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Tan XT, Mokhtar NNB, Hii S, Amran F. Antifungal Susceptibility and Genotypic Analysis of cyp51A Mutations in Aspergillus fumigatus Isolates in Malaysia. Infect Drug Resist 2024; 17:2159-2168. [PMID: 38828376 PMCID: PMC11144424 DOI: 10.2147/idr.s452619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/09/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Azole resistance in Aspergillus fumigatus poses a significant challenge in the management of invasive aspergillosis. This study aimed to investigate the antifungal susceptibility and cyp51A mutation profiles of A. fumigatus isolates in Malaysia. Patients and Methods Sixty clinical A. fumigatus isolates were collected and subjected to antifungal susceptibility testing (AFST) and molecular analysis. The antifungal susceptibility testing was performed according to CLSI M38 guideline. The geometric mean (GM) minimum inhibitory concentration (MIC), MIC50/MIC90 for voriconazole, itraconazole, posaconazole, amphotericin B, and isavuconazole against A. fumigatus in non-invasive cases and invasive cases were calculated. In addition, the presence of cyp51A mutations was also identified. Results The present study revealed an overall resistance rate of 6.7% among the isolates. In non-invasive cases, isavuconazole and posaconazole demonstrated the lowest GM MIC of 0.08 µg/mL. Following them were itraconazole, voriconazole, and amphotericin B with concentrations of 0.15µg/mL, 0.16µg/mL and 0.90µg/mL, respectively. Similarly, in invasive cases, isavuconazole and posaconazole exhibited the lowest GM MIC of 0.09µg/mL. Following them were itraconazole, voriconazole, and amphotericin B with concentrations of 0.14µg/mL, 0.17µg/mL and 0.80µg/mL, respectively. Genotypic analysis revealed various cyp51A mutations, including F46Y, M172V, N248K, R34L, V244A, V244S, and E427K. However, not all mutations corresponded to antifungal resistance. Conclusion The majority of clinical Aspergillus fumigatus isolates demonstrated susceptibility to the antifungal agents tested, with isavuconazole and posaconazole demonstrating the lowest MIC values. However, cyp51A mutations were discovered without a consistent correlation to antifungal resistance, emphasising the need for additional research.
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Affiliation(s)
- Xue Ting Tan
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Nurin Nazirah Binti Mokhtar
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Shirley Yi Fen Hii
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
| | - Fairuz Amran
- Bacteriology Unit, Infectious Diseases Research Centre, Institute for Medical Research, National Institute of Health, Ministry of Health Malaysia, Setia Alam, Selangor, Malaysia
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Rybak JM, Xie J, Martin-Vicente A, Guruceaga X, Thorn HI, Nywening AV, Ge W, Souza ACO, Shetty AC, McCracken C, Bruno VM, Parker JE, Kelly SL, Snell HM, Cuomo CA, Rogers PD, Fortwendel JR. A secondary mechanism of action for triazole antifungals in Aspergillus fumigatus mediated by hmg1. Nat Commun 2024; 15:3642. [PMID: 38684680 PMCID: PMC11059170 DOI: 10.1038/s41467-024-48029-2] [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: 06/27/2023] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
Triazole antifungals function as ergosterol biosynthesis inhibitors and are frontline therapy for invasive fungal infections, such as invasive aspergillosis. The primary mechanism of action of triazoles is through the specific inhibition of a cytochrome P450 14-α-sterol demethylase enzyme, Cyp51A/B, resulting in depletion of cellular ergosterol. Here, we uncover a clinically relevant secondary mechanism of action for triazoles within the ergosterol biosynthesis pathway. We provide evidence that triazole-mediated inhibition of Cyp51A/B activity generates sterol intermediate perturbations that are likely decoded by the sterol sensing functions of HMG-CoA reductase and Insulin-Induced Gene orthologs as increased pathway activity. This, in turn, results in negative feedback regulation of HMG-CoA reductase, the rate-limiting step of sterol biosynthesis. We also provide evidence that HMG-CoA reductase sterol sensing domain mutations previously identified as generating resistance in clinical isolates of Aspergillus fumigatus partially disrupt this triazole-induced feedback. Therefore, our data point to a secondary mechanism of action for the triazoles: induction of HMG-CoA reductase negative feedback for downregulation of ergosterol biosynthesis pathway activity. Abrogation of this feedback through acquired mutations in the HMG-CoA reductase sterol sensing domain diminishes triazole antifungal activity against fungal pathogens and underpins HMG-CoA reductase-mediated resistance.
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Affiliation(s)
- Jeffrey M Rybak
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jinhong Xie
- Graduate Program in Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adela Martin-Vicente
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Xabier Guruceaga
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Harrison I Thorn
- Graduate Program in Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ashley V Nywening
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
- Integrated Program in Biomedical Sciences, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Microbiology, Immunology, and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Wenbo Ge
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ana C O Souza
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Amol C Shetty
- Institute of Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carrie McCracken
- Institute of Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vincent M Bruno
- Institute of Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Josie E Parker
- Molecular Biosciences Division, School of Biosciences, Cardiff University, Cardiff, Wales, UK
| | - Steven L Kelly
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK
| | - Hannah M Snell
- Infectious Diseases and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Christina A Cuomo
- Infectious Diseases and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P David Rogers
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jarrod R Fortwendel
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA.
