific region. The frequency of azole non-wildtype A. fumigatus isolates from Europe increased steadily from 2010-2017 for all 3 triazoles (0.0%-5.0%). The azole non-wildtype A. fumigatus rates from the other geographic areas were stable over time. Fusarium and/or Scedosporium spp. isolates were highly resistant to azoles and echinocandins. Posaconazole and amphotericin B were the most active agents against the Mucorales. Posaconazole was very active against most species of Aspergillus and was comparable to itraconazole and voriconazole against the less common moulds. Posaconazole should provide a useful addition to the anti-mould grouping of antifungal agents.

A Low-Cost Tebuconazole-Based Screening Test for Azole-Resistant Aspergillus fumigatus

The global emergence of azole resistance in Aspergillus fumigatus is resulting in health and food security concerns. Rapid diagnostics and environmental surveillance methods are key to understanding the distribution and prevalence of azole resistance. However, such methods are often associated with high costs and are not always applicable to laboratories based in the least-developed countries. Here, we present and validate a low-cost screening protocol that can be used to differentiate between azole-susceptible "wild-type" and azole-resistant A. fumigatus isolates. © 2020 The Authors. Basic Protocol 1: Preparation of Tebucheck multi-well plates Basic Protocol 2: Inoculation of Tebucheck multi-well plates.

Global Divergence of Antifungal Prescribing Patterns: Data From the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children Surveys

BACKGROUND

Globally, invasive fungal diseases (IFDs) have a significant impact in human health. With an increasing pediatric population at risk of IFD, effective antifungal drugs access and affordability should be ensured universally. The aim of our study was to characterize the global antifungal drug use in neonates and children and its variability between countries in different income groups.

METHODS

Data were extracted from the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children Point Prevalence Survey project, consisting in 1 pilot and four 1-day Point Prevalence Survey between 2015 and 2017. The data had been entered through a study-specific web-based data collection tool.

RESULTS

From a total of 13,410 children included, 7.8% (1048/13,410) received at least 1 systemic antifungal drug: 9.5% (95% confidence interval: 8.9%-10.1%) in high income countries (HIC) versus 5.0% (95% confidence interval: 4.4%-5.6%) in low-middle income countries (LMIC) (P < 0.01). A significant proportion of patients on antifungals belonged to high-risk group for IFD (67.4%; 706/1048); most of these were managed in HIC (72.8%, P < 0.01). The likelihood of receiving antifungals being in high-risk group was higher in HIC compared with LMIC (ratio of 5.8 vs. 3.4, P < 0.01). Antifungal prophylaxis was more likely prescribed in HIC (67.2% vs. 30.4%, P < 0.01). Fluconazole was the most frequently prescribed drug. The proportional use of fluconazole was higher in LMIC compared with HIC.

CONCLUSIONS

A significant variability of antifungal prescribing patterns was observed. The proportional use of systemic antifungals was twice as high in HIC compared with LMIC. More detailed data on access and antifungal use in limited-resource settings should be explored.

In vitro antifungal susceptibility of yeasts and molds isolated from sputum of tuberculosis relapse and retreatment patients

INTRODUCTION

opportunistic fungal infections due to immunosuppression coupled with antifungal drug resistance are an emerging challenge globally. The present study examined the antifungal susceptibility of yeasts and molds from sputum of tuberculosis retreatment and relapse patients at selected reference facilities in Kenya.

METHODS

a total of 340 sputa samples from patients who gave written informed consent were examined. Fungal culture was done on sabouraud dextrose agar (SDA). Molds were identified by macroscopic and microscopic features while yeasts were inoculated on CHROMTMagar Candida and confirmed using API 20C AUXTM. Itraconazole (ICZ), voriconazole (VCZ), fluconazole (FCZ) and amphotericin B (AMB) were tested using broth micro-dilution methods according to Clinical and Laboratory Standards Institute (CLSI).

RESULTS

out of the 340 samples, 14.4% (n=49) and 15.6% (n=53) were positive for yeasts and molds respectively. Candida albicans and C. krusei were the most predominant isolates constituting 49.0% (n=24) and 20.4% (n=10) of the total yeasts respectively. Aspergillus spp. were the most frequent (22.6%) molds and isolates with MICs ≥4μg/ml on the antifungal agents were noted. All the molds except two (n=2) isolates of Scedosporium aspiopermum exhibited MICs >4μg/ml for fluconazole. Overall, molds were more sensitive to AMB and VCZ. Candida albicans had MIC50 <0.06μg/ml, and MIC90<4μg/ml. There was a statistically significant difference (F=3.7, P=0.004<0.05) in the overall sensitivity pattern of molds for the four antifungal agents while there was no significant difference (F=1.7, P=0.154>0.05) in sensitivity exhibited by the yeasts.

