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Dladla M, Gyzenhout M, Marias G, Ghosh S. Azole resistance in Aspergillus fumigatus- comprehensive review. Arch Microbiol 2024; 206:305. [PMID: 38878211 DOI: 10.1007/s00203-024-04026-z] [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: 05/02/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
Aspergillus fumigatus is a ubiquitous filamentous fungus commonly found in the environment. It is also an opportunistic human pathogen known to cause a range of respiratory infections, such as invasive aspergillosis, particularly in immunocompromised individuals. Azole antifungal agents are widely used for the treatment and prophylaxis of Aspergillus infections due to their efficacy and tolerability. However, the emergence of azole resistance in A. fumigatus has become a major concern in recent years due to their association with increased treatment failures and mortality rates. The development of azole resistance in A. fumigatus can occur through both acquired and intrinsic mechanisms. Acquired resistance typically arises from mutations in the target enzyme, lanosterol 14-α-demethylase (Cyp51A), reduces the affinity of azole antifungal agents for the enzyme, rendering them less effective, while intrinsic resistance refers to a natural resistance of certain A. fumigatus isolates to azole antifungals due to inherent genetic characteristics. The current review aims to provide a comprehensive overview of azole antifungal resistance in A. fumigatus, discusses underlying resistance mechanisms, including alterations in the target enzyme, Cyp51A, and the involvement of efflux pumps in drug efflux. Impact of azole fungicide uses in the environment and the spread of resistant strains is also explored.
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Affiliation(s)
- Mthokozisi Dladla
- Department of Genetics, Faculty of Natural and Agricultural Sciences, University of the Free State, Bloemfontein, 9301, South Africa
| | - Marieka Gyzenhout
- Department of Genetics, Faculty of Natural and Agricultural Sciences, University of the Free State, Bloemfontein, 9301, South Africa.
| | - Gert Marias
- Department of Plant Sciences, Division of Plant Pathology, Faculty of Natural and Agricultural Sciences, University of the Free State, Bloemfontein, South Africa
| | - Soumya Ghosh
- Department of Genetics, Faculty of Natural and Agricultural Sciences, University of the Free State, Bloemfontein, 9301, South Africa.
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa 616, Birkat Al Mawz, Oman.
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Tan XT, Mokhtar NNB, Hii S, Amran F. Antifungal Susceptibility and Genotypic Analysis of cyp51A Mutations in Aspergillus fumigatus Isolates in Malaysia. Infect Drug Resist 2024; 17:2159-2168. [PMID: 38828376 PMCID: PMC11144424 DOI: 10.2147/idr.s452619] [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: 12/08/2023] [Accepted: 04/09/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Azole resistance in Aspergillus fumigatus poses a significant challenge in the management of invasive aspergillosis. This study aimed to investigate the antifungal susceptibility and cyp51A mutation profiles of A. fumigatus isolates in Malaysia. Patients and Methods Sixty clinical A. fumigatus isolates were collected and subjected to antifungal susceptibility testing (AFST) and molecular analysis. The antifungal susceptibility testing was performed according to CLSI M38 guideline. The geometric mean (GM) minimum inhibitory concentration (MIC), MIC50/MIC90 for voriconazole, itraconazole, posaconazole, amphotericin B, and isavuconazole against A. fumigatus in non-invasive cases and invasive cases were calculated. In addition, the presence of cyp51A mutations was also identified. Results The present study revealed an overall resistance rate of 6.7% among the isolates. In non-invasive cases, isavuconazole and posaconazole demonstrated the lowest GM MIC of 0.08 µg/mL. Following them were itraconazole, voriconazole, and amphotericin B with concentrations of 0.15µg/mL, 0.16µg/mL and 0.90µg/mL, respectively. Similarly, in invasive cases, isavuconazole and posaconazole exhibited the lowest GM MIC of 0.09µg/mL. Following them were itraconazole, voriconazole, and amphotericin B with concentrations of 0.14µg/mL, 0.17µg/mL and 0.80µg/mL, respectively. Genotypic analysis revealed various cyp51A mutations, including F46Y, M172V, N248K, R34L, V244A, V244S, and E427K. However, not all mutations corresponded to antifungal resistance. Conclusion The majority of clinical Aspergillus fumigatus isolates demonstrated susceptibility to the antifungal agents tested, with isavuconazole and posaconazole demonstrating the lowest MIC values. However, cyp51A mutations were discovered without a consistent correlation to antifungal resistance, emphasising the need for additional research.
