1
|
Kofoed VC, Campion C, Rasmussen PU, Møller SA, Eskildsen M, Nielsen JL, Madsen AM. Exposure to resistant fungi across working environments and time. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 923:171189. [PMID: 38447726 DOI: 10.1016/j.scitotenv.2024.171189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
Antifungal resistance has emerged as a significant health concern with increasing reports of resistant variants in previously susceptible species. At present, little is known about occupational exposure to antifungal-resistant fungi. This study aimed to investigate Danish workers' occupational exposure to airborne fungi resistant to first-line treatment drugs. A retrospective study was performed on a unique collection of personal exposure samples gathered over a twenty-year period from Danish working environments, in sectors including agriculture, animal handling, waste management, and healthcare. A total of 669 samples were cultivated at 37 °C and fungal colonies were identified using MALDI-TOF MS. Subsequently, identification was confirmed by amplicon sequencing the genes of calmodulin and beta-tubulin to unveil potential cryptic species. Infectious fungi (495 isolates from 23 species) were tested for resistance against Itraconazole, Voriconazole, Posaconazole, and Amphotericin B. Working environments were highly variable in the overall fungal exposure, and showed vastly different species compositions. Resistance was found in 30 isolates of the species Aspergillus fumigatus (4 of 251 isolates), A. nidulans (2 of 13), A. niger complex (19 of 131), A. versicolor (3 of 18), and A. lentulus (2 of 2). Sequence analysis revealed several cryptic species within the A. niger complex including A. tubingensis, A. luchuensis, and A. phoenicis. Among the resistant A. fumigatus isolates, two contained the well-described TR34/L98H mutation in the cyp51A gene and promoter region, while the remainder harbored silent mutations. The results indicate that the working environment significantly contributes to exposure to resistant fungi, with particularly biofuel plant workers experiencing high exposure. Differences in the prevalence of resistance across working environments may be linked to the underlying species composition.
Collapse
Affiliation(s)
- Victor Carp Kofoed
- National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark
| | - Christopher Campion
- National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark
| | - Pil Uthaug Rasmussen
- National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark
| | - Signe Agnete Møller
- National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark; Department of Chemistry and Bioscience, Aalborg University, Fredrik Bajers Vej 7H, 9220 Aalborg Ø, Denmark
| | - Mathias Eskildsen
- Department of Chemistry and Bioscience, Aalborg University, Fredrik Bajers Vej 7H, 9220 Aalborg Ø, Denmark
| | - Jeppe Lund Nielsen
- Department of Chemistry and Bioscience, Aalborg University, Fredrik Bajers Vej 7H, 9220 Aalborg Ø, Denmark
| | - Anne Mette Madsen
- National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark.
| |
Collapse
|
2
|
Schwarz C, Eschenhagen PN, Mainz JG, Schmidergall T, Schuette H, Romanowska E. Pulmonary Aspergillosis in People with Cystic Fibrosis. Semin Respir Crit Care Med 2024; 45:128-140. [PMID: 38286138 DOI: 10.1055/s-0043-1777267] [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: 01/31/2024]
Abstract
In the last decade, fungal respiratory diseases have been increasingly investigated for their impact on the clinical course of people with cystic fibrosis (CF), with a particular focus on infections caused by Aspergillus spp. The most common organisms from this genus detected from respiratory cultures are Aspergillus fumigatus and Aspergillus terreus, followed by Aspergillus flavus, Aspergillus niger, and Aspergillus nidulans. These species have been identified to be both chronic colonizers and sources of active infection and may negatively impact lung function in people with CF. This review article discusses definitions of aspergillosis, challenges in clinical practice, and current literature available for laboratory findings, clinical diagnosis, and treatment options for pulmonary diseases caused by Aspergillus spp. in people with CF.
Collapse
Affiliation(s)
- C Schwarz
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - P N Eschenhagen
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - J G Mainz
- Department of Paediatric Pneumology, Allergology, Cystic Fibrosis Center, Klinikum Westbrandenburg, Brandenburg a. d. Havel, Germany
- University Hospital of the Brandenburg Medical School, Brandenburg a. d. Havel, Germany
| | - T Schmidergall
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - H Schuette
- Pneumology and Respiratory Medicine, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - E Romanowska
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| |
Collapse
|
3
|
Gyurtane Szabo N, Joste V, Houzé S, Dannaoui E, Bonnal C. Comparison of the Micronaut-AM System and the EUCAST Broth Microdilution Reference Method for MIC Determination of Four Antifungals against Aspergillus fumigatus. J Fungi (Basel) 2023; 9:721. [PMID: 37504710 PMCID: PMC10381152 DOI: 10.3390/jof9070721] [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: 04/25/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
The Antifungal Susceptibility Testing method of the European Committee on Antimicrobial Susceptibility Testing (EUCAST-AFST) is a reference technique for the determination of the Minimum Inhibitory Concentration (MIC) of antifungals for Aspergillus fumigatus. However, it is time-consuming and requires expertise. Micronaut-AM (M-AM) is a fast, simple, time-saving, and ready-to-use new colorimetric method using an indicator (resazurin) to facilitate the visual reading. The aim of this retrospective study was to evaluate the performance of the M-AM system and compare it with the EUCAST broth microdilution reference method to determine the susceptibility of 77 A. fumigatus clinical strains to amphotericin B, itraconazole, voriconazole, and posaconazole. Overall, the essential agreements within ±2 dilutions were 100%, 62%, 58%, and 30% and the categorical agreements were 100%, 97%, 91%, and 87% for amphotericin B, itraconazole, voriconazole, and posaconazole, respectively. No categorical discrepancy was found for amphotericin B, but several categorical discordances were observed with azole antifungals. However, only 2 of the 16 azole-resistant strains confirmed by the cyp51A sequencing would have been misclassified by M-AM. The use of M-AM is probably suitable for the determination of the MICs of amphotericin B, but further evaluations are needed to confirm its usefulness for the determination of the MICs of azoles for A. fumigatus.
Collapse
Affiliation(s)
- Nikolett Gyurtane Szabo
- Laboratoire de Parasitologie-Mycologie, AP-HP, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - Valentin Joste
- Laboratoire de Parasitologie-Mycologie, AP-HP, CHU Bichat-Claude-Bernard, 75018 Paris, France
- MERIT, IRD, Université Paris Cité, 75006 Paris, France
| | - Sandrine Houzé
- Laboratoire de Parasitologie-Mycologie, AP-HP, CHU Bichat-Claude-Bernard, 75018 Paris, France
- MERIT, IRD, Université Paris Cité, 75006 Paris, France
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, 75015 Paris, France
- DYNAMYC 7380, Faculté de Santé, Université Paris-Est Créteil (UPEC), 94010 Créteil, France
- Faculté de Médecine, Université Paris Cité, 75006 Paris, France
| | - Christine Bonnal
- Laboratoire de Parasitologie-Mycologie, AP-HP, CHU Bichat-Claude-Bernard, 75018 Paris, France
| |
Collapse
|
4
|
Naicker S, Mohanlall V, Ngubane S, Mellem J, Mchunu NP. Phenotypic Array for Identification and Screening of Antifungals against Aspergillus Isolates from Respiratory Infections in KwaZulu Natal, South Africa. J Fungi (Basel) 2023; 9:616. [PMID: 37367552 DOI: 10.3390/jof9060616] [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: 03/14/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
The rapid emergence of invasive fungal infections correlates with the increasing population of immunocompromised individuals, with many cases leading to death. The progressive increase in the incidence of Aspergillus isolates is even more severe due to the clinical challenges in treating invasive infections in immunocompromised patients with respiratory conditions. Rapid detection and diagnosis are needed to reduce mortality in individuals with invasive aspergillosis-related infections and thus efficient identification impacts clinical success. The phenotypic array method was compared to conventional morphology and molecular identification on thirty-six Aspergillus species isolated from patients with respiratory infections at the Inkosi Albert Luthuli Hospital in Kwa-Zulu Natal. In addition, an antimicrobial array was also carried out to screen for possible novel antimicrobial compounds for treatment. Although traditional morphological techniques are useful, genetic identification was the most reliable, assigning 26 to Aspergillus fumigatus species, 8 Aspergillus niger, and 2 Aspergillus flavus including cryptic species of A. niger, A. tubingensis and A. welwitschiae. The phenotypic array technique was only able to identify isolates up to the genus level due to a lack of adequate reference clinical species in the database. However, this technique proved crucial in assessing a wide range of possible antimicrobial options after these isolates exhibited some resistance to azoles. Antifungal profiles of the thirty-six isolates on the routine azole voriconazole showed a resistance of 6%, with 61% having moderate susceptibility. All isolates resistant to the salvage therapy drug, posaconazole pose a serious concern. Significantly, A. niger was the only species resistant (25%) to voriconazole and has recently been reported as the species isolated from patients with COVID-19-associated pulmonary aspergillosis (CAPA). Phenotypic microarray showed that 83% of the isolates were susceptible to the 24 new compounds and novel compounds were identified for potentially effective combination treatment of fungal infections. This study also reports the first TR34/98 mutation in Aspergillus clinical isolates which is located in the cyp51A gene.
