Estimation of Direct Healthcare Costs of Fungal Diseases in the United States

Temporal Trends of Fungal Infections in Cirrhotic Patients: A Retrospective Cohort Study 2016-2020

Background

Patients with cirrhosis are susceptible to infections due to abnormalities in humoral and cell-mediated immunity. Fungal infections are associated with delayed diagnosis and high mortality rates, emphasizing the importance of performing fungal cultures and maintaining elevated levels of suspicion in this patient population.

Methods

This retrospective cohort study analyzes cirrhotic patients readmitted with bacterial and fungal infections and investigates outcomes, including in-hospital mortality and hospital resource utilization. Data was acquired from the Nationwide Readmission Database (NRD) from 2016 to 2020. Total hospital costs were calculated using HCUP Cost-to-Charge Ratio files and adjusted for inflation based on the Consumer Price Index (CPI) for medical care services in the U.S., with 2020 as the reference year. The NRD dataset lacks details like ascitic fluid cell counts, antifungal/antibacterial drugs used, and treatment responses, limiting the clinical insights that can be derived.

Results

The study analyzed 393,195 index hospitalizations. Among these, 102,505 account for 30-day and 157,079 account for 90-day readmissions. The 30-day and 90-day readmissions for spontaneous bacterial peritonitis (SBP) are 8478 and 15,690 respectively. The 30-day and 90-day readmissions for spontaneous fungal peritonitis (SFP) are 3106 and 5798 respectively. The mean age of patients was 57.9 years (standard deviation between 57.7 and 58.1). The mean length of stay (LOS) for SBP at 30 days is 9.4 days, while SFP has ranged from 14.9 to 32.3 days for various fungal infections. Aspergilloses have the longest LOS among SFP. There is an increased rate of mortality as well as hospital charges with SFP compared to SBP (P < 0.001). The 30-day index admission total charges for SBP are $42,258 and SFP are $51,739. The 30-day readmission total charges for SBP are 64, 266 and for SFP 89,913.

Conclusions

There is increased mortality, LOS, and hospital costs for SFP compared to SBP. It is important to consider SFP in the diagnostic workup for patients who do not respond to antibiotics. Early recognition and administration of antifungals can be associated with improved outcomes.

Treating and Protecting against Recurrent Vulvovaginal Candidiasis Using the Vaginal Epithelial Cell Membrane-Based Photoimmunotherapeutic Nanoplatform

Recurrent vulvovaginal candidiasis (RVVC) is an opportunistic infection predominantly caused by Candida albicans (C. albicans) and is particularly prevalent among individuals on immunosuppressants. Currently, there are no FDA-approved therapies for specifically controlling RVVC, mainly due to the need for therapeutics against RVVC that require both antifungal treatments to resolve active infections and strategies to prevent recurrence. This study introduces a biomimetic photoimmunotherapeutic nanoplatform consisting of an adjuvant-encapsulated polymeric core stabilized by a photosensitizer-loaded vaginal epithelial cell membrane coating to treat and protect against RVVC. With its cell membrane camouflaging, the nanoplatforms target and enhance adherence to the intravaginal site of C. albicans infection, allowing the nanoplatform to resist being flushed away by vaginal fluids. Upon subsequent near-infrared irradiation, the nanoplatform's targeted photothermal power effectively eliminates C. albicans while minimizing thermal damage to surrounding healthy tissue. Postphotothermal treatment, the generated C. albicans-based debris and candidalysin-captured nanoplatform (serving as a nanotoxoid), along with adjuvant, are processed by resident antigen-presenting cells to promote multiantigenic immunity. This response provides protection against secondary intravaginal C. albicans infection (RVVC model) and C. albicans-induced systemic infection even under immunosuppressive conditions (septicemia model). Notably, anti-C. albicans antibodies produced in the pretreated mice exhibit comparable affinity to clinically isolated C. albicans strains, indicating potential for clinical application. Overall, this study underscores the potential of the proposed photoimmunotherapeutic nanoplatform for the effective treatment and prevention of RVVC.

Antifungal Efficacy of Luliconazole-Loaded Nanostructured Lipid-Carrier Gel in an Animal Model of Dermatophytosis

Background:Trichophyton indotineae terbinafine-resistant infections are emerging in healthy individuals. Luliconazole, an imidazole antifungal that is effective against skin infections, faces challenges due to low water solubility and poor skin penetration. This study aimed to formulate a luliconazole-loaded nanostructured lipid-carrier (NLC) gel in a Carbopol-based system to enhance drug absorption and efficacy in a guinea pig model of dermatophytosis. Methods: Luliconazole-loaded nanostructured lipid carriers (NLCs) were prepared using a solvent evaporation method and gel formulation. Skin absorption and retention were assessed via Franz diffusion cells. The antifungal efficacy was tested against T. indotineae in thirty guinea pigs with induced tinea corporis, divided into five treatment groups. Mycological, clinical, and histopathological evaluations were conducted, along with skin irritation studies for safety. Results: LCZ-NLC demonstrated significantly better skin penetration than simple luliconazole gel, with cumulative drug penetration of 71.8 ± 3.7 μg/cm2 versus 50.9 ± 4.2 μg/cm2 after 24 h. Both formulations achieved complete infection resolution after 21 and 28 days, with reduced inflammation and no local irritations. On day 21, the LCZ-NLC 1% gel significantly reduced lesion scores and mycological evidence of infection compared to the terbinafine-treated groups, untreated controls, and NLC-gel-treated group (p < 0.05). Histopathological analysis indicated a reduction in both epidermal thickening and fungal burden in the models that received treatment with the LCZ-NLC 1% gel. Conclusions: Luliconazole-loaded lipid carriers enhance drug absorption and efficacy, suggesting shorter treatment durations and improved patient outcomes for resistant fungal infections. However, further studies are warranted to correlate these findings with clinical outcomes.

Candida albicans Recovered From Persistent Candidemia Exhibits Enhanced Virulence Traits

Candida albicans catheter-related candidemia is largely driven by microbial adhesion and biofilm formation on central venous catheters. Cells that disperse from these biofilms can enter the bloodstream, spread to distant organs, and sustain the cycle of infection. In this study, we investigated the virulence potential of C. albicans isolates obtained from the blood of catheterized patients experiencing persistent candidemia, comparing them to isolates that were cleared from the bloodstream early in the infection. Our results show that isolates persisting in the bloodstream for 4 days or longer, despite antifungal treatment, exhibited enhanced adherence, filamentation, and biofilm formation in vitro, along with increased expression of key virulence-related genes. Notably, cells dispersed from second-generation biofilms formed by these persistent isolates displayed even more pronounced pathogenic characteristics, including improved immune evasion. Furthermore, in vivo experiments using Galleria mellonella revealed that persistent isolates were significantly more virulent than their nonpersistent counterparts.

Epidemiology, clinical characteristics, and outcome in candidemia: a retrospective five-year analysis from two tertiary general hospitals

BACKGROUND

Candidemia is linked with high mortality, highlighting the critical importance of timely empirical antimicrobial therapy and precise medical intervention before a definite etiologic diagnosis. The current study aimed to investigate the prevalence of pathogens in patients with candidemia and evaluate the potential independent risk factors for Candida albicans bloodstream infections (BSI), as well as the prognosis of candidemia.

METHODS

A retrospective bicentric observational study was performed, incorporating 132 candidemia episodes from two tertiary general hospitals in the Linyi area between January 2019 and December 2023. Data on demographic characteristics, underlying diseases, medical intervention, and antimicrobial sensitivity were collected and analyzed using SPSS version 27.0. Univariate analysis and binary logistic regression analyses were performed to identify risk factors for non-albicans Candida infections and candidemia-related mortality.

RESULTS

A total of 132 strains of Candida species were isolated from 132 patients with candidemia, with non-albicans Candida accounting for 71.97% (95/132) and Candida albicans for 28.03%. Although Candida albicans remains the predominant species, the proportion of Candida tropicalis, mainly from the Hematology Ward, is approaching that of Candida albicans, which was mainly found in the intensive care unit (ICU) (27.27% versus 28.03%). Moreover, Candida tropicalis, the most frequently isolated non-albicans Candida species, exhibited poorer sensitivity to triazole drugs than other Candida species. Multivariate analysis identified gastrointestinal surgery (non-tumor) as an independent risk factor for Candida albicans BSI (odds ratio [OR] = 6.683, 95% confidence interval [CI]: 1.253-35.632, P = 0.026). The 30-day mortality rate of candidemia in the current study was 30.3%. Binary logistic regression analysis identified several factors significantly associated with mortality, including age (OR = 1.038, 95% CI: 1.007-1.071, P = 0.018) and septic shock (OR = 3.307, 95% CI: 1.205-9.071, P = 0.020).

CONCLUSION

The mortality rate of candidemia in the current study reached 30.3%, indicating a high disease burden. Recently, the proportion of non-albicans Candida, especially Candida tropicalis, has increased markedly. Therefore, increased attention should be given to patients with the identified risk factors to improve candidemia management and outcomes.

CLINICAL TRIAL NUMBER

Not applicable.