- Department of Microbiology, Immunology, and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
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3
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Evans TJ, Lawal A, Kosmidis C, Denning DW. Chronic Pulmonary Aspergillosis: Clinical Presentation and Management. Semin Respir Crit Care Med 2024; 45:88-101. [PMID: 38154471 DOI: 10.1055/s-0043-1776914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Chronic pulmonary aspergillosis (CPA) refers to a number of clinical syndromes resulting from the presence and local proliferation of Aspergillus organisms in the lungs of patients with chronic lung disease. CPA is more common than was realized two decades ago. Recognition remains poor, despite recent studies from many countries highlighting the high prevalence in at-risk populations. In low- and middle-income countries, CPA may be misdiagnosed and treated as tuberculosis (TB). In addition, CPA may develop following successful TB treatment. The coronavirus disease pandemic has resulted in significant disruption to provision of TB care, likely leading to more extensive lung damage, which could increase the risk for CPA.Although CPA refers to various syndromes, the classic presentation is that of chronic cavitary pulmonary aspergillosis, which manifests as one or more progressive cavities with or without a fungal ball, accompanied by systemic and respiratory symptoms for at least 3 months. Diagnosis relies on Aspergillus immunoglobulin G in serum, as sputum culture lacks sensitivity. Differential diagnosis includes mycobacterial infection, bacterial lung abscess or necrotizing pneumonia, lung cancer, and endemic fungi.The aim of antifungal treatment in CPA is to improve symptoms and quality of life, and to halt progression, and possibly reverse radiological changes. Current recommendations suggest treatment for 6 months, although in practice many patients remain on long-term treatment. Improvement may manifest as weight gain and improvement of symptoms such as productive cough, hemoptysis, and fatigue. Surgical management should be considered in cases of diagnostic uncertainty, in significant hemoptysis, and when there is concern for lack of response to therapy. Itraconazole and voriconazole are the first-line azoles, with more experience now accumulating with posaconazole and isavuconazole. Side effects are frequent and careful monitoring including therapeutic drug monitoring is essential. Intravenous antifungals such as echinocandins and amphotericin B are used in cases of azole intolerance or resistance, which often develop on treatment. Relapse is seen after completion of antifungal therapy in around 20% of cases, mostly in bilateral, high-burden disease.Several research priorities have been identified, including characterization of immune defects and genetic variants linked to CPA, pathogenetic mechanisms of Aspergillus adaptation in the lung environment, the contribution of non-fumigatus Aspergillus species, and the role of new antifungal agents, immunotherapy, and combination therapy.
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Affiliation(s)
- Terry J Evans
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao PDR
| | - AbdulAzeez Lawal
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Chris Kosmidis
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, United Kingdom
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - David W Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Simmons BC, Rhodes J, Rogers TR, Verweij PE, Abdolrasouli A, Schelenz S, Hemmings SJ, Talento AF, Griffin A, Mansfield M, Sheehan D, Bosch T, Fisher MC. Genomic Epidemiology Identifies Azole Resistance Due to TR 34/L98H in European Aspergillus fumigatus Causing COVID-19-Associated Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:1104. [PMID: 37998909 PMCID: PMC10672581 DOI: 10.3390/jof9111104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Aspergillus fumigatus has been found to coinfect patients with severe SARS-CoV-2 virus infection, leading to COVID-19-associated pulmonary aspergillosis (CAPA). The CAPA all-cause mortality rate is approximately 50% and may be complicated by azole resistance. Genomic epidemiology can help shed light on the genetics of A. fumigatus causing CAPA, including the prevalence of resistance-associated alleles. We present a population genomic analysis of 21 CAPA isolates from four European countries with these isolates compared against 240 non-CAPA A. fumigatus isolates from a wider population. Bioinformatic analysis and antifungal susceptibility testing were performed to quantify resistance and identify possible genetically encoded azole-resistant mechanisms. The phylogenetic analysis of the 21 CAPA isolates showed that they were representative of the wider A. fumigatus population with no obvious clustering. The prevalence of phenotypic azole resistance in CAPA was 14.3% (n = 3/21); all three CAPA isolates contained a known resistance-associated cyp51A polymorphism. The relatively high prevalence of azole resistance alleles that we document poses a probable threat to treatment success rates, warranting the enhanced surveillance of A. fumigatus genotypes in these patients. Furthermore, potential changes to antifungal first-line treatment guidelines may be needed to improve patient outcomes when CAPA is suspected.