CONCLUSION

the study demonstrates the significance of fungal colonization in presumptive tuberculosis retreatment or relapse with evidence of triazole resistance. There is need to strengthen fungal diagnostic and clinical management capabilities in susceptible populations.

Immune Resolution Dilemma: Host Antimicrobial Factor S100A8/A9 Modulates Inflammatory Collateral Tissue Damage During Disseminated Fungal Peritonitis

Intra-abdominal infection (peritonitis) is a leading cause of severe disease in surgical intensive care units, as over 70% of patients diagnosed with peritonitis develop septic shock. A critical role of the immune system is to return to homeostasis after combating infection. S100A8/A9 (calprotectin) is an antimicrobial and pro-inflammatory protein complex used as a biomarker for diagnosis of numerous inflammatory disorders. Here we describe the role of S100A8/A9 in inflammatory collateral tissue damage (ICTD). Using a mouse model of disseminated intra-abdominal candidiasis (IAC) in wild-type and S100A8/A9-deficient mice in the presence or absence of S100A9 inhibitor paquinimod, the role of S100A8/A9 during ICTD and fungal clearance were investigated. S100A8/A9-deficient mice developed less ICTD than wild-type mice. Restoration of S100A8/A9 in knockout mice by injection of recombinant protein resulted in increased ICTD and fungal clearance comparable to wild-type levels. Treatment with paquinimod abolished ICTD and S100A9-deficient mice showed increased survival compared to wild-type littermates. The data indicates that S100A8/A9 controls ICTD levels and antimicrobial activity during IAC and that targeting of S100A8/A9 could serve as promising adjunct therapy against this challenging disease.

Chemical Analysis and the Study of Quality Indicators of the Immunobiological Drug for Preventing and Treating Candidal Infections

Quality indicators such as protein content, polysaccharide content, phenol content, and pH of the developed vaccine solution for injection (VSI) “Candidocyde” based on cells of C. albicans and C. tropicalis fungi have been found to meet the standard requirements. It was determined that by the indicator of transparency and degree of turbidity the test solution is transparent, by the coloration degree it is colorless, by the sterility indicator it is sterile. The sterility period, determined after the first opening, is 8 hours. It was found that no solid particles were present in the solution; the container with the solution is hermetic; the volume of the container with a solution is not less than 5.0 ml. The test solution is stable for 2 years of storage at 275-265 K.

Estimates of serious fungal infection burden in Côte d'Ivoire and country health profile

Due to limited access to more powerful diagnostic tools, there are few data on the burden of fungal infections in Côte d'Ivoire, despite a high HIV and TB burden and many cutaneous diseases. Here we estimate the burden of serious fungal infections in this sub-Saharan country with a health profiling description. National demographics were used and PubMed searches to retrieve all published articles on fungal infections in Côte d'Ivoire and other bordering countries in West Africa. When no data existed, risk populations were used to estimate frequencies of fungal infections, using previously described methodology by LIFE (www.LIFE-Worldwide.org). The population of Côte d'Ivoire is around 25 million; 37% are children (≤14 years), and 9% are>65 years. Tinea capitis in children is common, measured at 13.9% in 2013. Considering the prevalence of HIV infection (2.6% of the population, a total of ∼500,000) and a hospital incidence of 12.7% of cryptococcosis, it is estimated that 4590 patients per year develop cryptococcosis. For pneumocystosis, it is suggested that 2640 new cases occur each year with the prevalence of 11% of newly diagnosed HIV adults, and 33% of children with HIV/AIDS. Disseminated histoplasmosis is estimated a 1.4% of advanced HIV disease - 513 cases. An estimated 6568 news cases of chronic pulmonary aspergillosis (CPA) occur after pulmonary tuberculosis (a 5-year prevalence of 6568 cases [26/100,000]). Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) were estimated in 104/100,000 and 151/100,000 respectively, in 1,152,178 adult asthmatics. Vulvovaginal candidiasis (VVC) is common and recurrent VVC affects ∼6% of women in their fertile years - 421,936 women. An unknown number develop candidaemia and invasive aspergillosis. The annual incidence of fungal keratitis is estimated at 3350. No cases of sporotrichosis, mucormycosis and chromoblastomycosis are described, although some cases of mycetoma and Conidiobolus infection have been reported. This study indicates that around to 7.25% (1.8 million) of the population is affected by a serious fungal infection, predominently tinea capitis in children and rVVC in women. These data should be used to inform epidemiological studies, diagnostic needs and therapeutic strategies in Côte d'Ivoire.

Prevalence of Common Nosocomial Infections and Evaluation of Antibiotic Resistance Patterns in Patients with Secondary Infections in Hamadan, Iran

Introduction

The prevalence of nosocomial infections in patients hospitalized to three hospitals of Shahid Beheshti, Farshchian, and Be’ saat in Hamadan was investigated for 2 years (2018 to 2020).