Forward genetic screen in zebrafish identifies new fungal regulators that limit host-protective Candida-innate immune interaction

Candida is one of the most frequent causes of bloodstream infections, and our first line of defense against these invasive infections is the innate immune system. The early immune response is critical in controlling Candida albicans infection, but C. albicans has several strategies to evade host immune attack. Phagocytosis of C. albicans blocks hyphal growth, limiting host damage and virulence, but how C. albicans limits early recruitment and phagocytosis in vertebrate infection is poorly understood. To study innate immune evasion by intravital imaging, we utilized the transparent larval zebrafish infection model to screen 131 C. albicans mutants for altered virulence and phagocyte response. Infections with each of the seven hypovirulent mutants led to altered phagocyte recruitment and/or phagocytosis, falling into four categories. Of particular interest among these is NMD5, a predicted β-importin and newly identified virulence factor. The nmd5∆/∆ mutant fails to limit phagocytosis, and its virulence defects are eliminated when phagocyte activity is compromised, suggesting that its role in virulence is limited to immune evasion. These quantitative intravital imaging experiments are the first to document altered Candida-phagocyte interactions for several additional mutants and clearly distinguish recruitment from phagocytic uptake, suggesting that Candida modulates both events. This initial large-scale screen of individual C. albicans mutants in a vertebrate, coupled with high-resolution imaging of Candida-phagocyte interactions, provides a more nuanced view of how diverse mutations can lead to more effective phagocytosis, a key immune process that blocks germination and drives anti-fungal immunity.

IMPORTANCE

Candida albicans is part of the human microbial community and is a dangerous opportunistic pathogen, able to prevent its elimination by the host immune system. Although Candida avoids immune attack through several strategies, we still understand little about how it regulates when immune phagocytes get recruited to the infection site and when they engulf fungal cells. We tested over 130 selected Candida mutants for their ability to cause lethal infection and found several hypovirulent mutants, which provoked altered innate immune responses, resulting in lower overall inflammation and greater host survival. Of particular interest is NMD5, which acts to limit fungal phagocytosis and is predicted to regulate the activity of stress-associated transcription factors. Our high-content screening was enabled by modeling Candida infection in transparent vertebrate zebrafish larva. Our findings help us understand how Candida survives immune attack during commensal and pathogenic growth, and may eventually inform new strategies for controlling disease.

Antimicrobial Silicon Rubber Crosslinked with Bornyl-Siloxane

Silicone rubber (SiR) has a wide range of medical applications, but it lacks antimicrobial properties, leading to potential infection issues with related implants or medical devices. Most studies focus on adding anti-bacterial agents or surface modification, which usually result in composites with anti-bacterial properties, rather than synthesizing SiR with intrinsically antimicrobial performances. To tackle this issue, a double substituted bornyl-siloxane crosslinker (BC) is designed. This crosslinker can react with hydroxy-terminated polydimethylsiloxane (PDMS) at room temperature to yield SiR with borneol side groups. The process is simple without using additional solvents. Antimicrobial assay on SiR cured with different ratios of BC/PDMS showed that 20 wt.% BC cross-linked network exhibited outstanding anti-bacterial adhesion (Escherichia coli 99.4%, Staphylococcus aureus 97.3%) performance and long-lasting anti-mold (Aspergillus niger over 99% for 30 days) adhesion properties. Moreover, the subcutaneous implantation model in mice demonstrated its excellent anti-infection, biocompatibility and safety. Therefore, this material is promising for widespread adoption in the medical field, especially in silicon-based products or coatings.

When to suspect and how properly early detect and treat patients with endemic mycoses

Endemic mycoses are caused by dimorphic fungi and eventually molds, as the case of implantation mycoses. In general, these diseases are acquired through trauma or inhalation of fungal elements in the environment, and less frequently by zoonotic acquisition or transmitted during organ transplantation. The target population for endemic mycoses is usually represented by normal hosts with low-income and intensive outdoor activities. Awareness of these diseases remains limited, even in regions with high prevalence, resulting in delayed diagnosis, and affecting the quality of life and outcomes of patients who suffer from these entities. In this review, we summarized relevant information about epidemiological, clinical, diagnostic, and treatment aspects of the most common endemic mycoses, including blastomycosis, coccidioidomycosis, histoplasmosis, paracoccidioidomycoses, talaromycosis, and implantation mycoses. The main goal of this review is to provide key concepts in terms of when to suspect, how early diagnose, and properly treat patients with these mycoses.

Correlation analysis between IL-1R/TLRs pathway and superficial dermatomycosis

OBJECTIVE

This study explored the correlation between interleukin-1 receptor/Toll-like receptor (IL-1R/TLRs)-mediated inflammatory signaling pathways and the severity of superficial dermatomycosis.

METHODS

From May 2020 to August 2022, 76 patients with superficial dermatomycosis (infected group) and 52 patients without infection (non-infected group) were enrolled. The indicators related to IL-1R/TLRs pathway were analyzed, and the diagnostic value of the combined detection of each index for superficial dermatomycosis and disease severity was analyzed. The correlation between each index and the severity of infection was analyzed.

RESULTS

IL-1β, TLR4, IL-6, and TNF-α in the infected group were higher than those in the non-infected group (P < 0.05). The AUC of IL-1R/TLRs combined detection in the group diagnosed with a superficial dermatomycosis was higher than that of each single detection (P < 0.05). IL-1β, TLR4, IL-6, and TNF-α in the severe group were higher than those in the mild group (P < 0.05). IL-1β, TLR4, IL-6, and TNF-α were positively correlated with the degree of infection (P < 0.05). The AUC of IL-1R/TLRs combined detection was higher than that of each single test (P < 0.05). IL-1β ≥ 2.87 ng/L, TLR4 ≥ 3.12 ng/L, IL-6 ≥ 4.58 ng/L, TNF-α ≥ 70.53 ng/L were the influencing factors of severe superficial dermatomycosis (P < 0.05).

CONCLUSION

IL-1R/TLRs pathway is related to the severity of superficial dermatomycosis, and the collective identification of each indicator provides diagnostic insight into infection severity.

Beyond Conventional Antifungals: Combating Resistance Through Novel Therapeutic Pathways

The rising burden of fungal infections presents a significant challenge to global healthcare, particularly with increasing antifungal resistance limiting treatment efficacy. Early detection and timely intervention remain critical, yet fungal pathogens employ diverse mechanisms to evade host immunity and develop resistance, undermining existing therapeutic options. Limited antifungal options and rising resistance necessitate novel treatment strategies. This review provides a comprehensive overview of conventional antifungal agents, their mechanisms of action, and emerging resistance pathways. Furthermore, it highlights recently approved and investigational antifungal compounds while evaluating innovative approaches such as nanotechnology, drug repurposing, and immunotherapy. Addressing antifungal resistance requires a multifaceted strategy that integrates novel therapeutics, enhanced diagnostic tools, and future research efforts to develop sustainable and effective treatment solutions.

An Update on Fungal Disease Outbreaks of Public Health Concern

For this narrative review, we describe recent high-profile and severe outbreaks of emerging fungal infections, emphasizing lessons learned and opportunities to improve future prevention and response efforts. Several themes and challenges remain consistent across a diverse array of fungal outbreaks, including the multidisciplinary need for improved diagnostic testing to determine species and perform antifungal susceptibility testing, clinical awareness, and optimization of antifungal use. Recent outbreaks exemplify the growing promise of non-culture-based tools in identifying fungal outbreaks and improving responses, although access remains limited. Culture-based tools remain critical for performing antifungal-susceptibility to guide therapy.

Deletion of core septin gene aspB in Aspergillus fumigatus results in fungicidal activity of caspofungin

Septins are a family of GTP-binding proteins found in many eukaryotic lineages. Although highly conserved throughout many eukaryotes, their functions vary across species. In Aspergillus fumigatus, the etiological agent of invasive aspergillosis, septins participate in a variety of processes such as cell wall organization of conidia, septation, and response to cell wall stress. Previous studies determined that the ΔaspB strain had a greater sensitivity to anti-cell wall drugs, especially the echinocandin caspofungin, yet mechanisms behind this augmented sensitivity are unknown. We performed cell viability staining of the deletion strains post-caspofungin exposure and found that the ΔaspA, ΔaspB, and ΔaspC strains have significantly lower cell viability. Concomitant with the reduced viability, deletion strains are more susceptible to caspofungin on solid media. These results indicate that the septin cytoskeleton is important for A. fumigatus survival in the presence of caspofungin. Due to the potential of improved therapeutic outcome, we followed up using a neutropenic murine model of invasive aspergillosis. Animals infected with the ΔaspB strain and treated with caspofungin showed improved survival compared to the animals infected with akuB KU80 wild-type or complemented strains. Additionally, histological analysis showed reduced fungal burden and inflammation in the ΔaspB infected, caspofungin-treated group. Affinity purification coupled with quantitative proteomics identified proteins involved in the septin-dependent response to caspofungin, includng four candidate interactors involved in cell wall stress response. Deletion of these candidate genes resulted in increased susceptibility to caspofungin and moderately reduced viability post-drug exposure. Taken together, these data suggest that septin AspB contributes to the fungistatic response to caspofungin.

A screen to identify antifungal antagonists reveals a variety of pharmacotherapies induce echinocandin tolerance in Candida albicans

Through screening a comprehensive collection of drugs approved for human use, we identified over 20 that oppose the antifungal activity of the echinocandins upon the infectious yeast, Candida albicans . More detailed evaluation of five such drugs, including the atypical antipsychotic aripiprazole and the tyrosine kinase inhibitor ponatinib, indicated they promote C. albicans survival following exposure to the echinocandin antifungals. The activity of the five selected antagonists was dependent upon the Mkc1p MAPK pathway, however, ponatinib was paradoxically shown to suppress phosphorylation and therefore activation of Mkc1p itself. Components of several other signaling pathways are also required, including those of calcineurin and casein kinase-2, suggesting the observed antagonism required much of the cell wall stress responses previously described for C. albicans . Transcriptome analysis revealed that the antagonists stimulated the expression of genes involved in xenobiotic and antifungal resistance, and suppressed the expression of genes associated with hyphal growth. Thus, the echinocandin antagonistic drugs modulate C. albicans physiology in ways that could impact its pathogenicity and/or response to therapeutic intervention. Finally, a mutant lacking the Efg1p transcription factor, which has a central role in the activation of C. albicans hyphal growth was found to have intrinsically high levels of echinocandin tolerance, suggesting a link between modulation of morphogenesis related signaling and echinocandin tolerance.