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Affiliation(s)
- Benjamin C. Simmons
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- UK Health Security Agency, London EP14 4PU, UK
| | - Johanna Rhodes
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
| | - Thomas R. Rogers
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
- Radboudumc-CWZ Center of Expertise for Mycology, Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Alireza Abdolrasouli
- Department of Infectious Diseases, Imperial College London, London W2 1NY, UK;
- Department of Infectious Diseases, King’s College Hospital, London SE5 9RS, UK
| | - Silke Schelenz
- Infection Sciences, King’s College Hospital, London SE5 9RS, UK;
- School of Immunology & Microbial Sciences, King’s College London, London WC2R 2LS, UK
| | - Samuel J. Hemmings
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
| | - Alida Fe Talento
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
- Department of Microbiology, Our Lady of Lourdes Hospital, A92 VW28 Drogheda, Ireland
- Department of Microbiology, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - Auveen Griffin
- Department of Microbiology, St. James’ Hospital, D08 NHY1 Dublin, Ireland;
| | - Mary Mansfield
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - David Sheehan
- Department of Clinical Microbiology, St. James’ Hospital Campus, Trinity College Dublin, D08 NHY1 Dublin, Ireland; (T.R.R.); (A.F.T.); (M.M.); (D.S.)
| | - Thijs Bosch
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands;
| | - Matthew C. Fisher
- Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London W2 1PG, UK; (J.R.); (S.J.H.); (M.C.F.)
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Barac A, Vujovic A, Drazic A, Stevanovic G, Paglietti B, Lukic K, Stojanovic M, Stjepanovic M. Diagnosis of Chronic Pulmonary Aspergillosis: Clinical, Radiological or Laboratory? J Fungi (Basel) 2023; 9:1084. [PMID: 37998889 PMCID: PMC10672318 DOI: 10.3390/jof9111084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a chronic progressive lung disease associated with a poor prognosis and a 5-year mortality rate of approximately 40-50%. The disease is characterized by slowly progressive destruction of the lung parenchyma, in the form of multiple cavities, nodules, infiltrates or fibrosis. CPA can be challenging to diagnose due to its non-specific symptoms and similarities with other respiratory conditions combined with the poor awareness of the medical community about the disease. This can result in delayed treatment even for years and worsening of the patient's condition. Serological tests certainly play a significant role in diagnosing CPA but cannot be interpreted without radiological confirmation of CPA. Although many data are published on this hot topic, there is yet no single definitive test for diagnosing CPA, and a multidisciplinary approach which involves a combination of clinical picture, radiological findings, microbiological results and exclusion of other mimicking diseases, is essential for the accurate diagnosis of CPA.
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Affiliation(s)
- Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Ankica Vujovic
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Ana Drazic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Goran Stevanovic
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Bianca Paglietti
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Katarina Lukic
- Center for Radiology and MRI, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Maja Stojanovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
- Clinic of Allergy and Immunology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mihailo Stjepanovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Zhang Y, Wang S, Zhou C, Zhang Y, Pan J, Pan B, Wang B, Hu B, Guo W. Epidemiology of Clinically Significant Aspergillus Species from a Large Tertiary Hospital in Shanghai, China, for the Period of Two Years. Infect Drug Resist 2023; 16:4645-4657. [PMID: 37484905 PMCID: PMC10361289 DOI: 10.2147/idr.s417840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Aspergillus species are becoming a major public health concern worldwide due to the increase in the incidence of aspergillosis and emergence of antifungal resistance. In this study, we surveyed all Aspergillus species isolated from aspergillosis patients in Zhongshan Hospital Fudan University, Shanghai, China, from 2019 to 2021. Methods We characterized the susceptibility profiles of these Aspergillus species to medical azoles (voriconazole, itraconazole and posaconazole) using YeastOneTM broth microdilution system. To determine the underlying antifungal resistance mechanisms in azole-resistant A. fumigatus (ARAf) isolates, we characterized mutations in the cyp51A gene. Genotypic diversity of sampled A. fumigatus was investigated using CSP-typing. Results A total of 112 Aspergillus isolates (81 A. fumigatus, 17 A. flavus, 5 A. niger, 2 A. terreus, 2 A. lentulus, 2 A. oryzae, 1 A. nidulans, 1 A. versicolor and 1 A. sydowii) from 105 patients diagnosed with aspergillosis (including proven or probable invasive aspergillosis, chronic pulmonary aspergillosis, allergic bronchopulmonary aspergillosis and cutaneous aspergillosis) were obtained. Eight isolates (7 A. fumigatus and 1 A. niger) from seven patients were either azole non-susceptible or non-wild type. Azole non-susceptible or non-wild type rate was 7.1%/isolate and 6.7%/patient analysed. Four ARAf harbored TR34/L98H mutation, whereas one carried TR46/Y121F/T289A allele. The 81 A. fumigatus isolates were spread across 8 CSP types with t01 to be the predominant type (53.1%). ARAf isolates were distributed over CSP types t01, t02, t04A and t11. Conclusion Results from this study provided us with an understanding of the antifungal resistance and related characteristics of Aspergillus species in Eastern China. Further comparisons of our results with those in other countries reflect potential clonal expansion of A. fumigatus in our region. Further surveillance study is warranted to guide antifungal therapy and for epidemiological purposes.