Collapse
Affiliation(s)
- Sarla Naicker
- Department of Biotechnology and Food Science, Durban University of Technology, Durban 4000, Kwa-Zulu Natal, South Africa
| | - Viresh Mohanlall
- Department of Biotechnology and Food Science, Durban University of Technology, Durban 4000, Kwa-Zulu Natal, South Africa
| | - Sandile Ngubane
- Department of Biotechnology and Food Science, Durban University of Technology, Durban 4000, Kwa-Zulu Natal, South Africa
| | - John Mellem
- Department of Biotechnology and Food Science, Durban University of Technology, Durban 4000, Kwa-Zulu Natal, South Africa
| | | |
Collapse
|
5
|
The Evolving Landscape of Diagnostics for Invasive Fungal Infections in Lung Transplant Recipients. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
6
|
Vermeulen P, Gruez A, Babin AL, Frippiat JP, Machouart M, Debourgogne A. CYP51 Mutations in the Fusarium solani Species Complex: First Clue to Understand the Low Susceptibility to Azoles of the Genus Fusarium. J Fungi (Basel) 2022; 8:jof8050533. [PMID: 35628788 PMCID: PMC9148147 DOI: 10.3390/jof8050533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 02/05/2023] Open
Abstract
Members of Fusarium solani species complex (FSSC) are cosmopolitan filamentous fungi responsible for invasive fungal infections in immunocompromised patients. Despite the treatment recommendations, many strains show reduced sensitivity to voriconazole. The objective of this work was to investigate the potential relationship between azole susceptibility and mutations in CYP51 protein sequences. Minimal inhibitory concentrations (MICs) for azole antifungals have been determined using the CLSI (Clinical and Laboratory Standards Institute) microdilution method on a panel of clinical and environmental strains. CYP51A, CYP51B and CYP51C genes for each strain have been sequenced using the Sanger method. Amino acid substitutions described in multiple azole-resistant Aspergillus fumigatus (mtrAf) strains have been sought and compared with other Fusarium complexes’ strains. Our results show that FSSC exhibit point mutations similar to those described in mtrAf. Protein sequence alignments of CYP51A, CYP51B and CYP51C have highlighted different profiles based on sequence similarity. A link between voriconazole MICs and protein sequences was observed, suggesting that these mutations could be an explanation for the intrinsic azole resistance in the genus Fusarium. Thus, this innovative approach provided clues to understand low azole susceptibility in FSSC and may contribute to improving the treatment of FSSC infection.
Collapse
Affiliation(s)
- Pierre Vermeulen
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
| | - Arnaud Gruez
- IMoPA, CNRS, Université de Lorraine, F-54000 Nancy, France;
| | - Anne-Lyse Babin
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
| | - Jean-Pol Frippiat
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
| | - Marie Machouart
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
| | - Anne Debourgogne
- Laboratoire Stress Immunité Pathogènes, UR 7300, Faculté de Médecine, Université de Lorraine, 9 Avenue de la Forêt de Haye, F-54500 Vandœuvre-lès-Nancy, France; (P.V.); (A.-L.B.); (J.-P.F.); (M.M.)
- Service de Microbiologie, CHRU de Nancy, Hôpitaux de Brabois, 11 Allée du Morvan, F-54511 Vandœuvre-lès-Nancy, France
- Correspondence: ; Tel.: +33-(0)3-83-15-43-96
| |
Collapse
|
7
|
Montemari AL, Marzano V, Essa N, Levi Mortera S, Rossitto M, Gardini S, Selan L, Vrenna G, Onetti Muda A, Putignani L, Fiscarelli EV. A Shaving Proteomic Approach to Unveil Surface Proteins Modulation of Multi-Drug Resistant Pseudomonas aeruginosa Strains Isolated From Cystic Fibrosis Patients. Front Med (Lausanne) 2022; 9:818669. [PMID: 35355602 PMCID: PMC8959810 DOI: 10.3389/fmed.2022.818669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Cystic fibrosis (CF) is the most common rare disease caused by a mutation of the CF transmembrane conductance regulator gene encoding a channel protein of the apical membrane of epithelial cells leading to alteration of Na+ and K+ transport, hence inducing accumulation of dense and sticky mucus and promoting recurrent airway infections. The most detected bacterium in CF patients is Pseudomonas aeruginosa (PA) which causes chronic colonization, requiring stringent antibiotic therapies that, in turn induces multi-drug resistance. Despite eradication attempts at the first infection, the bacterium is able to utilize several adaptation mechanisms to survive in hostile environments such as the CF lung. Its adaptive machinery includes modulation of surface molecules such as efflux pumps, flagellum, pili and other virulence factors. In the present study we compared surface protein expression of PA multi- and pan-drug resistant strains to wild-type antibiotic-sensitive strains, isolated from the airways of CF patients with chronic colonization and recent infection, respectively. After shaving with trypsin, microbial peptides were analyzed by tandem-mass spectrometry on a high-resolution platform that allowed the identification of 174 differentially modulated proteins localized in the region from extracellular space to cytoplasmic membrane. Biofilm assay was performed to characterize all 26 PA strains in term of biofilm production. Among the differentially expressed proteins, 17 were associated to the virulome (e.g., Tse2, Tse5, Tsi1, PilF, FliY, B-type flagellin, FliM, PyoS5), six to the resistome (e.g., OprJ, LptD) and five to the biofilm reservoir (e.g., AlgF, PlsD). The biofilm assay characterized chronic antibiotic-resistant isolates as weaker biofilm producers than wild-type strains. Our results suggest the loss of PA early virulence factors (e.g., pili and flagella) and later expression of virulence traits (e.g., secretion systems proteins) as an indicator of PA adaptation and persistence in the CF lung environment. To our knowledge, this is the first study that, applying a shaving proteomic approach, describes adaptation processes of a large collection of PA clinical strains isolated from CF patients in early and chronic infection phases.
Collapse
Affiliation(s)
- Anna Lisa Montemari
- Department of Diagnostics and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Cystic Fibrosis Diagnostics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Valeria Marzano
- Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Nour Essa
- Department of Diagnostics and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Cystic Fibrosis Diagnostics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Stefano Levi Mortera
- Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Martina Rossitto
- Department of Diagnostics and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Cystic Fibrosis Diagnostics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Laura Selan
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Gianluca Vrenna
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Andrea Onetti Muda
- Department of Diagnostics and Laboratory Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Lorenza Putignani
- Department of Diagnostics and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Microbiomics, and Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ersilia Vita Fiscarelli
- Department of Diagnostics and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Cystic Fibrosis Diagnostics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| |
Collapse
|
8
|
Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Aggarwal AN. Allergic Bronchopulmonary Aspergillosis. Clin Chest Med 2022; 43:99-125. [DOI: 10.1016/j.ccm.2021.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
9
|
Risum M, Hare RK, Gertsen JB, Kristensen L, Rosenvinge FS, Sulim S, Abou-Chakra N, Bangsborg J, Løwe Røder B, Marmolin ES, Marie Thyssen Astvad K, Pedersen M, Dzajic E, Andersen SL, Arendrup MC. Azole Resistance in Aspergillus fumigatus. The first 2-year's Data from the Danish National Surveillance Study, 2018-2020. Mycoses 2022; 65:419-428. [PMID: 35104010 PMCID: PMC9302650 DOI: 10.1111/myc.13426] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Azole resistance complicates treatment of patients with invasive aspergillosis with an increased mortality. Azole resistance in Aspergillus fumigatus is a growing problem and associated with human and environmental azole use. Denmark has a considerable and highly efficient agricultural sector. Following reports on environmental azole resistance in A. fumigatus from Danish patients the ministry of health requested a prospective national surveillance of azole resistant A. fumigatus and particularly that of environmental origin. OBJECTIVES To present the data from the first two years of the surveillance programme. METHODS Unique isolates regarded as clinically relevant and any A. fumigatus isolated on a preferred weekday (background samples) were included. EUCAST susceptibility testing was performed and azole-resistant isolates underwent cyp51A gene sequencing. RESULTS The azole resistance prevalence was 6.1% (66/1083) at patient level. The TR34 /L98H prevalence was 3.6% (39/1083) and included the variants TR34 /L98H, TR34 3 /L98H and TR34 /L98H/S297T/F495I. Resistance caused by other Cyp51A variants accounted for 1.3% (14/1083) and included G54R, P216S, F219L, G54W, M220I, M220K, M220R, G432S, G448S and Y121F alterations. Non-Cyp51A mediated resistance accounted for 1.2% (13/1083). Proportionally, TR34 /L98H, other Cyp51A variants and non-Cyp51A mediated resistance accounted for 59.1% (39/66), 21.2% (14/66) and 19.7% (13/66), respectively, of all resistance. Azole resistance was detected in all five Regions in Denmark, and TR34 /L98H specifically, in four of five regions during the surveillance period. CONCLUSION The azole resistance prevalence does not lead to a change in the initial treatment of aspergillosis at this point, but causes concern and leads to therapeutic challenges in the affected patients.
Collapse
Affiliation(s)
| | | | | | - Lise Kristensen
- Department of Clinical Microbiology, Aarhus University Hospital
| | - Flemming Schønning Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, and Research Unit of Clinical Microbiology, University of Southern Denmark, Odense
| | - Sofia Sulim
- Department of Clinical Microbiology, Aalborg University Hospital
| | | | - Jette Bangsborg
- Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen
| | | | - Ea Sofie Marmolin
- Department of Clinical Microbiology, Sygehus Lillebaelt, Vejle Sygehus
| | - Karen Marie Thyssen Astvad
- Mycology Unit, Statens Serum Institut.,Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen
| | - Michael Pedersen
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen
| | - Esad Dzajic
- Department of Clinical Microbiology, Sydvestjysk Sygehus, Esbjerg Sygehus
| | | | - Maiken Cavling Arendrup
- Mycology Unit, Statens Serum Institut.,Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen.,Department of Clinical Medicine, Copenhagen University
| |
Collapse
|
10
|
Al Shakirchi M, Sorjonen K, Klingspor L, Bergman P, Hjelte L, de Monestrol I. The Effects of Aspergillus fumigatus Colonization on Lung Function in Patients with Cystic Fibrosis. J Fungi (Basel) 2021; 7:jof7110944. [PMID: 34829231 PMCID: PMC8618016 DOI: 10.3390/jof7110944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022] Open
Abstract
Aspergillus fumigatus is commonly isolated from CF airways. However, the impact on CF lung progression is not completely understood. In this study, using a 16-year retrospective observational cohort study (2000–2015) that included 132 patients, we determined the annual lung function, measured as percent predicted forced expiratory volume in the first second (ppFEV1), decline before and after the first colonization with A. fumigatus. Further, in the same individual, the ratios of lung function when patients were colonized with A. fumigatus and when they were not were calculated. The impact of eradication, with antifungal treatment or spontaneously, was assessed. The annual ppFEV1 was significantly lower after the first colonization with A. fumigatus. Furthermore, within the same individual, colonization with A. fumigatus for two and three years in a row was associated with 4.3% and 7.9% lower ppFEV1, respectively, compared to when not colonized. Finally, patients who eradicated A. fumigatus the following two years after colonization exhibited 9.9% and 14.5% higher ppFEV1 compared to patients who continued to produce cultures with A. fumigatus for two and three years. Our study demonstrated that A. fumigatus colonization was associated with a negative impact on lung function in the long term and eradication, spontaneously or with treatment, was associated with a better pulmonary outcome.