Importance

We report a substantial number of previously unknown drug interactions that modulate the echinocandin sensitivity of one of the most prevalent human fungal pathogens, Candida albicans . The echinocandins are the first line therapy for treating disseminated and often lethal Candida infections, that account for >75% of invasive fungal infections in the U.S.. For largely unknown reasons, a substantial number of patients with invasive candidiasis fail to respond to treatment with these drugs. The finding of this study suggest that co-administered medications have the potential to influence the therapeutic outcomes of invasive fungal infections through modulating antifungal drug tolerance and/or fungal pathogenicity. The potential for echinocandin antagonistic medications to influence therapeutic outcomes is discussed.

Antifungal Policy and Practice Across Five Countries: A Qualitative Review

The burden of invasive fungal infections (IFIs) is increasing worldwide. National, regional, and local policies on IFI management should respond to the changing landscape. We assessed antifungal policies from five countries of varying size, IFI burden, and geography: the Netherlands, Italy, South Korea, China, and India. These countries were selected as a representative sample reflecting different types of economic and health systems that patients and providers access worldwide. This assessment focused on a comprehensive range of antifungal policy elements, including recognition and prioritization, awareness and education, prevention and monitoring, diagnosis and coordinated care, access to appropriate treatment, and diagnostic and treatment innovation. Although countries in this analysis all have some form of policy for IFI management, we have identified substantial gaps, including low prioritization of IFI diagnostics, omission of fungal pathogens from antimicrobial resistance policies, and a general lack of awareness and healthcare professional (HCP) training on IFI management. The gaps identified are intended to inform HCPs and policy- and decision-makers about aspects to consider in reducing the IFI burden for patients and health systems while demonstrating responsible antifungal stewardship.

The Burden of Hospital Illness Associated with Disseminated Versus Isolated Pulmonary Coccidioidomycosis in the United States

There are scarce data comparing inpatient mortality, length of stay (LOS) and all-cause hospital costs in disseminated coccidioidomycosis (DCM) vs. isolated pulmonary coccidioidomycosis (IPCM). We assessed the burden of hospital illness associated with DCM versus IPCM. This study was performed using National Inpatient Sample data from 2019 to 2021. DCM was defined as having a primary International Classification of Diseases-Tenth Revision (ICD-10) code for coccidioidal meningitis, a non-primary code for coccidioidal meningitis in the presence of a primary code for a meningitis complication or a procedure code depicting the need for a meningitis-related procedure, or a primary code for DCM without a code for unspecified disease. IPCM was defined as a primary code for pulmonary coccidioidomycosis without codes for DCM or unspecified disease. Multivariable regression was used to compare the odds of in-hospital mortality, LOS and all-cause hospital costs (2023 US$) for DCM versus IPCM, after covariate adjustment. A total of 6195 hospitalizations were identified, 2305 for DCM and 3890 for IPCM. Patients experiencing a DCM hospitalization had a 19.7% incidence of concomitant pulmonary coccidioidomycosis. Coccidioidal meningitis constituted 81.3% of all DCM hospitalizations, of which 78.1% received a meningitis-related procedure or were admitted for a meningitis complication. DCM was associated with an increased odds of death (odds ratio = 2.76, 95% confidence interval [CI] = 1.26-6.04) versus IPCM. DCM was associated with a longer mean hospital LOS (4.51 days, 95%CI = 3.39-5.63) and higher mean all-cause costs ($20,008, 95%CI = $15,313-$24,704) versus IPCM. DCM hospitalizations were associated with higher odds of inpatient mortality, longer LOS, and higher costs versus IPCM.

Forward genetic screen in zebrafish identifies new fungal regulators that limit host-protective Candida-innate immune interaction

Candida is one of the most frequent causes of bloodstream infections, and our first line of defense against these invasive infections is the innate immune system. The early immune response is critical in controlling C. albicans infection, but C. albicans has several strategies to evade host immune attack. Phagocytosis of C. albicans blocks hyphal growth, limiting host damage and virulence, but how C. albicans limits early recruitment and phagocytosis in vertebrate infection is poorly understood. To study innate immune evasion by intravital imaging, we utilized the transparent larval zebrafish infection model to screen 131 C. albicans mutants for altered virulence and phagocyte response. Infections with each of seven hypovirulent mutants led to altered phagocyte recruitment and/or phagocytosis, falling into four categories. Of particular interest among these is NMD5, a predicted β-importin and newly-identified virulence factor. The nmd5∆/∆ mutant fails to limit phagocytosis and its virulence defects are eliminated when phagocyte activity is compromised, suggesting that its role in virulence is limited to immune evasion. These quantitative intravital imaging experiments are the first to document altered Candida-phagocyte interactions for several additional mutants, and clearly distinguish recruitment from phagocytic uptake, suggesting that Candida modulates both events. This initial large-scale screen of individual C. albicans mutants in a vertebrate, coupled with high-resolution imaging of Candida-phagocyte interactions, provides a more nuanced view of how diverse mutations can lead to more effective phagocytosis, a key immune process which blocks germination and drives anti-fungal immunity.

Fungal biofilms in human health and disease

Increased use of implanted medical devices, use of immunosuppressants and an ageing population have driven the rising frequency of fungal biofilm-related diseases. Fungi are now recognized by the World Health Organization (WHO) as an emergent threat to human health, with most medically important species defined as critical or high-priority organisms capable of forming biofilms. Although we strive for a better understanding of diagnostic and therapeutic approaches to detect and treat these fungal diseases more generally, the issue of hard-to-treat biofilms is an ever-increasing problem. These are communities of interspersed cells that are attached to one another on a surface, such as a catheter, or trapped into a cavity such as a paranasal sinus. Biofilms are difficult to detect, difficult to remove and intrinsically tolerant to most antifungal agents. These factors can lead to devastating consequences for the patient, including unnecessary morbidity and mortality, need for reoperations and prolonged hospital stay. This Review describes the breadth and growing impact fungal biofilms have on patient management and explains the mechanisms promoting biofilm formation, focusing on how targeting these can improve therapeutic options.

Acute Exacerbation of Idiopathic Pulmonary Fibrosis in the Setting of Acute Eosinophilic Pneumonia

Description Idiopathic pulmonary fibrosis (IPF) is a progressive disease characterized by gradual destruction and replacement of pulmonary parenchyma with fibrous tissue, which occurs in conjunction with chronic inflammation. It is often considered a prototypical interstitial lung disease and is both the most prevalent and perhaps the most dangerous in that family. Although the disease is uncommon in the general population, its prevalence increases with age and is typically diagnosed around the age of 65. This does not preclude the development of IPF in younger individuals, and the mean survival is 2 to 5 years post-diagnosis regardless of age. Contemporary studies have provided insight into how altered pulmonary parenchyma results in increased susceptibility to opportunistic infections. It has also been demonstrated that pulmonary insults that cause inflammation, such as pneumonia, may accelerate the progression of IPF. Eosinophilic pneumonias are a collection of pulmonary diseases in which eosinophil-mediated inflammation results in respiratory compromise. Early recognition and appropriate intervention are imperative to minimize the risk of residual pulmonary function deficits, a risk that is increased in individuals with separate pulmonary risk factors. While prompt diagnosis and pharmacologic interventions are associated with improved outcomes, patients with IPF remain at risk of deterioration to the point of requiring lung transplantation. Early screening for those at risk continues to be a topic of interest. Despite the prevalence of IPF, its pathogenesis remains poorly understood and few management options are available. In this article, we document a unique case of previously undiagnosed IPF in a young individual that acutely worsened in the setting of acute eosinophilic pneumonia and the involvement of an opportunistic organism, Aspergillus niger. The case section will serve as a transition into a discussion of each of the major pathologic factors at play, supported by a review of recent literature.

Carbon dioxide suppresses filamentous growth in the human fungal pathogen Candida tropicalis

A striking characteristic of the human fungal pathogen Candida albicans is its ability to switch between budding yeast morphology and the filamentous form, facilitating its adaptation to changing host environments. The filamentous growth of C. albicans is mediated by various environmental factors, such as carbon dioxide (CO2), N-acetylglucosamine (GlcNAc), serum, and high temperature. Despite extensive studies in C. albicans, the regulatory mechanism of filamentation in Candida tropicalis, a fungal species that is closely related to C. albicans, has not been well characterized. In this study, we reveal opposite roles of CO2 in regulating filamentation among Candida species: CO2 promotes filamentous growth in C. albicans and Candida dubliniensis, whereas it inhibits filamentation in C. tropicalis. Despite the critical role of the canonical cAMP pathway in filamentation, it is dispensable in CO2-regulated filamentation in C. tropicalis. A CO2-specific signaling is involved in the regulation of filamentous growth in C. tropicalis. Additionally, we identify two key elements involved in CO2 sensing in C. tropicalis: a single carbonic anhydrase (CA) Nce103 and the bZIP transcription factor Rca1. Both Nce103 and Rca1 are important for cellular growth in ambient air and negatively regulate filamentous development in response to CO2 in C. tropicalis. These findings reveal a distinct mechanism underlying CO2-regulated filamentation in C. tropicalis, contributing to a deeper understanding of its unique survival strategies in diverse environmental niches and providing new insights into the adaptive evolution of CO2 sensing mechanisms among various fungal pathogens.