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Affiliation(s)
- Yuyi Zhang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Suzhen Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Chunmei Zhou
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yao Zhang
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jue Pan
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Bijie Hu
- Department of Infectious Disease, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
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Souza ACO, Ge W, Wiederhold NP, Rybak JM, Fortwendel JR, Rogers PD. hapE and hmg1 Mutations Are Drivers of cyp51A-Independent Pan-Triazole Resistance in an Aspergillus fumigatus Clinical Isolate. Microbiol Spectr 2023; 11:e0518822. [PMID: 37140376 PMCID: PMC10269825 DOI: 10.1128/spectrum.05188-22] [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: 01/09/2023] [Accepted: 04/05/2023] [Indexed: 05/05/2023] Open
Abstract
Aspergillus fumigatus is a ubiquitous environmental mold that can cause severe disease in immunocompromised patients and chronic disease in individuals with underlying lung conditions. Triazoles are the most widely used class of antifungal drugs to treat A. fumigatus infections, but their use in the clinic is threatened by the emergence of triazole-resistant isolates worldwide, reinforcing the need for a better understanding of resistance mechanisms. The predominant mechanisms of A. fumigatus triazole resistance involve mutations affecting the promoter region or coding sequence of the target enzyme of the triazoles, Cyp51A. However, triazole-resistant isolates without cyp51A-associated mutations are frequently identified. In this study, we investigate a pan-triazole-resistant clinical isolate, DI15-105, that simultaneously carries the mutations hapEP88L and hmg1F262del, with no mutations in cyp51A. Using a Cas9-mediated gene-editing system, hapEP88L and hmg1F262del mutations were reverted in DI15-105. Here, we show that the combination of these mutations accounts for pan-triazole resistance in DI15-105. To our knowledge, DI15-105 is the first clinical isolate reported to simultaneously carry mutations in hapE and hmg1 and only the second with the hapEP88L mutation. IMPORTANCE Triazole resistance is an important cause of treatment failure and high mortality rates for A. fumigatus human infections. Although Cyp51A-associated mutations are frequently identified as the cause of A. fumigatus triazole resistance, they do not explain the resistance phenotypes for several isolates. In this study, we demonstrate that hapE and hmg1 mutations additively contribute to pan-triazole resistance in an A. fumigatus clinical isolate lacking cyp51-associated mutations. Our results exemplify the importance of and the need for a better understanding of cyp51A-independent triazole resistance mechanisms.
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Affiliation(s)
- Ana C. O. Souza
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Wenbo Ge
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nathan P. Wiederhold
- Fungus Testing Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jeffrey M. Rybak
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jarrod R. Fortwendel
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - P. David Rogers
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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8
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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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9
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de Almeida Campos L, Fin MT, Santos KS, de Lima Gualque MW, Freire Cabral AKL, Khalil NM, Fusco-Almeida AM, Mainardes RM, Mendes-Giannini MJS. Nanotechnology-Based Approaches for Voriconazole Delivery Applied to Invasive Fungal Infections. Pharmaceutics 2023; 15:pharmaceutics15010266. [PMID: 36678893 PMCID: PMC9863752 DOI: 10.3390/pharmaceutics15010266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
Invasive fungal infections increase mortality and morbidity rates worldwide. The treatment of these infections is still limited due to the low bioavailability and toxicity, requiring therapeutic monitoring, especially in the most severe cases. Voriconazole is an azole widely used to treat invasive aspergillosis, other hyaline molds, many dematiaceous molds, Candida spp., including those resistant to fluconazole, and for infections caused by endemic mycoses, in addition to those that occur in the central nervous system. However, despite its broad activity, using voriconazole has limitations related to its non-linear pharmacokinetics, leading to supratherapeutic doses and increased toxicity according to individual polymorphisms during its metabolism. In this sense, nanotechnology-based drug delivery systems have successfully improved the physicochemical and biological aspects of different classes of drugs, including antifungals. In this review, we highlighted recent work that has applied nanotechnology to deliver voriconazole. These systems allowed increased permeation and deposition of voriconazole in target tissues from a controlled and sustained release in different routes of administration such as ocular, pulmonary, oral, topical, and parenteral. Thus, nanotechnology application aiming to delivery voriconazole becomes a more effective and safer therapeutic alternative in the treatment of fungal infections.
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Affiliation(s)
- Laís de Almeida Campos
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Margani Taise Fin
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Kelvin Sousa Santos
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Marcos William de Lima Gualque
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Ana Karla Lima Freire Cabral
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Najeh Maissar Khalil
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
| | - Ana Marisa Fusco-Almeida
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
| | - Rubiana Mara Mainardes
- Pharmaceutical Nanotechnology Laboratory, Department of Pharmacy, Midwest State University (UNICENTRO), Alameda Élio Antonio Dalla Vecchia St, 838, Guarapuava 85040-167, PR, Brazil
- Correspondence: (R.M.M.); (M.J.S.M.-G.)
| | - Maria José Soares Mendes-Giannini
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Rodovia Araraquara Jaú, Km 01, Araraquara 14801-902, SP, Brazil
- Correspondence: (R.M.M.); (M.J.S.M.-G.)
