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Yerbanga IW, Lagrou K, Merckx R, Nakanabo Diallo S, Gangneux JP, Delabarre A, Denis O, Rodriguez-Villalobos H, Montesinos I, Bamba S. First detection of triazole-resistant aspergillus fumigatus harbouring the TR34/L98H Cyp51A mutation in Burkina Faso. Mycoses 2024; 67:e13732. [PMID: 38712846 DOI: 10.1111/myc.13732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Triazole-resistant Aspergillus fumigatus (TRAF) isolates are a growing public health problem with worldwide distribution. Epidemiological data on TRAF is limited in Africa, particularly in West Africa. OBJECTIVES This study aimed to screen for the environmental presence of TRAF isolates in the indoor air of two hospitals in Burkina Faso. MATERIALS AND METHODS Air samples were collected in wards housing patients at risk for invasive aspergillosis, namely infectious diseases ward, internal medicine ward, nephrology ward, pulmonology ward, medical emergency ward and paediatric ward. Sabouraud Dextrose Agar supplemented with triazoles was used to screen the suspected TRAF isolates and EUCAST method to confirm the resistance of suspected isolates. Sequencing of cyp51A gene was used to identify the resistance mechanism of confirmed TRAF isolates. RESULTS Of the 198 samples collected and analysed, 67 showed growth of A. fumigatus isolates. The prevalence of TRAF isolates was 3.23% (4/124). One TRAF isolate exhibited a pan-triazole resistance. Sequencing of cyp51A gene identified the TR34/L98H mutation for this pan-triazole resistant isolate. This study showed for the first time the circulation of the pan-azole resistant isolate harbouring the TR34/L98H mutation in Burkina Faso. CONCLUSIONS These findings emphasise the need to map these TRAF isolates in all parts of Burkina Faso and to establish local and national continuous surveillance of environmental and clinical TRAF isolates in this country.
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Affiliation(s)
- Isidore W Yerbanga
- Centre Hospitalier Universitaire Régional de Ouahigouya, Ouahigouya, Burkina Faso
- Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, Excellence Center for Medical Mycology (ECMM), University Hospitals Leuven, Leuven, Belgium
| | - Rita Merckx
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, Excellence Center for Medical Mycology (ECMM), University Hospitals Leuven, Leuven, Belgium
| | - Seydou Nakanabo Diallo
- Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
- Centre Muraz/Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | - Jean-Pierre Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), European ECMM Excellence Center in Medical Mycology, Rennes, France
| | - Aymeric Delabarre
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), European ECMM Excellence Center in Medical Mycology, Rennes, France
| | - Olivier Denis
- Department of Microbiology, CHU Namur site-Godinne, Université Catholique de Louvain, Brussels, Belgium
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Hector Rodriguez-Villalobos
- Department of Microbiology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain, Brussels, Belgium
| | - Isabel Montesinos
- Department of Microbiology, CHU Namur site-Godinne, Université Catholique de Louvain, Brussels, Belgium
| | - Sanata Bamba
- Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
- Centre Hospitalier Universitaire Sourô Sanou, Bobo-Dioulasso, Burkina Faso
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2
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Ghazanfari M, Abastabar M, Haghani I, Kermani F, Keikha N, Kholoujini M, Minooeianhaghighi MH, Jeddi SA, Shokri A, Ghojoghi A, Amirizad K, Azish M, Nasirzadeh Y, Roohi B, Nosratabadi M, Hedayati S, Ghanbari S, Valadan R, Hedayati MT. Electronic equipment and appliances in special wards of hospitals as a source of azole-resistant Aspergillus fumigatus: a multi-centre study from Iran. J Hosp Infect 2024; 145:65-76. [PMID: 38199436 DOI: 10.1016/j.jhin.2023.12.011] [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: 09/01/2023] [Revised: 12/05/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Azole-resistant Aspergillus fumigatus (ARAf), reported as a global public health concern, has been unexpectedly observed in different countries. AIM To identify ARAf and detect azole resistance related to the CYP51A mutation in different hospital environmental samples. METHODS In this multi-centre study from Iran, surfaces of electronic equipment and appliances from different hospitals in Iran were sampled using cotton swabs. All samples were cultured using azole-containing agar plates (ACAPs). Recovered Aspergillus isolates were identified at the species level using partial DNA sequencing of the β-tubulin gene. The azole susceptibility testing of A. fumigatus isolates was performed using the Clinical and Laboratory Standards Institute M38-A3 guideline. The sequencing of the CYP51A gene was also performed to detect mutations related to resistance. FINDINGS Out of the 693 collected samples, 89 (12.8%) Aspergillus species were recovered from ACAPs. Aspergillus fumigatus (41.6%) was the most prevalent, followed by A. tubingensis (23.6%) and A. niger (15.6%). Among 37 isolates of A. fumigatus, 19 (51.3%) showed high minimum inhibitory concentration (MIC) values to at least one of the three azoles, voriconazole, itraconazole, and posaconazole. CYP51A polymorphisms were detected in all 19 isolates, of which 52.6% showed the TR34/L98H mutation. Other detected mutations were G432C, G448S, G54E/G138C, F46Y, and Y121F/M220I/D255E. T289F and G432C were the first reported mutations in ARAf. CONCLUSION There was a considerable level of azole resistance in hospital environmental samples, a serious warning for patients vulnerable to aspergillosis. Our findings have also revealed a different mutation pattern in the CYP51A gene.
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Affiliation(s)
- M Ghazanfari
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - I Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - F Kermani
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - N Keikha
- Infectious Disease and Tropical Medicine Research Center, Research Institute of Cellular and Molecular Sciences in Infectious Diseases, Zahedan University of Medical Sciences, Zahedan, Iran
| | - M Kholoujini
- Beheshti Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - M H Minooeianhaghighi
- Department of Medical Microbiology, Faculty of Medicine, Infectious Diseases Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - S A Jeddi
- Department of Laboratory Sciences, School of Allied Sciences, Abadan University of Medical Sciences, Abadan, Iran
| | - A Shokri
- Vector-Borne Diseases Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - A Ghojoghi
- Department of Medical Mycology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - K Amirizad
- Department of Mycology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - M Azish
- Department of Medical Parasitology and Mycology, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran
| | - Y Nasirzadeh
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - B Roohi
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M Nosratabadi
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Laboratory Sciences, Sirjan Faculty of Medical Sciences, Sirjan, Iran
| | - S Hedayati
- Student Research Committee Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - S Ghanbari
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran; Student Research Committee Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - R Valadan
- Department of Immunology/Molecular and Cell Biology Research Center (MCBRC), Mazandaran University of Medical Sciences, Sari, Iran
| | - M T Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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3
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Lockhart SR, Chowdhary A, Gold JAW. The rapid emergence of antifungal-resistant human-pathogenic fungi. Nat Rev Microbiol 2023; 21:818-832. [PMID: 37648790 DOI: 10.1038/s41579-023-00960-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
During recent decades, the emergence of pathogenic fungi has posed an increasing public health threat, particularly given the limited number of antifungal drugs available to treat invasive infections. In this Review, we discuss the global emergence and spread of three emerging antifungal-resistant fungi: Candida auris, driven by global health-care transmission and possibly facilitated by climate change; azole-resistant Aspergillus fumigatus, driven by the selection facilitated by azole fungicide use in agricultural and other settings; and Trichophyton indotineae, driven by the under-regulated use of over-the-counter high-potency corticosteroid-containing antifungal creams. The diversity of the fungi themselves and the drivers of their emergence make it clear that we cannot predict what might emerge next. Therefore, vigilance is critical to monitoring fungal emergence, as well as the rise in overall antifungal resistance.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Medical Mycology Unit, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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4
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Stewart AG, Isler B, Simos P, Farquhar D, George N, Golmayo M, Heney C. Aspergillus Species Causing Invasive Fungal Disease in Queensland, Australia. Mycopathologia 2023:10.1007/s11046-023-00713-5. [PMID: 37067664 DOI: 10.1007/s11046-023-00713-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/05/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Aspergillus species are important causes of invasive fungal disease, particularly among those with an impaired immune system. Increasing reports have revealed a rising incidence of antifungal drug resistance among Aspergillus spp., particularly among cryptic species. Understanding local antifungal susceptibility patterns is paramount to delivering optimal clinical care. METHODS Aspergillus spp. recovered from clinical specimens between 2000 and 2021 from Pathology Queensland were collected. Aspergillus spp. were identified routinely morphologically, and where there was ambiguity or a lack of sporulation, by sequencing of the internal transcribed spacer (ITS) region. All Aspergillus spp. that underwent antifungal susceptibility testing according to the CLSI M38-A3 method and were recorded and included in the study. Amphotericin B, voriconazole, posaconazole, isavuconazole, micafungin, caspofungin, and anidulafungin were tested. Pathology Queensland services all public healthcare facilities in Queensland, Australia. RESULTS 236 Aspergillus spp. were identified from clinical specimens during the study period. The most frequent species identified were Aspergillus section Fumigati (n = 119), Aspergillus section Flavi (n = 35), Aspergillus terreus (n = 32) and Aspergillus niger (n = 29). Overall, MIC50/90 values for voriconazole, posaconazole, itraconazole, and isavuconazole were 0.25/1, 0.25/0.5, 0.25/0.5, and 0.5/2 mg/L respectively. Echinocandins demonstrated low MIC values overall with micafungin and anidulafungin both having an MIC50/90 of 0.015/0.03 mg/L. A total of 15 cryptic species were identified; high triazole MIC values were observed with a voriconazole MIC50/90 of 2/8 mg/L. From 2017 to 2021 we observed an increase in incidence of isolates with high voriconazole MIC values. There was no difference in voriconazole MIC values between Aspergillus spp. acquired in North Queensland when compared to Southeast Queensland, Australia. CONCLUSION Increasing reports of antifungal resistance among Aspergillus spp. is concerning and warrants further investigation both locally and worldwide. Active surveillance of both the emergence of different Aspergillus spp. and changes in antifungal susceptibility patterns over time is crucial to informing clinicians and treatment guidelines.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia.
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Central Microbiology, Pathology Queensland, Brisbane, Australia.
| | - Burcu Isler
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Peter Simos
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Drew Farquhar
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Narelle George
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Mila Golmayo
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Claire Heney
- Central Microbiology, Pathology Queensland, Brisbane, Australia
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5
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Amona MF, Oladele RO, Resendiz-Sharpe A, Denning DW, Kosmidis C, Lagrou K, Zhong H, Han L. Triazole resistance in Aspergillus fumigatus isolates in Africa: a systematic review. Med Mycol 2022; 60:6652216. [PMID: 35906879 DOI: 10.1093/mmy/myac059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Emergence of triazole resistance has been observed in Aspergillus fumigatus over the past decade including in Africa. This review summarizes the current published data on the epidemiology and reported mechanisms of triazole-resistant Aspergillus fumigatus (TRAF) in both environmental and clinical isolates from Africa. Searches on databases Medline, PubMed, HINARI, Science Direct, Scopus and Google Scholar on triazole resistance published between 2000 and 2021 from Africa were performed. Isolate source, antifungal susceptibility using internationally recognized methods, cyp51A mechanism of resistance and genotype were collected. Eleven published African studies were found that fitted the search criteria; these were subsequently analyzed. In total this constituted of 1686 environmental and 46 clinical samples. A TRAF prevalence of 17.1% (66/387) and 1,3% (5/387) was found in respectively environmental and clinical settings in African studies. Resistant to itraconazole, voriconazole, and posaconazole was documented. Most of the triazole-resistant isolates (30/71, 42.25%) were found to possess the TR34/L98H mutation in the cyp51A-gene; fewer with TR46/Y121F/T289A (n = 8), F46Y/M172V/E427K (n = 1), G54E (n = 13), and M172V (n = 1) mutations. African isolates with the TR34/L98H, TR46/Y121F/T289A and the G54E mutations were closely related and could be grouped in one of two clusters (cluster-B), whereas the cyp51A-M172V mutation clustered with most cyp51A- WT strains (cluster-A). A single case from Kenya shows that TR34/L98H from environmental and clinical isolates are closely related. Our findings highlight that triazole resistance in environmental and clinical A. fumigatus is a cause for concern in a number of African countries. There is need for epidemiological surveillance to determine the true burden of the problem in Africa.