Clotrimazole mucoadhesive films with extended-release properties for vaginal candidiasis-A hot-melt extrusion application

Clotrimazole, an antifungal agent for treating vaginal candidiasis, faces challenges in localized delivery due to poor solubility, complexity of the vaginal environment, limited fluid for dissolution, and rapid self washout of the vagina. The study aimed to enhance clotrimazole solubility using hot-melt extrusion (HME) to develop vaginal films with adequate bioadhesion, mechanical strength, and extended-release properties. Different formulations were created by varying the ratios of polyethylene oxide (PEO) grades (N750 and N10) to adjust the films' properties. The films demonstrated extended-release profiles, prolonging clotrimazole release for up to eight hours, with a cumulative gradual and complete in- vitro release in 100 mL of simulated vaginal fluid with 0.5% sodium dodecyl sulfate. In contrast, the marketed vaginal ovules exhibited a rapid and complete release within 30 minutes of shell rupture. The release kinetics followed Krosmeyer-Peppas model, and zero-order release mechanism. Films containing 25% clotrimazole, 56.25% PEO N750, and 18.75% PEO N10 exhibited strength of 87.9 N, stiffness of 35 N/sec, and adhesive force of 3.85 N.mm. In conclusion, the novel clotrimazole-loaded vaginal films developed using HME technology enhanced the solubility and localized vaginal delivery of clotrimazole. The extended-release profile may reduce the dosing frequency, enhance patient adherence, and improve therapeutic outcomes.

Prevalence of T. rubrum and T. interdigitale Exhibiting High MICs to Terbinafine in Clinical Samples Analyzed in the Portuguese Mycology Reference Laboratory

Cutaneous fungal infections represent a significant burden worldwide with a high impact on public health. Accurate identification of dermatophyte species causing these infections is vital for an appropriate treatment. Terbinafine is the primary agent against Trichophyton species due to its clinical efficacy; however, cases of elevated minimum inhibitory concentration (MIC) have been reported, raising clinical and epidemiological concerns. Herein, we aimed to detect Trichophyton rubrum and Trichophyton interdigitale isolates collected from clinical samples with terbinafine-high MICs (TRB-hMIC). A total of 168 isolates, recovered from 2017 to 2023, were identified as T. rubrum complex (140/83.4%) or T. interdigitale (28/16.7%) and further screened regarding their terbinafine susceptibility. Four isolates with capacity to grow in terbinafine media were detected by screening, and these and a further sixteen random isolates were submitted to the broth microdilution method. This methodology confirmed the four (2.4%) isolates as TRB-hMIC. One T. rubrum and three T. interdigitale showed a minimum inhibitory concentration (MIC) higher than 1 mg/L. Partial sequencing of the SQLE gene identified point mutations in T. rubrum (Phe397Iso) and in one T. interdigitale (Phe397Leu) isolate. Notably, in the other two T. interdigitale isolates with TRB-hMIC, no point mutations in the SQLE gene were identified. In conclusion, TRB-hMIC isolates (T. rubrum and T. interdigitale) were identified in clinical samples analyzed in Portugal, as antifungal susceptibility testing is a crucial routine for identifying treatment failures and also for epidemiological purposes aiming to monitor the dynamics of terbinafine resistance.

Gelatin Nanoemulsion-Based Co-Delivery of Terbinafine and Essential Oils for Treatment of Candida albicans Biofilms

Fungal infections represent a significant global health challenge. Candida albicans is a particularly widespread pathogen, with both molecular and biofilm-based mechanisms making it resistant to or tolerant of available antifungal drugs. This study reports a combination therapy, active against C. albicans, utilizing terbinafine and essential oils incorporated into a gelatin-based nanoemulsion system (T-GNE). Eugenol and methyl eugenol/terbinafine T-GNEs had an additive efficacy, while carvacrol (CT-GNE) worked synergistically with terbinafine, providing effective antifungal treatment with minimal mammalian cell toxicity. Confocal microscopy demonstrated that CT-GNE penetrated the dense C. albicans biofilm and disrupted the fungal cell membrane. Overall, the combination of essential oils with terbinafine in GNE provided a promising treatment for fungal biofilms.

Rapid Identification of Clinically Relevant Candida spp. by I-dOne Software Using Attenuated Total Reflectance Fourier Transform Infrared (ATR-FTIR) Spectroscopy

Attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy is a spectrum-based technique that quantifies the absorption of infrared light by molecules present in the microbial cell. The aim of the present study was to evaluate the performance of the ATR-FTIR spectroscopic technique via I-dOne software (Version 2.0) compared with the MALDI-TOF MS in identifying Candida spp. Each infrared spectrum was compared with spectra stored in the software database. The updated version of the I-dOne software was used to analyze ATR-FTIR spectra. All Candida isolates 284/284 (100%) were classified correctly according to the genus. Overall species identification yielded 272/284 (95.8%) concordant identification results with MALDI-TOF MS. Additionally, all 79 isolates belonging to the Candida parapsilosis species complex were identified correctly to the species level with the updated version of the I-dOne software. Only 12 (4.2%) isolates were misidentified at the species level. The present study highlights the potential diagnostic performance of the I-dOne software with ATR-FTIR spectroscopic technique referral spectral database as a real alternative for routine identification of the most frequently isolated Candida spp.

Antifungal Stewardship in Invasive Fungal Infections, a Systematic Review

INTRODUCTION

Invasive fungal infections (IFI) are a group of life-threatening diseases associated with significant morbidity, mortality and high healthcare costs. Some modern management programs known as AFS (antifungal stewardship programs) have now been developed. The purpose of this systematic review is to evaluate the different declinations of antifungal stewardship programs (AFPs).

METHODS

Articles were systematically reviewed using the PRISMA checklist 2020. EMBASE and MEDLINE/PubMED were searched using the term "antifungal stewardship" (2012-2022 data) on 2 January 2023. Eligible studies were those that described an AFS and included an intervention, performance evaluation and outcome measures.

RESULTS

A total of 22/796 studies were included. Approximately two-thirds (16) were published between 2018 and 2022. 16 (72.7%) stated a minimal complete AFS team. 12 (54.5%) adopted a non-compulsory AFS approach, 6(27.3%) had an Educational AFS and 4(18.2%) a compulsory AFS. Cost analyses of 12 studies showed a decrease for 7 (31.8%) compared to an increase for 5 (22.7%). In terms of outcomes, 18 studies showed a lower (10;45.5%) or the same (8;36.4%) pre-post intervention mortality rate.

CONCLUSION

AFS programs seem to be related to lower costs and better outcomes and should thus be implemented in tandem with antimicrobial stewardship programs.

Unlocking the potential of titanium dioxide nanoparticles: an insight into green synthesis, optimizations, characterizations, and multifunctional applications

This comprehensive review explores the emergence of titanium dioxide nanoparticles (TiO2-NPs) as versatile nanomaterials, particularly exploring their biogenic synthesis methods through different biological entities such as plants, bacteria, fungi, viruses, and algae. These biological entities provide eco-friendly, cost-effective, biocompatible, and rapid methods for TiO2-NP synthesis to overcome the disadvantages of traditional approaches. TiO2-NPs have distinctive properties, including high surface area, stability, UV protection, and photocatalytic activity, which enable diverse applications. Through detailed analysis, this review demonstrates significant applications of green fabricated TiO2-NPs in biomedicine, explicitly highlighting their antimicrobial, anticancer, and antioxidant activities, along with applications in targeted drug delivery, photodynamic therapy, and theragnostic cancer treatment. Additionally, the review underscores their pivotal significance in biosensors, bioimaging, and agricultural applications such as nanopesticides and nanofertilizers. Also, this review proves valuable incorporation of TiO2-NPs in the treatment of contaminated soil and water with various environmental contaminants such as dyes, heavy metals, radionuclides, agricultural effluents, and pathogens. These comprehensive findings establish the foundation for future innovations in nanotechnology, underscoring the importance of further investigating bio-based synthetic approaches and bioactivity mechanisms to enhance their efficacy and safety across healthcare, agricultural, and environmental applications.

Antifungal activities of Equol against Candida albicans in vitro and in vivo

Candida albicans is an opportunistic fungal pathogen that can cause systemic infections in immunocompromised individuals. Morphological transition and biofilm formation are major virulence factors of C. albicans. Moreover, biofilm enhances resistance to antifungal agents. Therefore, it is urgent to identify new and effective compounds to target the biofilm of C. albicans. In the present study, the antifungal activities of equol against C. albicans were investigated. In vitro, the microdilution analysis and spot assay result showed that equol exhibited potent inhibitory activities against C. albicans. Further investigations confirmed that the antifungal effects of equol involved interference with the transition from yeast to hypha and biofilm formation of C. albicans. In addition, transcriptome sequencing and reverse transcription-quantitative PCR (qRT-PCR) analysis showed that equol significantly downregulated the expression of several genes in the Ras1-cAMP-PKA pathway related to hyphae and biofilm formation and significantly upregulated the expression of the negative transcriptional repressors RFG1 and TUP1. Moreover, equol effectively reduced the production of cAMP, a key messenger in the Ras1-cAMP-PKA pathway, while supplementation with cAMP partly rescued the equol-induced defects in hyphal development. Furthermore, in a mouse model of systemic candidiasis (SC), equol treatment significantly decreased the fungal burden (liver, kidneys, and lung) in mice and local tissue damage, while enhancing the production of interleukin-10 (IL-10). Together, these findings confirm that equol is a potentially effective agent for treatment of SC.