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10
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Hsu TH, Huang PY, Fan YC, Sun PL. Azole Resistance and cyp51A Mutation of Aspergillus fumigatus in a Tertiary Referral Hospital in Taiwan. J Fungi (Basel) 2022; 8:jof8090908. [PMID: 36135633 PMCID: PMC9504549 DOI: 10.3390/jof8090908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/20/2022] [Accepted: 08/24/2022] [Indexed: 01/30/2023] Open
Abstract
Azole resistance in Aspergillus fumigatus has increasingly been reported worldwide. Its major mechanism of resistance is mediated by mutations in cyp51A. The objective of this study was to test the antifungal susceptibilities of A. fumigatus isolates from Chang Gung Memorial Hospital (CGMH), the largest tertiary referral hospital in Taiwan, and to investigate cyp51A mutations in azole-resistant strains. A. fumigatus isolates preserved in the Research Laboratory of Medical Mycology of CGMH from 2015 to 2021 were used. Antifungal susceptibility testing was performed using the YeastOneTM method. Isolates with high minimal inhibitory concentrations (MICs) against antifungals were further tested using the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method. Mutations in the cyp51A in azole-resistant strains were detected by Sanger sequencing. The overall prevalence of azole-resistant isolates was 1.77% (two out of 113 isolates). The two azole-resistant strains had tandem repeats (TR) in the promoter region and mutations in the cyp51A gene (TR34/L98H and TR34/L98H/S297T/F495I). One strain showed intermediate susceptibility to voriconazole, and its Cyp51A protein had five amino acid substitutions (F46Y/M172V/N248T/D255E/E427K). TR34/L98H and TR34/L98H/S297T/F495I are the most prevalent cyp51A mutations in Taiwan, mediating azole resistance based on current publications and our results. YeastOneTM was validated as a rapid tool for the antifungal susceptibility test; however, further confirmation by CLSI should be considered when MIC values of voriconazole, posaconazole, and amphotericin B are close to the clinical breakpoints or ecological cutoff values.
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Affiliation(s)
- Tsun-Hao Hsu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
| | - Po-Yen Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Yun-Chen Fan
- Research Laboratory of Medical Mycology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
| | - Pei-Lun Sun
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Research Laboratory of Medical Mycology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- Correspondence: ; Tel.: +886-3-328-1200 (ext. 8778)
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11
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Non- fumigatus Aspergillus infection associated with a negative Aspergillus precipitin test in patients with chronic pulmonary aspergillosis. J Clin Microbiol 2021; 60:e0201821. [PMID: 34878803 PMCID: PMC8849204 DOI: 10.1128/jcm.02018-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aspergillus antibody testing is key for the clinical diagnosis of chronic pulmonary aspergillosis (CPA) with high sensitivity. However, false-negative results in patients with CPA might be obtained, depending on the Aspergillus species. The aim of this study was to investigate which factors are associated with false-negative results in Aspergillus precipitin tests and whether the sensitivity of precipitin tests in CPA is influenced by Aspergillus fumigatus and non-fumigatus Aspergillus species. Between February 2012 and December 2020, 116 consecutive antifungal treatment-naïve patients with CPA were identified and included in this retrospective chart review. Aspergillus species isolated from the respiratory tract of patients were identified by DNA sequencing. Characteristics of patients with positive and negative results for Aspergillus precipitin tests were compared. The sensitivity of the Aspergillus precipitin tests was compared between patients with A. fumigatus-associated CPA and non-fumigatus Aspergillus-associated CPA. A non-fumigatus Aspergillus species was the only factor significantly associated with negative Aspergillus precipitin test results in patients with CPA in the multivariate analysis (hazard ratio: 8.3, 95% confidence interval: 3.2-22.1, p < 0.0001). The positivity of the Aspergillus precipitin test in patients with non-fumigatus Aspergillus-associated CPA was lower than that in patients with A. fumigatus-associated CPA (84.8% vs. 37.9%; p < 0.0001). These results revealed that the presence of non-fumigatus Aspergillus-associated CPA should be considered with a negative Aspergillus precipitin test; this finding may prevent diagnostic delay or misdiagnosis for CPA.