Collapse
Affiliation(s)
- Mahasin Al Shakirchi
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence:
| | - Kimmo Sorjonen
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Lena Klingspor
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
- Department of Infectious Diseases, The Immunodeficiency Unit, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Lena Hjelte
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Isabelle de Monestrol
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
| |
Collapse
|
11
|
Rocchi S, Sewell TR, Valot B, Godeau C, Laboissiere A, Millon L, Fisher MC. Molecular Epidemiology of Azole-Resistant Aspergillus fumigatus in France Shows Patient and Healthcare Links to Environmentally Occurring Genotypes. Front Cell Infect Microbiol 2021; 11:729476. [PMID: 34660341 PMCID: PMC8512841 DOI: 10.3389/fcimb.2021.729476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/09/2021] [Indexed: 01/14/2023] Open
Abstract
Resistance of the human pathogenic fungus Aspergillus fumigatus to antifungal agents is on the rise. However, links between patient infections, their potential acquisition from local environmental sources, and links to global diversity remain cryptic. Here, we used genotyping analyses using nine microsatellites in A. fumigatus, in order to study patterns of diversity in France. In this study, we genotyped 225 local A. fumigatus isolates, 112 azole susceptible and 113 azole resistant, collected from the Bourgogne-Franche-Comté region (Eastern France) and sampled from both clinical (n = 34) and environmental (n = 191) sources. Azole-resistant clinical isolates (n = 29) were recovered mainly from cystic fibrosis patients and environmental isolates (n = 84) from market gardens and sawmills. In common with previous studies, the TR34/L98H allele predominated and comprised 80% of resistant isolates. The genotypes obtained for these local TR34/L98H isolates were integrated into a broader analysis including all genotypes for which data are available worldwide. We found that dominant local TR34/L98H genotypes were isolated in different sample types at different dates (different patients and types of environments) with hospital air and patient's isolates linked. Therefore, we are not able to rule out the possibility of some nosocomial transmission. We also found genotypes in these same environments to be highly diverse, emphasizing the highly mixed nature of A. fumigatus populations. Identical clonal genotypes were found to occur both in the French Eastern region and in the rest of the world (notably Australia), while others have not yet been observed and could be specific to our region. Our study demonstrates the need to integrate patient, healthcare, and environmental sampling with global databases in order to contextualize the local-scale epidemiology of antifungal resistant aspergillosis.
Collapse
Affiliation(s)
- Steffi Rocchi
- Department of Parasitology and Mycology, Centre Hospitalier Universitaire, Besançon, France.,Chrono-Environnement Research Team UMR/CNRS-6249, Bourgogne-Franche-Comté University, Besançon, France
| | - Thomas R Sewell
- Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial School of Public Health, Imperial College London, London, United Kingdom
| | - Benoit Valot
- Chrono-Environnement Research Team UMR/CNRS-6249, Bourgogne-Franche-Comté University, Besançon, France
| | - Chloé Godeau
- Chrono-Environnement Research Team UMR/CNRS-6249, Bourgogne-Franche-Comté University, Besançon, France
| | - Audrey Laboissiere
- Chrono-Environnement Research Team UMR/CNRS-6249, Bourgogne-Franche-Comté University, Besançon, France
| | - Laurence Millon
- Department of Parasitology and Mycology, Centre Hospitalier Universitaire, Besançon, France.,Chrono-Environnement Research Team UMR/CNRS-6249, Bourgogne-Franche-Comté University, Besançon, France
| | - Matthew C Fisher
- Medical Research Council (MRC) Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial School of Public Health, Imperial College London, London, United Kingdom
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Majima H, Arai T, Kusuya Y, Takahashi H, Watanabe A, Miyazaki Y, Kamei K. Genetic differences between Japan and other countries in cyp51A polymorphisms of Aspergillus fumigatus. Mycoses 2021; 64:1354-1365. [PMID: 34558115 DOI: 10.1111/myc.13370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mutations in cyp51A gene are known as main mechanisms of azole resistance in Aspergillus fumigatus, whereas azole-susceptible strains also carry cyp51A mutations (polymorphisms). The polymorphisms found in Europe mainly consist of two combinations of mutations, that is combinations of five single-nucleotide polymorphisms (SNPs) of cyp51A, referred to as cyp51A-5SNPs, and combinations of three SNPs of cyp51A, referred to as cyp51A-3SNPs. Few studies have compared the distributions of cyp51A polymorphisms between different regions. OBJECTIVES The aim of this study was to investigate the regional differences of cyp51A polymorphisms. METHODS We compared the proportions of cyp51A polymorphisms in clinical and environmental strains isolated in various countries, and analysed the strains phylogenetically using short tandem repeats (STRs) and whole-genome sequence (WGS). RESULTS Among the Japanese strains, 15 out of 98 (15.3%) clinical strains and 8 out of 95 (8.4%) environmental strains had cyp51A polymorphisms. A mutation of cyp51AN248K was the most prevalent polymorphism in both clinical (n = 14, 14.3%) and environmental strains (n = 3, 3.2%). Only one environmental strain harboured cyp51A-5SNPs, which was reported to be the most prevalent in Europe. For phylogenetic analyses using STRs and WGS, 183 and 134 strains, respectively, were employed. They showed that most of the strains with cyp51AN248K clustered in the clades different from those of the strains with cyp51A-5SNPs and cyp51A-3SNPs as well as from those with TR34 /L98H mutations. CONCLUSIONS This study suggests that there are genetic differences between cyp51A polymorphisms of A. fumigatus in Japan and Europe.
Collapse
Affiliation(s)
- Hidetaka Majima
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan.,Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Teppei Arai
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Yoko Kusuya
- Division of Bioresources, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Hiroki Takahashi
- Division of Bioresources, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Katsuhiko Kamei
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| |
Collapse
|
14
|
Badali H, Shokohi T, Khodavaisy S, Moazeni M, Farhadi M, Nabili M. Molecular typing of clinical and environmental Aspergillus fumigatus isolates from Iran using microsatellites. Curr Med Mycol 2021; 7:25-30. [PMID: 34553094 PMCID: PMC8443879 DOI: 10.18502/cmm.7.1.6180] [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: 10/26/2020] [Revised: 11/17/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose Because of the growing incidence of Aspergillus infection, typing methods of Aspergillus species are increasingly being used. Accordingly, studying the spread and population dynamics of strains isolating from clinical and environment, from a single host to large-scale ecosystems is definitely needed. In the current study, we carried out a genetic analysis of nine microsatellite loci in isolates from different regions of Iran to compare and explore the genetic diversity between environmental and clinical A. fumigatus strains. Materials and Methods Sixty-six clinical (n=43) and environmental (n= 23) isolates of A. fumigatus, have collected from six cities of Iran. All A. fumigatus isolates identified based on macroscopic and microscopic characters, the ability to grow at above 45°C, and confirmed using DNA sequencing of the partial b-tubulin gene. Sixty-six A. fumigatus isolates were subjected by microsatellite typing using three separate multiplex PCRs with a panel of nine short tandem repeats (STR) to evaluate the genetic relatedness. Results The STR typing of 66 A. fumigatus isolates revealed 38 distinct genotypes distributed among environmental and clinical isolates. We identified 12 clones including 40 different isolates representing 60% of all isolates tested, which each clone included 2-7 isolates. Conclusion The STR typing is considered as a valuable tool with excellent discriminatory power to study the molecular epidemiology and genotypic diversity of A. fumigatus isolates. These findings show that the high genetic diversity observed of Iranian A. fumigatus isolates with those outside Iran and formed a separate cluster.
Collapse
Affiliation(s)
- Hamid Badali
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sadegh Khodavaisy
- Department of Medical Mycology and Parasitology, Tehran University of Medical Science, Tehran, Iran
| | - Maryam Moazeni
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Masoumeh Farhadi
- Department of Medical Laboratory Sciences, Faculty of Medicine, Sari Branch, Islamic Azad University, Sari, Iran
| | - Mojtaba Nabili
- Department of Medical Laboratory Sciences, Faculty of Medicine, Sari Branch, Islamic Azad University, Sari, Iran
| |
Collapse
|
15
|
Ross BS, Lofgren LA, Ashare A, Stajich JE, Cramer RA. Aspergillus fumigatus In-Host HOG Pathway Mutation for Cystic Fibrosis Lung Microenvironment Persistence. mBio 2021; 12:e0215321. [PMID: 34465017 PMCID: PMC8406193 DOI: 10.1128/mbio.02153-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
The prevalence of Aspergillus fumigatus colonization in individuals with cystic fibrosis (CF) and subsequent fungal persistence in the lung is increasingly recognized. However, there is no consensus for clinical management of A. fumigatus in CF individuals, due largely to uncertainty surrounding A. fumigatus CF pathogenesis and virulence mechanisms. To address this gap in knowledge, a longitudinal series of A. fumigatus isolates from an individual with CF were collected over 4.5 years. Isolate genotypes were defined with whole-genome sequencing that revealed both transitory and persistent A. fumigatus in the lung. Persistent lineage isolates grew most readily in a low-oxygen culture environment, and conidia were more sensitive to oxidative stress-inducing conditions than those from nonpersistent isolates. Closely related persistent isolates harbored a unique allele of the high-osmolarity glycerol (HOG) pathway mitogen-activated protein kinase kinase, Pbs2 (pbs2C2). Data suggest this novel pbs2C2 allele arose in vivo and is necessary for the fungal response to osmotic stress in a low-oxygen environment through hyperactivation of the HOG (SakA) signaling pathway. Hyperactivation of the HOG pathway through pbs2C2 comes at the cost of decreased conidial stress resistance in the presence of atmospheric oxygen levels. These novel findings shed light on pathoadaptive mechanisms of A. fumigatus in CF, lay the foundation for identifying persistent A. fumigatus isolates that may require antifungal therapy, and highlight considerations for successful culture of persistent Aspergillus CF isolates. IMPORTANCE Aspergillus fumigatus infection causes a spectrum of clinical manifestations. For individuals with cystic fibrosis (CF), allergic bronchopulmonary aspergillosis (ABPA) is an established complication, but there is a growing appreciation for A. fumigatus airway persistence in CF disease progression. There currently is little consensus for clinical management of A. fumigatus long-term culture positivity in CF. A better understanding of A. fumigatus pathogenesis mechanisms in CF is expected to yield insights into when antifungal therapies are warranted. Here, a 4.5-year longitudinal collection of A. fumigatus isolates from a patient with CF identified a persistent lineage that harbors a unique allele of the Pbs2 mitogen-activated protein kinase kinase (MAPKK) necessary for unique CF-relevant stress phenotypes. Importantly for A. fumigatus CF patient diagnostics, this allele provides increased fitness under CF lung-like conditions at a cost of reduced in vitro growth under standard laboratory conditions. These data illustrate a molecular mechanism for A. fumigatus CF lung persistence with implications for diagnostics and antifungal therapy.