Activity of thonningianin A against Candida albicans in vitro and in vivo

Fungal infections are increasing rapidly, and antifungal agents used in clinics are limited. Therefore, novel antifungal agents with high efficiency are urgently required. In this study, we investigated the antifungal activity of thonningianin A (THA), a natural compound that is widely found in plants. We first determined the activity of THA against Candida albicans, one of the most common fungal pathogens, and found that THA showed antifungal activity against all C. albicans tested, including several fluconazole-resistant isolates. THA also inhibits the growth of non-Candida albicans species. In addition, THA displayed antibiofilm activity and could not only inhibit biofilm formation but also destroy mature biofilms. The in vivo antifungal efficacy of THA was confirmed in a Galleria mellonella infection model. Further studies revealed that THA could enhance intracellular reactive oxygen species (ROS) production and regulate the transcription of several redox-related genes. Specifically, caspase activity and expression of CaMCA1, a caspase-encoding gene in C. albicans, were remarkably increased upon THA treatment. Consistent with this, in the presence of THA, the Camca1 null mutant displayed higher survival rates and reduced caspase activity compared to the wild-type or CaMCA1-reintroduced strains, indicating an important role of CaMCA1 in the antifungal activity of THA. Taken together, our results indicate that THA possesses excellent antifungal activity and may be a promising novel antifungal candidate. KEY POINTS: • THA exhibits activity against Candida species, including fluconazole-resistant isolates • THA inhibits biofilm formation and destroys mature biofilm • Elevated ROS production and CaMCA1-mediated caspase activity are involved in the antifungal mechanisms of THA.

Skin mycosis distribution, and burden of visits over a decade in Colombia: ecological study

Objectives

To describe the sociodemographic distribution of dermatomycosis and the visits burden over a 10-year period of care.

Methods

An ecological study was conducted using data on visits and people treated in the Colombian Health System during 2010-2019 using the International Classification of Diseases, Tenth Revision codes (ICD-10). Departments and geopolitical regions were the units of analysis, and visit burden was reported as frequency, intensity (visits per person), and rate of dermatomycosis visits (per 10,000 visits; 95% confidence interval).

Results

A total of 4,570,593 visits were analyzed. The most used ICD-10 codes were B369 (superficial mycosis, unspecified), B360 (pityriasis versicolor), B354 (Tinea corporis), B359 (dermatophytosis), and B351 (Tinea unguium) (56.5%), with visits primarily involving the adult population (27-59 years; 32.2%), women (43.4%), and urban populations (57.3%). Amazonas department had the highest rate of visits (2.36 per 10,000), while Nariño had the highest intensity of visits (1.94 visits per person). Caribbean region had the highest rate of visits (17.0 per 10,000 visits; 17.0-17.0), followed by the Amazon region (16.3 per 10,000 visits; 16.2-16.4).

Conclusions

The annual visits burden of dermatomycosis in Colombia is high and concentrated in susceptible geographic areas, possibly due to socio-environmental factors. This health problem is overshadowed by chronic diseases and trauma but is often recurrent, and chronic, and induces out-of-pocket costs for treatment.

Using staged tree models for health data: Investigating invasive fungal infections by aspergillus and other filamentous fungi

Machine learning models are increasingly used in the medical domain to study the association between risk factors and diseases to support practitioners in understanding health outcomes. In this paper, we showcase the use of machine-learned staged tree models for investigating complex asymmetric dependence structures in health data. Staged trees are a specific class of generative, probabilistic graphical models that formally model asymmetric conditional independence and non-regular sample spaces. An investigation of the risk factors in invasive fungal infections demonstrates the insights staged trees provide to support medical decision-making.

Effects of global change drivers on the expression of pathogenicity and stress genes in dryland soil fungi

The impacts of global climate change on dryland fungi have been understudied even though fungi are extremely sensitive to changes in the environment. Considering that many fungi are pathogens of plants and animals, including humans, their responses to anthropogenic change could have important implications for public health and food security. In this study, we investigated the potential physiological responses (i.e., metatranscriptomics) of pathogenicity and stress in dryland fungi exposed to global change drivers, drought, and the physical disturbance associated with land use. Specifically, we wanted to assess if there was an increase in the transcription of genes associated to pathogenicity and stress in response to global change drivers. In addition, we wanted to investigate which pathogenicity and stress genes were consistently differentially expressed under the different global change conditions across the heterogeneous landscape (i.e., microsite) of the Chihuahuan desert. We observed increased transcription of pathogenicity and stress genes, with specific genes being most upregulated in response to global change drivers. Additionally, climatic conditions linked to different microsites, such as those found under patches of vegetation, may play a significant role. We provide evidence supporting the idea that environmental stress caused by global change could contribute to an increase of pathogenicity as global climate changes. Specifically, increases in the transcription of stress and virulence genes, coupled with variations in gene expression, could lead to the onset of pathogenicity. Our work underscores the importance of studying dryland fungi exposed to global climate change and increases in existing fungal pathogens, as well as the emergence of new fungal pathogens, and consequences to public health and food security.

IMPORTANCE

The effects of global climate change on dryland fungi and consequences to our society have been understudied despite evidence showing that pathogenic fungi increase in abundance under global climate change. Moreover, there is a growing concern that global climate change will contribute to the emergence of new fungal pathogens. Yet, we do not understand what mechanisms might be driving this increase in virulence and the onset of pathogenicity. In this study, we investigate how fungi respond to global change drivers, physical disturbance, and drought, in a dryland ecosystem in terms of pathogenicity and stress. We find that indeed, under global change drivers, there is an increase in the transcription and expression of genes associated to pathogenicity and stress, but that microclimatic conditions matter. Our study shows the importance of investigating dryland fungi exposed to global climate change and impacts on our society, which may include threats to public health and food security.

Proline-Modified RWn Peptides: Enhanced Antifungal Efficacy and Synergy with Conventional Antibiotics for Combating Resistant Fungal Infections

Candida albicans (Ca) and Cryptococcus neoformans (Cn) infections pose a growing threat due to rising antifungal resistance. This study explores a new class of antifungal agents, the RWn series (n = 4, 6, 8) peptides. These synthetic peptides were evaluated for their ability to inhibit Ca and Cn growth. All peptides except RW4 displayed antifungal activity, with RW6 exhibiting exceptional potency against Cn. Importantly, the incorporation of a proline residue significantly reduced cytotoxicity while maintaining antifungal activity against Cn for all RWnP peptides. Notably, RW6P demonstrated broad-spectrum activity against both Ca and Cn with low minimum inhibitory concentrations (MICs) and minimal toxicity. Furthermore, combining RW6P with trace amounts of traditional antibiotics (penicillin, vancomycin, and ampicillin) achieved synergistic effects, significantly reducing MICs against both fungi. These findings suggest that RWnP peptides, particularly RW6P, have promising potential as novel antifungal agents due to their high potency, broad-spectrum activity, and ability to resensitize fungi to existing antibiotics.

Molecular Identification of Etiological Agents in Fungal and Bacterial Skin Infections: United States, 2020-2024

Background/Objectives: Cutaneous infections of fungal and bacterial origins are common. An accurate diagnosis-especially concerning pathogens that are difficult to isolate on culture-can be achieved using molecular methods (PCR) with a short turnaround time. Methods: We reviewed records of skin specimens (superficial scrapings) submitted by dermatologists across the United States with a clinically suspected dermatitis. As per physician's order, specimens were tested for infections either fungal (N = 4262) or bacterial (N = 1707) in origin. All unique specimens (one per patient) were subjected to real-time PCR assays where cases suspected of a fungal etiology were tested for dermatophytes, Malassezia and Candida, and cases suspected of a bacterial etiology were tested for Streptococcus pyogenes, Staphylococcus aureus, and the mecA gene potentially conferring β-lactam resistance. Results: Fungal agents were detected in 32.8% (SD: 4.5) of the submitted specimens, with most attributed to dermatophytes (19.3% (SD: 4.9)), followed by Malassezia (8.7% (SD: 2.8)) and Candida (2.9% (SD: 1.0)). Dermatophyte detection was more common in the elderly (≥65 years) compared to young adults (18-44 years) (OR: 1.8 (95% CI: 1.5, 2.2)), whereas Malassezia was more commonly detected in younger age groups (12.1-13.6%) than the elderly (5.6%). Candida was more frequently observed in females while dermatophytes and Malassezia were more frequently observed in males. Approximately one quarter of the submitted skin specimens tested positive for S. aureus (23.6% (SD: 3.4)), of which 34.4% (SD: 9.8) exhibited concurrent detection of the mecA gene. An S. aureus detection was more frequently observed in males (OR: 1.5 (95% CI: 1.2, 1.9)) and in children (OR: 1.7 (95% CI: 1.2, 2.5)). Streptococcus pyogenes was rarely detected. Among specimens positive for dermatophytes, 12.0% (20/166) showed co-detection of S. aureus and mecA, which is in contrast to 6.8% (70/1023) detected in samples without a fungal co-detection and 6.2% (8/130) in samples positive for Malassezia. Conclusions: PCR testing, when available, can be valuable as a part of routine care for diagnosing patients with clinically suspected skin infections. Further studies are warranted to survey the prevalence of resistant S. aureus isolates in dermatology outpatients, in particular with regard to the association with dermatophyte infections.