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Takeda K, Suzuki J, Watanabe A, Sekiguchi R, Sano T, Watanabe M, Narumoto O, Kawashima M, Fukami T, Sasaki Y, Tamura A, Nagai H, Matsui H, Kamei K. The accuracy and clinical impact of the morphological identification of Aspergillus species in the age of cryptic species: A single-centre study. Mycoses 2021; 65:164-170. [PMID: 34783396 DOI: 10.1111/myc.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aspergillus spp. is identified morphologically without antifungal susceptibility tests (ASTs) in most clinical laboratories. The aim of this study was to examine the clinical impact of the morphological identification of Aspergillus spp. to ensure the adequate clinical management of Aspergillus infections. PATIENTS/METHODS Aspergillus isolates (n = 126) from distinct antifungal treatment-naïve patients with aspergillosis were first identified morphologically, followed by species-level identification via DNA sequencing. An AST for itraconazole (ITC) and voriconazole (VRC) was performed on each Aspergillus isolate. RESULTS Based on the genetic test results, morphology-based identification was accurate for >95% of the isolates at the species sensu lato level although the test concordance of Aspergillus spp. with low detection rates was low. The rates of cryptic species were found to be 1.2% among the isolates of A. fumigatus complex and 96.8% in the A. niger complex. Cryptic species with lower susceptibilities to antifungal drugs than sensu stricto species among the same Aspergillus section were as follows: The A. lentulus (n = 1) isolates had low susceptibilities to azoles among the A. fumigatus complex species (n = 86), and A. tubingensis isolates (n = 18) exhibited lower susceptibility to azoles among the A. niger complex species (n = 31). CONCLUSION Diagnostic accuracy was high at the A. fumigatus and A. niger complex level. However, in the presence of cryptic species, a solely morphological identification was insufficient. Particularly, ITC and VRC might be inappropriate for aspergillosis treatment when the A. niger complex is identified morphologically because it is possible that the Aspergillus isolate is A. tubingensis.
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Affiliation(s)
- Keita Takeda
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Junko Suzuki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Ryo Sekiguchi
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Tomoya Sano
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Masato Watanabe
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Osamu Narumoto
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Masahiro Kawashima
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Takeshi Fukami
- Department of Thoracic Surgery, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Yuka Sasaki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Atsuhisa Tamura
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Hideaki Nagai
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Hirotoshi Matsui
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Katsuhiko Kamei
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
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13
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Gonzalez-Jimenez I, Lucio J, Roldan A, Alcazar-Fuoli L, Mellado E. Are Point Mutations in HMG-CoA Reductases (Hmg1 and Hmg2) a Step towards Azole Resistance in Aspergillus fumigatus? Molecules 2021; 26:5975. [PMID: 34641518 PMCID: PMC8512156 DOI: 10.3390/molecules26195975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
Invasive aspergillosis, mainly caused by Aspergillus fumigatus, can lead to severe clinical outcomes in immunocompromised individuals. Antifungal treatment, based on the use of azoles, is crucial to increase survival rates. However, the recent emergence of azole-resistant A. fumigatus isolates is affecting the efficacy of the clinical therapy and lowering the success rate of azole strategies against aspergillosis. Azole resistance mechanisms described to date are mainly associated with mutations in the azole target gene cyp51A that entail structural changes in Cyp51A or overexpression of the gene. However, strains lacking cyp51A modifications but resistant to clinical azoles have recently been detected. Some genes have been proposed as new players in azole resistance. In this study, the gene hmg1, recently related to azole resistance, and its paralogue hmg2 were studied in a collection of fifteen azole-resistant strains without cyp51A modifications. Both genes encode HMG-CoA reductases and are involved in the ergosterol biosynthesis. Several mutations located in the sterol sensing domain (SSD) of Hmg1 (D242Y, G307D/S, P309L, K319Q, Y368H, F390L and I412T) and Hmg2 (I235S, V303A, I312S, I360F and V397C) were detected. The role of these mutations in conferring azole resistance is discussed in this work.
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Affiliation(s)
- Irene Gonzalez-Jimenez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain; (I.G.-J.); (J.L.); (A.R.); (L.A.-F.)
| | - Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain; (I.G.-J.); (J.L.); (A.R.); (L.A.-F.)
| | - Alejandra Roldan
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain; (I.G.-J.); (J.L.); (A.R.); (L.A.-F.)
| | - Laura Alcazar-Fuoli
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain; (I.G.-J.); (J.L.); (A.R.); (L.A.-F.)
- Spanish Network for Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), ISCIII, 28220 Majadahonda, Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), 28220 Majadahonda, Madrid, Spain; (I.G.-J.); (J.L.); (A.R.); (L.A.-F.)
- Spanish Network for Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), ISCIII, 28220 Majadahonda, Madrid, Spain
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14
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Triazole resistant Aspergillus fumigatus in an Israeli patient with Chronic Cavitary Pulmonary Aspergillosis due to a novel E306K Substitution in Hmg1. Antimicrob Agents Chemother 2021; 65:e0108921. [PMID: 34280014 DOI: 10.1128/aac.01089-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Triazole resistance in the pathogenic mold Aspergillus fumigatus has increased worldwide, posing a growing therapeutic challenge. Recently, mutations in the 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase gene (hmg1) have been associated with triazole resistance. Here, we describe a novel E306K triazole resistance-conferring mutation in the HMG-CoA reductase gene from an Israeli patient with chronic cavitary pulmonary aspergillosis (CCPA).