Collapse
Affiliation(s)
- Brandon S. Ross
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lotus A. Lofgren
- Department of Microbiology and Plant Pathology, Institute for Integrative Genome Biology, University of California Riverside, Riverside, California, USA
| | - Alix Ashare
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jason E. Stajich
- Department of Microbiology and Plant Pathology, Institute for Integrative Genome Biology, University of California Riverside, Riverside, California, USA
| | - Robert A. Cramer
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| |
Collapse
|
16
|
Multiresistance to Nonazole Fungicides in Aspergillus fumigatus TR 34/L98H Azole-Resistant Isolates. Antimicrob Agents Chemother 2021; 65:e0064221. [PMID: 34152819 DOI: 10.1128/aac.00642-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Drug resistance is a worldwide problem affecting all pathogens. The human fungal pathogen Aspergillus fumigatus coexists in the environment with other fungi targeted by crop protection compounds, being unintentionally exposed to the selective pressure of multiple antifungal classes and leading to the selection of resistant strains. A. fumigatus azole-resistant isolates are emerging in both clinical and environmental settings. Since their approval, azole drugs have dominated clinical treatment for aspergillosis infections and the agriculture fungicide market. However, other antifungal classes are used for crop protection, including benzimidazoles (methyl benzimidazole carbamates [MBCs]), strobilurins (quinolone oxidation inhibitors [QoIs]), and succinate dehydrogenase inhibitors (SDHIs). Mutations responsible for resistance to these fungicides have been widely researched in plant pathogens, but resistance has not been explored in A. fumigatus. In this work, the genetic basis underlying resistance to MBCs, QoIs, and SDHIs was studied in azole-susceptible and -resistant A. fumigatus strains. E198A/Q and F200Y mutations in β-tubulin conferred resistance to MBCs, G143A and F129L substitutions in cytochrome b conferred resistance to QoIs, and H270R/Y mutations in SdhB conferred resistance to SDHIs. Characterization of susceptibility to azoles showed a correlation between strains resistant to these fungicides and the ones with tandem-repeat (TR)-based azole resistance mechanisms. Whole-genome sequencing analysis showed a genetic relationship among fungicide multiresistant strains, which grouped into subclusters that included only strains carrying the TR-based azole resistance mechanisms, indicating a common ancestor/evolution pattern and confirming the environmental origin of this type of azole-resistant A. fumigatus.
Collapse
|
17
|
Abstract
In the past three decades, fungal respiratory colonization and fungal respiratory infections increasingly raised concern in cystic fibrosis (CF). Reasons for this are a better knowledge of the pathogenicity of fungi, whereby detection is sought in more and more CF centers, but also improvement of detection methods. However, differences in fungal detection rates within and between geographical regions exist and indicate the need for standardization of mycological examination of respiratory secretions. The still existing lack of standardization also complicates the assessment of fungal pathogenicity, relevance of fungal detection and risk factors for fungal infections. Nevertheless, numerous studies have now been conducted on differences in detection methods, epidemiology, risk factors, pathogenicity and therapy of fungal diseases in CF. Meanwhile, some research groups now have classified fungal disease entities in CF and developed diagnostic criteria as well as therapeutic guidelines.The following review presents an overview on fungal species relevant in CF. Cultural detection methods with their respective success rates as well as susceptibility testing will be presented, and the problem of increasing azole resistance in Aspergillus fumigatus will be highlighted. Next, current data and conflicting evidence on the epidemiology and risk factors for fungal diseases in patients with CF will be discussed. Finally, an overview of fungal disease entities in CF with their current definitions, diagnostic criteria and therapeutic options will be presented.
Collapse
|
18
|
Duong TMN, Le TV, Tran KLH, Nguyen PT, Nguyen BPT, Nguyen TA, Nguyen HLP, Nguyen BNT, Fisher MC, Rhodes J, Marks G, Fox GJ, Chen SCA, Walsh MG, Barrs VR, Talbot J, Halliday CL, Sorrell TC, Day JN, Beardsley J. Azole-resistant Aspergillus fumigatus is highly prevalent in the environment of Vietnam, with marked variability by land use type. Environ Microbiol 2021; 23:7632-7642. [PMID: 34232541 DOI: 10.1111/1462-2920.15660] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/16/2021] [Accepted: 07/03/2021] [Indexed: 11/30/2022]
Abstract
Azole-resistant environmental Aspergillus fumigatus presents a threat to public health but the extent of this threat in Southeast Asia is poorly described. We conducted environmental surveillance in the Mekong Delta region of Vietnam, collecting air and ground samples across key land-use types, and determined antifungal susceptibilities of Aspergillus section Fumigati (ASF) isolates and azole concentrations in soils. Of 119 ASF isolates, 55% were resistant (or non-wild type) to itraconazole, 65% to posaconazole and 50% to voriconazole. Azole resistance was more frequent in A. fumigatus sensu stricto isolates (95%) than other ASF species (32%). Resistant isolates and agricultural azole residues were overrepresented in samples from cultivated land. cyp51A gene sequence analysis showed 38/56 resistant A. fumigatus sensu stricto isolates carried known resistance mutations, with TR34 /L98H most frequent (34/38).
Collapse
Affiliation(s)
- Tra-My N Duong
- Faculty of Medicine and Health, The University of Sydney, Sydney, 2145, Australia.,Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam
| | - Thanh-Van Le
- Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam
| | - Khanh-Linh H Tran
- Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam
| | | | | | - Thu-Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, 10000, Vietnam
| | | | - Bich-Ngoc T Nguyen
- National Lung Hospital, Hanoi, 10000, Vietnam.,Hanoi Medical University, Hanoi, 10000, Vietnam
| | - Matthew C Fisher
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, W2 1NY, UK
| | - Johanna Rhodes
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, W2 1NY, UK
| | - Guy Marks
- Woolcock Institute of Medical Research, Hanoi, 10000, Vietnam
| | - Greg J Fox
- Faculty of Medicine and Health, The University of Sydney, Sydney, 2145, Australia.,Woolcock Institute of Medical Research, Hanoi, 10000, Vietnam
| | - Sharon C-A Chen
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney, 2145, Australia
| | - Michael G Walsh
- Faculty of Medicine and Health, The University of Sydney, Sydney, 2145, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia
| | - Vanessa R Barrs
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia.,Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Jessica Talbot
- Faculty of Veterinary Science, The University of Sydney, Sydney, 2145, Australia
| | - Catriona L Halliday
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney, 2145, Australia
| | - Tania C Sorrell
- Faculty of Medicine and Health, The University of Sydney, Sydney, 2145, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia.,Westmead Institute for Medical Research, Westmead, Sydney, 2145, Australia
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Justin Beardsley
- Faculty of Medicine and Health, The University of Sydney, Sydney, 2145, Australia.,Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, 2145, Australia.,Westmead Institute for Medical Research, Westmead, Sydney, 2145, Australia
| |
Collapse
|
19
|
Jørgensen KM, Guinea J, Meletiadis J, Hare RK, Arendrup MC. Revision of EUCAST breakpoints: consequences for susceptibility of contemporary Danish mould isolates to isavuconazole and comparators. J Antimicrob Chemother 2021; 75:2573-2581. [PMID: 32556315 DOI: 10.1093/jac/dkaa212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND EUCAST recently revised the definition of the 'I' category from 'intermediate' to 'susceptible, increased exposure'. Consequently, all current antifungal breakpoints have been reviewed and revised breakpoints (v 10.0) have been released. OBJECTIVES We investigated isavuconazole and comparator MICs (mg/L) against contemporary moulds and the consequences of the breakpoint revision for susceptibility classification. METHODS Six hundred and ninety-six Aspergillus and 46 other moulds were included. EUCAST E.Def 10.1 azole resistance screening was performed for Aspergillus fumigatus and E.Def 9.3.1 testing of non-susceptible A. fumigatus and other moulds. Most non-wildtype/resistant isolates underwent cyp51A sequencing. RESULTS Isavuconazole MIC50/MIC90s were ≤1/≤2 mg/L for Aspergillus flavus, A. fumigatus and Aspergillus nidulans versus 2/4 mg/L for Aspergillus niger and 2/16 mg/L for Aspergillus terreus. For the remaining moulds, MICs were highest for Fusarium (16 to >16 mg/L), lowest for dermatophytes (0.06-0.5 mg/L) and in between for Mucorales and others (1 to >16 mg/L). A very strong isavuconazole-voriconazole MIC correlation was found for A. fumigatus (Pearson r = 0.888) and itraconazole-posaconazole correlation for A. fumigatus (r = 0.905) and A. terreus (r = 0.848). For A. fumigatus, the revised breakpoints lowered isavuconazole resistance (22.6% to 7.7%, P < 0.0001) and increased voriconazole resistance (3.8% to 6.7%, P = 0.025), resulting in similar resistance rates across the four azoles (range: 6.7%-7.7%). For A. terreus, isavuconazole resistance remained unchanged (81.3%) and higher than itraconazole (43.8%, P = 0.004) and posaconazole (53.1%, P = 0.03) resistance. Azole cross-resistance was found in 24/24, 13/20 and 4/90 isolates, and Cyp51A alterations in 16/18, 1/7 and 2/4 sequenced isolates with isavuconazole MICs of >4, 4 and 2 mg/L, respectively. CONCLUSIONS Isavuconazole displays broad anti-mould activity. The revised breakpoints result in fewer misclassifications of wildtype isolates without compromising detection of resistant mutants.