Materials and Methods

The samples were cultured and characterized using morphological and diagnostic biochemical tests. The analysis of the frequency of the isolates and their antibiotic resistance were calculated using SPSS (version 22) at a significant level of P-value < 0.05.

Results

Bacterial isolates were collected from the 1194 clinical specimens, of which 1394 were isolated from urine, 16 from CSF, and 588 from tracheal aspiration. Also, 654 (54.8%) isolates were obtained from females and 540 (45.2%) from males with the age range 15–73 years (P> 0.05). The results showed that 22.1% were gram-positive and 77.9% were gram-negative. In our study, the frequency of Klebsiella pneumoniae bacteria was higher than in some studies, and this indicates the genetic changes and resistance of this bacterium to many antibiotics.

Conclusion

To prevent further spread of resistance, increase the effectiveness of antibiotics and prevent multidrug resistance, it is essential to establish a precise schedule for the use of antibiotics and assess the resistance pattern periodically in each region based on the antibiotic resistance pattern.

Updates in Laboratory Diagnostics for Invasive Fungal Infections

Appropriate diagnosis of invasive fungal infections (IFIs) is critical due to the high rates of morbidity and mortality, as well as the substantial economic burden, associated with the management of these diseases. The recognition of IFI and differentiation from other infections with similar clinical presentations can be challenging, which can lead to diagnostic error that not only has an impact on individual patient health outcomes but also on antimicrobial drug usage and the growing threat of antimicrobial resistance in bacteria. Therefore, there is a significant need for improved stewardship related to diagnostic testing for and treatment of IFIs. The purpose of this review is to highlight recent advances related to current fungal diagnostics, as well as explore some of the most innovative technology that has emerged with the potential to shift the paradigm of clinical mycology. In general, this review will discuss research related to enhanced fungal culture utilization and identification techniques, expanded applications of fungal antigen testing, and recently developed molecular assays and other novel nonculture fungal diagnostic approaches. Specifically, the application of mass spectrometry, novel glycobiomarker detection, and detection of fungal-specific volatile organic compounds will be reviewed, along with other key updates, to provide the reader with an updated review that extends beyond the basics of IFI laboratory diagnostics. Where appropriate, the reader will be directed to more comprehensive reviews of certain aspects of clinical mycology laboratory testing to provide a broader context for the critical consideration of these updates.

US database study: burden and healthcare resource utilization in adults with systemic endemic mycoses and aspergillosis

Aim: This study evaluated burden of illness in immunocompromised patients with systemic mycoses (SM) eligible for itraconazole treatment, specifically, histoplasmosis, blastomycosis and aspergillosis. Methods: A cross-sectional study used an electronic medical record network integrating information from 30 US hospitals, including >34 million patients, to evaluate burden and healthcare resource utilization over 6 months following initiation of antifungal therapy. Results: Symptomatic burden experienced by each of the otherwise healthy or age >65 or immunosuppressed cohorts receiving antifungal therapy for SM was comparable but significantly greater in cancer or HIV patients and transplant recipients. Across groups, there was substantially higher healthcare resource utilization in patients with SM versus matched controls without SM. Conclusion: The total impact of SM is particularly severe in high-risk or vulnerable populations.

The cost-effectiveness of isavuconazole compared to the standard of care in the treatment of patients with invasive fungal infection prior to differential pathogen diagnosis in the United Kingdom

Aims: To estimate the cost-effectiveness of isavuconazole compared with the standard of care, voriconazole, for the treatment of patients with invasive fungal infection disease when differential diagnosis of the causative pathogen has not yet been achieved at treatment initiation.Materials and methods: The economic model was developed from the perspective of the UK National Health Service (NHS) and used a decision-tree approach to reflect real-world treatment of patients with invasive fungal infection (IFI) prior to differential pathogen diagnosis. It was assumed that 7.8% of patients with IFI prior to differential pathogen diagnosis at treatment initiation actually had mucormycosis, and confirmation of pathogen identification was achieved for 50% of all patients during treatment. To extrapolate to a lifetime horizon, the model considered expected survival based on the patients' underlying condition. The model estimated the incremental costs (costs of drugs, laboratory analysis, hospitalization, and management of adverse events) and clinical outcomes (life-years (LYs) and quality-adjusted life-years (QALYs)) of first-line treatment with isavuconazole compared with voriconazole. The robustness of the results was assessed by conducting deterministic and probabilistic sensitivity analyses.Results: Isavuconazole delivered 0.48 more LYs and 0.39 more QALYs per patient at an incremental cost of £3,228, compared with voriconazole in the treatment of patients with IFI prior to differential pathogen diagnosis. This equates to an incremental cost-effectiveness ratio (ICER) of £8,242 per additional QALY gained and £6,759 per LY gained. These results were driven by a lack of efficacy of voriconazole in mucormycosis. Results were most sensitive to the mortality of IA patients and treatment durations.Conclusions: At a willingness to pay (WTP) threshold of £30,000 per additional QALY, the use of isavuconazole for the treatment of patients with IFI prior to differential pathogen diagnosis in the UK can be considered a cost-effective allocation of healthcare resources compared with voriconazole.