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Affiliation(s)
- Modeste Fructueux Amona
- Faculty of Health Sciences, Marien Ngouabi University, Brazzaville, Republic of Congo.,Research Center and Study of Infectious and Tropical Pathologies, Oyo, Republic of Congo
| | - Rita Okeoghene Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria.,Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Agustin Resendiz-Sharpe
- Department of Microbiology, Laboratory of Clinical Bacteriology and Mycology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Imaging and Pathology, Biomedical MRI, KU Leuven, Leuven, Belgium
| | - David W Denning
- Manchester Fungal Infection Group, the University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Chris Kosmidis
- National Aspergillosis Centre, Manchester University Foundation Trust, UK, and Manchester Academic Health Science Centre, the University of Manchester, Manchester, UK
| | - Katrien Lagrou
- Department of Microbiology, Laboratory of Clinical Bacteriology and Mycology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Hanying Zhong
- Department for Disinfection and Infection Control, Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Li Han
- Department for Disinfection and Infection Control, Chinese PLA Center for Disease Control and Prevention, Beijing, China
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6
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Novel Treatment Approach for Aspergilloses by Targeting Germination. J Fungi (Basel) 2022; 8:jof8080758. [PMID: 35893126 PMCID: PMC9331470 DOI: 10.3390/jof8080758] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/03/2022] [Accepted: 07/19/2022] [Indexed: 12/24/2022] Open
Abstract
Germination of conidia is an essential process within the Aspergillus life cycle and plays a major role during the infection of hosts. Conidia are able to avoid detection by the majority of leukocytes when dormant. Germination can cause severe health problems, specifically in immunocompromised people. Aspergillosis is most often caused by Aspergillus fumigatus (A. fumigatus) and affects neutropenic patients, as well as people with cystic fibrosis (CF). These patients are often unable to effectively detect and clear the conidia or hyphae and can develop chronic non-invasive and/or invasive infections or allergic inflammatory responses. Current treatments with (tri)azoles can be very effective to combat a variety of fungal infections. However, resistance against current azoles has emerged and has been increasing since 1998. As a consequence, patients infected with resistant A. fumigatus have a reported mortality rate of 88% to 100%. Especially with the growing number of patients that harbor azole-resistant Aspergilli, novel antifungals could provide an alternative. Aspergilloses differ in defining characteristics, but germination of conidia is one of the few common denominators. By specifically targeting conidial germination with novel antifungals, early intervention might be possible. In this review, we propose several morphotypes to disrupt conidial germination, as well as potential targets. Hopefully, new antifungals against such targets could contribute to disturbing the ability of Aspergilli to germinate and grow, resulting in a decreased fungal burden on patients.
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7
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Stevenson EM, Gaze WH, Gow NAR, Hart A, Schmidt W, Usher J, Warris A, Wilkinson H, Murray AK. Antifungal Exposure and Resistance Development: Defining Minimal Selective Antifungal Concentrations and Testing Methodologies. FRONTIERS IN FUNGAL BIOLOGY 2022; 3:918717. [PMID: 37746188 PMCID: PMC10512330 DOI: 10.3389/ffunb.2022.918717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/16/2022] [Indexed: 09/26/2023]
Abstract
This scoping review aims to summarise the current understanding of selection for antifungal resistance (AFR) and to compare and contrast this with selection for antibacterial resistance, which has received more research attention. AFR is an emerging global threat to human health, associated with high mortality rates, absence of effective surveillance systems and with few alternative treatment options available. Clinical AFR is well documented, with additional settings increasingly being recognised to play a role in the evolution and spread of AFR. The environment, for example, harbours diverse fungal communities that are regularly exposed to antifungal micropollutants, potentially increasing AFR selection risk. The direct application of effect concentrations of azole fungicides to agricultural crops and the incomplete removal of pharmaceutical antifungals in wastewater treatment systems are of particular concern. Currently, environmental risk assessment (ERA) guidelines do not require assessment of antifungal agents in terms of their ability to drive AFR development, and there are no established experimental tools to determine antifungal selective concentrations. Without data to interpret the selective risk of antifungals, our ability to effectively inform safe environmental thresholds is severely limited. In this review, potential methods to generate antifungal selective concentration data are proposed, informed by approaches used to determine antibacterial minimal selective concentrations. Such data can be considered in the development of regulatory guidelines that aim to reduce selection for AFR.
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Affiliation(s)
- Emily M. Stevenson
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
| | - William H. Gaze
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
| | - Neil A. R. Gow
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Alwyn Hart
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Wiebke Schmidt
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Jane Usher
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Adilia Warris
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Helen Wilkinson
- Chief Scientist’s Group, Environment Agency, Horizon House, Bristol, England, United Kingdom
| | - Aimee K. Murray
- European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall, United Kingdom
- Environment and Sustainability Institute, University of Exeter Medical School, Cornwall, United Kingdom
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8
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Kirchhoff L, Braun L, Schmidt D, Dittmer S, Dedy J, Herbstreit F, Stauf R, Steckel NK, Buer J, Rath PM, Steinmann J, Verhasselt HL. COVID-19-associated pulmonary aspergillosis in ICU patients in a German reference centre: phenotypic and molecular characterization of Aspergillus fumigatus isolates. Mycoses 2022; 65:458-465. [PMID: 35138651 PMCID: PMC9115305 DOI: 10.1111/myc.13430] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 01/08/2023]
Abstract
Background COVID‐19‐associated invasive pulmonary aspergillosis (CAPA) is associated with increased mortality. Cases of CAPA caused by azole‐resistant Aspergillus fumigatus strains have been reported. Objectives To analyse the twelve‐month CAPA prevalence in a German tertiary care hospital and to characterise clinical A. fumigatus isolates from two German hospitals by antifungal susceptibility testing and microsatellite genotyping. Patients/Methods. Retrospective observational study in critically ill adults from intensive care units with COVID‐19 from 17 February 2020 until 16 February 2021 and collection of A. fumigatus isolates from two German centres. EUCAST broth microdilution for four azole compounds and microsatellite PCR with nine markers were performed for each collected isolate (N = 27) and additional for three non‐COVID A. fumigatus isolates. Results welve‐month CAPA prevalence was 7.2% (30/414), and the rate of azole‐resistant A. fumigatus isolates from patients with CAPA was 3.7% with detection of one TR34/L98H mutation. The microsatellite analysis revealed no major clustering of the isolates. Sequential isolates mainly showed the same genotype over time. Conclusions Our findings demonstrate similar CAPA prevalence to other reports and a low azole‐resistance rate. Genotyping of A. fumigatus showed polyclonal distribution except for sequential isolates.
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Affiliation(s)
- Lisa Kirchhoff
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Lukas Braun
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Dirk Schmidt
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Silke Dittmer
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Jutta Dedy
- University Hospital Essen, Pharmacy, Germany
| | - Frank Herbstreit
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, Germany
| | - Raphael Stauf
- Institute of Hospital Hygiene and Clinical Microbiology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Nina Kristin Steckel
- Department of Bone Marrow Transplantation, West German Cancer Centre, University Hospital Essen, Essen, Germany
| | - Jan Buer
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Peter-Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
| | - Joerg Steinmann
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany.,Institute of Clinical Hygiene, Medical Microbiology and Infectiology, General Hospital Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Hedda Luise Verhasselt
- Institute of Medical Microbiology, University Hospital Essen, ECMM Centre of Excellence in Mycology, Germany
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9
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Bader O. Phylogenetic Distribution of csp1 Types in Aspergillus fumigatus and Their Correlates to Azole Antifungal Drug Resistance. Microbiol Spectr 2021; 9:e0121421. [PMID: 34787484 PMCID: PMC8597649 DOI: 10.1128/spectrum.01214-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
In Aspergillus fumigatus, the repetitive region of the csp1 gene is one of the most frequently used loci for intraspecies typing of this human pathogenic mold. Using PCR amplification and Sanger sequencing of only a single marker, csp1 typing is readily available to most laboratories and highly reproducible. Here, I evaluate the usefulness of the csp1 marker for resistance detection and epidemiologic stratification among A. fumigatus isolates. After resolving nomenclature conflicts from published studies and adding novel csp1 types, the number of known types now adds up to 38. Their distribution mostly correlates with A. fumigatus population structure, and they are also meaningful for narrowly defined cases of azole resistance phenotypes. Isolates carrying the pandemic resistance allele TR34/L98H show signs of interclade crossing of strains with t02 or t04A, into the t11 clade. Furthermore, absolute differences in voriconazole MIC values between t02/t04B versus t11 TR34/L98H isolates indicate that the genetic background of resistance mutations may have a pivotal role in cross-resistance phenotypes and, thus, clinical outcome and environmental selection. Despite the general genetic similarity of isolates with identical csp1 types, outcrossing into other clades is also observed. The csp1 type alone, therefore, does not sufficiently discriminate genetic clades to be used as the sole marker in epidemiologic studies. IMPORTANCE Aspergillus fumigatus is a ubiquitously distributed saprophytic mold and a leading cause of invasive aspergillosis in human hosts. Pandemic azole-resistant strains have emerged on a global scale, which are thought to be propagated through use of azole-based fungicides in agriculture. To perform epidemiologic studies, genetic typing of large cohorts is key. Here, I evaluate the usefulness of the frequently used csp1 marker for resistance detection and epidemiologic stratification among A. fumigatus isolates. The phylogenetic distribution of csp1 types mostly correlates with A. fumigatus population structure and is also meaningful for narrowly defined cases of azole resistance phenotypes. Nevertheless, outcrossing of csp1 into other clades is also observed. The csp1 type alone, therefore, does not sufficiently discriminate genetic clades and should not be used as the sole marker in epidemiologic studies.
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Affiliation(s)
- Oliver Bader
- Institute for Medical Microbiology and Virology, University Medical Center Göttingen, Göttingen, Germany
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10
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Rivelli Zea SM, Toyotome T. Azole-resistant Aspergillus fumigatus as an emerging worldwide pathogen. Microbiol Immunol 2021; 66:135-144. [PMID: 34870333 DOI: 10.1111/1348-0421.12957] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/19/2022]
Abstract
Aspergillus fumigatus, a ubiquitous pathogen, causes aspergillosis in humans, especially in immunodeficient patients. Azoles are frontline antifungal drugs for treating aspergillosis. The recent global emergence of azole resistance in A. fumigatus has become a serious problem worldwide. It has arisen through two routes: long-term azole medical therapy, called the patient route, and the use of azole fungicides in its habitats especially for agricultural activities, called the environmental route. Resistant strains developed through the latter route show cross-resistance to medical azoles because of the identical molecular target Cyp51A between azole compounds used for medical treatment and agricultural disease control. In azole-resistant strains arising through the environmental route, A. fumigatus is observed frequently possessing mutations in the cyp51A gene linked to tandem repeats in the promoter region such as TR34 /L98H and TR46 /Y121F/T289A. Results of microsatellite genotyping analyses of resistant A. fumigatus strains have suggested a transboundary spread of this microorganism in many countries. Diverse actors are involved in the global highway of transmission. Therefore, the matter must be addressed as a "One Health" issue. This review presents a background of azole resistance in A. fumigatus and introduces newly discovered difficulties generated as this pathogen spreads worldwide. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Takahito Toyotome
- Department of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine.,Diagnostic Center for Animal Health and Food Safety, Obihiro University of Agriculture and Veterinary Medicine.,Medical Mycology Research Center, Chiba University
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11
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Bastos RW, Rossato L, Goldman GH, Santos DA. Fungicide effects on human fungal pathogens: Cross-resistance to medical drugs and beyond. PLoS Pathog 2021; 17:e1010073. [PMID: 34882756 PMCID: PMC8659312 DOI: 10.1371/journal.ppat.1010073] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fungal infections are underestimated threats that affect over 1 billion people, and Candida spp., Cryptococcus spp., and Aspergillus spp. are the 3 most fatal fungi. The treatment of these infections is performed with a limited arsenal of antifungal drugs, and the class of the azoles is the most used. Although these drugs present low toxicity for the host, there is an emergence of therapeutic failure due to azole resistance. Drug resistance normally develops in patients undergoing azole long-term therapy, when the fungus in contact with the drug can adapt and survive. Conversely, several reports have been showing that resistant isolates are also recovered from patients with no prior history of azole therapy, suggesting that other routes might be driving antifungal resistance. Intriguingly, antifungal resistance also happens in the environment since resistant strains have been isolated from plant materials, soil, decomposing matter, and compost, where important human fungal pathogens live. As the resistant fungi can be isolated from the environment, in places where agrochemicals are extensively used in agriculture and wood industry, the hypothesis that fungicides could be driving and selecting resistance mechanism in nature, before the contact of the fungus with the host, has gained more attention. The effects of fungicide exposure on fungal resistance have been extensively studied in Aspergillus fumigatus and less investigated in other human fungal pathogens. Here, we discuss not only classic and recent studies showing that environmental azole exposure selects cross-resistance to medical azoles in A. fumigatus, but also how this phenomenon affects Candida and Cryptococcus, other 2 important human fungal pathogens found in the environment. We also examine data showing that fungicide exposure can select relevant changes in the morphophysiology and virulence of those pathogens, suggesting that its effect goes beyond the cross-resistance.