Collapse
Affiliation(s)
| | - Jesus Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Athens, Greece
| | | | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
20
|
Brackin AP, Shelton JMG, Abdolrasouli A, Fisher MC, Sewell TR. A Low-Cost Tebuconazole-Based Screening Test for Azole-Resistant Aspergillus fumigatus. ACTA ACUST UNITED AC 2021; 58:e112. [PMID: 32857921 DOI: 10.1002/cpmc.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The global emergence of azole resistance in Aspergillus fumigatus is resulting in health and food security concerns. Rapid diagnostics and environmental surveillance methods are key to understanding the distribution and prevalence of azole resistance. However, such methods are often associated with high costs and are not always applicable to laboratories based in the least-developed countries. Here, we present and validate a low-cost screening protocol that can be used to differentiate between azole-susceptible "wild-type" and azole-resistant A. fumigatus isolates. © 2020 The Authors. Basic Protocol 1: Preparation of Tebucheck multi-well plates Basic Protocol 2: Inoculation of Tebucheck multi-well plates.
Collapse
Affiliation(s)
- Amelie P Brackin
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Jennifer M G Shelton
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Alireza Abdolrasouli
- Diagnostic Mycology Service, Department of Medical Microbiology, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Matthew C Fisher
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Thomas R Sewell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| |
Collapse
|
21
|
Sass G, Shrestha P, Stevens DA. Pseudomonas aeruginosa Virulence Factors Support Voriconazole Effects on Aspergillus fumigatus. Pathogens 2021; 10:pathogens10050519. [PMID: 33925818 PMCID: PMC8146861 DOI: 10.3390/pathogens10050519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 12/20/2022] Open
Abstract
Pseudomonas aeruginosa and Aspergillus fumigatus are pathogens that are associated with deterioration of lung function, e.g., in persons with cystic fibrosis (CF). There is evidence that co-infections with these pathogens cause airway inflammation and aggravate pathology in CF lungs. Intermicrobial competition of P. aeruginosa and A. fumigatus has been described, but it is unknown how anti-fungal therapy is affected. The anti-fungal azole voriconazole (VCZ), supernatants of P. aeruginosa laboratory isolates PA14 or PAO1, or clinical isolate Pa10 independently inhibited biofilm metabolism of A. fumigatus isolates 10AF and AF13073. When VCZ and supernatants were combined at their IC50s, synergistic effects on A. fumigatus were found. Synergistic effects were no longer observed when P. aeruginosa supernatants were prepared in the presence of iron, or when P. aeruginosa mutants were lacking the ability to produce pyoverdine and pyochelin. Combination of pure P. aeruginosa products pyoverdine, pyochelin, and pyocyanin with VCZ showed synergistic anti-fungal effects. Combining VCZ with P. aeruginosa supernatants also improved its MIC and MFC against planktonic A. fumigatus. In summary, in the case of P. aeruginosa–A. fumigatus co-infections, it appeared that the P. aeruginosa co-infection facilitated therapy of the Aspergillus; lower concentrations of VCZ might be sufficient to control fungal growth.
Collapse
Affiliation(s)
- Gabriele Sass
- California Institute for Medical Research, San Jose, CA 95128, USA; (G.S.); (P.S.)
| | - Pallabi Shrestha
- California Institute for Medical Research, San Jose, CA 95128, USA; (G.S.); (P.S.)
| | - David A. Stevens
- California Institute for Medical Research, San Jose, CA 95128, USA; (G.S.); (P.S.)
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
- Correspondence:
| |
Collapse
|
22
|
Mills R, Rautemaa-Richardson R, Wilkinson S, Patel L, Maitra A, Horsley A. Impact of airway Exophiala spp. on children with cystic fibrosis. J Cyst Fibros 2021; 20:702-707. [PMID: 33775601 DOI: 10.1016/j.jcf.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Isolation of Exophiala species from sputum samples has become increasingly reported in Cystic Fibrosis (CF). However, the clinical significance of Exophiala spp. with regards to the paediatric CF population is unknown. METHODS A case control study was undertaken to compare CF children with and without chronic Exophiala spp. in their sputum samples. Demographic and clinical data were collected retrospectively for each case from the date of Exophiala isolation and for 12 months preceding isolation. Each case was compared to three age and year-matched controls. To determine the effect of Exophiala on clinical course, patients were then followed for 12 months post isolation. RESULTS In total, 27 of 244 eligible paediatric CF patients (11%) isolated Exophiala spp. on more than one occasion. There were no significant differences in the key clinical parameters: spirometry, mean number of intravenous (IV) antibiotic days and body mass index (BMI), between cases and controls (p = 0.91, p = 0.56 and p = 0.63 respectively). A higher proportion of cases isolated Candida spp. (67% vs 21%, p < 0.0001) and Aspergillus fumigatus (37% vs 26%, p = 0.37). There was no clinically significant difference in spirometry, mean number of IV antibiotic days and BMI in cases pre and post Exophiala spp. isolation. Posaconazole was the only drug used that successfully eradicated Exophiala. CONCLUSION Despite the frequent isolation of Exophiala spp. in this cohort, in most patients it is not associated with significant clinical deterioration. It does however seem to be associated with isolation of other fungi.
Collapse
Affiliation(s)
- Rowena Mills
- Mycology Reference Centre Manchester, ECMM Centre of Excellence for Medical Mycology and the Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK; Paediatric Respiratory Department, Royal Manchester Children's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK; Department of General Paediatrics, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester, ECMM Centre of Excellence for Medical Mycology and the Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK; Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Wilkinson
- Paediatric Respiratory Department, Royal Manchester Children's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Latifa Patel
- Paediatric Respiratory Department, Royal Manchester Children's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Anirban Maitra
- Paediatric Respiratory Department, Royal Manchester Children's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Alex Horsley
- Division of Infection, Immunity & Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Manchester Adult Cystic Fibrosis Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| |
Collapse
|
23
|
Jørgensen KM, Helleberg M, Hare RK, Jørgensen LN, Arendrup MC. Dissection of the Activity of Agricultural Fungicides against Clinical Aspergillus Isolates with and without Environmentally and Medically Induced Azole Resistance. J Fungi (Basel) 2021; 7:jof7030205. [PMID: 33799556 PMCID: PMC8001900 DOI: 10.3390/jof7030205] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Azole resistance is an emerging problem in patients with aspergillosis. The role of fungicides for resistance development and occurrence is not fully elucidated. EUCAST reference MICs of 17 fungicides (11 azoles and 6 others), five azole fungicide metabolites and four medical triazoles were examined against two reference and 28 clinical isolates of A. fumigatus, A. flavus and A. terreus with (n = 12) and without (n = 16) resistance mutations. Eight/11 azole fungicides were active against wild-type A. fumigatus, A. flavus and A. terreus, including four (metconazole, prothioconazole-desthio, prochloraz and imazalil) with low MIC50 (≤2 mg/L) against all three species and epoxiconazole, propiconazole, tebuconazole and difenoconazole also against wild-type A. terreus. Mefentrifluconazole, azole metabolites and non-azole fungicides MICs were >16 mg/L against A. fumigatus although partial growth inhibition was found with mefentrifluconazole. Moreover, mefentrifluconazole and axozystrobin were active against wild-type A. terreus. Increased MICs (≥3 dilutions) were found for TR34/L98H, TR34(3)/L98H, TR46/Y121F/T289A and G432S compared to wild-type A. fumigatus for epoxiconazole, propiconazole, tebuconazole, difenoconazole, prochloraz, imazalil and metconazole (except G432S), and for prothioconazole-desthio against TR46/Y121F/T289A, specifically. Increased MICs were found in A. fumigatus harbouring G54R, M220K and M220R alterations for five, one and one azole fungicides, respectively, compared to MICs against wild-type A. fumigatus. Similarly, increased MICs wer found for A. terreus with G51A, M217I and Y491H alterations for five, six and two azole fungicides, respectively. Azole fungicides showed activity against wild-type A. fumigatus, A. terreus and A. flavus, but not against all mutant isolates, suggesting the environmental route of azole resistance may have a role for all three species.
Collapse
Affiliation(s)
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Rasmus Krøger Hare
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
| | - Lise Nistrup Jørgensen
- Department of Agroecology—Crop Health, Aarhus University-Flakkebjerg, 4200 Slagelse, Denmark;
| | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark; (K.M.J.); (R.K.H.)
- Department of Clinical Medicine, Copenhagen University, 2100 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
- Correspondence:
| |
Collapse
|
24
|
Di Paolo M, Hewitt L, Nwankwo E, Ni M, Vidal-Diaz A, Fisher MC, Armstrong-James D, Shah A. A retrospective 'real-world' cohort study of azole therapeutic drug monitoring and evolution of antifungal resistance in cystic fibrosis. JAC Antimicrob Resist 2021; 3:dlab026. [PMID: 34223100 PMCID: PMC8210303 DOI: 10.1093/jacamr/dlab026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) have an increased susceptibility to fungal infection/allergy, with triazoles often used as first-line therapy. Therapeutic drug monitoring (TDM) is essential due to significant pharmacokinetic variability and the recent emergence of triazole resistance worldwide. OBJECTIVES In this retrospective study we analysed the 'real-world' TDM of azole therapy in a large CF cohort, risk factors for subtherapeutic dosing, and the emergence of azole resistance. METHODS All adults with CF on azole therapy in a large single UK centre were included. Clinical demographics, TDM and microbiology were analysed over a 2 year study period (2015-17) with multivariate logistic regression used to identify risk factors for subtherapeutic dosing. RESULTS 91 adults were treated with azole medication during the study period. A high prevalence of chronic subtherapeutic azole dosing was seen with voriconazole (60.8%) and itraconazole capsule (59.6%) use, representing significant risk factors for subtherapeutic levels. Rapid emergence of azole resistance was additionally seen over the follow-up period with a 21.4% probability of CF patients developing a resistant fungal isolate after 2 years. No significant relationship was found however between subtherapeutic azole dosing and azole resistance emergence. CONCLUSIONS Our study demonstrates a high prevalence of subtherapeutic azole levels in CF adults with increased risk using itraconazole capsules and voriconazole therapy. We show rapid emergence of azole resistance highlighting the need for effective antifungal stewardship. Further large longitudinal studies are needed to understand the effects of antifungal resistance on outcome in CF and the implications of subtherapeutic dosing on resistance evolution.