Design, synthesis, and evaluation of novel 2-substituted 1,4-benzenediol library as antimicrobial agents against clinically relevant pathogens

Development of new antimicrobial agents, capable of combating resistant and multidrug-resistant fungal and bacterial clinical strains, is necessary. This study presents the synthesis and antimicrobial screening of 42 2-substituted-1,4-benzenediols, being 10 novel compounds. In total, 23 compounds showed activity against fungi and/or bacteria. Benzenediol compounds 2, 5, 6, 8, 11, and 12 demonstrated broad spectrum antimicrobial actions, including resistant and multidrug-resistant species of dermatophytes (Trichophyton mentagrophytes), Candida spp. and the ESKAPE panel of bacteria. Minimum inhibitory concentrations of these compounds for fungi and bacterial strains ranged from 25 to 50 µg/ml and 8-128 µg/ml, respectively. The antifungal mechanism of action is related to the fungal cell wall of dermatophytes and membrane disruption to dermatophytes and yeasts, in the presence of compound 8. Specific structural changes, such as widespread thinning along the hyphae and yeast lysis, were observed by scanning electron microscopy. The effects of compound 8 on cell viability are dose-dependent; however they did not cause genotoxicity and mutagenicity in human leukocyte cells nor haemolysis. Moreover, the compounds were identified as nonirritant by the ex-vivo Hen's egg test-chorioallantoic membrane (HET-CAM). The furan-1,4-benzenediol compound 5 showed in vivo efficacy to combat S. aureus infection using embryonated chicken eggs. Therefore, the compounds 8, and 5 are promising as hits for the development of new antimicrobial drugs with reduced toxicity.

Impact of a diagnostics-driven antifungal stewardship programme in a UK tertiary referral teaching hospital

Objectives

A concise invasive candidosis guideline (based on the ESCMID candidaemia guideline) utilizing an informative biomarker [serum β-1-3-d-glucan (BDG)] was developed in 2013 by an antifungal stewardship (AFS) team and implemented with the help of an AFS champion in 2014. The main aims of the AFS programme were to reduce inappropriate use of antifungals and improve patient outcomes. The aim of this project was to evaluate the compliance of the ICU teams with the invasive candidosis guideline and the impact of the AFS programme on mortality and antifungal consumption on the ICUs (total of 71 beds).

Methods

All patients who were prescribed micafungin for suspected or proven invasive candidosis during 4 month audit periods in 2014 and 2016 were included. Prescriptions and patient records were reviewed against the guideline. Antifungal consumption and mortality data were analysed.

Results

The number of patients treated for invasive candidosis decreased from 39 in 2014 to 29 in 2016. This was mainly due to the reduction in patients initiated on antifungal therapy inappropriately: 18 in 2014 and 2 in 2016. Antifungal therapy was stopped following negative biomarker results in 12 patients in 2014 and 10 patients in 2016. Crude mortality due to proven or probable invasive candidosis decreased to 19% from 45% over the period 2003-07. Antifungal consumption reduced by 49% from 2014 to 2016.

Conclusions

The AFS programme was successful in reducing the number of inappropriate initiations of antifungals by 90%. Concurrently, mortality due to invasive candidosis was reduced by 58%. BDG testing can guide safe cessation of antifungals in ICU patients at risk of invasive candidosis.

Airway mycosis in allergic airway disease

The allergic airway diseases, including chronic rhinosinusitis (CRS), asthma, allergic bronchopulmonary mycosis (ABPM) and many others, comprise a heterogeneous collection of inflammatory disorders affecting the upper and lower airways and lung parenchyma that represent the most common chronic diseases of humanity. In addition to their shared tissue tropism, the allergic airway diseases are characterized by a distinct pattern of inflammation involving the accumulation of eosinophils, type 2 macrophages, innate lymphoid cells type 2 (ILC2), IgE-secreting B cells, and T helper type 2 (Th2) cells in airway tissues, and the prominent production of type 2 cytokines including interleukin (IL-) 33, IL-4, IL-5, IL-13, and many others. These factors and related inflammatory molecules induce characteristic remodeling and other changes of the airways that include goblet cell metaplasia, enhanced mucus secretion, smooth muscle hypertrophy, tissue swelling and polyp formation that account for the major clinical manifestations of nasal obstruction, headache, hyposmia, cough, shortness of breath, chest pain, wheezing, and, in the most severe cases of lower airway disease, death due to respiratory failure or disseminated, systemic disease. The syndromic nature of the allergic airway diseases that now include many physiological variants or endotypes suggests that distinct endogenous or environmental factors underlie their expression. However, findings from different perspectives now collectively link these disorders to a single infectious source, the fungi, and a molecular pathogenesis that involves the local production of airway proteinases by these organisms. In this review, we discuss the evidence linking fungi and their proteinases to the surprisingly wide variety of chronic airway and systemic disorders and the immune pathogenesis of these conditions as they relate to environmental fungi. We further discuss the important implications these new findings have for the diagnosis and future therapy of these common conditions.