Length of hospital and intensive care unit stay in patients with invasive candidiasis and/or candidemia treated with rezafungin: a pooled analysis of two randomised controlled trials

BACKGROUND

Invasive candidiasis/candidemia (IC/C) is associated with a substantial health economic burden driven primarily by prolonged hospital stay. The once-weekly IV echinocandin, rezafungin acetate, has demonstrated non-inferiority to caspofungin in the treatment of IC/C. This paper reports a post hoc pooled exploratory analysis of length of stay (LoS) for hospital and intensive care unit (ICU) stays in two previously published clinical trials (ReSTORE [NCT03667690] and STRIVE [NCT02734862], that compared rezafungin with daily IV caspofungin (stable patients in the caspofungin group who met relevant criteria could step down to fluconazole after 3 days or more).

METHODS

LoS outcomes were analysed descriptively in the pooled modified intention to treat (mITT) population (all patients who had a documented Candida infection in line with trial requirements and received at least one dose of study drug). In addition, to adjust for an imbalance between treatment groups in the proportion receiving mechanical ventilation at baseline, a generalised linear model with mechanical ventilation as a binary covariate was applied. Responses to an exploratory question in the phase 3 trial on possible earlier discharge with weekly rezafungin are also reported.

RESULTS

294 patients were included (rezafungin 139, caspofungin 155), of whom 126 (43%) had ICU admission. Patients treated with rezafungin had a numerically shorter LoS than with caspofungin in all analyses. Mean total LoS was 25.2 days, vs 28.3 days with caspofungin, and mean ICU LoS was 16.1 vs 21.6 days for rezafungin and caspofungin, respectively. After adjustment for mechanical ventilation status the difference in ICU LoS was 4.1 days, a relative difference of 24% (95% CI -11%, 72%). Physicians would have considered earlier discharge for 16% of patients (30/187) with weekly rezafungin, an average of 5-6 days earlier.

CONCLUSIONS

Rezafungin may enable shorter hospital and ICU LoS in IC/C compared with daily IV caspofungin, with accompanying savings in resource use. Further research is needed to confirm this in the real-world setting.

TRIAL REGISTRATION

NCT03667690 (ReSTORE; September 12, 2018); NCT02734862 (STRIVE; April 12, 2016).

A novel, rapid, ultrasensitive diagnosis platform for detecting Candida albicans using restriction endonuclease-mediated real-time loop-mediated isothermal amplification

Introduction

Candida albicans (C. albicans, CA) is an essential invasive fungus in clinical diagnosis. Although several detection methods exist, none meet the need for early diagnosis. A rapid, sensitive, and specific diagnostic tool is crucial for effective prevention and control of C. albicans infections.

Methods

This study aimed to develop a new, rapid, and ultrasensitive diagnostic tool for C. albicans detection based on restriction endonuclease-mediated real-time loop-mediated isothermal amplification (ERT-LAMP-CA). The ERT-LAMP-CA technology combines LAMP amplification, restriction endonuclease cleavage, and real-time fluorescence detection in a single reaction tube, which can complete a diagnosis of C. albicans in a short time (approximately 1 h).

Results

Herein, we developed the primer sequences required for ERT-LAMP-CA based on the ITS2 gene of C. albicans and found that ERT-LAMP-CA limit of detection was approximately 500 ag/μL genomic DNA and can present negative results for non-C. albicans templates. We tested sputum samples from 64 patients with suspected C. albicans infections to validate ERT-LAMP-CA applicability in clinical sample testing and found that ERT-LAMP-CA was consistent with multiplex PCR-capillary electrophoresis.

Discussion

In conclusion, ERT-LAMP-CA is a rapid, accurate, and sensitive assay with excellent potential for clinical and basic laboratory diagnosis and an efficient screening strategy.

Characterization of a New Hsp110 Inhibitor as a Potential Antifungal

Fungal infections present a significant global health challenge, prompting ongoing research to discover innovative antifungal agents. The 110 kDa heat shock proteins (Hsp110s) are molecular chaperones essential for maintaining cellular protein homeostasis in eukaryotes. Fungal Hsp110s have emerged as a promising target for innovative antifungal strategies. Notably, 2H stands out as a promising candidate in the endeavor to target Hsp110s and combat fungal infections. Our study reveals that 2H exhibits broad-spectrum antifungal activity, effectively disrupting the in vitro chaperone activity of Hsp110 from Candida auris and inhibiting the growth of Cryptococcus neoformans. Pharmacokinetic analysis indicates that oral administration of 2H may offer enhanced efficacy compared to intravenous delivery, emphasizing the importance of optimizing the AUC/MIC ratio for advancing its clinical therapy.

Magnetic Nanobead Paper-Based Biosensors for Colorimetric Detection of Candida albicans

Candida albicans (C. albicans) infections pose significant challenges in clinical settings due to their high morbidity and mortality rates in addition to their role in tumor progression. Current diagnostic methods, while effective, often suffer from limitations that hinder a timely intervention. Therefore, there is an urgent need for a simple, sensitive, specific, and low-cost colorimetric biosensor for the rapid detection of C. albicans. This new biosensing platform comprises a gold platform carrying a specific C. albicans peptide substrate conjugated with magnetic nanobeads. Hence, the sensing platform was black, and the operation was based on the proteolytic activity of C. albicans, offering a visual color change to yellow upon cleavage of the conjugated peptide substrates on the magnetic nanobeads. Specificity testing demonstrated the biosensor's ability to distinguish C. albicans from other Candida species and microorganisms, while stability testing confirmed its long-term performance. Clinical testing revealed the biosensor's high sensitivity in detecting C. albicans in both standard cultures and clinically isolated samples with a lower limit of detestation of 3.5 × 103 CFU/mL. Although further validation against conventional and molecular methods is warranted, our colorimetric biosensor holds promise as a rapid (5 min) and cheap (Less than 2 $) point-of-care solution for the early detection of C. albicans infections, facilitating a timely intervention and improving patient outcomes in clinical practice.

Drug Repurposing: Research Progress of Niclosamide and Its Derivatives on Antibacterial Activity

The development of antibiotic resistance complicates the treatment of infectious diseases and is a global public health threat. However, drug repurposing can address this resistance issue and reduce research and development costs. Niclosamide is a salicylanilide compound approved by the Food and Drug Administration (FDA), and it has been used clinically for treating parasitic infections for many years. Recent studies have shown that niclosamide can inhibit bacterial and fungus activity by affecting the quorum sensing system, biofilm formation, cell membrane potential, and other mechanisms. Here, we discuss recent advances in the antimicrobial applications of niclosamide and its derivatives to provide new perspectives in treating infectious diseases.

Knowledge, Attitudes, and Practices of Filipino Medical Interns on the Management of Superficial Cutaneous Mycoses: A Cross-sectional Study

Background

Superficial mycoses are one of the most common skin conditions encountered in the outpatient clinics, causing significant morbidity amongst patients. Since these are highly prevalent diseases of the skin, the general practitioner should be able to manage uncomplicated cases, with no need for evaluation by a specialist.

Objectives

The study aimed to determine the knowledge, attitudes, and practices of Filipino medical interns on the management of superficial cutaneous mycoses using a self-administered questionnaire. This may help identify possible gaps in knowledge, as well as obstacles these future clinicians may encounter when managing superficial mycoses. This in turn may assist in the development or improvement of dermatology training among medical students and continuing medical education programs amongst non-dermatologist physicians.

Methods

This is a descriptive cross-sectional study among medical interns of the Philippine General Hospital to investigate their knowledge, attitudes, and practices regarding the management of superficial mycoses. Eligible participants were asked to complete an online self-administered survey questionnaire which assessed their capacity to recognize and manage uncomplicated superficial mycoses, and determined their attitudes regarding dermatology training in medical school.

Results

The study included 170 medical interns, with majority having only 1-4 weeks of cumulative duration of dermatology training in medical school. Many of the participants (67.1%) had inadequate overall knowledge scores, but this was not significantly associated with their cumulative duration of dermatology training, as well as with their frequency of encounters with superficial mycosis patients. Most deem dermatology training (92.4%) and learning about the management of superficial mycoses (91.2%) during medical school very important. Majority are interested in attending more courses or training in the subject. Recommendations to improve medical school training on superficial mycoses include more practical approach in dermatology modules, integration of dermatology electives in medical school, and longer duration of dermatology modules/rotations during medical school.

CONCLUSION

While knowledge scores of medical interns were not significantly associated with the duration of their dermatology training during medical school as well as their encounters with patients with superficial mycoses, it is shown that they have low confidence scores regarding management of superficial mycoses. They deem that learning more about this disease and dermatology in general is vital to their medical education and are desirous of more training in this subject. Recommendations to improve medical school training on superficial mycoses include dermatology modules, rotations or electives in medical school. Additionally, better training during medical school, and formulation of clinical practice guidelines specific to cutaneous mycoses were recommended to improve healthcare delivery for patients with such diseases.