Collapse
Affiliation(s)
- M Di Paolo
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - L Hewitt
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Faculty of Medicine, Department of Infectious Diseases, Imperial College London, London, UK
| | - E Nwankwo
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - M Ni
- London In Vitro Diagnostics Collaborative, Department of Surgery and Cancer, Imperial College London, UK
| | - A Vidal-Diaz
- London In Vitro Diagnostics Collaborative, Department of Surgery and Cancer, Imperial College London, UK
| | - M C Fisher
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, UK
| | - D Armstrong-James
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Faculty of Medicine, Department of Infectious Diseases, Imperial College London, London, UK
| | - A Shah
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, UK
| |
Collapse
|
25
|
van der Torre MH, Shen H, Rautemaa-Richardson R, Richardson MD, Novak-Frazer L. Molecular Epidemiology of Aspergillus fumigatus in Chronic Pulmonary Aspergillosis Patients. J Fungi (Basel) 2021; 7:jof7020152. [PMID: 33672698 PMCID: PMC7924367 DOI: 10.3390/jof7020152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/17/2022] Open
Abstract
Molecular fungal genotyping techniques developed and employed for epidemiological studies have understandably concentrated on establishing the genetic diversity of Aspergillus fumigatus in invasive aspergillosis due to its severity, the urgency for treatment, and the need to demonstrate possible sources. Some early studies suggested that these strains were phenotypically, if not genotypically, different from others. However, with improved discrimination and evaluations, incorporating environmental as well as clinical isolates from other Aspergillus conditions (e.g., chronic pulmonary aspergillosis and cystic fibrosis), this premise is no longer upheld. Moreover, with the onset of increased global triazole resistance, there has been a concerted effort to incorporate resistance profiling into genotyping studies and the realisation that the wider population of non-immunocompromised aspergillosis patients are at risk. This review summarises the developments in molecular genotyping studies that incorporate resistance profiling with attention to chronic pulmonary aspergillosis and an example of our UK experience.
Collapse
Affiliation(s)
- Mireille H. van der Torre
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Hongwei Shen
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Riina Rautemaa-Richardson
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
- Department of Infectious Diseases, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Malcolm D. Richardson
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Lilyann Novak-Frazer
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK; (M.H.v.d.T.); (R.R.-R.); (M.D.R.)
- Division of Infection, Inflammation and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
- Correspondence: ; Tel.: +44-161-2915856
| |
Collapse
|
26
|
Guegan H, Prat E, Robert-Gangneux F, Gangneux JP. Azole Resistance in Aspergillus fumigatus: A Five-Year Follow Up Experience in a Tertiary Hospital With a Special Focus on Cystic Fibrosis. Front Cell Infect Microbiol 2021; 10:613774. [PMID: 33680981 PMCID: PMC7930226 DOI: 10.3389/fcimb.2020.613774] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/24/2020] [Indexed: 12/17/2022] Open
Abstract
Azole-resistant Aspergillus fumigatus (ARAf) has emerged worldwide during the last decades. Drug pressure after long term treatments of chronically infected patients and the propagation of environmental clones selected under the pressure of imidazoles fungicides used in agriculture and farming both account for this emergence. The objectives of this study were to determine the rate of azole resistance in Aspergillus fumigatus during a 5-year period, taking into account (i) differences between underlying diseases of the patients treated, (ii) cross-resistance between azoles, and (iii) focusing on the 5-year evolution of our center’s cystic fibrosis cohort. Overall, the rates of voriconazole (VRC)-resistant and itraconazole (ITC)-resistant A. fumigatus isolates were 4.1% (38/927) and 14.5% (95/656), respectively, corresponding to 21/426 (4.9%) and 44/308 (14.3%) patients, respectively. Regarding cross-resistance, among VRC-R isolates tested for ITC, nearly all were R (20/21;95%), compared to only 27% (20/74) of VRC-R among ITC-R isolates. The level of azole resistance remained somewhat stable over years but greatly varied according to the azole drug, patient origin, and clinical setting. Whereas azole resistance during invasive aspergillosis was very scarce, patients with cystic fibrosis were infected with multiple strains and presented the highest rate of resistance: 5% (27/539) isolates were VRC-R and 17.9% (78/436) were ITC-R. These results underline that the interpretation of the azole resistance level in Aspergilllus fumigatus in a routine setting may consider the huge variability depending on the azole drug, the clinical setting, the patient background and the type of infection.
Collapse
Affiliation(s)
- Hélène Guegan
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Univ Rennes, CHU, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Emilie Prat
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Florence Robert-Gangneux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Univ Rennes, CHU, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Jean-Pierre Gangneux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Univ Rennes, CHU, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| |
Collapse
|
27
|
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.
Collapse
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.)
| |
Collapse
|
28
|
Engel T, Verweij PE, van den Heuvel J, Wangmo D, Zhang J, Debets AJM, Snelders E. Parasexual recombination enables Aspergillus fumigatus to persist in cystic fibrosis. ERJ Open Res 2020; 6:00020-2020. [PMID: 33313304 PMCID: PMC7720686 DOI: 10.1183/23120541.00020-2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 09/15/2020] [Indexed: 01/13/2023] Open
Abstract
Aspergillus fumigatus is a saprobic fungus that causes a range of pulmonary diseases, some of which are characterised by fungal persistence such as is observed in cystic fibrosis (CF) patients. Creation of genetic variation is critical for A. fumigatus to adapt to the lung environment, but biofilm formation, especially in CF patients, may preclude mutational supply in A. fumigatus due to its confinement to the hyphal morphotype. We tested our hypothesis that genetic variation is created through parasexual recombination in chronic biofilms by phenotypic and genetic analysis of A. fumigatus isolates cultured from different origins. As diploids are the hallmark of parasex, we screened 799 A. fumigatus isolates obtained from patients with CF, chronic pulmonary lung disease and acute invasive aspergillosis, and from the environment for spore size. Benomyl sensitivity, nuclear content measurements through fluorescence-activated cell sorting and scanning electron microscopy were used to confirm the diploid state of large size spores. Whole genome sequencing was used to characterise diploid-associated genetic variation. We identified 11 diploids in isolates recovered from six of 11 (55%) CF patients and from one of 24 (4%) chronic aspergillosis patients, but not in 368 isolates from patients with acute Aspergillus infection and the environment. Diploid formation was associated with accumulation of mutations and variable haploid offspring including a voriconazole-resistant isolate. Parasexual recombination allows A. fumigatus to adapt and persist in CF patients, and plays a role in azole resistance development. Our findings are highly significant for understanding the genetics and biology of A. fumigatus in the human lung. Aspergillus fumigatus can undergo parasexual recombination in the lungs of chronically colonised individuals. This is highly relevant, as the parasexual cycle can facilitate genetic variation and, consequently, in-host adaptation.https://bit.ly/3kAtrXd
Collapse
Affiliation(s)
- Tobias Engel
- Radboud University Medical Center, Nijmegen, the Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
| | - Paul E Verweij
- Radboud University Medical Center, Nijmegen, the Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
| | - Joost van den Heuvel
- Laboratory of Genetics, Wageningen University and Research, Wageningen, the Netherlands
| | - Dechen Wangmo
- Laboratory of Genetics, Wageningen University and Research, Wageningen, the Netherlands
| | - Jianhua Zhang
- Laboratory of Genetics, Wageningen University and Research, Wageningen, the Netherlands
| | - Alfons J M Debets
- Laboratory of Genetics, Wageningen University and Research, Wageningen, the Netherlands
| | - Eveline Snelders
- Laboratory of Genetics, Wageningen University and Research, Wageningen, the Netherlands
| |
Collapse
|
29
|
Risum M, Hare RK, Gertsen JB, Kristensen L, Johansen HK, Helweg-Larsen J, Abou-Chakra N, Pressler T, Skov M, Jensen-Fangel S, Arendrup MC. Azole-Resistant Aspergillus fumigatus Among Danish Cystic Fibrosis Patients: Increasing Prevalence and Dominance of TR 34/L98H. Front Microbiol 2020; 11:1850. [PMID: 32903400 PMCID: PMC7438406 DOI: 10.3389/fmicb.2020.01850] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
Azole-resistant (azole-R) Aspergillus is an increasing challenge worldwide. Patients with cystic fibrosis (CF) are at risk of Aspergillus colonization and disease due to a favorable lung environment for microorganisms. We performed a nationwide study in 2018 of azole-non-susceptible Aspergillus in CF patients and compared with data from two prior studies. All airway samples with mold isolates from patients monitored at the two CF centers in Denmark (RH, Jan-Sept and AUH, Jan-Jun) were included. Classical species identification (morphology and thermo-tolerance) was performed and MALDI-TOF/β-tubulin sequencing was performed if needed. Susceptibility was determined using EUCAST E.Def 10.1, and E.Def 9.3.2. cyp51A sequencing and STRAf genotyping were performed for azole-non-susceptible isolates and relevant sequential isolates. In total, 340 mold isolates from 159 CF patients were obtained. The most frequent species were Aspergillus fumigatus (266/340, 78.2%) and Aspergillus terreus (26/340, 7.6%). Azole-R A. fumigatus was cultured from 7.3% (10/137) of patients, including 9.5% (9/95) of patients at RH and 2.4% at AUH (1/42), respectively. In a 10-year perspective, azole-non-susceptibility increased numerically among patients at RH (10.5% in 2018 vs 4.5% in 2007-2009). Cyp51A resistance mechanisms were found in nine azole-R A. fumigatus from eight CF patients. Five were of environmental origin (TR34/L98H), three were human medicine-driven (two M220K and one M220R), and one was novel (TR34 3/L98H) and found in a patient who also harbored a TR34/L98H isolate. STRAf genotyping identified 27 unique genotypes among 45 isolates and ≥2 genotypes in 8 of 12 patients. This included one patient carrying two unique TR34/L98H isolates, a rare phenomenon. Genotyping of sequential TR34 3/L98H and TR34/L98H isolates from the same patient showed only minor differences in 1/9 markers. Finally, azole-R A. terreus was found in three patients including two with Cyp51A alterations (M217I and G51A, respectively). Azole-R A. fumigatus is increasing among CF patients in Denmark with the environmentally associated resistance TR34/L98H mechanism being dominant. Mixed infections (wildtype/non-wildtype and several non-wildtypes) and a case of potential additional tandem repeat acquisition in vivo were found. However, similar genotypes were identified from another patient (and outside this study), potentially suggesting a predominant TR34/L98H clone in DK. These findings suggest an increasing prevalence and complexity of azole resistance in A. fumigatus.