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15
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Emergence of W272C Substitution in Hmg1 in a Triazole-Resistant Isolate of Aspergillus fumigatus from a Chinese Patient with Chronic Cavitary Pulmonary Aspergillosis. Antimicrob Agents Chemother 2021; 65:e0026321. [PMID: 33941517 DOI: 10.1128/aac.00263-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recently, mutations in the 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase gene (hmg1) have been identified to be associated with triazole resistance in Aspergillus fumigatus. Here, we describe the first case of the G929C mutation in the hmg1 gene, leading to the W272C amino acid substitution, in a triazole-resistant isolate of A. fumigatus recovered from a chronic cavitary pulmonary aspergillosis patient who failed voriconazole therapy in China.
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16
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Hospital Environment as a Source of Azole-Resistant Aspergillus fumigatus Strains with TR34/L98H and G448S Cyp51A Mutations. J Fungi (Basel) 2021; 7:jof7010022. [PMID: 33401764 PMCID: PMC7824632 DOI: 10.3390/jof7010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/22/2023] Open
Abstract
Azole-resistant Aspergillus fumigatus is an emerging worldwide problem with increasing reports of therapy failure cases produced by resistant isolates. A case of azole-resistant A. fumigatus hospital colonization in a patient is reported here. Investigations of the hospital environment led to the recovery of A. fumigatus strains harboring the TR34/L98H and the G448S Cyp51A azole resistance mechanisms. Isolate genotyping showed that one strain from the environment was isogenic with the patient strains. These are the first environmental A. fumigatus azole resistant strains collected in a hospital in Spain; it supports the idea of the hospital environment as a source of dissemination and colonization/infection by azole resistant A. fumigatus in patients. The isolation of an azole-resistant strain from an azole-naïve patient is an interesting finding, suggesting that an effective analysis of clinical and environmental sources must be done to detect azole resistance in A. fumigatus. The emergence and spread of these resistance mechanisms in A. fumigatus is of major concern because it confers high resistance to voriconazole and is associated with treatment failure in patients with invasive aspergillosis.
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17
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Arastehfar A, Gabaldón T, Garcia-Rubio R, Jenks JD, Hoenigl M, Salzer HJF, Ilkit M, Lass-Flörl C, Perlin DS. Drug-Resistant Fungi: An Emerging Challenge Threatening Our Limited Antifungal Armamentarium. Antibiotics (Basel) 2020; 9:antibiotics9120877. [PMID: 33302565 PMCID: PMC7764418 DOI: 10.3390/antibiotics9120877] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/02/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
The high clinical mortality and economic burden posed by invasive fungal infections (IFIs), along with significant agricultural crop loss caused by various fungal species, has resulted in the widespread use of antifungal agents. Selective drug pressure, fungal attributes, and host- and drug-related factors have counteracted the efficacy of the limited systemic antifungal drugs and changed the epidemiological landscape of IFIs. Species belonging to Candida, Aspergillus, Cryptococcus, and Pneumocystis are among the fungal pathogens showing notable rates of antifungal resistance. Drug-resistant fungi from the environment are increasingly identified in clinical settings. Furthermore, we have a limited understanding of drug class-specific resistance mechanisms in emerging Candida species. The establishment of antifungal stewardship programs in both clinical and agricultural fields and the inclusion of species identification, antifungal susceptibility testing, and therapeutic drug monitoring practices in the clinic can minimize the emergence of drug-resistant fungi. New antifungal drugs featuring promising therapeutic profiles have great promise to treat drug-resistant fungi in the clinical setting. Mitigating antifungal tolerance, a prelude to the emergence of resistance, also requires the development of effective and fungal-specific adjuvants to be used in combination with systemic antifungals.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Toni Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, 08034 Barcelona, Spain;
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), 08024 Barcelona, Spain
- Catalan Institution for Research and Advanced Studies. Pg. Lluís Companys 23, 08010 Barcelona, Spain
| | - Rocio Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
| | - Jeffrey 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;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Martin Hoenigl
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA;
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | | | - Macit Ilkit
- Division of Mycology, University of Çukurova, 01330 Adana, Turkey
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA; (A.A.); (R.G.-R.)
- Correspondence: (M.I.); (D.S.P.); Tel.: +90-532-286-0099 (M.I.); +1-201-880-3100 (D.S.P.)
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18
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Gonzalez-Jimenez I, Lucio J, Amich J, Cuesta I, Sanchez Arroyo R, Alcazar-Fuoli L, Mellado E. A Cyp51B Mutation Contributes to Azole Resistance in Aspergillus fumigatus. J Fungi (Basel) 2020; 6:jof6040315. [PMID: 33255951 PMCID: PMC7712412 DOI: 10.3390/jof6040315] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
The emergence and spread of Aspergillus fumigatus azole resistance has been acknowledged worldwide. The main problem of azole resistance is the limited therapeutic options for patients suffering aspergillosis. Azole resistance mechanisms have been mostly linked to the enzyme Cyp51A, a target of azole drugs, with a wide variety of modifications responsible for the different resistance mechanisms described to date. However, there are increasing reports of A. fumigatus strains showing azole resistance without Cyp51A modifications, and thus, novel resistance mechanisms are being explored. Here, we characterized two isogenic A. fumigatus clinical strains isolated two years apart from the same patient. Both strains were resistant to clinical azoles but showed different azole resistance mechanisms. One strain (CM8940) harbored a previously described G54A mutation in Cyp51A while the other strain (CM9640) had a novel G457S mutation in Cyp51B, the other target of azoles. In addition, this second strain had a F390L mutation in Hmg1. CM9640 showed higher levels of gene expression of cyp51A, cyp51B and hmg1 than the CM8940 strain. The role of the novel mutation found in Cyp51B together with the contribution of a mutation in Hmg1 in azole resistance is discussed.