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Affiliation(s)
- Xue Ting Tan
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Nurin Nazirah Binti Mokhtar
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Shirley Yi Fen Hii
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Fairuz Amran
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
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Stover KR, Hawkins BK, Keck JM, Barber KE, Cretella DA. Antifungal resistance, combinations and pipeline: oh my! Drugs Context 2023; 12:2023-7-1. [PMID: 38021410 PMCID: PMC10653594 DOI: 10.7573/dic.2023-7-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 12/01/2023] Open
Abstract
Invasive fungal infections are a strong contributor to healthcare costs, morbidity and mortality, especially amongst hospitalized patients. Historically, Candida was responsible for approximately 15% of all nosocomial bloodstream infections. In the past 10 years, the epidemiology of Candida species has altered, with increasing prevalence of resistant species. With rising fungal resistance, especially in Candida spp., the demand for novel antifungal therapies has exponentially increased over the last decade. Newer antifungal agents have become an attractive option for patients needing long-term therapy for infections or those requiring antifungal prophylaxis. Despite advances in coverage of non-Candida pathogens with newer agents, clinical scenarios involving multidrug-resistant fungal pathogens continue to arise in practice. Combination antifungal therapy can lead to a host of side-effects, some of which can be drug limiting. Additional antifungal therapies with enhanced fungal spectrum of activity and decreased rates of adverse effects are warranted. Fosmanogepix, ibrexafungerp, olorofim and rezafungin may help fill some of these gaps in the antifungal armamentarium. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.
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Affiliation(s)
- Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Brandon K Hawkins
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center, Knoxville, TN, USA
| | - J Myles Keck
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - David A Cretella
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
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Zhang Y, Wang S, Zhou C, Zhang Y, Pan J, Pan B, Wang B, Hu B, Guo W. Epidemiology of Clinically Significant Aspergillus Species from a Large Tertiary Hospital in Shanghai, China, for the Period of Two Years. Infect Drug Resist 2023; 16:4645-4657. [PMID: 37484905 PMCID: PMC10361289 DOI: 10.2147/idr.s417840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Aspergillus species are becoming a major public health concern worldwide due to the increase in the incidence of aspergillosis and emergence of antifungal resistance. In this study, we surveyed all Aspergillus species isolated from aspergillosis patients in Zhongshan Hospital Fudan University, Shanghai, China, from 2019 to 2021. Methods We characterized the susceptibility profiles of these Aspergillus species to medical azoles (voriconazole, itraconazole and posaconazole) using YeastOneTM broth microdilution system. To determine the underlying antifungal resistance mechanisms in azole-resistant A. fumigatus (ARAf) isolates, we characterized mutations in the cyp51A gene. Genotypic diversity of sampled A. fumigatus was investigated using CSP-typing. Results A total of 112 Aspergillus isolates (81 A. fumigatus, 17 A. flavus, 5 A. niger, 2 A. terreus, 2 A. lentulus, 2 A. oryzae, 1 A. nidulans, 1 A. versicolor and 1 A. sydowii) from 105 patients diagnosed with aspergillosis (including proven or probable invasive aspergillosis, chronic pulmonary aspergillosis, allergic bronchopulmonary aspergillosis and cutaneous aspergillosis) were obtained. Eight isolates (7 A. fumigatus and 1 A. niger) from seven patients were either azole non-susceptible or non-wild type. Azole non-susceptible or non-wild type rate was 7.1%/isolate and 6.7%/patient analysed. Four ARAf harbored TR34/L98H mutation, whereas one carried TR46/Y121F/T289A allele. The 81 A. fumigatus isolates were spread across 8 CSP types with t01 to be the predominant type (53.1%). ARAf isolates were distributed over CSP types t01, t02, t04A and t11. Conclusion Results from this study provided us with an understanding of the antifungal resistance and related characteristics of Aspergillus species in Eastern China. Further comparisons of our results with those in other countries reflect potential clonal expansion of A. fumigatus in our region. Further surveillance study is warranted to guide antifungal therapy and for epidemiological purposes.
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Affiliation(s)
- Yuyi Zhang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Suzhen Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Chunmei Zhou
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yao Zhang
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jue Pan
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Bijie Hu
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
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Pulmonary Aspergillosis in Humboldt Penguins—Susceptibility Patterns and Molecular Epidemiology of Clinical and Environmental Aspergillus fumigatus Isolates from a Belgian Zoo, 2017–2022. Antibiotics (Basel) 2023; 12:antibiotics12030584. [PMID: 36978451 PMCID: PMC10044460 DOI: 10.3390/antibiotics12030584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Aspergillus fumigatus is the main causative agent of avian aspergillosis and results in significant health problems in birds, especially those living in captivity. The fungal contamination by A. fumigatus in the environment of Humboldt penguins (Spheniscus humboldti), located in a Belgian zoo, was assessed through the analysis of air, water, sand and nest samples during four non-consecutive days in 2021–2022. From these samples, potential azole-resistant A. fumigatus (ARAF) isolates were detected using a selective culture medium. A total of 28 veterinary isolates obtained after necropsy of Humboldt penguins and other avian species from the zoo were also included. All veterinary and suspected ARAF isolates from the environment were characterized for their azole-resistance profile by broth microdilution. Isolates displaying phenotypic resistance against at least one medical azole were systematically screened for mutations in the cyp51A gene. A total of 14 (13.6%) ARAF isolates were identified from the environment (n = 8) and from Humboldt penguins (n = 6). The TR34/L98H mutation was observed in all resistant environmental strains, and in two resistant veterinary strains. To the best of our knowledge, this is the first description of this mutation in A. fumigatus isolates from Humboldt penguins. During the period 2017–2022, pulmonary aspergillosis was confirmed in 51 necropsied penguins, which reflects a death rate due to aspergillosis of 68.0%, mostly affecting adults. Microsatellite polymorphism analysis revealed a high level of diversity among environmental and veterinary A. fumigatus isolates. However, a cluster was observed between one veterinary isolate and six environmental strains, all resistant to medical azoles. In conclusion, the environment of the Humboldt penguins is a potential contamination source of ARAF, making their management even more complex.