Collapse
Affiliation(s)
- Malene Risum
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Jan Berg Gertsen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Kristensen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helle Krogh Johansen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Tacjana Pressler
- Cystic Fibrosis Center Copenhagen, Department of Pediatrics and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Skov
- Cystic Fibrosis Center Copenhagen, Department of Pediatrics and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
30
|
Chadeganipour M, Mohammadi R. A 9-Year Experience of Aspergillus Infections from Isfahan, Iran. Infect Drug Resist 2020; 13:2301-2309. [PMID: 32765006 PMCID: PMC7368557 DOI: 10.2147/idr.s259162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/25/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose Aspergillosis is an important fungal disease affecting millions of individuals worldwide. The genus of Aspergillus consist of various complexes, causing a wide spectrum of diseases from superficial infections in immunocompetent hosts to life-threatening disseminated infections among immunocompromised patients. This study aimed to identify Aspergillus species by phenotypic (total isolates) and molecular tests (35 isolates), obtained from patients in Isfahan (the third-largest city of Iran) between 2010 and 2018, and determine the susceptibility of 35 clinical isolates to itraconazole (ITR), amphotericin-B (AMB), and voriconazole (VOR). Patients and Methods Based on clinical signs, a total of 2385 suspected cases were included in this retrospective study from January 2010 to December 2018. Direct microscopic examination with potassium hydroxide, sabouraud dextrose agar with chloramphenicol, and czapekdox agar media was applied to identify etiologic agents. Thirty-five Aspergillus species collected from January 2016 to December 2018 were identified by PCR-sequencing of ITS1-5.8SrDNA-ITS2 region, and their susceptibility to ITR, AMB, and VOR was determined using E-test. Results Based on direct microscopy and positive culture, 132 out of 2385 suspected cases had Aspergillus infection (5.5%). Fifty-four patients were male, and 78 patients were female. Patients in the age groups of 41–50 and 21–30 years had the highest and lowest frequencies, respectively. Aspergillus flavus/oryzae (n=54), A. fumigatus (n=24), A. niger (n=15), and A. terreus (n=12) were the most prevalent Aspergillus species, respectively. Among 35 Aspergillus species, the MIC ranges of AMB, ITR, and VOR for A. flavus/oryzae, A. niger, and A. terreus were (0.5–4 μg/mL; 0.5–16 μg/mL; 0.25–8 μg/mL), (1 μg/mL, 1 μg/mL, 1 μg/mL), and (4–4 μg/mL, 0.5–1 μg/mL, 0.5–1 μg/mL), respectively. Conclusion Aspergillus infections have a wide spectrum of clinical manifestations and often occur in immunocompromised patients. Accurate identification at the species level is essential since the emergence of cryptic species is connected to different patterns of AFST that affect patient treatment outcomes. Azole-resistant Aspergillus spp. is a global concern, and the detection of the route of resistance is pivotal to prevent and control infection.
Collapse
Affiliation(s)
- Mostafa Chadeganipour
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
31
|
Oral prevalence and antifungal susceptibility of Candida species in cystic fibrosis patients. Arch Oral Biol 2020; 116:104772. [PMID: 32474212 DOI: 10.1016/j.archoralbio.2020.104772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed at assessing the oral prevalence ofCandida species in cystic fibrosis patients and the antifungal susceptibility of the isolates. DESIGN One hundred patients aged 3-20 years old were included in the study and were divided into three groups: G1 (low severity disease): 25 cystic fibrosis patients with Shwachman-Kulczycki score (SK) between 100 and 71; G2 (high severity disease): 25 cystic fibrosis patients with SK score under 40; and G3 (control): 50 healthy patients age- and gender-matched to cystic fibrosis patients. Stimulated saliva samples were collected and the oral fungal concentrations were assessed. Isolates were identified by phenotypic and genotypic tests. Antifungal susceptibilities to amphotericin B, flucytosine and fluconazole were determined by CLSI methodology. Fungal counts were compared by Kruskal Wallis and Dunn's test (5%). RESULTS A total of 68 % of Group 1, 80 % of Group 2, and 44 % of controls yielded positive Candida cultures. Oral concentrations of fungi were significantly higher in cystic fibrosis patients in relation to the control group (p < 0.0005). No significant difference was observed between low and high severity cystic fibrosis groups (p > 0.05). C. albicans was most frequently isolated species in all groups. Higher variability of Candida species was observed in the control group. C. dubliniensis and C. tropicalis were only detected among cystic fibrosis groups. All the isolates were susceptible to flucytosine and fluconazole. CONCLUSIONS Patients with cystic fibrosis were more frequently colonized by Candida species and showed higher oral fungal burden. No antifungal resistant isolates were detected.
Collapse
|
32
|
High-Frequency Direct Detection of Triazole Resistance in Aspergillus fumigatus from Patients with Chronic Pulmonary Fungal Diseases in India. J Fungi (Basel) 2020; 6:jof6020067. [PMID: 32443672 PMCID: PMC7345705 DOI: 10.3390/jof6020067] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Aspergillosis due to azole-resistant Aspergillus fumigatus is a worldwide problem with major therapeutic implications. In patients with invasive aspergillosis, a low yield of fungal cultures results in underestimation of azole resistance. To detect azole resistance in A. fumigatus, we applied the AsperGenius® Resistance multiplex real-time polymerase chain reaction (PCR) assay to detect TR34/L98H, and TR46/T289A/Y121F mutations and the AsperGenius® G54/M220 RUO PCR assay to detect G54/M220 mutations directly in bronchoalveolar lavage (BAL) samples of 160 patients with chronic respiratory diseases in Delhi, India. Only 23% of samples were culture-positive compared to 83% positivity by A. fumigatus species PCR highlighting concerns about the low yield of cultures. Notably, 25% of BAL samples (33/160 patients) had azole resistance-associated mutation by direct detection using PCR assay. Detection of resistance-associated mutations was found mainly in 59% and 43% patients with chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA), respectively. Overall, a G54 mutation, conferring itraconazole resistance, was the predominant finding in 87.5% and 67% of patients with CPA and ABPA, respectively. In culture-negative, PCR-positive samples, we detected azole-resistant mutations in 34% of BAL samples. Azole resistance in chronic Aspergillus diseases remains undiagnosed, warranting standardization of respiratory culture and inclusion of rapid techniques to detect resistance markers directly in respiratory samples.
Collapse
|
33
|
Beekman CN, Ene IV. Short-term evolution strategies for host adaptation and drug escape in human fungal pathogens. PLoS Pathog 2020; 16:e1008519. [PMID: 32407384 PMCID: PMC7224449 DOI: 10.1371/journal.ppat.1008519] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Chapman N. Beekman
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, United States of America
| | - Iuliana V. Ene
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| |
Collapse
|
34
|
Prasad KT, Muthu V, Sehgal IS, Dhooria S, Singh P, Sachdeva MUS, Chakrabarti A, Aggarwal AN, Agarwal R. The utility of the basophil activation test in differentiating asthmatic subjects with and without allergic bronchopulmonary aspergillosis. Mycoses 2020; 63:588-595. [PMID: 32227377 DOI: 10.1111/myc.13081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/18/2020] [Accepted: 03/21/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Asthma with Aspergillus sensitisation (ASA) and allergic bronchopulmonary aspergillosis (ABPA) are distinct clinical conditions, with different management strategies. OBJECTIVE To determine the utility of the basophil activation test (BAT) in differentiating between asthmatic subjects with and without ABPA. METHODS We performed the BAT using flow cytometry for the basophil activation markers CD63, CD193, and CD203c in consecutive subjects with unsensitised asthma (UA), ASA and ABPA. The BAT was performed unstimulated (baseline) and after stimulation with peanut and Aspergillus fumigatus antigens. Stimulation indices (SI) for CD63, CD193 and CD203c were compared between the study groups. RESULTS We enrolled 82 (UA [n = 25], ASA [n = 25], ABPA [n = 32]) subjects. Only those subjects without peanut sensitisation on serological testing were included in further analyses (n = 50). The receiver operating characteristic analysis of SI for CD63, CD193 and CD203c for the diagnosis of ABPA vs other asthmatics (UA and ASA) showed an area under the curve of 0.577, 0.317 and 0.625, respectively. The SI CD203c at a cut-off of 1.2 (sensitivity 50.0%, specificity 88.9%) and the SI CD63 at a cut-off of 1.3 (sensitivity 42.9%, specificity 91.7%) also had limited utility for the diagnosis of ABPA. CONCLUSION The BAT cannot be used as a diagnostic test in distinguishing ABPA complicating asthma from ASA and UA.
Collapse
Affiliation(s)
- Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pawan Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Mycology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
35
|
Tsuchido Y, Tanaka M, Nakano S, Yamamoto M, Matsumura Y, Nagao M. Prospective multicenter surveillance of clinically isolated Aspergillus species revealed azole-resistant Aspergillus fumigatus isolates with TR34/L98H mutation in the Kyoto and Shiga regions of Japan. Med Mycol 2020; 57:997-1003. [PMID: 30690480 DOI: 10.1093/mmy/myz003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/28/2018] [Accepted: 01/10/2019] [Indexed: 11/14/2022] Open
Abstract
The prevalence of azole-resistant Aspergillus fumigatus (ARAF) in Japan is unclear. We aimed to investigate the epidemiology of clinically isolated Aspergillus species and the frequency of azole resistance in Aspergillus species, particularly Aspergillus fumigatus, in the Kyoto and Shiga regions of Japan. Strains of clinically isolated Aspergillus species were prospectively collected from nine acute care hospitals. Species identification was performed by DNA sequence analysis, and all strains were subjected to antifungal susceptibility testing. Sequencing of the Aspergillus cyp51A gene and promoter region and genotyping by short tandem repeats were performed for ARAF isolates. A total of 149 strains were collected, and 130 strains were included for the subsequent analysis after the exclusion of duplicate isolates. The most commonly isolated species was Aspergillus fumigatus, accounting for 43.1% (56 isolates) overall, and seven (12.7%) of 55 strains of A. fumigatus were azole-resistant. Azole-resistance of other Aspergillus species were also found that two (22.2%) of nine strains of A. tubingensis and two (28.6%) of seven strains of A. flavus were azole-resistant. DNA sequence analysis of the ARAF strains revealed that two carried the cyp51A TR34/L98H mutation, one carried G448S, one carried M220I, and three had no relevant mutations (wild type). Genotyping and phylogenetic analyses showed that the TR34/L98H strains were clustered with the strains from the Netherlands and France. These data suggest the emergence of ARAF with TR34/L98H in Japan, and continuous surveillance will be important to identify trends in resistance.