Effects of laboratory capabilities on combating antimicrobial resistance, 2013-2016: A static model panel data analysis

OBJECTIVES

Antimicrobial resistance (AMR) has become a serious global public health problem. The World Health Organization (WHO) and European Union (EU) have taken actions to combat this issue, in which laboratory capability construction is a crucial part. This study aimed to explore the relationship between laboratory capabilities and antimicrobial resistance from a macro perspective.

METHODS

The study used annual national level penal data from the EU Laboratory Capability Monitoring System and Antimicrobial Resistance Surveillance Europe 2013-2016. A conventional static panel data analysis was constructed to establish the relationship between the antimicrobial resistance rates and laboratory capabilities.

RESULTS

Laboratory capability on antimicrobial drug resistance characterisation and monitoring (LC8) showed a positive effect on Escherichia coli (E. coli) combined resistance rate (Y5), E. coli resistant rate of aminoglycosides (Y4), and Klebsiella pneumoniae resistant rate of carbapenems (Y8) (OR=0.929, 0.957, and 0.861; P=0.035, 0.007, and 0.026, respectively). However, following the diagnostic testing guidelines (LC2) caused higher resistance rates of Klebsiella pneumoniae to fluoroquinolones (Y6), third-generation cephalosporins (Y7), and aminoglycosides (Y9) (OR=1.076, 1.093, and1.065; P=0.011, 0.032, and 0.002, respectively).

CONCLUSIONS

Antimicrobial drug resistance characterisation and monitoring by laboratories has contributed to minimising antimicrobial resistance, while the mechanism of laboratory capabilities to pose an ineffective or negative impact on AMR remains to be further studied.

A systematic review of interventions and performance measures for antifungal stewardship programmes

Objectives

Antifungal resistance is a significant and emerging threat. Stewardship programmes (SPs) have been proposed as an opportunity to optimize antifungal use. While examples of antifungal SP implementation have been recently described, there is yet to be an overview of interventions and their impacts on performance measures.

Methods

We systematically reviewed published articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses check-list 2009. MEDLINE was searched using the term 'antifungal stewardship' on 15 February 2017. Eligible studies were those that described an antifungal SP and included an intervention and an evaluation of performance measures.

Results

A total of 97 studies were identified and 14 were included. Only five studies reported an antifungal stewardship team composed of all the recommended members. The main intervention was the formulation of recommendations to change treatment (12 of 14). The main performance measure collected was antifungal consumption (10 of 14), followed by antifungal expenditure (7 of 14), adherence to therapeutic advice (4 of 14) and impact on mortality (4 of 14). Antifungal consumption was reduced by 11.8% to 71% and antifungal expenditure by as much as 50%. Adherence to therapeutic advice ranged from 40% to 88%, whereas antifungal SPs had no impact on mortality.

Conclusions

All antifungal SPs had an impact, in particular on antifungal consumption and antifungal expenditure. Active intervention including a review of prescriptions seems to have more impact than implementation of treatment guidelines only. According to available published studies, antifungal consumption appears to be the most achievable performance measure to evaluate the impact of an antifungal SP.

Characterization of Pathogenic Sepsis Etiologies and Patient Profiles: A Novel Approach to Triage and Treatment

Pathogenic sepsis is not a monolithic condition. Three major types of sepsis exist within this category: bacterial, viral, and fungal, each with its own mechanism of action. While similar in symptoms, the etiologies and immune mechanisms of these types differ enough that a discrete patient base can be recognized for each one. Non-specific treatment, such as broad-spectrum antibiotics, without determination of sepsis origins may worsen sepsis symptoms and leads to increased morbidity and mortality in patients. However, recognition of current and historical patterns in likely patients for each sepsis type may aid in differentiation between pathogens prior to definitive blood testing. Clinicians may ultimately be able to diagnose and treat bacterial, viral, and fungal sepsis using analysis of previous patient patterns and circumstances in addition to standard care. This method is likely to decrease incidence of multidrug-resistant organisms, organ failure due to ineffective treatment, and turnaround time to the correct treatment for each sepsis patient. Ultimately, we aim to provide classification information on these patient populations and to suggest epidemiology-based screening methods that can be integrated into critical care medicine, specifically triage and treatment of sepsis.

Developing definitions for invasive fungal diseases in critically ill adult patients in intensive care units. Protocol of the FUNgal infections Definitions in ICU patients (FUNDICU) project

BACKGROUND

The reliability of diagnostic criteria for invasive fungal diseases (IFD) developed for severely immunocompromised patients is questionable in critically ill adult patients in intensive care units (ICU).