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Affiliation(s)
- Rafael W. Bastos
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto-SP, Brazil
| | - Luana Rossato
- Federal University of Grande Dourados, Dourados-MS, Brazil
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto-SP, Brazil
| | - Daniel A. Santos
- Laboratory of Mycology, Federal University of Minas Gerais, Belo Horizonte-MG, Brazil
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12
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Doughty KJ, Sierotzki H, Semar M, Goertz A. Selection and Amplification of Fungicide Resistance in Aspergillus fumigatus in Relation to DMI Fungicide Use in Agronomic Settings: Hotspots versus Coldspots. Microorganisms 2021; 9:2439. [PMID: 34946041 PMCID: PMC8704312 DOI: 10.3390/microorganisms9122439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 12/18/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprophytic fungus. Inhalation of A. fumigatus spores can lead to Invasive Aspergillosis (IA) in people with weakened immune systems. The use of triazole antifungals with the demethylation inhibitor (DMI) mode of action to treat IA is being hampered by the spread of DMI-resistant "ARAf" (azole-resistant Aspergillus fumigatus) genotypes. DMIs are also used in the environment, for example, as fungicides to protect yield and quality in agronomic settings, which may lead to exposure of A. fumigatus to DMI residues. An agronomic setting can be a "hotspot" for ARAf if it provides a suitable substrate and favourable conditions for the growth of A. fumigatus in the presence of DMI fungicides at concentrations capable of selecting ARAf genotypes at the expense of the susceptible wild-type, followed by the release of predominantly resistant spores. Agronomic settings that do not provide these conditions are considered "coldspots". Identifying and mitigating hotspots will be key to securing the agronomic use of DMIs without compromising their use in medicine. We provide a review of studies of the prevalence of ARAf in various agronomic settings and discuss the mitigation options for confirmed hotspots, particularly those relating to the management of crop waste.
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Affiliation(s)
- Kevin J. Doughty
- Bayer AG, Alfred Nobel Strasse 50, 40789 Monheim-am-Rhein, Germany;
| | - Helge Sierotzki
- Syngenta Crop Protection, Schaffhauserstrasse 101, 4332 Stein, Switzerland;
| | - Martin Semar
- BASF SE, Speyerer Strasse 2, 67117 Limburgerhof, Germany;
| | - Andreas Goertz
- Bayer AG, Alfred Nobel Strasse 50, 40789 Monheim-am-Rhein, Germany;
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13
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Otu A, Osaigbovo I, Orefuwa E, Ebenso B, Ojumu T. Collaborative One Health approaches can mitigate increasing azole-resistant Aspergillus fumigatus in Africa. THE LANCET MICROBE 2021; 2:e490-e491. [DOI: 10.1016/s2666-5247(21)00218-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/02/2021] [Indexed: 11/24/2022] Open
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14
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Campbell CA, Osaigbovo II, Oladele RO. Triazole susceptibility of Aspergillus species: environmental survey in Lagos, Nigeria and review of the rest of Africa. Ther Adv Infect Dis 2021; 8:20499361211044330. [PMID: 34532039 PMCID: PMC8438939 DOI: 10.1177/20499361211044330] [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: 03/25/2021] [Accepted: 08/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Triazole resistance is an emerging problem in the management of human aspergillosis globally and can arise in Aspergillus species which have been exposed to azole fungicides in the environment. We surveyed local government and council development areas in Lagos, Nigeria, to determine the distribution of Aspergillus species in the environment and their susceptibility to locally available triazole antifungal agents. We also reviewed the literature on the subject from the rest of Africa. Methods: A total of 168 soil samples from six locations in Lagos, Nigeria were processed and cultured on Saboraud dextrose agar impregnated with chloramphenicol to isolate Aspergillus species. Isolates were tested for susceptibility to itraconazole and voriconazole by microbroth dilution according to the European Committee on Antimicrobial Susceptibility Testing reference method. Relevant databases were searched to identify published work pertaining to triazole susceptibility of Aspergillus species in Africa. Results: A total of 117 Aspergillus species were isolated. Aspergillus niger was the most frequently isolated species (42.7%). Other species isolated were Aspergillus flavus, 37 (31.6%), Aspergillus terreus, 20 (17.1%), Aspergillus fumigatus, 5 (4.3%) and Aspergillus nidulans, 5 (4.3%). All isolates were susceptible to itraconazole and voriconazole. The literature review showed documented evidence of triazole-resistant Aspergillus species from East and West Africa. Conclusions: We found no triazole resistance in environmental isolates of Aspergillus in Lagos, Nigeria. Nevertheless, regular surveillance in clinical and environmental isolates is necessary in the light of findings from other African studies.
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Affiliation(s)
- Cynthia Abosede Campbell
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Rita Okeoghene Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
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15
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Arastehfar A, Carvalho A, Houbraken J, Lombardi L, Garcia-Rubio R, Jenks J, Rivero-Menendez O, Aljohani R, Jacobsen I, Berman J, Osherov N, Hedayati M, Ilkit M, Armstrong-James D, Gabaldón T, Meletiadis J, Kostrzewa M, Pan W, Lass-Flörl C, Perlin D, Hoenigl M. Aspergillus fumigatus and aspergillosis: From basics to clinics. Stud Mycol 2021; 100:100115. [PMID: 34035866 PMCID: PMC8131930 DOI: 10.1016/j.simyco.2021.100115] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The airborne fungus Aspergillus fumigatus poses a serious health threat to humans by causing numerous invasive infections and a notable mortality in humans, especially in immunocompromised patients. Mould-active azoles are the frontline therapeutics employed to treat aspergillosis. The global emergence of azole-resistant A. fumigatus isolates in clinic and environment, however, notoriously limits the therapeutic options of mould-active antifungals and potentially can be attributed to a mortality rate reaching up to 100 %. Although specific mutations in CYP 51A are the main cause of azole resistance, there is a new wave of azole-resistant isolates with wild-type CYP 51A genotype challenging the efficacy of the current diagnostic tools. Therefore, applications of whole-genome sequencing are increasingly gaining popularity to overcome such challenges. Prominent echinocandin tolerance, as well as liver and kidney toxicity posed by amphotericin B, necessitate a continuous quest for novel antifungal drugs to combat emerging azole-resistant A. fumigatus isolates. Animal models and the tools used for genetic engineering require further refinement to facilitate a better understanding about the resistance mechanisms, virulence, and immune reactions orchestrated against A. fumigatus. This review paper comprehensively discusses the current clinical challenges caused by A. fumigatus and provides insights on how to address them.
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Affiliation(s)
- A. Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - A. Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J. Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - L. Lombardi
- UCD Conway Institute and School of Medicine, University College Dublin, Dublin 4, Ireland
| | - R. Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - J.D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA, 92093, USA
| | - O. Rivero-Menendez
- Medical Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, 28222, Spain
| | - R. Aljohani
- Department of Infectious Diseases, Imperial College London, London, UK
| | - I.D. Jacobsen
- Department of Microbial Pathogenicity Mechanisms, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - J. Berman
- Research Group Microbial Immunology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
| | - N. Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, 69978, Israel
| | - M.T. Hedayati
- Invasive Fungi Research Center/Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M. Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Çukurova University, 01330, Adana, Turkey
| | | | - T. Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, Barcelona, 08034, Spain
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluís Companys 23, 08010, Barcelona, Spain
| | - J. Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - W. Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - C. Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - D.S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - M. Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
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16
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Yang X, Chen W, Liang T, Tan J, Liu W, Sun Y, Wang Q, Xu H, Li L, Zhou Y, Wang Q, Wan Z, Song Y, Li R, Liu W. A 20-Year Antifungal Susceptibility Surveillance (From 1999 to 2019) for Aspergillus spp. and Proposed Epidemiological Cutoff Values for Aspergillus fumigatus and Aspergillus flavus: A Study in a Tertiary Hospital in China. Front Microbiol 2021; 12:680884. [PMID: 34367087 PMCID: PMC8339419 DOI: 10.3389/fmicb.2021.680884] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
The emergence of resistant Aspergillus spp. is increasing worldwide. Long-term susceptibility surveillance for clinically isolated Aspergillus spp. strains is warranted for understanding the dynamic change in susceptibility and monitoring the emergence of resistance. Additionally, neither clinical breakpoints (CBPs) nor epidemiological cutoff values (ECVs) for Aspergillus spp. in China have been established. In this study, we performed a 20-year antifungal susceptibility surveillance for 706 isolates of Aspergillus spp. in a clinical laboratory at Peking University First Hospital from 1999 to 2019; and in vitro antifungal susceptibility to triazoles, caspofungin, and amphotericin B was determined by the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method. It was observed that Aspergillus fumigatus was the most common species, followed by Aspergillus flavus and Aspergillus terreus. Forty isolates (5.7%), including A. fumigatus, A. flavus, A. terreus, Aspergillus niger, and Aspergillus nidulans, were classified as non-wild type (non-WT). Importantly, multidrug resistance was observed among A. flavus, A. terreus, and A. niger isolates. Cyp51A mutations were characterized for 19 non-WT A. fumigatus isolates, and TR34/L98H/S297T/F495I was the most prevalent mutation during the 20-year surveillance period. The overall resistance trend of A. fumigatus increased over 20 years in China. Furthermore, based on ECV establishment principles, proposed ECVs for A. fumigatus and A. flavus were established using gathered minimum inhibitory concentration (MIC)/minimum effective concentration (MEC) data. Consequently, all the proposed ECVs were identical to the CLSI ECVs, with the exception of itraconazole against A. flavus, resulting in a decrease in the non-WT rate from 6.0 to 0.6%.
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Affiliation(s)
- Xinyu Yang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Wei Chen
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Tianyu Liang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - JingWen Tan
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Weixia Liu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yi Sun
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Qian Wang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Hui Xu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Lijuan Li
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yabin Zhou
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Qiqi Wang
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Zhe Wan
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Yinggai Song
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Ruoyu Li
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
| | - Wei Liu
- Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- Research Center for Medical Mycology, Peking University, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
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17
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Burks C, Darby A, Gómez Londoño L, Momany M, Brewer MT. Azole-resistant Aspergillus fumigatus in the environment: Identifying key reservoirs and hotspots of antifungal resistance. PLoS Pathog 2021; 17:e1009711. [PMID: 34324607 PMCID: PMC8321103 DOI: 10.1371/journal.ppat.1009711] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aspergillus fumigatus is an opportunistic human pathogen that causes aspergillosis, a spectrum of environmentally acquired respiratory illnesses. It has a cosmopolitan distribution and exists in the environment as a saprotroph on decaying plant matter. Azoles, which target Cyp51A in the ergosterol synthesis pathway, are the primary class of drugs used to treat aspergillosis. Azoles are also used to combat plant pathogenic fungi. Recently, an increasing number of azole-naive patients have presented with pan-azole-resistant strains of A. fumigatus. The TR34/L98H and TR46/Y121F/T289A alleles in the cyp51A gene are the most common ones conferring pan-azole resistance. There is evidence that these mutations arose in agricultural settings; therefore, numerous studies have been conducted to identify azole resistance in environmental A. fumigatus and to determine where resistance is developing in the environment. Here, we summarize the global occurrence of azole-resistant A. fumigatus in the environment based on available literature. Additionally, we have created an interactive world map showing where resistant isolates have been detected and include information on the specific alleles identified, environmental settings, and azole fungicide use. Azole-resistant A. fumigatus has been found on every continent, except for Antarctica, with the highest number of reports from Europe. Developed environments, specifically hospitals and gardens, were the most common settings where azole-resistant A. fumigatus was detected, followed by soils sampled from agricultural settings. The TR34/L98H resistance allele was the most common in all regions except South America where the TR46/Y121F/T289A allele was the most common. A major consideration in interpreting this survey of the literature is sampling bias; regions and environments that have been extensively sampled are more likely to show greater azole resistance even though resistance could be more prevalent in areas that are under-sampled or not sampled at all. Increased surveillance to pinpoint reservoirs, as well as antifungal stewardship, is needed to preserve this class of antifungals for crop protection and human health.