Evolutionary origin and population diversity of a cryptic hybrid pathogen

Cryptic fungal pathogens pose disease management challenges due to their morphological resemblance to known pathogens. Here, we investigated the genomes and phenotypes of 53 globally distributed isolates of Aspergillus section Nidulantes fungi and found 30 clinical isolates-including four isolated from COVID-19 patients-were A. latus, a cryptic pathogen that originated via allodiploid hybridization. Notably, all A. latus isolates were misidentified. A. latus hybrids likely originated via a single hybridization event during the Miocene and harbor substantial genetic diversity. Transcriptome profiling of a clinical isolate revealed that both parental subgenomes are actively expressed and respond to environmental stimuli. Characterizing infection-relevant traits-such as drug resistance and growth under oxidative stress-revealed distinct phenotypic profiles among A. latus hybrids compared to parental and closely related species. Moreover, we identified four features that could aid A. latus taxonomic identification. Together, these findings deepen our understanding of the origin of cryptic pathogens.

Strain heterogeneity in a non-pathogenic Aspergillus fungus highlights factors associated with virulence

Fungal pathogens exhibit extensive strain heterogeneity, including variation in virulence. Whether closely related non-pathogenic species also exhibit strain heterogeneity remains unknown. Here, we comprehensively characterized the pathogenic potentials (i.e., the ability to cause morbidity and mortality) of 16 diverse strains of Aspergillus fischeri, a non-pathogenic close relative of the major pathogen Aspergillus fumigatus. In vitro immune response assays and in vivo virulence assays using a mouse model of pulmonary aspergillosis showed that A. fischeri strains varied widely in their pathogenic potential. Furthermore, pangenome analyses suggest that A. fischeri genomic and phenotypic diversity is even greater. Genomic, transcriptomic, and metabolic profiling identified several pathways and secondary metabolites associated with variation in virulence. Notably, strain virulence was associated with the simultaneous presence of the secondary metabolites hexadehydroastechrome and gliotoxin. We submit that examining the pathogenic potentials of non-pathogenic close relatives is key for understanding the origins of fungal pathogenicity.

Role of ERG11 and MDR1 genes in cycloheximide and multidrug resistance in Candida species

Candida species are amongst the commensals of the mucosal surfaces of the human body which include the oral cavity, vagina, and intestinal mucosa. Fungal infections are on the rise worldwide. The overall burden of infections due to fungi is difficult to estimate because the majority of them remain undiagnosed. The present study aims to determine the burden of antifungal resistance in low socioeconomic country, Pakistan and the frequency of ERG11 and MDR1 genes involved. A total of 636 Candida isolates were obtained from various tertiary care institutions in Lahore in the form of culture on various culture plates. Sabouraud agar culture plates were used to culture the Candida spp. Antifungal resistance was determined against Fluconazole, Itraconazole, Ketoconazole, and Nystatin via disk diffusion technique. Most resistance was observed against Fluconazole followed by Itraconazole, Ketoconazole, and Nystatin. The Candida isolates recovering from CVP tip and tissue have a high resistance profile. Candida species resistant to at least two antifungals were chosen for further ERG11 and MDR1 detection through real-time PCR. Among 255 Candida isolates, 240 contained ERG11 gene while MDR1 gene is present in 149 Candida isolates. The isolates carrying both genes were tested by the broth microdilution technique for the susceptibility against cycloheximide, all of them were able to grow in cycloheximide. The genetic determinants of antifungal resistance such as ERG11 and MDR1 are as important in the multidrug resistance against a variety of compounds and antifungal drugs.

Development of a Multiplex Real-Time PCR Assay for the Simultaneous Detection of Two Fungal Pathogens Causing Pneumonia

Infectious diseases caused by fungal sources are of great interest owing to their increasing prevalence. Invasive fungal infections, including invasive pulmonary aspergillosis caused by Aspergillus fumigatus, and Pneumocystis pneumonia caused by Pneumocystis jirovecii, are significant causes of morbidity and mortality among immunocompromised patients. The accurate and timely detection of these pathogens in this high-risk population is crucial for effective patient management. We developed a multiplex real-time polymerase chain reaction (PCR) assay, RF2 mRT-PCR, specifically designed to detect two respiratory fungi, P. jirovecii and A. fumigatus, and evaluated its performance in specimens of patients with lower respiratory tract infection. The performance was evaluated using 731 clinical samples, 55 reference species, and one synthetic DNA. The reproducibility test yielded a probit curve with a lower limit of detection of 19.82 copies/reaction for P. jirovecii and 64.20 copies/reaction for A. fumigatus. The RF2 mRT-PCR assay did not cross-react with non-A. fumigatus Aspergillus species or other common bacterial and viral species, and showed 100% in vitro sensitivity and specificity with reference assays. Additionally, it simultaneously detected A. fumigatus and P. jirovecii in co-infected samples. Therefore, the RF2 mRT-PCR assay is an efficient and reliable tool for in vitro diagnosis of A. fumigatus and P. jirovecii pulmonary infections.

Epidemiology of Invasive Candidiasis

Invasive candidiasis (IC) is an increasingly prevalent, costly, and potentially fatal infection brought on by the opportunistic yeast, Candida. Previously, IC has predominantly been caused by C. albicans which is often drug susceptible. There has been a global trend towards decreasing rates of infection secondary to C. albicans and a rise in non-albicans species with a corresponding increase in drug resistance creating treatment challenges. With advances in management of malignancies, there has also been an increase in the population at risk from IC along with a corresponding increase in incidence of breakthrough IC infections. Additionally, the emergence of C. auris creates many challenges in management and prevention due to drug resistance and the organism's ability to transmit rapidly in the healthcare setting. While the development of novel antifungals is encouraging for future management, understanding the changing epidemiology of IC is a vital step in future management and prevention.

Hospitalizations for opportunistic infections following transplantation and associated risk factors: A national cohort study of Medicare beneficiaries

BACKGROUND

Opportunistic infections (OIs) are a significant cause of morbidity and mortality after organ transplantation, though data in the liver transplant (LT) population are limited.

METHODS

We performed a retrospective cohort study of LT recipients between January 1, 2007 and Deceber 31, 2016 using Medicare claims data linked to the Organ Procurement and Transplantation Network database. Multivariable Cox regression models evaluated factors independently associated with hospitalizations for early (≤1 year post transplant) and late (>1 year) OIs, with a particular focus on immunosuppression.

RESULTS

There were 11 320 LT recipients included in the study, of which 13.2% had at least one OI hospitalization during follow-up. Of the 2638 OI hospitalizations, 61.9% were early post-LT. Cytomegalovirus was the most common OI (45.4% overall), although relative frequency decreased after the first year (25.3%). Neither induction or maintenance immunosuppression were associated with early OI hospitalization (all p > .05). The highest risk of early OI was seen with primary sclerosing cholangitis (aHR 1.74; p = .003 overall). Steroid-based and mechanistic target of rapamycin inhibitor-based immunosuppression at 1 year post LT were independently associated with increased late OI (p < .001 overall).

CONCLUSION

This study found OI hospitalizations to be relatively common among LT recipients and frequently occur later than previously reported. Immunosuppression regimen may be an important modifiable risk factor for late OIs.

Catalase Deactivation Increases Dermatophyte Sensitivity to ROS Sources

As the leading cause of fungal skin infections around the globe, dermatophytes are responsible for a multitude of skin ailments, ranging from athlete's foot to ringworm. Due to the combination of its growing prevalence and antifungal misuse, antifungal-resistant dermatophyte strains like Trichophyton indotineae have begun to emerge, posing a significant global health risk. The emergence of these resistant dermatophytes highlights a critical need to identify alternative methods of treating dermatophyte infections. In our study, we utilized a 405 nm LED to establish that blue light can effectively inactivate catalase within a variety of both susceptible and resistant dermatophytes. Through this catalase inactivation process, light-treated dermatophytes were found to exhibit increased sensitivity to reactive oxygen species (ROS)-producing agents, improving the performance of antimicrobial agents such as H2O2 and amphotericin B. Our findings further demonstrate that light-induced catalase inactivation can inhibit the formation and polarized growth of hyphae from dermatophytes, suppressing biomass formation. Thus, by increasing ROS sensitization and inhibiting hyphal development, catalase-deactivating blue light offers a potential non-invasive and non-drug-reliant method of managing dermatophyte infections, opening new avenues for the potential treatment of these common infections in conjunction with existing treatments.

What are the 100 most cited fungal genera?