OBJECTIVES

To develop a standard set of definitions for IFD in critically ill adult patients in ICU.

METHODS

Based on a systematic literature review, a list of potential definitions to be applied to ICU patients will be developed by the ESCMID Study Group for Infections in Critically Ill Patients (ESGCIP) and the ESCMID Fungal Infection Study Group (EFISG) chairpersons. The proposed definitions will be evaluated by a panel of 30 experts using the RAND/UCLA appropriateness methods. The panel will rank each of the proposed definitions on a 1-9 scale trough a dedicated questionnaire, in two rounds: one remote and one face-to-face. Based on their median rank and the level of agreement across panel members, selected definitions will be organised in a main consensus document and in an executive summary. The executive summary will be made available online for public comments.

CONCLUSIONS

The present consensus project will seek to provide standard definitions for IFD in critically ill adult patients in ICU, with the ultimate aims of improving their clinical outcome and facilitating the comparison and generalizability of research findings.

The Role of Antifungals in Pediatric Critical Care Invasive Fungal Infections

Invasive fungal infections (IFIs) have seen considerable increase in pediatric intensive care units over the past several decades. IFIs are predominantly caused by Candida species, and candidemia is the third most common cause of healthcare-associated bloodstream infections (BSIs) in children. IFIs are opportunistic infections that affect pediatric patients in critical care resulting in significant morbidity and mortality especially in those with a compromised immune system. IFIs are the leading cause of death in children with comorbidities such as immunosuppression, and pediatric ICU admission has been shown to be an independent risk factor for mortality. Management of IFI and fungal sepsis is broad and encompasses several key components that include prompt initiation of therapy and rapid source identification and control. This study reviews important antifungals in the pediatric critical care setting including the pharmacologic properties, antifungal spectrum, adverse effects, and clinical uses of agents belonging to the four major classes of antifungals—the polyenes, azoles, echinocandins, and pyrimidine analogue flucytosine. The polyenes and azoles are the most often used classes of antifungals. The echinocandins are a relatively newer class of antifungal agents that offer excellent Candida activity and are currently recommended as the first-line therapy for invasive candidiasis.

Fluorescent peptides for imaging of fungal cells

Fungal infections, especially with the advent of antimicrobial resistance, represent a major burden to our society. As a result, there has been an increasing interest in the development of new probes that accelerate the study of fungi-related biological processes and facilitate novel clinical diagnostic and treatment strategies. Fluorescence-based reporters can provide dynamic information at the molecular level with high spatial resolution. However, conventional fluorescent probes for microbes often suffer from low specificity. In the last decade, numerous studies have been reported on the chemical design and application of fluorescent peptides for both in vitro and in vivo imaging of fungal cells. In this article, we review different strategies used in the preparation of fluorescent peptides for pathogenic fungi as well as some of their applications in medical imaging and in mode-of-action mechanistic studies.

Susceptibility Testing of Fungi to Antifungal Drugs

Susceptibility testing of fungi against antifungal drugs commonly used for therapy is a key component of the care of patients with invasive fungal infections. Antifungal susceptibility testing (AFST) has progressed in recent decades to finally become standardized and available as both Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methods and in commercial manual/automated phenotypic methods. In clinical practice, the Sensititre YeastOne and Etest methods are widely used for AFST, particularly for sterile site isolates of Candida. Nevertheless, AFST is moving toward new phenotypic methods, such as matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), that are capable of providing rapid, and potentially more actionable, results for the treating clinician. Our objective is to summarize updated data on phenotypic methods for AFST of Candida and Aspergillus species and to assess their significance in view of opposing, but emerging, molecular genotypic methods.

The Elusive Anti-Candida Vaccine: Lessons From the Past and Opportunities for the Future

Candidemia is a bloodstream fungal infection caused by Candida species and is most commonly observed in hospitalized patients. Even with proper antifungal drug treatment, mortality rates remain high at 40–50%. Therefore, prophylactic or preemptive antifungal medications are currently recommended in order to prevent infections in high-risk patients. Moreover, the majority of women experience at least one episode of vulvovaginal candidiasis (VVC) throughout their lifetime and many of them suffer from recurrent VVC (RVVC) with frequent relapses for the rest of their lives. While there currently exists no definitive cure, the only available treatment for RVVC is again represented by antifungal drug therapy. However, due to the limited number of existing antifungal drugs, their associated side effects and the increasing occurrence of drug resistance, other approaches are greatly needed. An obvious prevention measure for candidemia or RVVC relapse would be to immunize at-risk patients with a vaccine effective against Candida infections. In spite of the advanced and proven techniques successfully applied to the development of antibacterial or antiviral vaccines, however, no antifungal vaccine is still available on the market. In this review, we first summarize various efforts to date in the development of anti-Candida vaccines, highlighting advantages and disadvantages of each strategy. We next unfold and discuss general hurdles encountered along these efforts, such as the existence of large genomic variation and phenotypic plasticity across Candida strains and species, and the difficulty in mounting protective immune responses in immunocompromised or immunosuppressed patients. Lastly, we review the concept of “trained immunity” and discuss how induction of this rapid and nonspecific immune response may potentially open new and alternative preventive strategies against opportunistic infections by Candida species and potentially other pathogens.