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Affiliation(s)
- Caroline Burks
- Plant Pathology Department and Fungal Biology Group, University of Georgia, Athens, Georgia, United States of America
| | - Alexandria Darby
- Plant Pathology Department and Fungal Biology Group, University of Georgia, Athens, Georgia, United States of America
| | - Luisa Gómez Londoño
- Plant Pathology Department and Fungal Biology Group, University of Georgia, Athens, Georgia, United States of America
| | - Michelle Momany
- Plant Biology Department and Fungal Biology Group, University of Georgia, Athens, Georgia, United States of America
| | - Marin T. Brewer
- Plant Pathology Department and Fungal Biology Group, University of Georgia, Athens, Georgia, United States of America
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18
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Azole Resistance in Clinical and Environmental Aspergillus Isolates from the French West Indies (Martinique). J Fungi (Basel) 2021; 7:jof7050355. [PMID: 33946598 PMCID: PMC8147181 DOI: 10.3390/jof7050355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022] Open
Abstract
The emergence of azole resistant Aspergillus spp., especially Aspergillus fumigatus, has been described in several countries around the world with varying prevalence depending on the country. To our knowledge, azole resistance in Aspergillus spp. has not been reported in the West Indies yet. In this study, we investigated the antifungal susceptibility of clinical and environmental isolates of Aspergillus spp. from Martinique, and the potential resistance mechanisms associated with mutations in cyp51A gene. Overall, 208 Aspergillus isolates were recovered from clinical samples (n = 45) and environmental soil samples (n = 163). They were screened for resistance to azole drugs using selective culture media. The Minimum Inhibitory Concentrations (MIC) towards voriconazole, itraconazole, posaconazole and isavuconazole, as shown by the resistant isolates, were determined using the European Committee on Antimicrobial Susceptibility Testing (EUCAST) microdilution broth method. Eight isolates (A. fumigatus, n = 6 and A. terreus, n = 2) had high MIC for at least one azole drug. The sequencing of cyp51A gene revealed the mutations G54R and TR34/L98H in two A. fumigatus clinical isolates. Our study showed for the first time the presence of azole resistance in A. fumigatus and A. terreus isolates in the French West Indies.
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Potency of olorofim (F901318) compared to contemporary antifungal agents against clinical Aspergillus fumigatus isolates, and review of azole resistance phenotype and genotype epidemiology in China. Antimicrob Agents Chemother 2021; 65:AAC.02546-20. [PMID: 33685896 PMCID: PMC8092882 DOI: 10.1128/aac.02546-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Triazole resistance in A. fumigatus is an increasing worldwide problem that causes major challenges in the management of aspergillosis. New antifungal drugs are needed with novel targets, that are effective in triazole-resistant infection. In this study, we retrospectively evaluated potency of the novel drug olorofim compared to contemporary antifungal agents against 111 clinical A. fumigatus isolates collected from Huashan Hospital, Shanghai, China, using EUCAST methodology, and reviewed the literature on triazole resistant A. fumigatus published between 1966 and 2020 in China. Olorofim was active in vitro against all tested A. fumigatus isolates with MIC90 of 0.031mg/L (range 0.008-0.062 mg/L). For 4 triazole-resistant A. fumigatus (TRAF) isolates, the olorofim MIC ranged between 0.016-0.062mg/L. The reported rates of TRAF in China is 2.5% - 5.56% for clinical isolates, and 0-1.4% for environmental isolates.TR34/L98H/S297T/F495I is the predominant resistance mechanism, followed by TR34/L98H. Non TR-mediated TRAF isolates, mostly harboring a cyp51A single point mutation, showed greater genetic diversity than TR-mediated resistant isolates. Resistance due toTR34/L98H and TR34/L98H/S297T/F495I mutations among TRAF isolates might have evolved from separate local isolates in China. Continuous isolation of TRAF in China underscores the need for systematic resistance surveillance as well as the need for novel drug targets such as olorofim.
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Resendiz-Sharpe A, Dewaele K, Merckx R, Bustamante B, Vega-Gomez MC, Rolon M, Jacobs J, Verweij PE, Maertens J, Lagrou K. Triazole-Resistance in Environmental Aspergillus fumigatus in Latin American and African Countries. J Fungi (Basel) 2021; 7:jof7040292. [PMID: 33921497 PMCID: PMC8070258 DOI: 10.3390/jof7040292] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 01/10/2023] Open
Abstract
Triazole-resistance has been reported increasingly in Aspergillus fumigatus. An international expert team proposed to avoid triazole monotherapy for the initial treatment of invasive aspergillosis in regions with >10% environmental-resistance, but this prevalence is largely unknown for most American and African countries. Here, we screened 584 environmental samples (soil) from urban and rural locations in Mexico, Paraguay, and Peru in Latin America and Benin and Nigeria in Africa for triazole-resistant A. fumigatus. Samples were screened using triazole-containing agars and confirmed as triazole-resistant by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth dilution reference method. Isolates were further characterized by cyp51A sequencing and short-tandem repeat typing. Fungicide presence in samples was likewise determined. Among A. fumigatus positive samples, triazole-resistance was detected in 6.9% (7/102) of samples in Mexico, 8.3% (3/36) in Paraguay, 9.8% (6/61) in Peru, 2.2% (1/46) in Nigeria, and none in Benin. Cyp51A gene mutations were present in most of the triazole-resistant isolates (88%; 15/17). The environmentally-associated mutations TR34/L98H and TR46/Y121F/T289A were prevalent in Mexico and Peru, and isolates harboring these mutations were closely related. For the first time, triazole-resistant A. fumigatus was found in environmental samples in Mexico, Paraguay, Peru, and Nigeria with a prevalence of 7-10% in the Latin American countries. Our findings emphasize the need to establish triazole-resistance surveillance programs in these countries.
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Affiliation(s)
- Agustin Resendiz-Sharpe
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Klaas Dewaele
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Rita Merckx
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
| | - Beatriz Bustamante
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
| | - Maria Celeste Vega-Gomez
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Miriam Rolon
- Centro para el Desarrollo de la Investigación Científica, CEDIC, Asunción 1255, Paraguay; (M.C.V.-G.); (M.R.)
| | - Jan Jacobs
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerpen, Belgium
| | - Paul E. Verweij
- Radboud University Medical Center, Department of Medical Microbiology, 6500 HB Nijmegen, The Netherlands;
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (R.M.); (J.J.); (J.M.)
- Excellence Center for Medical Mycology (ECMM), Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium;
- Correspondence: ; Tel.: +32-016-34-70-98
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Jørgensen KM, Helleberg M, Hare RK, Jørgensen LN, Arendrup MC. Dissection of the Activity of Agricultural Fungicides against Clinical Aspergillus Isolates with and without Environmentally and Medically Induced Azole Resistance. J Fungi (Basel) 2021; 7:jof7030205. [PMID: 33799556 PMCID: PMC8001900 DOI: 10.3390/jof7030205] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Azole resistance is an emerging problem in patients with aspergillosis. The role of fungicides for resistance development and occurrence is not fully elucidated. EUCAST reference MICs of 17 fungicides (11 azoles and 6 others), five azole fungicide metabolites and four medical triazoles were examined against two reference and 28 clinical isolates of A. fumigatus, A. flavus and A. terreus with (n = 12) and without (n = 16) resistance mutations. Eight/11 azole fungicides were active against wild-type A. fumigatus, A. flavus and A. terreus, including four (metconazole, prothioconazole-desthio, prochloraz and imazalil) with low MIC50 (≤2 mg/L) against all three species and epoxiconazole, propiconazole, tebuconazole and difenoconazole also against wild-type A. terreus. Mefentrifluconazole, azole metabolites and non-azole fungicides MICs were >16 mg/L against A. fumigatus although partial growth inhibition was found with mefentrifluconazole. Moreover, mefentrifluconazole and axozystrobin were active against wild-type A. terreus. Increased MICs (≥3 dilutions) were found for TR34/L98H, TR34(3)/L98H, TR46/Y121F/T289A and G432S compared to wild-type A. fumigatus for epoxiconazole, propiconazole, tebuconazole, difenoconazole, prochloraz, imazalil and metconazole (except G432S), and for prothioconazole-desthio against TR46/Y121F/T289A, specifically. Increased MICs were found in A. fumigatus harbouring G54R, M220K and M220R alterations for five, one and one azole fungicides, respectively, compared to MICs against wild-type A. fumigatus. Similarly, increased MICs wer found for A. terreus with G51A, M217I and Y491H alterations for five, six and two azole fungicides, respectively. Azole fungicides showed activity against wild-type A. fumigatus, A. terreus and A. flavus, but not against all mutant isolates, suggesting the environmental route of azole resistance may have a role for all three species.
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Affiliation(s)
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Rasmus Krøger Hare
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
| | - Lise Nistrup Jørgensen
- Department of Agroecology—Crop Health, Aarhus University-Flakkebjerg, 4200 Slagelse, Denmark;
| | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
- Department of Clinical Medicine, Copenhagen University, 2100 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
- Correspondence:
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Cao D, Wang F, Yu S, Dong S, Wu R, Cui N, Ren J, Xu T, Wang S, Wang M, Fang H, Yu Y. Prevalence of Azole-Resistant Aspergillus fumigatus is Highly Associated with Azole Fungicide Residues in the Fields. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:3041-3049. [PMID: 33544588 DOI: 10.1021/acs.est.0c03958] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Triazole resistance in Aspergillus fumigatus is a growing public health concern. In addition to its emergence in the therapy of invasive aspergillosis by triazole medicines, it has been frequently detected in agricultural fields all over the world. Here, we explore the potential link between residues of azole fungicides with similar chemical structure to triazole medicines in soil and the emergence of resistant A. fumigatus (RAF) through 855 500 km2 monitoring survey in Eastern China covering 6 provinces. In total, 67.3%, 15.2%, 12.3%, 2.9%, 1.5%, 0.4%, and 0.3% of the soil samples contained these five fungicides (tebuconazole, difenoconazole, propiconazole, hexaconazole, and prochloraz) of 0-100, 100-200, 200-400, 400-600, 600-800, 800-1000, and >1000 ng/g, respectively. The fractions of samples containing RAF isolates were 2.4%, 5.2%, 6.4%, 7.7%, 7.4%, 14.3%, and 20.0% of the samples with total azole fungicide residues of 0-100, 100-200, 200-400, 400-600, 600-800, 800-1000, and >1000 ng/g, respectively. We find that the prevalence of RAFs is positively (P < 0.0001) correlated with residual levels of azole fungicides in soils. Our results suggest that the use of azole fungicides in agriculture should be minimized and the intervals between treatments expanded to reduce the selective pressure toward the development of resistance in A. fumigatus in agricultural fields.