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Chen X, Lei W, Meng H, Jiang Y, Zhang S, Chen H, Du M, Xue X. Succinylation modification provides new insights for the treatment of immunocompromised individuals with drug-resistant Aspergillus fumigatus infection. Front Immunol 2023; 14:1161642. [PMID: 37138872 PMCID: PMC10150703 DOI: 10.3389/fimmu.2023.1161642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 05/05/2023] Open
Abstract
Invasive Aspergillus fumigatus infection poses a serious threat to global human health, especially to immunocompromised individuals. Currently, triazole drugs are the most commonly used antifungals for aspergillosis. However, owing to the emergence of drug-resistant strains, the effect of triazole drugs is greatly restricted, resulting in a mortality rate as high as 80%. Succinylation, a novel post-translational modification, is attracting increasing interest, although its biological function in triazole resistance remains unclear. In this study, we initiated the screening of lysine succinylation in A. fumigatus. We discovered that some of the succinylation sites differed significantly among strains with unequal itraconazole (ITR) resistance. Bioinformatics analysis showed that the succinylated proteins are involved in a broad range of cellular functions with diverse subcellular localizations, the most notable of which is cell metabolism. Further antifungal sensitivity tests confirmed the synergistic fungicidal effects of dessuccinylase inhibitor nicotinamide (NAM) on ITR-resistant A. fumigatus. In vivo experiments revealed that treatment with NAM alone or in combination with ITR significantly increased the survival of neutropenic mice infected with A. fumigatus. In vitro experiments showed that NAM enhanced the killing effect of THP-1 macrophages on A. fumigatus conidia. Our results suggest that lysine succinylation plays an indispensable role in ITR resistance of A. fumigatus. Dessuccinylase inhibitor NAM alone or in combination with ITR exerted good effects against A. fumigatus infection in terms of synergistic fungicidal effect and enhancing macrophage killing effect. These results provide mechanistic insights that will aid in the treatment of ITR-resistant fungal infections.
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Affiliation(s)
- Xianzhen Chen
- Institute of Dermatology, Naval Medical University, Shanghai, China
- Department of Dermatology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wenzhi Lei
- Institute of Dermatology, Naval Medical University, Shanghai, China
| | - Hui Meng
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
| | - Yi Jiang
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
| | - Sanli Zhang
- Department of Nephrology, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Huyan Chen
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
| | - Mingwei Du
- Department of Cardiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
| | - Xiaochun Xue
- Department of Pharmacy, 905th Hospital of People's Liberation Army of China (PLA) Navy, Shanghai, China
- *Correspondence: Huyan Chen, ; Mingwei Du, ; Xiaochun Xue,
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Verweij PE, Arendrup MC, Alastruey-Izquierdo A, Gold JAW, Lockhart SR, Chiller T, White PL. Dual use of antifungals in medicine and agriculture: How do we help prevent resistance developing in human pathogens? Drug Resist Updat 2022; 65:100885. [PMID: 36283187 PMCID: PMC10693676 DOI: 10.1016/j.drup.2022.100885] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/27/2022]
Abstract
Azole resistance in Aspergillus fumigatus is a One Health resistance threat, where azole fungicide exposure compromises the efficacy of medical azoles. The use of the recently authorized fungicide ipflufenoquin, which shares its mode-of-action with a new antifungal olorofim, underscores the need for risk assessment for dual use of antifungals.
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Affiliation(s)
- Paul E Verweij
- Department of Medical Microbiology and Radboudumc-CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, the Netherlands; Centre for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
| | - Maiken C Arendrup
- Unit for Mycology, Statens Serum Insitut, Copenhagen, Denmark; Department of Medical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | | | - Jeremy A W Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - P Lewis White
- Public Health Wales Mycology Reference Laboratory, Cardiff, United Kingdom
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