Bis-guanylhydrazones as efficient anti-Candida compounds through DNA interaction

Candida spp. are leading causes of opportunistic mycoses, including life-threatening hospital-borne infections, and novel antifungals, preferably aiming targets that have not been used before, are constantly needed. Hydrazone- and guanidine-containing molecules have shown a wide range of biological activities, including recently described excellent antifungal properties. In this study, four bis-guanylhydrazone derivatives (BG1-4) were generated following a previously developed synthetic route. Anti-Candida (two C. albicans, C. glabrata, and C. parapsilosis) minimal inhibitory concentrations (MICs) of bis-guanylhydrazones were between 2 and 15.6 μg/mL. They were also effective against preformed 48-h-old C. albicans biofilms. In vitro DNA interaction, circular dichroism, and molecular docking analysis showed the great ability of these compounds to bind fungal DNA. Competition with DNA-binding stain, exposure of phosphatidylserine at the outer layer of the cytoplasmic membrane, and activation of metacaspases were shown for BG3. This pro-apoptotic effect of BG3 was only partially due to the accumulation of reactive oxygen species in C. albicans, as only twofold MIC and higher concentrations of BG3 caused depolarization of mitochondrial membrane which was accompanied by the decrease of the activity of fungal mitochondrial dehydrogenases, while the activity of oxidative stress response enzymes glutathione reductase and catalase was not significantly affected. BG3 showed synergistic activity with amphotericin B with a fractional inhibitory concentration index of 0.5. It also exerted low cytotoxicity and the ability to inhibit epithelial cell (TR146) invasion and damage by virulent C. albicans SC5314. With further developments, BG3 may further progress in the antifungal pipeline as a DNA-targeting agent.

Antimicrobial activity of ceftobiprole and comparator agents when tested against contemporary Gram-positive and -negative organisms collected from Europe (2015)

Susceptibility testing of ceftobiprole and comparators against 12,240 isolates was performed following CLSI/EUCAST guidelines. The percentage of susceptible MRSA isolates was higher for ceftobiprole (96.5% susceptible) than for ceftaroline (86.2% susceptible). Both ceftobiprole (MIC_50/90, 0.5/2 mg/L) and ceftaroline (MIC_50/90, 0.25/1 mg/L) demonstrated potent activity against coagulase-negative staphylococci. Ceftobiprole demonstrated good potency against Enterococcus faecalis (MIC_50/90 values of 0.5/2 mg/L); ceftaroline (MIC_50/90, 2/8 mg/L) was 4-fold less active against these strains. Ceftobiprole activity was comparable to that of the other β-lactam agents tested against S. pneumoniae (MIC_90, 0.5 mg/L vs 0.12-2 mg/L [other β-lactams]), viridans-group streptococci (MIC₉₀,0.25 mg/L vs 0.006-1 mg/L [other β-lactams]), and β-hemolytic streptococci (MIC_90,0.03 mg/L vs 0.015-0.06 mg/L [other β-lactams]). Overall, 73.8% of Enterobacteriaceae isolates tested were susceptible to ceftobiprole. Ceftobiprole inhibited 70.4% of P. aeruginosa at ≤4 mg/L and all isolates of Haemophilus influenzae and Moraxella catarrhalis at ≤ 0.5 mg/L. Ceftobiprole was active in vitro against a broad range of clinically-relevant contemporary Gram-positive and Gram-negative bacterial isolates.

Bacterial Nosocomial Infections and Antimicrobial Susceptibility Pattern among Patients Admitted at Hiwot Fana Specialized University Hospital, Eastern Ethiopia