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van der Torre MH, Shen H, Rautemaa-Richardson R, Richardson MD, Novak-Frazer L. Molecular Epidemiology of Aspergillus fumigatus in Chronic Pulmonary Aspergillosis Patients. J Fungi (Basel) 2021; 7:jof7020152. [PMID: 33672698 PMCID: PMC7924367 DOI: 10.3390/jof7020152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/17/2022] Open
Abstract
Molecular fungal genotyping techniques developed and employed for epidemiological studies have understandably concentrated on establishing the genetic diversity of Aspergillus fumigatus in invasive aspergillosis due to its severity, the urgency for treatment, and the need to demonstrate possible sources. Some early studies suggested that these strains were phenotypically, if not genotypically, different from others. However, with improved discrimination and evaluations, incorporating environmental as well as clinical isolates from other Aspergillus conditions (e.g., chronic pulmonary aspergillosis and cystic fibrosis), this premise is no longer upheld. Moreover, with the onset of increased global triazole resistance, there has been a concerted effort to incorporate resistance profiling into genotyping studies and the realisation that the wider population of non-immunocompromised aspergillosis patients are at risk. This review summarises the developments in molecular genotyping studies that incorporate resistance profiling with attention to chronic pulmonary aspergillosis and an example of our UK experience.
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Affiliation(s)
- Mireille H. van der Torre
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Hongwei Shen
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
- Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Malcolm D. Richardson
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Lilyann Novak-Frazer
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
- Correspondence: ; Tel.: +44-161-2915856
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Characterization of Aspergillus fumigatus cross-resistance between clinical and DMI azole drugs. Appl Environ Microbiol 2021; 87:AEM.02539-20. [PMID: 33355104 PMCID: PMC8090891 DOI: 10.1128/aem.02539-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drug resistance poses a serious threat to human health and agricultural production. Azole drugs are the largest group of 14-α sterol demethylation inhibitor fungicides that are used both in agriculture and in clinical practice. As plant pathogenic molds share their natural environment with fungi that cause opportunistic infections in humans, both are exposed to a strong and persistent pressure of demethylase inhibitor (DMI) fungicides, including imidazole and triazole drugs. As a result, a loss of efficacy has occurred for this drug class in several species. In the clinical setting, Aspergillus fumigatus azole resistance is a growing public health problem and finding the source of this resistance has gained much attention. It is urgent to determine if there is a direct link between the agricultural use of azole compounds and the different A. fumigatus resistance mechanisms described for clinical triazoles. In this work we have performed A. fumigatus susceptibility testing to clinical triazoles and crop protection DMIs using a collection of azole susceptible and resistant strains which harbor most of the described azole resistance mechanisms. Various DMI susceptibility profiles have been found in the different A. fumigatus populations groups based on their azole resistance mechanism and previous WGS analysis, which suggests that the different resistance mechanisms have different origins and are specifically associated to the local use of a particular DMI.Importance Due to the worldwide emergence of A. fumigatus azole resistance, this opportunistic pathogen poses a serious health threat and, therefore, it has been included in the Watch List of the CDC 2019 Antimicrobial Resistance Threats Report. Azoles play a critical role in the control and management of fungal diseases, not only in the clinical setting but also in agriculture. Thus, azole resistance leads to a limited therapeutic arsenal which reduces the treatment options for aspergillosis patients, increasing their mortality risk. Evidence is needed to understand whether A. fumigatus azole resistance is emerging from an agricultural source due to the extended use of demethylase inhibitors as fungicides, or whether it is coming from somewhere else such as the clinical setting. If the environmental route is demonstrated, the current use and management of azole antifungal compounds might be forced to change in the forthcoming years.
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Sabino R, Gonçalves P, Martins Melo A, Simões D, Oliveira M, Francisco M, Viegas C, Carvalho D, Martins C, Ferreira T, Toscano C, Simões H, Veríssimo C. Trends on Aspergillus Epidemiology-Perspectives from a National Reference Laboratory Surveillance Program. J Fungi (Basel) 2021; 7:jof7010028. [PMID: 33418997 PMCID: PMC7825284 DOI: 10.3390/jof7010028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022] Open
Abstract
Identification of Aspergillus to species level is important since sibling species may display variable susceptibilities to multiple antifungal drugs and also because correct identification contributes to improve the knowledge of epidemiological studies. Two retrospective laboratory studies were conducted on Aspergillus surveillance at the Portuguese National Mycology Reference Laboratory. The first, covering the period 2017–2018, aimed to study the molecular epidemiology of 256 Aspergillus isolates obtained from patients with respiratory, subcutaneous, or systemic infections and from environmental samples. The second, using our entire collection of clinical and environmental A. fumigatus isolates (N = 337), collected between 2012 and 2019, aimed to determine the frequency of azole-resistant A. fumigatus isolates. Aspergillus fumigatus sensu stricto was the most frequent species in both clinical and environmental samples. Overall, and considering all Aspergillus sections identified, a high frequency of cryptic species was detected, based on beta-tubulin or calmodulin sequencing (37% in clinical and 51% in environmental isolates). Regarding all Fumigati isolates recovered from 2012–2019, the frequency of cryptic species was 5.3% (18/337), with the identification of A. felis (complex), A. lentulus, A. udagawae, A. hiratsukae, and A. oerlinghauensis. To determine the frequency of azole resistance of A. fumigatus, isolates were screened for azole resistance using azole-agars, and 53 possible resistant isolates were tested by the CLSI microdilution reference method. Nine A. fumigatus sensu stricto and six Fumigati cryptic isolates showed high minimal inhibitory concentrations to itraconazole, voriconazole, and/or posaconazole. Real-time PCR to detect cyp51A mutations and sequencing of cyp51A gene and its promoter were performed. The overall frequency of resistance to azoles in A. fumigatus sensu stricto was 3.0%. With this retrospective analysis, we were able to detect one azole-resistant G54R mutant A. fumigatus environmental isolate, collected in 2015. The TR34/L98H mutation, linked to environmental transmission route of azole resistance, was the most frequently detected mutation (N = 4; 1.4%). Our findings underline the demand for correct identification and susceptibility testing of Aspergillus isolates.
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Affiliation(s)
- Raquel Sabino
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
- Correspondence: ; Tel.: +351-217519247
| | - Paulo Gonçalves
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
- European Programme for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control, 16973 Solna, Sweden
| | - Aryse Martins Melo
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
- Programa de Pós-Graduação em Microbiologia e Parasitologia, Instituto de Biologia, Universidade Federal de Pelotas, Avenida Eliseu Maciel, Pelotas 96010-610, Brazil
| | - Daniela Simões
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
| | - Mariana Oliveira
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
| | - Mariana Francisco
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
| | - Carla Viegas
- H&TRC—Health & Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal;
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, 1600-560 Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), 1169-056 Lisbon, Portugal
| | - Dinah Carvalho
- Centro Hospitalar Universitário Lisboa Norte EPE, 1649-028 Lisbon, Portugal; (D.C.); (C.M.)
| | - Carlos Martins
- Centro Hospitalar Universitário Lisboa Norte EPE, 1649-028 Lisbon, Portugal; (D.C.); (C.M.)
| | - Teresa Ferreira
- Centro Hospitalar Universitário Lisboa Central, 1050-099 Lisbon, Portugal;
| | - Cristina Toscano
- Microbiology Laboratory, Centro Hospitalar Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal;
| | - Helena Simões
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
| | - Cristina Veríssimo
- Infectious Diseases Department, National Health Institute Dr. Ricardo Jorge, 1649-016 Lisbon, Portugal; (P.G.); (A.M.M.); (D.S.); (M.O.); (M.F.); (H.S.); (C.V.)
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Verweij PE, Lucas JA, Arendrup MC, Bowyer P, Brinkmann AJ, Denning DW, Dyer PS, Fisher MC, Geenen PL, Gisi U, Hermann D, Hoogendijk A, Kiers E, Lagrou K, Melchers WJ, Rhodes J, Rietveld AG, Schoustra SE, Stenzel K, Zwaan BJ, Fraaije BA. The one health problem of azole resistance in Aspergillus fumigatus: current insights and future research agenda. FUNGAL BIOL REV 2020. [DOI: 10.1016/j.fbr.2020.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Molecular Epidemiology of Azole-Resistant Aspergillus fumigatus in Sawmills of Eastern France by Microsatellite Genotyping. J Fungi (Basel) 2020; 6:jof6030120. [PMID: 32722533 PMCID: PMC7559097 DOI: 10.3390/jof6030120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/10/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Wood chipping has been described as a potential hotspot for the selection of azole-resistant Aspergillus fumigatus (ARAf). We previously reported ARAf isolates in sawmills (Eastern France), most of which contained the TR34/L98H mutation. Methods: To study genotypic relatedness, microsatellite genotyping (short tandem repeat for A. fumigatus (STRAf)) was performed on 41 azole-susceptible A. fumigatus (ASAf) and 23 ARAf isolated from 18 sawmills and two clinical A. fumigatus (sensitive and resistant) isolated from a sinus sample of a woodworker. Results: Fifty-four unique multilocus genotypes (MLGs) were described among the 66 isolates: 13/24 ARAf and 41/42 ASAf. Allelic diversity was higher for ASAf than for ARAf. Among the 24 ARAf, five isolates had their own MLGs. Thirteen ARAf (54%) belonged to the same group, composed of four close MLGs, defined using Bruvo’s distance. Thirty-two of the 42 ASAf (76%) had their own MLGs and could not be grouped with the Bruvo’s distance cutoff used (0.2). Conclusion: Thus, at a regional scale and in the particular environment of the wood industry, common but also different distinct genotypes, even in the same sawmill, were identified. This suggests that the hypothesis of ARAf clonal expansion from a common strain is probably insufficient to explain genotype emergence and distribution.
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Colley T, Sharma C, Alanio A, Kimura G, Daly L, Nakaoki T, Nishimoto Y, Bretagne S, Kizawa Y, Strong P, Rapeport G, Ito K, Meis JF, Chowdhary A. Anti-fungal activity of a novel triazole, PC1244, against emerging azole-resistant Aspergillus fumigatus and other species of Aspergillus. J Antimicrob Chemother 2020; 74:2950-2958. [PMID: 31361006 PMCID: PMC6753496 DOI: 10.1093/jac/dkz302] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/10/2019] [Accepted: 06/14/2019] [Indexed: 12/18/2022] Open
Abstract
Objectives The growing emergence of azole-resistant Aspergillus fumigatus strains worldwide is a major concern for current systemic antifungal treatment. Here we report antifungal activities of a novel inhaled triazole, PC1244, against a collection of multi-azole-resistant A. fumigatus strains. Methods MICs of PC1244 were determined for A. fumigatus carrying TR34/L98H (n = 81), TR46/Y121F/T289A (n = 24), M220 (n = 6), G54 (n = 11), TR53 (n = 1), TR463/Y121F/T289A (n = 2), G448S (n = 1), G432C (n = 1) and P216S (n = 1) resistance alleles originating from either India, the Netherlands or France. The effects of PC1244 were confirmed in an in vitro model of the human alveolus and in vivo in temporarily neutropenic, immunocompromised mice. Results PC1244 exhibited potent inhibition [geometric mean MIC (range), 1.0 mg/L (0.125 to >8 mg/L)] of growth of A. fumigatus strains carrying cyp51A gene mutations, showing much greater potency than voriconazole [15 mg/L (0.5 to >16 mg/L)], and an effect similar to those on other azole-susceptible Aspergillus spp. (Aspergillus flavus, Aspergillus terreus, Aspergillus tubingensis, Aspergillus nidulans, Aspergillus niger, Aspergillus nomius, Aspergillus tamarii) (0.18–1 mg/L). In TR34/L98H and TR46/Y121F/T289A A. fumigatus-infected in vitro human alveolus models, PC1244 achieved superior inhibition (IC50, 0.25 and 0.34 mg/L, respectively) compared with that of voriconazole (IC90, >3 mg/L and >10 mg/L, respectively). In vivo, once-daily intranasal administration of PC1244 (0.56–70 μg/mouse) to the A. fumigatus (AF91 with M220V)-infected mice reduced pulmonary fungal load and serum galactomannan more than intranasal posaconazole. Conclusions PC1244 has the potential to become a novel topical treatment of azole-resistant pulmonary aspergillosis.