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Affiliation(s)
- Irene Gonzalez-Jimenez
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain; (I.G.-J.); (J.L.); (L.A.-F.)
| | - Jose Lucio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain; (I.G.-J.); (J.L.); (L.A.-F.)
| | - Jorge Amich
- Manchester Fungal Infection Group (MFIG), Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester M13 9PL, UK;
| | - Isabel Cuesta
- Bioinformatics Unit, Common Scientific Technical Units, Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain;
| | | | - Laura Alcazar-Fuoli
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain; (I.G.-J.); (J.L.); (L.A.-F.)
- Spanish Network for Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain; (I.G.-J.); (J.L.); (L.A.-F.)
- Spanish Network for Research in Infectious Diseases (REIPI RD16/CIII/0004/0003), Instituto de Salud Carlos III (ISCIII), Majadahonda, 28222 Madrid, Spain
- Correspondence:
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19
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Resendiz-Sharpe A, Hokken MWJ, Mercier T, Merckx R, Verhagen K, Dewitte L, Melchers WJG, Verweij PE, Maertens J, Lagrou K. Hmg1 Gene Mutation Prevalence in Triazole-Resistant Aspergillus fumigatus Clinical Isolates. J Fungi (Basel) 2020; 6:jof6040227. [PMID: 33081232 PMCID: PMC7711918 DOI: 10.3390/jof6040227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/02/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022] Open
Abstract
Recently, mutations in the 3-hydroxy-3-methylglutaryl-coenzyme-A-reductase-encoding gene (hmg1), a gene involved in ergosterol production, were associated with triazole-resistance in Aspergillus fumigatus. In this study, we determined the prevalence and characteristics of hmg1 mutations in a collection of clinical triazole-resistant A. fumigatus isolates collected during 2001–2019 from two international mycology reference centers: the Belgian National Reference Center for Mycosis and the Center of Expertise in Mycology Radboudumc/CWZ. Clinical isolates with and without cyp51A gene mutations and randomly selected wild-type (WT) controls were included. Isolates were characterized by in vitro susceptibility testing, cyp51A and hmg1 sequencing, and short tandem repeat typing. Available clinical records were analyzed for previous triazole exposure. In 23 isolates (24%) of the 95 triazole-resistant A. fumigatus isolates, hmg1 gene mutations were observed; including 5/23 (22%) isolates without cyp51A gene mutations and 18/72 (25%) with cyp51A mutations. Four previously described hmg1 gene mutations (E105K, G307R/D, G466V, and S541G) and two novel mutations (W273S and L304P) were found; 4/23 (17%) in the sterol-sensing-domain region. No triazole-antifungal exposure was reported in 75% (9/12) of patients harboring an isolate with hmg1 gene mutations. Three of 39 WT isolates (8%) contained a hmg1 gene mutation; E105K (2-isolates) and S541G. Hmg1 gene mutations were predominantly found in A. fumigatus with cyp51A mutations with voriconazole MICs ≥ 8 mg/L.
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Affiliation(s)
- Agustin Resendiz-Sharpe
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
| | - Margriet W. J. Hokken
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, Radboud Institute for Molecular Life Sciences, 6525 Nijmegen, The Netherlands; (M.W.J.H.); (K.V.); (W.J.G.M.); (P.E.V.)
| | - Toine Mercier
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rita Merckx
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
| | - Kamiel Verhagen
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, Radboud Institute for Molecular Life Sciences, 6525 Nijmegen, The Netherlands; (M.W.J.H.); (K.V.); (W.J.G.M.); (P.E.V.)
| | - Lisa Dewitte
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
| | - Willem J. G. Melchers
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, Radboud Institute for Molecular Life Sciences, 6525 Nijmegen, The Netherlands; (M.W.J.H.); (K.V.); (W.J.G.M.); (P.E.V.)
- Center of Expertise in Mycology, Radboudumc/CWZ, 6525 Nijmegen, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, Radboud Institute for Molecular Life Sciences, 6525 Nijmegen, The Netherlands; (M.W.J.H.); (K.V.); (W.J.G.M.); (P.E.V.)
- Center of Expertise in Mycology, Radboudumc/CWZ, 6525 Nijmegen, The Netherlands
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, 3000 Leuven, Belgium; (A.R.-S.); (T.M.); (R.M.); (L.D.); (J.M.)
- Department of Laboratory Medicine and National Reference Center for Mycosis, Excellence Center for Medical Mycology (ECMM), University Hospitals Leuven, 3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-016-34-70-98
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