Nosocomial infections remain a major cause of mortality and morbidity worldwide. Despite the highly specialized interventions and policies, the rate of infection is still high due to the emergence of antimicrobial-resistant bacteria. This study described the prevalence of bacterial nosocomial infections and antimicrobial susceptibility pattern of isolates among patients admitted at Hiwot Fana Specialized University Hospital, Eastern Ethiopia. A hospital-based cross-sectional study was conducted among 394 nosocomial infection-suspected patients from March 2017 to July 2017. Data were collected using a structured questionnaire. Specimens from the respective site of infections were collected and examined for the presence of pathogenic bacteria and their antimicrobial susceptibility using standard culture and serological tests. Data were summarized using descriptive statistics. The prevalence of culture-confirmed bacterial nosocomial infection was 6.9% (95% CI: 4.3-7.9). Staphylococcus aureus (18.5%) was the most common isolate followed by Escherichia coli (16.7%). S. aureus showed 80% resistance to chloramphenicol and erythromycin, and 70% to cephalexin and tetracycline, respectively. A methicillin-resistant S. aureus made up 88.9% of all S. aureus isolates. Pseudomonas aeruginosa showed 83.7% resistance to each of ceftazidime and cephalexin, and 66.7% to chloramphenicol. The most common multidrug-resistant isolates were P. aeruginosa (30.4%) and S. aureus (21.7%). The prevalence of nosocomial infections in this study was comparable with other findings; however, the high rates of antimicrobial resistant isolates represent a substantial threat to the patients, communities, health care providers, and modern medical practices. Bacterial nosocomial infection treatment should be supported by culture isolation and antimicrobial susceptibility testing.

An investigation of antifungal stewardship programmes in England

PURPOSE

We sought to explore the current status of antifungal stewardship (AFS) initiatives across National Health Service (NHS) Trusts within England, the challenges and barriers, as well as ways to improve current AFS programmes.

METHODOLOGY

An electronic survey was sent to all 155 acute NHS Trusts in England. A total of 47 Trusts, corresponding to 30 % of English acute Trusts, responded to the the survey; 46 Trusts (98 %) had an antimicrobial stewardship (AMS) programme but only 5 (11 %) had a dedicated AFS programme. Overall, 20 (43 %) Trusts said they included AFS as part of their AMS programmes. From those conducting AFS programmes, 7 (28 %) have an AFS/management team, 16 (64 %) monitor and report on antifungal usage, 5 (20 %) have dedicated AFS ward rounds and 12 (48 %) are directly involved in the management of invasive fungal infections.Results/Key findings. Altogether, 13 acute Trusts (52 %) started their AFS programme to manage costs, whilst 12 (48 %) commenced the programme due to clinical need; 27 (73 %) declared that they would increase their AFS initiatives if they could. Of those without an AFS programme, 14 (67 %) responded that this was due to lack of resources/staff time. Overall, 12 Trusts (57 %) responded that the availability of rapid diagnostics and clinical support would enable them to conduct AFS activities.

CONCLUSION

Although a minority of Trusts conduct dedicated AFS programmes, nearly half include AFS as part of routine AMS activities. Cost issues are the main driver for AFS, followed by clinical need. The availability of rapid diagnostics and clinical support could help increase AFS initiatives.

Readiness for antimicrobial resistance (AMR) surveillance in Pakistan; a model for laboratory strengthening

BACKGROUND

Limited capacity of laboratories for antimicrobial susceptibility testing (AST) presents a critical diagnostic bottleneck in resource limited countries. This paper aims to identify such gaps and to explore whether laboratory networks could contribute towards improving AST in low resource settings.

METHODS

A self-assessment tool to assess antimicrobial susceptibility testing capacity was administered as a pre-workshop activity to participants from 30 microbiology laboratories in 3 cities in Pakistan. Data from public and private laboratories was analyzed and capacity of each scored in percentage terms. Laboratories from Karachi were invited to join a support network. A cohort of five laboratories that consented were provided additional training and updates sessions over a period of 15 months. Impact of training activities in these laboratories was evaluated using a point scoring (0-11) tool.

RESULTS

Results of self-assessment component identified a number of areas that required strengthening (scores of ≤60%). These included; readiness for AMR surveillance; 38 and 46%, quality assurance; 49 and 55%, and detection of specific organisms; 56 and 60% for public and private laboratories respectively. No significant difference was detected in AST capacity between public and private laboratories [ANOVA; p > 0.05]. Scoring tool used to assess impact of training within the longitudinal cohort showed an increase from a baseline of 1-5.5 (August 2015) to improved post training scores of 7-11 (October 2016) for the 5 laboratories included. Moreover, statistical analysis using paired t-Test Analysis, assuming unequal variance, indicated that the increase in scored noted represents a statistically significant improvement in the components evaluated [p < 0.05].

CONCLUSION

Strengthening of laboratory capacity for AMR surveillance is important. Our data shows that close mentoring and support can help enhance capacity for antimicrobial sensitivity testing in resource limited settings. Our study further presents a model wherein laboratory networks can be successfully established and used towards improving diagnostic capacity in such settings.

Future Research Priorities in Fungal Resistance

Improved understanding of basic mycological, pharmacological, and immunological processes has led to important advances in the diagnosis and treatment of invasive fungal infections. However, the rise of fungi that are resistant to existing antifungal agents poses a substantial threat to human health. Addressing this expanding problem is an urgent priority for the international research community. In this article, we highlight important diagnostic and therapeutic advances that address the rise of resistant fungi as well as new public health initiatives that warrant further investigation to help curb the spread of these potentially lethal organisms.