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Affiliation(s)
| | - Cheshta Sharma
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Alexandre Alanio
- Institut Pasteur, CNRS, Molecular Mycology Unit, French National Reference Center for Invasive Mycoses & Antifungals, URA3012, Paris, France.,Paris Diderot, Sorbonne Paris Cité University, Paris, France.,Parasitology-Mycology Laboratory, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Genki Kimura
- Laboratory of Physiology and Anatomy, School of Pharmacy, Nihon University, Funabashi, Japan
| | | | - Takahiro Nakaoki
- Laboratory of Physiology and Anatomy, School of Pharmacy, Nihon University, Funabashi, Japan
| | - Yuki Nishimoto
- Laboratory of Physiology and Anatomy, School of Pharmacy, Nihon University, Funabashi, Japan
| | - Stéphane Bretagne
- Institut Pasteur, CNRS, Molecular Mycology Unit, French National Reference Center for Invasive Mycoses & Antifungals, URA3012, Paris, France.,Paris Diderot, Sorbonne Paris Cité University, Paris, France.,Parasitology-Mycology Laboratory, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Yasuo Kizawa
- Laboratory of Physiology and Anatomy, School of Pharmacy, Nihon University, Funabashi, Japan
| | | | | | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
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Bustamante B, Illescas LR, Posadas A, Campos PE. Azole resistance among clinical isolates of Aspergillus fumigatus in Lima-Peru. Med Mycol 2020; 58:54-60. [PMID: 31329931 DOI: 10.1093/mmy/myz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
Azole resistance among Aspergillus fumigatus isolates, which is mainly related to mutations in the cyp51A gene, is a concern because it is rising, worldwide disseminated, and associated with treatment failure and death. Data on azole resistance of aspergillus from Latin American countries is very scarce and do not exist for Peru. Two hundred and seven Aspergillus clinical isolates collected prospectively underwent mycology and molecular testing for specie identification, and 143 isolates were confirmed as A. fumigatus sensu stricto (AFSS). All AFSS were tested for in vitro azole susceptibility, and resistant isolates underwent PCR amplification and sequencing of the whole cyp51A gene and its promoter. The in vitro susceptibility showed a minimal inhibitory concentration (MIC) range, MIC50 and MIC90 of 0.125 to >16, 0.25, and 0.5 μg/ml for itraconazole; 0.25 to 2, 0.5, and 0.5 μg/ml for voriconazole; and 0.003 to 1, 0.06, and 0.125 μg/ml for posaconazole. Three isolates (2%) showed resistance to itraconazole and exhibited different mutations of the cyp51A gene. One isolate harbored the mutation M220K, while a second one exhibited the G54 mutation plus a modification in the cyp51A gene promoter. The third isolate, from an azole naive patient, presented an integration of a 34-bp tandem repeat (TR34) in the promoter region of the gene and a substitution of leucine 98 by histidine (L98H). The three source patients had a diagnosis or suspicion of chronic pulmonary aspergillosis.
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Affiliation(s)
- Beatriz Bustamante
- Nacional Cayetano Heredia, Lima, Perú, and Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Andrés Posadas
- Unidad de Epidemiología Molecular-Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
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High-Frequency Direct Detection of Triazole Resistance in Aspergillus fumigatus from Patients with Chronic Pulmonary Fungal Diseases in India. J Fungi (Basel) 2020; 6:jof6020067. [PMID: 32443672 PMCID: PMC7345705 DOI: 10.3390/jof6020067] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Aspergillosis due to azole-resistant Aspergillus fumigatus is a worldwide problem with major therapeutic implications. In patients with invasive aspergillosis, a low yield of fungal cultures results in underestimation of azole resistance. To detect azole resistance in A. fumigatus, we applied the AsperGenius® Resistance multiplex real-time polymerase chain reaction (PCR) assay to detect TR34/L98H, and TR46/T289A/Y121F mutations and the AsperGenius® G54/M220 RUO PCR assay to detect G54/M220 mutations directly in bronchoalveolar lavage (BAL) samples of 160 patients with chronic respiratory diseases in Delhi, India. Only 23% of samples were culture-positive compared to 83% positivity by A. fumigatus species PCR highlighting concerns about the low yield of cultures. Notably, 25% of BAL samples (33/160 patients) had azole resistance-associated mutation by direct detection using PCR assay. Detection of resistance-associated mutations was found mainly in 59% and 43% patients with chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA), respectively. Overall, a G54 mutation, conferring itraconazole resistance, was the predominant finding in 87.5% and 67% of patients with CPA and ABPA, respectively. In culture-negative, PCR-positive samples, we detected azole-resistant mutations in 34% of BAL samples. Azole resistance in chronic Aspergillus diseases remains undiagnosed, warranting standardization of respiratory culture and inclusion of rapid techniques to detect resistance markers directly in respiratory samples.
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Chen P, Liu J, Zeng M, Sang H. Exploring the molecular mechanism of azole resistance in Aspergillus fumigatus. J Mycol Med 2020; 30:100915. [DOI: 10.1016/j.mycmed.2019.100915] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/24/2019] [Accepted: 11/24/2019] [Indexed: 12/20/2022]
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Chen P, Liu M, Zeng Q, Zhang Z, Liu W, Sang H, Lu L. Uncovering New Mutations Conferring Azole Resistance in the Aspergillus fumigatus cyp51A Gene. Front Microbiol 2020; 10:3127. [PMID: 32038564 PMCID: PMC6986205 DOI: 10.3389/fmicb.2019.03127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022] Open
Abstract
The opportunistic pathogen Aspergillus fumigatus has developed worldwide resistance to azoles largely through mutations in cytochromeP450 enzyme Cyp51. In this study, we indicated that in vitro azole situation results in emergence of azole-resistant mutations. There are previously identified azole-resistant cyp51A mutations (M220K, M220I, M220R, G54E and G54W mutations) and we successfully identified in this study two new mutations (N248K/V436A, Y433N substitution) conferring azole resistance among 18 independent stable azole-resistant isolates. The Galleria mellonella model of A. fumigatus infection experiment verified that Cyp51A mutations N248K/V436A and Y433N reduce efficacy of azole therapy. In addition, a predicted Cyp51A 3D structural model suggested that Y433N mutation causes the reduced affinities between drug target Cyp51A and azole antifungals. This study suggests that drug selection pressure make it possible to isolate unidentified cyp51A mutations conferring azole resistance in A. fumigatus.
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Affiliation(s)
- Peiying Chen
- Department of Dermatology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Musang Liu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Qiuqiong Zeng
- Department of Dermatology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zheng Zhang
- Department of Dermatology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Hong Sang
- Department of Dermatology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Ling Lu
- Jiangsu Key Laboratory for Microbes and Functional Genomics, Jiangsu Engineering and Technology Research Center for Microbiology, College of Life Sciences, Nanjing Normal University, Nanjing, China
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cyp51A Mutations, Extrolite Profiles, and Antifungal Susceptibility in Clinical and Environmental Isolates of the Aspergillus viridinutans Species Complex. Antimicrob Agents Chemother 2019; 63:AAC.00632-19. [PMID: 31451501 PMCID: PMC6811395 DOI: 10.1128/aac.00632-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/16/2019] [Indexed: 02/06/2023] Open
Abstract
The past decade has seen an increase in aspergillosis in humans and animals due to Aspergillus viridinutans species complex members. Azole resistance is common to these infections, carrying a poor prognosis. cyp51A gene mutations are the main cause of acquired azole resistance in Aspergillus fumigatus. This study aimed to determine if the azole-resistant phenotype in A. viridinutans complex members is associated with cyp51A mutations or extrolite profiles. The past decade has seen an increase in aspergillosis in humans and animals due to Aspergillus viridinutans species complex members. Azole resistance is common to these infections, carrying a poor prognosis. cyp51A gene mutations are the main cause of acquired azole resistance in Aspergillus fumigatus. This study aimed to determine if the azole-resistant phenotype in A. viridinutans complex members is associated with cyp51A mutations or extrolite profiles. The cyp51A gene of clinical and environmental isolates was amplified using novel primers, antifungal susceptibility was tested using the Clinical and Laboratory Standards Institute methodology, and extrolite profiling was performed using agar plug extraction. Very high azole MICs were detected in 84% of the isolates (31/37). The MICs of the newer antifungals luliconazole and olorofim (F901318) were low for all isolates. cyp51A sequences revealed 113 nonsynonymous mutations compared to the sequence of wild-type A. fumigatus. M172A/V and D255G, previously associated with A. fumigatus azole resistance, were common among all isolates but were not correlated with azole MICs. Two environmental isolates with nonsusceptibility to itraconazole and high MICs of voriconazole and isavuconazole harbored G138C, previously associated with azole-resistant A. fumigatus. Some novel mutations were identified only among isolates with high azole MICs. However, cyp51A homology modeling did not cause a significant protein structure change for these mutations. There was no correlation between extrolite patterns and susceptibility. For A. viridinutans complex isolates, cyp51A mutations and the extrolites that they produced were not major causes of antifungal resistance. Luliconazole and olorofim show promise for treating azole-resistant infections caused by these cryptic species.
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Azole-resistant Aspergillus fumigatus: A global phenomenon originating in the environment? Med Mal Infect 2019; 50:389-395. [PMID: 31472992 DOI: 10.1016/j.medmal.2019.07.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/09/2018] [Accepted: 07/24/2019] [Indexed: 11/22/2022]
Abstract
Aspergillus fumigatus is the predominant etiological agent of invasive aspergillosis (IA), a difficult-to-manage fungal disease associated with a high case fatality rate. Azole antifungals, particularly voriconazole, have significantly improved the survival rate of patients with IA. However, the clinical advances made possible through the use of medical azoles could be threatened by the emergence of azole-resistant strains which has been reported in an ever-increasing number of countries over the last 10 years. The major resistance mechanism, that combines point mutation(s) in the coding sequence of cyp51A gene and an insertion of a tandem repeat in the promoter region of this gene which leads to its overexpression (TR34/L98H and TR46/Y121F/T289A), is presumed to be of environmental origin. However, the emergence of clinical and environmental azole-resistant strains without the cyp51A gene mutation suggests that other mechanisms could also be responsible for azole resistance (for example, overexpression of efflux pumps). The development of resistance may be linked to either long-term use of azole antifungals in patients with chronic aspergillosis (patient-acquired route) or selection pressure of the fungicides in the environment (environmental route). The fungicide-driven route could be responsible for resistance in azole-naive patients with IA. This literature review aims to summarize recent findings, focusing on the current situation of azole-resistance in A. fumigatus, and provides better understanding of the importance of the environmental route in resistance acquisition.
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Elevated Prevalence of Azole-Resistant Aspergillus fumigatus in Urban versus Rural Environments in the United Kingdom. Antimicrob Agents Chemother 2019; 63:AAC.00548-19. [PMID: 31235621 DOI: 10.1128/aac.00548-19] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/01/2019] [Indexed: 12/17/2022] Open
Abstract
Azole resistance in the opportunistic pathogen Aspergillus fumigatus is increasing, dominated primarily by the following two environmentally associated resistance alleles: TR34/L98H and TR46/Y121F/T289A. By sampling soils across the South of England, we assess the prevalence of azole-resistant A. fumigatus (ARAf) in samples collected in both urban and rural locations. We characterize the susceptibility profiles of the resistant isolates to three medical azoles, identify the underlying genetic basis of resistance, and investigate their genetic relationships. ARAf was detected in 6.7% of the soil samples, with a higher prevalence in urban (13.8%) than rural (1.1%) locations. Twenty isolates were confirmed to exhibit clinical breakpoints for resistance to at least one of three medical azoles, with 18 isolates exhibiting resistance to itraconazole, 6 to voriconazole, and 2 showing elevated minimum inhibitory concentrations to posaconazole. Thirteen of the resistant isolates harbored the TR34/L98H resistance allele, and six isolates carried the TR46/Y121F/T289A allele. The 20 azole-resistant isolates were spread across five csp1 genetic subtypes, t01, t02, t04B, t09, and t18 with t02 being the predominant subtype. Our study demonstrates that ARAf can be easily isolated in the South of England, especially in urban city centers, which appear to play an important role in the epidemiology of environmentally linked drug-resistant A. fumigatus.