The global diversity of fungi has been estimated between 2 to 11 million species, of which only about 155 000 have been named. Most fungi are invisible to the unaided eye, but they represent a major component of biodiversity on our planet, and play essential ecological roles, supporting life as we know it. Although approximately 20 000 fungal genera are presently recognised, the ecology of most remains undetermined. Despite all this diversity, the mycological community actively researches some fungal genera more commonly than others. This poses an interesting question: why have some fungal genera impacted mycology and related fields more than others? To address this issue, we conducted a bibliometric analysis to identify the top 100 most cited fungal genera. A thorough database search of the Web of Science, Google Scholar, and PubMed was performed to establish which genera are most cited. The most cited 10 genera are Saccharomyces, Candida, Aspergillus, Fusarium, Penicillium, Trichoderma, Botrytis, Pichia, Cryptococcus and Alternaria. Case studies are presented for the 100 most cited genera with general background, notes on their ecology and economic significance and important research advances. This paper provides a historic overview of scientific research of these genera and the prospect for further research. Citation: Bhunjun CS, Chen YJ, Phukhamsakda C, Boekhout T, Groenewald JZ, McKenzie EHC, Francisco EC, Frisvad JC, Groenewald M, Hurdeal VG, Luangsa-ard J, Perrone G, Visagie CM, Bai FY, Błaszkowski J, Braun U, de Souza FA, de Queiroz MB, Dutta AK, Gonkhom D, Goto BT, Guarnaccia V, Hagen F, Houbraken J, Lachance MA, Li JJ, Luo KY, Magurno F, Mongkolsamrit S, Robert V, Roy N, Tibpromma S, Wanasinghe DN, Wang DQ, Wei DP, Zhao CL, Aiphuk W, Ajayi-Oyetunde O, Arantes TD, Araujo JC, Begerow D, Bakhshi M, Barbosa RN, Behrens FH, Bensch K, Bezerra JDP, Bilański P, Bradley CA, Bubner B, Burgess TI, Buyck B, Čadež N, Cai L, Calaça FJS, Campbell LJ, Chaverri P, Chen YY, Chethana KWT, Coetzee B, Costa MM, Chen Q, Custódio FA, Dai YC, Damm U, de Azevedo Santiago ALCM, De Miccolis Angelini RM, Dijksterhuis J, Dissanayake AJ, Doilom M, Dong W, Alvarez-Duarte E, Fischer M, Gajanayake AJ, Gené J, Gomdola D, Gomes AAM, Hausner G, He MQ, Hou L, Iturrieta-González I, Jami F, Jankowiak R, Jayawardena RS, Kandemir H, Kiss L, Kobmoo N, Kowalski T, Landi L, Lin CG, Liu JK, Liu XB, Loizides M, Luangharn T, Maharachchikumbura SSN, Makhathini Mkhwanazi GJ, Manawasinghe IS, Marin-Felix Y, McTaggart AR, Moreau PA, Morozova OV, Mostert L, Osiewacz HD, Pem D, Phookamsak R, Pollastro S, Pordel A, Poyntner C, Phillips AJL, Phonemany M, Promputtha I, Rathnayaka AR, Rodrigues AM, Romanazzi G, Rothmann L, Salgado-Salazar C, Sandoval-Denis M, Saupe SJ, Scholler M, Scott P, Shivas RG, Silar P, Souza-Motta CM, Silva-Filho AGS, Spies CFJ, Stchigel AM, Sterflinger K, Summerbell RC, Svetasheva TY, Takamatsu S, Theelen B, Theodoro RC, Thines M, Thongklang N, Torres R, Turchetti B, van den Brule T, Wang XW, Wartchow F, Welti S, Wijesinghe SN, Wu F, Xu R, Yang ZL, Yilmaz N, Yurkov A, Zhao L, Zhao RL, Zhou N, Hyde KD, Crous PW (2024). What are the 100 most cited fungal genera? Studies in Mycology 108: 1-411. doi: 10.3114/sim.2024.108.01.

Retracing the evolution of Pneumocystis species, with a focus on the human pathogen Pneumocystis jirovecii

SUMMARYEvery human being is presumed to be infected by the fungus Pneumocystis jirovecii at least once in his or her lifetime. This fungus belongs to a large group of species that appear to exclusively infect mammals, with P. jirovecii being the only one known to cause disease in humans. The mystery of P. jirovecii origin and speciation is just beginning to unravel. Here, we provide a review of the major steps of P. jirovecii evolution. The Pneumocystis genus likely originated from soil or plant-associated organisms during the period of Cretaceous ~165 million years ago and successfully shifted to mammals. The transition coincided with a substantial loss of genes, many of which are related to the synthesis of nutrients that can be scavenged from hosts or cell wall components that could be targeted by the mammalian immune system. Following the transition, the Pneumocystis genus cospeciated with mammals. Each species specialized at infecting its own host. Host specialization is presumably built at least partially upon surface glycoproteins, whose protogene was acquired prior to the genus formation. P. jirovecii appeared at ~65 million years ago, overlapping with the emergence of the first primates. P. jirovecii and its sister species P. macacae, which infects macaques nowadays, may have had overlapping host ranges in the distant past. Clues from molecular clocks suggest that P. jirovecii did not cospeciate with humans. Molecular evidence suggests that Pneumocystis speciation involved chromosomal rearrangements and the mounting of genetic barriers that inhibit gene flow among species.

The Combination of 3-Hydrazinoquinoxaline-2-Thiol with Thymoquinone Demonstrates Synergistic Activity Against Different Candida Strains

Introduction

Candida is the primary cause of invasive fungal disease, candidiasis, especially in developed nations. The increasing resistance observed in multiple antibiotics, coupled with the prolonged process of creating new antibiotics from the ground up, emphasizes the urgent requirement for innovative methods and new compounds to combat Candida infections. Employing a treatment strategy that combines antibiotics can improve efficacy, broaden the spectrum of targeted fungal, and reduce the chances of resistance emergence. This approach shows potential in tackling the escalating problem of antibiotic resistance. The objective of this research is to explore the potential synergistic effects of combining 3-hydrazinoquinoxaline-2-thiol and thymoquinone against a variety of Candida isolates. This investigation aims to offer an understanding of the collective antimicrobial action of these compounds.

Methods

Broth microdilution was utilized to assess the Minimum Inhibitory Concentrations (MICs) of 3-hydrazinoquinoxaline-2-thiol and thymoquinone for 22 clinical Candida isolates. Following this, a checkerboard assay was employed to analyze the interaction between 3-hydrazinoquinoxaline-2-thiol and thymoquinone, with a specific focus on the Fractional Inhibitory Concentration Index (FICI).

Results

The MICs of thymoquinone and 3-hydrazinoquinoxaline-2-thiol were determined for 22 clinical Candida strains, with thymoquinone exhibiting MICs ranging from 64 to 8 µg/mL, and 3-hydrazinoquinoxaline-2-thiol displaying MICs varying from 64 to 8 µg/mL. Notably, the combination of 3-hydrazinoquinoxaline-2-thiol and thymoquinone resulted in a synergistic effect, leading to a significant reduction in MICs, with reductions of up to 64-fold with FICI below 0.5 against tested strains.

Conclusion

The prospect of using 3-hydrazinoquinoxaline-2-thiol in combination with thymoquinone as an effective solution against Candida looks encouraging. Nevertheless, to validate its practical applicability, additional comprehensive testing and experiments are imperative.

Spectrum of activity and mechanisms of azole-bisphosphonate synergy in pathogenic Candida

Candidiasis places a significant burden on human health and can range from common superficial vulvovaginal and oral infections to invasive diseases with high mortality. The most common Candida species implicated in human disease is Candida albicans, but other species like Candida glabrata are emerging. The use of azole antifungals for treatment is limited by increasing rates of resistance. This study explores repositioning bisphosphonates, which are traditionally used for osteoporosis, as antifungal synergists that can improve and revitalize the use of azoles. Risedronate, alendronate, and zoledronate (ZOL) were tested against isolates from six different species of Candida, and ZOL produced moderate antifungal activity and strong synergy with azoles like fluconazole (FLC), particularly in C. glabrata. FLC:ZOL combinations had increased fungicidal and antibiofilm activity compared to either drug alone, and the combination prevented the development of antifungal resistance. Mechanistic investigations demonstrated that the synergy was mediated by the depletion of squalene, resulting in the inhibition of ergosterol biosynthesis and a compromised membrane structure. In C. glabrata, synergy compromised the function of membrane-bound multidrug transporters and caused an accumulation of reactive oxygen species, which may account for its acute sensitivity to FLC:ZOL. The efficacy of FLC:ZOL in vivo was confirmed in a Galleria mellonella infection model, where combinations improved the survival of larvae infected with C. albicans and C. glabrata to a greater extent than monotherapy with FLC or ZOL, and at reduced dosages. These findings demonstrate that bisphosphonates and azoles are a promising new combination therapy for the treatment of topical candidiasis.

IMPORTANCE

Candida is a common and often very serious opportunistic fungal pathogen. Invasive candidiasis is a prevalent cause of nosocomial infections with a high mortality rate, and mucocutaneous infections significantly impact the quality of life of millions of patients a year. These infections pose substantial clinical challenges, particularly as the currently available antifungal treatment options are limited in efficacy and often toxic. Azoles are a mainstay of antifungal therapy and work by targeting the biosynthesis of ergosterol. However, there are rising rates of acquired azole resistance in various Candida species, and some species are considered intrinsically resistant to most azoles. Our research demonstrates the promising therapeutic potential of synergistically enhancing azoles with non-toxic, FDA-approved bisphosphonates. Repurposing bisphosphonates as antifungal synergists can bypass much of the drug development pipeline and accelerate the translation of azole-bisphosphonate combination therapy.

Pneumocystis jirovecii Pneumonia in HIV-Negative, Non-transplant Patients: Epidemiology, Clinical Manifestations, Diagnosis, Treatment, and Prevention

Purpose of Review

Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that is increasingly seen in HIV-negative patients with immune compromise due to other etiologies. We lack comprehensive clinical recommendations for this population.

Recent Findings

In non-HIV cases, PJP has a mortality rate of up to 50%, which is unacceptable despite the presence of safe and effective prophylaxis and therapy. Steroid use is one of the most common risk factors for disease development. New data suggests that lower doses of the preferred treatment regimen, TMP-SMX, may be equally effective for treatment while limiting side effects. While commonly used, the benefit of corticosteroids for the treatment of PJP has recently been called into question, with a recent multicenter cohort demonstrating no benefit among solid organ transplant recipients.

Summary

A high suspicion of PJP in individuals with pneumonia during immunosuppressant use is crucial. Therapeutic options are evolving to decrease potential side effects while maintaining efficacy in this highly morbid disease.