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The fading boundaries between patient and environmental routes of triazole resistance selection in Aspergillus fumigatus. PLoS Pathog 2019; 15:e1007858. [PMID: 31437247 PMCID: PMC6705767 DOI: 10.1371/journal.ppat.1007858] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Emerging Fungal Infections: New Patients, New Patterns, and New Pathogens. J Fungi (Basel) 2019; 5:jof5030067. [PMID: 31330862 PMCID: PMC6787706 DOI: 10.3390/jof5030067] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/13/2023] Open
Abstract
The landscape of clinical mycology is constantly changing. New therapies for malignant and autoimmune diseases have led to new risk factors for unusual mycoses. Invasive candidiasis is increasingly caused by non-albicans Candida spp., including C. auris, a multidrug-resistant yeast with the potential for nosocomial transmission that has rapidly spread globally. The use of mould-active antifungal prophylaxis in patients with cancer or transplantation has decreased the incidence of invasive fungal disease, but shifted the balance of mould disease in these patients to those from non-fumigatus Aspergillus species, Mucorales, and Scedosporium/Lomentospora spp. The agricultural application of triazole pesticides has driven an emergence of azole-resistant A. fumigatus in environmental and clinical isolates. The widespread use of topical antifungals with corticosteroids in India has resulted in Trichophyton mentagrophytes causing recalcitrant dermatophytosis. New dimorphic fungal pathogens have emerged, including Emergomyces, which cause disseminated mycoses globally, primarily in HIV infected patients, and Blastomyceshelicus and B. percursus, causes of atypical blastomycosis in western parts of North America and in Africa, respectively. In North America, regions of geographic risk for coccidioidomycosis, histoplasmosis, and blastomycosis have expanded, possibly related to climate change. In Brazil, zoonotic sporotrichosis caused by Sporothrix brasiliensis has emerged as an important disease of felines and people.
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Triazole resistance in Aspergillus fumigatus: recent insights and challenges for patient management. Clin Microbiol Infect 2019; 25:799-806. [DOI: 10.1016/j.cmi.2018.11.027] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/07/2018] [Accepted: 11/30/2018] [Indexed: 01/18/2023]
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Alvarez-Moreno C, Lavergne RA, Hagen F, Morio F, Meis JF, Le Pape P. Fungicide-driven alterations in azole-resistant Aspergillus fumigatus are related to vegetable crops in Colombia, South America. Mycologia 2019; 111:217-224. [PMID: 30896313 DOI: 10.1080/00275514.2018.1557796] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aspergillus fumigatus resistant to azole as first-line therapy has been reported in azole-naïve patients. This worldwide resistance phenomenon has been linked to fungicide-driven alterations in the cyp51A gene and its promoter region (such as TR34/L98H and TR46/Y121F/T289A). Azole-resistant A. fumigatus related to the use of triazole fungicides in flower fields was recently reported In Colombia. The purpose of this study was to investigate the presence of azole-resistant A. fumigatus in soil samples from vegetable crops such as carrots, potatoes, maize, strawberries, and pea, and from prepared farming land surrounding the city of Bogotá. Species identification was based on sequencing of the β-tubulin and calmodulin genes. All A. fumigatus strains were screened for azole resistance on agar supplemented with itraconazole or voriconazole. Among the 60 soil samples, 34 (56.6%) were positive for A. fumigatus and 15 samples exhibited strains (n = 18) that grew on agar supplemented with itraconazole or voriconazole. Triazole-resistant strains were isolated from soil samples associated with carrot, potato, maize, and pea crops. Sequencing of the cyp51A gene and its promoter region indicated polymorphism, mainly with the presence of TR46/Y121F/T289A (n = 8), TR34/L98H, and TR53. Eight resistant isolates exhibited cyp51A wild type without alterations in the promoter region. Our study showed evidence of dissemination of azole-resistant A. fumigatus, with high genetic diversity, in vegetable crops in Colombia. These data underline the need to determine the prevalence of azole resistance in A. fumigatus in clinical and environmental settings for other regions of Colombia as well as Latin America.
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Affiliation(s)
- Carlos Alvarez-Moreno
- a Departamento de Medicina Interna, Facultad de Medicina , Universidad Nacional de Colombia , Bogotá , Colombia.,b Departamento Enfermedades Infecciosas , Clínica Universitaria Colombia, Colsanitas, Keralty group, Bogotá , Colombia.,c Département de Parasitologie et Mycologie Médicale , Université de Nantes, Nantes Atlantique Universités, EA1155-IICiMed, Institut de recherche en Santé 2 , Nantes , France
| | - Rose-Anne Lavergne
- c Département de Parasitologie et Mycologie Médicale , Université de Nantes, Nantes Atlantique Universités, EA1155-IICiMed, Institut de recherche en Santé 2 , Nantes , France.,d Laboratoire de Parasitologie-Mycologie, Institut de Biologie , Centre Hospitalier Universitaire de Nantes , France
| | - Ferry Hagen
- e Department of Medical Microbiology and Infectious Diseases , Canisius Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Florent Morio
- d Laboratoire de Parasitologie-Mycologie, Institut de Biologie , Centre Hospitalier Universitaire de Nantes , France
| | - Jacques F Meis
- e Department of Medical Microbiology and Infectious Diseases , Canisius Wilhelmina Hospital , Nijmegen , The Netherlands.,f Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Patrice Le Pape
- c Département de Parasitologie et Mycologie Médicale , Université de Nantes, Nantes Atlantique Universités, EA1155-IICiMed, Institut de recherche en Santé 2 , Nantes , France.,d Laboratoire de Parasitologie-Mycologie, Institut de Biologie , Centre Hospitalier Universitaire de Nantes , France
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Prigitano A, Esposto MC, Romanò L, Auxilia F, Tortorano AM. Azole-resistant Aspergillus fumigatus in the Italian environment. J Glob Antimicrob Resist 2019; 16:220-224. [DOI: 10.1016/j.jgar.2018.10.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 02/02/2023] Open
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Lackner M, Rambach G, Jukic E, Sartori B, Fritz J, Seger C, Hagleitner M, Speth C, Lass-Flörl C. Azole-resistant and -susceptible Aspergillus fumigatus isolates show comparable fitness and azole treatment outcome in immunocompetent mice. Med Mycol 2018; 56:703-710. [PMID: 29228287 DOI: 10.1093/mmy/myx109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/05/2017] [Indexed: 11/15/2022] Open
Abstract
No data are available on the in vivo impact of infections with in vitro azole-resistant Aspergillus fumigatus in immunocompetent hosts. Here, the aim was to investigate fungal fitness and treatment response in immunocompetent mice infected with A. fumigatus (parental strain [ps]) and isogenic mutants carrying either the mutation M220K or G54W (cyp51A). The efficacy of itraconazole (ITC) and posaconazole (PSC) was investigated in mice, intravenously challenged either with a single or a combination of ps and mutants (6 × 105 conidia/mouse). Organ fungal burden and clinical parameters were measured. In coinfection models, no fitness advantage was observed for the ps strain when compared to the mutants (M220K and G54W) independent of the presence or absence of azole-treatment. For G54W, M220K, and the ps, no statistically significant difference in ITC and PSC treatment was observed in respect to fungal kidney burden. However, clinical parameters suggest that in particular the azole-resistant strain carrying the mutation G54W caused a more severe disease than the ps strain. Mice infected with G54W showed a significant decline in body weight and lymphocyte counts, while spleen/body weight ratio and granulocyte counts were increased. In immunocompetent mice, in vitro azole-resistance did not translate into therapeutic failure by either ITC or PSC; the immune system appears to play the key role in clearing the infection.
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Affiliation(s)
- Michaela Lackner
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Günter Rambach
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Emina Jukic
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Sartori
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Fritz
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria
| | - Christoph Seger
- Division of Mass Spectrometry and Chromatography, Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital Innsbruck, Innsbruck, Austria
| | - Magdalena Hagleitner
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Speth
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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Rocchi S, Ponçot M, Morin-Crini N, Laboissière A, Valot B, Godeau C, Léchenault-Bergerot C, Reboux G, Crini G, Millon L. Determination of azole fungal residues in soils and detection of Aspergillus fumigatus-resistant strains in market gardens of Eastern France. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2018; 25:32015-32023. [PMID: 30215210 DOI: 10.1007/s11356-018-3177-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
Medical azole antifungals are major compounds used to prevent and to treat invasive aspergillosis (IA). Azole fungicides, called DMI (14-alpha demethylase inhibitors), are also widely used for crop protection and have been reported to be linked to azole-resistant A. fumigatus (aR-Af) development in the environment. The aim of this study was to determine whether or not market gardens that spray DMIs in Eastern France are also affected by the presence of aR-Af. Forty aR-Afs were detected in soils in only two of the four market gardens using DMIs, with 23% (7/30) and 10% (3/30) of soils containing aR-Af. A total of 87.5% of these isolates had the TR34/L98H mutation and 22.5% the TR46/Y121F/T289A mutation on the cyp51A gene. Analyses of residual azole concentrations in soils showed the presence of difenoconazole for up to 2 years after spraying, but only in soils of market gardens where aR-Af was detected. It is very important to identify professional activities that could lead to aR-Af development and to develop preventive measures for at-risk patients living near professional activities using DMIs. We have to better understand why, in some cases, the use of DMI is not linked to aR-Af. Measures should be taken to avoid the use of DMI conferring cross-resistance to preserve the efficiency of human therapeutics.
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Affiliation(s)
- Steffi Rocchi
- Parasitology-Mycology Department, University Hospital, Besançon, France.
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France.
| | - Manon Ponçot
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Nadia Morin-Crini
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Audrey Laboissière
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Benoit Valot
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Chloé Godeau
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | | | - Gabriel Reboux
- Parasitology-Mycology Department, University Hospital, Besançon, France
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Grégorio Crini
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
| | - Laurence Millon
- Parasitology-Mycology Department, University Hospital, Besançon, France
- Chrono-Environnement UMR 6249 CNRS, Bourgogne Franche-Comté University, Besançon, France
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43
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Buil JB, Hagen F, Chowdhary A, Verweij PE, Meis JF. Itraconazole, Voriconazole, and Posaconazole CLSI MIC Distributions for Wild-Type and Azole-Resistant Aspergillus fumigatus Isolates. J Fungi (Basel) 2018; 4:E103. [PMID: 30158470 PMCID: PMC6162657 DOI: 10.3390/jof4030103] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022] Open
Abstract
Azole resistance in Aspergillus fumigatus is most frequently conferred by mutations in the cyp51A gene encoding 14α-sterol demethylases. TR34/L98H and TR46/Y121F/T289A are the two most common mutations associated with environmental resistance selection. We studied the minimal inhibitory concentration (MIC) distribution of clinical A. fumigatus isolates to characterize the Clinical and Laboratory Standards Institute (CLSI) susceptibility profiles of isolates with the wild-type (WT) cyp51A genotype, and isolates with the TR34/L98H and TR46/Y121F/T289A cyp51A mutations. Susceptibility testing was performed according to CLSI M38-A2. The MICs of 363 A. fumigatus isolates were used in this study. Based on the CLSI epidemiological cut-off values (ECVs), 141 isolates were phenotypically non-WT and 222 isolates had a phenotypically WT susceptibility. All isolates with the TR34/L98H mutation had an itraconazole MIC > 1 mg/L which is above the CLSI ECV. Eighty-six of 89 (97%) isolates with the TR34/L98H mutation had voriconazole and posaconazole MICs above the CLSI ECV, i.e., MICs of 1 and 0.25 mg/L, respectively. The isolates with a TR46/Y121F/T289A mutation showed a different phenotype. All 37 isolates with a TR46/Y121F/T289A mutation had a voriconazole MIC above the CLSI ECV, while 28/37 (76%) isolates had an itraconazole MIC > 1 mg/L. Interestingly, only 13 of 37 (35%) isolates had a posaconazole MIC > 0.25 mg/L.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
- Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, 3584 Utrecht, The Netherlands.
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110021, India.
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Jacques F Meis
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
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44
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Garcia-Rubio R, Escribano P, Gomez A, Guinea J, Mellado E. Comparison of Two Highly Discriminatory Typing Methods to Analyze Aspergillus fumigatus Azole Resistance. Front Microbiol 2018; 9:1626. [PMID: 30079058 PMCID: PMC6062602 DOI: 10.3389/fmicb.2018.01626] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
Aspergillus fumigatus molecular typing has become increasingly more important for detecting outbreaks as well as for local and global epidemiological investigations and surveillance. Over the years, many different molecular methods have been described for genotyping this species. Some outstanding approaches are based on microsatellite markers (STRAf assay, which is the current gold standard), or based on sequencing data (TRESP typing improved in this work with a new marker and was renamed TRESPERG). Both methodologies were used to type a collection of 212 A. fumigatus isolates that included 70 azole resistant strains with diverse resistance mechanisms from different geographic locations. Our results showed that both methods are totally reliable for epidemiological investigations showing similar stratification of the A. fumigatus population. STRAf assay offered higher discriminatory power (D = 0.9993) than the TRESPERG typing method (D = 0.9972), but the latter does not require specific equipment or skilled personnel, allowing for a prompt integration into any clinical microbiology laboratory. Among azole resistant isolates, two groups were differentiated considering their resistance mechanisms: cyp51A single point mutations (G54, M220, or G448), and promoter tandem repeat integrations with or without cyp51A modifications (TR34/L98H, TR46/Y121F/A289T, or TR53). The genotypic differences were assessed to explore the population structure as well as the genetic relationship between strains and their azole resistance profile. Genetic cluster analyses suggested that our A. fumigatus population was formed by 6–7 clusters, depending on the methodology. Also, the azole susceptible and resistance population showed different structure and organization. The combination of both methodologies resolved the population structure in a similar way to what has been described in whole-genome sequencing works.
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Affiliation(s)
- Rocio Garcia-Rubio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Pilar Escribano
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Gomez
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jesus Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
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Kemoi EK, Nyerere A, Bii CC. Triazole-Resistant Aspergillus fumigatus from Fungicide-Experienced Soils in Naivasha Subcounty and Nairobi County, Kenya. Int J Microbiol 2018; 2018:7147938. [PMID: 30046310 PMCID: PMC6038473 DOI: 10.1155/2018/7147938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/06/2017] [Accepted: 05/03/2018] [Indexed: 11/18/2022] Open
Abstract
The mainstay in prevention and treatment of aspergillosis is the use triazole drugs. In Kenya, the use of agricultural azole is one of the predisposing factors in development of resistance. One hundred fifty-six (156) experienced soils were collected from agricultural farms and cultured on Sabouraud DextroseAagar. The study isolated 48 yielded Aspergillus fumigatus and 2 A. flavus. All the isolates were subjected to antifungal susceptibility testing against three triazoles: posaconazole, voriconazole, and itraconazole. Out of the isolates, 3 had MIC of 32 and 1 had MIC of 16 against itraconazole, and 1 isolate had MIC of 32 against posaconazole. CYP51A gene was sequenced, and TR34/L98H mutation was identified. Triazole resistance existing in Kenya calls for rational use of azole-based fungicides in agriculture over concerns of emerging antifungal resistance in clinical practice.
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Affiliation(s)
- Edson K. Kemoi
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- University of Kabianga, Kericho, Kenya
| | - Andrew Nyerere
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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46
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Does the use of antifungal agents in agriculture and food foster polyene resistance development? A reason for concern. J Glob Antimicrob Resist 2018; 13:40-48. [DOI: 10.1016/j.jgar.2017.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 10/03/2017] [Accepted: 10/30/2017] [Indexed: 01/11/2023] Open
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47
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Azole Resistance of Environmental and Clinical Aspergillus fumigatus Isolates from Switzerland. Antimicrob Agents Chemother 2018; 62:AAC.02088-17. [PMID: 29437612 PMCID: PMC5913999 DOI: 10.1128/aac.02088-17] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/22/2018] [Indexed: 11/21/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous opportunistic pathogen. This fungus can acquire resistance to azole antifungals due to mutations in the azole target (cyp51A). Recently, cyp51A mutations typical for environmental azole resistance acquisition (for example, TR34/L98H) have been reported. These mutations can also be found in isolates recovered from patients. Environmental azole resistance acquisition has been reported on several continents. Here we describe, for the first time, the occurrence of azole-resistant A. fumigatus isolates of environmental origin in Switzerland with cyp51A mutations, and we show that these isolates can also be recovered from a few patients. While the TR34/L98H mutation was dominant, a single azole-resistant isolate exhibited a cyp51A mutation (G54R) that was reported only for clinical isolates. In conclusion, our study demonstrates that azole resistance with an environmental signature is present in environments and patients of Swiss origin and that mutations believed to be unique to clinical settings are now also observed in the environment.
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48
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Impact of Homologous Resistance Mutations from Pathogenic Yeast on Saccharomyces cerevisiae Lanosterol 14α-Demethylase. Antimicrob Agents Chemother 2018; 62:AAC.02242-17. [PMID: 29263059 DOI: 10.1128/aac.02242-17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/08/2017] [Indexed: 11/20/2022] Open
Abstract
Fungal infections frequently affect immunodeficient individuals and are estimated to kill 1.35 million people per annum. Azole antifungals target the membrane-bound cytochrome P450 monooxygenase lanosterol 14α-demethylase (CYP51; Erg11p). Mutations in CYP51 can render the widely used triazole drugs less effective. The Candida albicans CYP51 mutation G464S and the double mutation Y132F G464S (Y140F and G464S by Saccharomyces cerevisiae numbering) as well as the CYP51A G54E/R/W mutations of Aspergillus fumigatus (G73E/R/W by S. cerevisiae numbering) have been reproduced in a recombinant C-terminal hexahistidine-tagged version of S. cerevisiae CYP51 (ScErg11p6×His). Phenotypes and X-ray crystal structures were determined for the mutant enzymes. Liquid microdilution assays showed that the G464S mutation in ScErg11p6×His conferred no difference in the susceptibility of yeast to triazole drugs but in combination with the Y140F mutation gave a 4-fold reduction in susceptibility to the short-tailed triazole fluconazole. The ScErg11p6×His Y140F G464S mutant was unstable during purification and was not crystallized. The ScErg11p6×His G73E/R/W mutations conferred increased susceptibly to all triazoles tested in liquid microdilution assays. High-resolution X-ray crystal structures reveal two different conformations of the ligand itraconazole, including a previously unseen conformation, as well as interactions between the tail of this triazole and the E/W73 residue. This study shows that S. cerevisiae CYP51 adequately represents some but not all mutations in CYP51s of pathogenic fungi. Insight into the molecular mechanisms of resistance mutations in CYP51 will assist the development of inhibitors that will overcome antifungal resistance.
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49
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Tangwattanachuleeporn M, Minarin N, Saichan S, Sermsri P, Mitkornburee R, Groß U, Chindamporn A, Bader O. Prevalence of azole-resistant Aspergillus fumigatus in the environment of Thailand. Med Mycol 2018; 55:429-435. [PMID: 27664994 DOI: 10.1093/mmy/myw090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/07/2016] [Indexed: 12/18/2022] Open
Abstract
Occurrence of azole-resistant Aspergillus fumigatus (ARAF) in the environment is an emerging problem worldwide, likely impacting on patient treatment. Several resistance mutations are thought to have initially arisen through triazole-based fungicide use in agriculture and subsequently being propagated in a similar manner. Here we investigated the prevalence of ARAF in the environment of Thailand and characterized their susceptibility profiles toward clinically used azole compounds along with underlying resistance mutations. Three hundred and eight soil samples were collected and analyzed, out of which 3.25% (n = 10) were positive for ARAF. All isolates obtained were resistant to itraconazole (MIC ≥ 8 μg/ml), two showed additional increased MIC values toward posaconazole (MIC = 0.5 μg/ml), and one other toward voriconazole (MIC = 2 μg/ml). Sequencing of the respective cyp51A genes revealed that eight of the isolates carried the TR34/L98H allele and those two with elevated MIC values to posaconazole the G54R substitution. Although a clear correlation between the use of triazole-based fungicides and isolation of ARAF strains from agricultural lands could not be established for Thailand, but this study clearly demonstrates the spread of globally observed ARAF strains to the environment of South East Asia.
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Affiliation(s)
| | - Nanthakan Minarin
- Medical Technology Unit, Faculty of Allied Health Sciences, Burapha University, Chon Buri, Thailand
| | - Saranya Saichan
- Biomedical Sciences Unit, Faculty of Allied Health Sciences, Burapha University, Chon Buri, Thailand
| | - Pornsuda Sermsri
- Biomedical Sciences Unit, Faculty of Allied Health Sciences, Burapha University, Chon Buri, Thailand
| | - Ruthairat Mitkornburee
- Biomedical Sciences Unit, Faculty of Allied Health Sciences, Burapha University, Chon Buri, Thailand
| | - Uwe Groß
- Institute for Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany
| | - Ariya Chindamporn
- Mycology Unit, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Oliver Bader
- Institute for Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, 37075 Göttingen, Germany
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50
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Deng S, Zhang L, Ji Y, Verweij PE, Tsui KM, Hagen F, Houbraken J, Meis JF, Abliz P, Wang X, Zhao J, Liao W. Triazole phenotypes and genotypic characterization of clinical Aspergillus fumigatus isolates in China. Emerg Microbes Infect 2017; 6:e109. [PMID: 29209054 PMCID: PMC5750463 DOI: 10.1038/emi.2017.97] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/09/2023]
Abstract
This study investigated the triazole phenotype and genotypic of clinical Aspergillus fumigatus isolates from China. We determined the triazole susceptibility profiles of 159 A. fumigatus isolates collected between 2011 and 2015 from four different areas in China tested against 10 antifungal drugs using the Clinical Laboratory Standard Institute M38-A2 method. For the seven itraconazole-resistant A. fumigatus isolates identified in the study, the cyp51A gene, including its promoter region, was sequenced and the mutation patterns were characterized. The resistant isolates were genotyped by microsatellite typing to determine the genetic relatedness to isolates from China and other countries. The frequency of itraconazole resistance in A. fumigatus isolates in our study was 4.4% (7/159). Six of the seven triazole-resistant isolates were recovered from the east and southeast of China, and one from was recovered from the west of China. No resistant isolates were found in the north. Three triazole-resistant isolates exhibited the TR34/L98H mutation, two carried the TR34/L98H/S297T/F495I mutation and one harbored a G54V mutation in the cyp51A gene. Analysis of the microsatellite markers from seven non-wild-type isolates indicated the presence of five unique genotypes, which clustered into two major genetic groups. The cyp51A gene mutations TR34/L98H and TR34/L98H/S297T were the most frequently found mutations, and the G54V mutation was reported for the first time in China. The geographic origin of the triazole-resistant isolates appeared to concentrate in eastern and south-eastern areas, which suggests that routine antifungal susceptibility testing in these areas should be performed for all clinically relevant A. fumigatus isolates to guide antifungal therapy and for epidemiological purposes.
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Affiliation(s)
- Shuwen Deng
- Department of Medical Microbiology, People's Hospital of Suzhou National New & Hi-Tech Industrial Development Zone, Jiangsu 215219, China
| | - Lili Zhang
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Yanfeng Ji
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen 6500HB, The Netherlands
| | - Kin Ming Tsui
- Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver V6H3Z6, Canada
| | - Ferry Hagen
- Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen 6500GS, The Netherlands.,Centre of Expertise in Mycology Radboud University Medical Centre/CWZ, Nijmegen 6500HB, The Netherlands
| | - Jos Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht 3584CT, The Netherlands
| | - Jacque F Meis
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen 6500HB, The Netherlands.,Department of Medical Microbiology & Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen 6500GS, The Netherlands.,Centre of Expertise in Mycology Radboud University Medical Centre/CWZ, Nijmegen 6500HB, The Netherlands
| | - Parida Abliz
- First Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Xiaodong Wang
- First Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Jingjun Zhao
- Department of Dermatology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai 200065, China
| | - Wanqing Liao
- Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
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