Collapse
Affiliation(s)
- Yasuhiro Tsuchido
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michio Tanaka
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Nakano
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Yamamoto
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
36
|
Engel TGP, Erren E, Vanden Driessche KSJ, Melchers WJG, Reijers MH, Merkus P, Verweij PE. Aerosol Transmission of Aspergillus fumigatus in Cystic Fibrosis Patients in the Netherlands. Emerg Infect Dis 2019; 25:797-799. [PMID: 30882308 PMCID: PMC6433022 DOI: 10.3201/eid2504.181110] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We collected sputum samples and cough plates from 15 cystic fibrosis patients in the Netherlands who were colonized with Aspergillus fumigatus; we recovered A. fumigatus of the same genotype in cough aerosols and sputum samples from 2 patients. The belief that transmission of A. fumigatus from cystic fibrosis patients does not occur should be reconsidered.
Collapse
|
37
|
Seufert R, Sedlacek L, Kahl B, Hogardt M, Hamprecht A, Haase G, Gunzer F, Haas A, Grauling-Halama S, MacKenzie CR, Essig A, Stehling F, Sutharsan S, Dittmer S, Killengray D, Schmidt D, Eskandarian N, Steinmann E, Buer J, Hagen F, Meis JF, Rath PM, Steinmann J. Prevalence and characterization of azole-resistant Aspergillus fumigatus in patients with cystic fibrosis: a prospective multicentre study in Germany. J Antimicrob Chemother 2019; 73:2047-2053. [PMID: 29684150 DOI: 10.1093/jac/dky147] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/23/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives Aspergillus fumigatus is the most prevalent filamentous fungus in the respiratory tract of patients with cystic fibrosis (CF). The aim of this prospective multicentre study was to investigate the prevalence of azole-resistant A. fumigatus (ARAF) in respiratory secretions from CF patients across Germany and to characterize ARAF isolates by phenotypic and molecular methods. Methods Twelve tertiary care centres from Germany participated in the study. In total, 2888 A. fumigatus isolates from 961 CF patients were screened for ARAF by using azole-containing agar plates. Antifungal susceptibility testing of isolates was performed by broth microdilution according to EUCAST guidelines. Analysis of mutations mediating resistance was performed using PCR and sequencing of the cyp51A gene. Furthermore, genotyping by microsatellite PCR was performed. Results Of a total of 2888 A. fumigatus isolates, 101 isolates from 51 CF patients were found to be azole resistant (prevalence per patient 5.3%). The Essen centre had the highest prevalence (9.1%) followed by Munich (7.8%), Münster (6.0%) and Hannover (5.2%). Most ARAF isolates (n = 89) carried the TR34/L98H mutation followed by eight G54E/R, one TR46/Y121F/T289A and one F219S mutation. In two isolates no mutation was found. Genotyping results showed no major clustering. Forty-five percent of CF patients with ARAF had previously received azole therapy. Conclusions This is the first multicentre study analysing the prevalence of ARAF isolates in German CF patients. Because of a resistance rate of up to 9%, susceptibility testing of A. fumigatus isolates from CF patients receiving antifungal treatment should be part of standard diagnostic work-up.
Collapse
Affiliation(s)
- R Seufert
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Nuremberg, Germany
| | - L Sedlacek
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - B Kahl
- Institute of Medical Microbiology, University Clinics Münster, Münster, Germany
| | - M Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - A Hamprecht
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - G Haase
- Clinical Laboratory and Diagnostic Services (LDZ), Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - F Gunzer
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - A Haas
- Max von Pettenkofer-Institute of Hygiene and Medical Microbiology, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - S Grauling-Halama
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - C R MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - A Essig
- Institute of Medical Microbiology and Hygiene, Ulm University Hospital, Ulm, Germany
| | - F Stehling
- Department of Pediatric Pulmonology and Sleep Medicine, University of Duisburg-Essen, Children's Hospital, Essen, Germany
| | - S Sutharsan
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - S Dittmer
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - D Killengray
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - D Schmidt
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - N Eskandarian
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - E Steinmann
- Institute for Experimental Virology, TWINCORE Centre for Experimental and Clinical Infection Research [a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI)], Hannover, Germany
- Department of Molecular and Medical Virology, Ruhr-University Bochum, Bochum, Germany
| | - J Buer
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - F Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Centre of Expertise in Mycology, Radboud University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P-M Rath
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - J Steinmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Nuremberg, Germany
| |
Collapse
|
38
|
cyp51A Mutations, Extrolite Profiles, and Antifungal Susceptibility in Clinical and Environmental Isolates of the Aspergillus viridinutans Species Complex. Antimicrob Agents Chemother 2019; 63:AAC.00632-19. [PMID: 31451501 PMCID: PMC6811395 DOI: 10.1128/aac.00632-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/16/2019] [Indexed: 02/06/2023] Open
Abstract
The past decade has seen an increase in aspergillosis in humans and animals due to Aspergillus viridinutans species complex members. Azole resistance is common to these infections, carrying a poor prognosis. cyp51A gene mutations are the main cause of acquired azole resistance in Aspergillus fumigatus. This study aimed to determine if the azole-resistant phenotype in A. viridinutans complex members is associated with cyp51A mutations or extrolite profiles. The past decade has seen an increase in aspergillosis in humans and animals due to Aspergillus viridinutans species complex members. Azole resistance is common to these infections, carrying a poor prognosis. cyp51A gene mutations are the main cause of acquired azole resistance in Aspergillus fumigatus. This study aimed to determine if the azole-resistant phenotype in A. viridinutans complex members is associated with cyp51A mutations or extrolite profiles. The cyp51A gene of clinical and environmental isolates was amplified using novel primers, antifungal susceptibility was tested using the Clinical and Laboratory Standards Institute methodology, and extrolite profiling was performed using agar plug extraction. Very high azole MICs were detected in 84% of the isolates (31/37). The MICs of the newer antifungals luliconazole and olorofim (F901318) were low for all isolates. cyp51A sequences revealed 113 nonsynonymous mutations compared to the sequence of wild-type A. fumigatus. M172A/V and D255G, previously associated with A. fumigatus azole resistance, were common among all isolates but were not correlated with azole MICs. Two environmental isolates with nonsusceptibility to itraconazole and high MICs of voriconazole and isavuconazole harbored G138C, previously associated with azole-resistant A. fumigatus. Some novel mutations were identified only among isolates with high azole MICs. However, cyp51A homology modeling did not cause a significant protein structure change for these mutations. There was no correlation between extrolite patterns and susceptibility. For A. viridinutans complex isolates, cyp51A mutations and the extrolites that they produced were not major causes of antifungal resistance. Luliconazole and olorofim show promise for treating azole-resistant infections caused by these cryptic species.
Collapse
|
39
|
Chen YC, Kuo SF, Wang HC, Wu CJ, Lin YS, Li WS, Lee CH. Azole resistance in Aspergillus species in Southern Taiwan: An epidemiological surveillance study. Mycoses 2019; 62:1174-1181. [PMID: 31549427 DOI: 10.1111/myc.13008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/11/2019] [Accepted: 09/19/2019] [Indexed: 12/01/2022]
Abstract
Poor clinical outcomes for invasive aspergillosis are associated with antifungal resistance. Performing antifungal susceptibility tests on clinically relevant Aspergillus isolates from patients and environmental regions with known azole resistance is recommended. The aim of the study was to assess the presence of azole resistance in clinical Aspergillus spp. isolates and those from hospital environments and farmlands within a 40 km radius of the hospital. Clinical Aspergillus spp. isolates were cultured, as well as environmental Aspergillus spp. isolates obtained from air samples. Samples were subcultured in azole-containing agar plates. Isolates with a positive screening test were subjected to YeastOne methods to determine their minimum inhibitory concentrations of antifungals. Resistance mechanisms were investigated in the azole-resistant Aspergillus spp. isolates. No azole-resistant clinical or environmental A flavus, A oryaze, A niger or A terreus isolates were found in the present study. All A fumigatus clinical isolates were azole-susceptible. Seven A fumigatus environmental isolates were associated with cyp51A mutations, including two that harboured TR34 /L98H mutations with S297T/F495I substitutions, two with TR34 /L98H mutations and three with TR46 /Y121F/T289A mutations. One of these isolates was collected from farmland, one was from A ward and five were from B ward. The proportion of azole-resistant A fumigatus was 10.2% (6/59) and 3.2% (1/31) in the hospital environments and the farmlands near the hospital, respectively. The results showed that azole-resistant A fumigatus existed within hospital environments. This emphasises the importance of periodic surveillance in hospital environments and monitoring for the emergence of azole-resistant A fumigatus clinical isolates.
Collapse
Affiliation(s)
- Yi-Chun Chen
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shu-Fang Kuo
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Chen Wang
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan
| | - Chi-Jung Wu
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Shiou Lin
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Sin Li
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Chang Gung University College of Medicine, Kaohsiung, Taiwan
| |
Collapse
|
40
|
Guinea J, Verweij PE, Meletiadis J, Mouton JW, Barchiesi F, Arendrup MC. How to: EUCAST recommendations on the screening procedure E.Def 10.1 for the detection of azole resistance in Aspergillus fumigatus isolates using four-well azole-containing agar plates. Clin Microbiol Infect 2019; 25:681-687. [PMID: 30268672 DOI: 10.1016/j.cmi.2018.09.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The emergence of azole-resistant Aspergillus fumigatus isolates is a matter of significant concern in Europe, with countries reporting resistance rates (which can be as high as 30%) in hospitalized patients. Consequently, the treatment guidelines in The Netherlands, the country with the highest documented prevalence of azole-resistant A. fumigatus, has just been revised to now recommend initial therapy with combination therapy until the susceptibility pattern is known. Therefore, susceptibility testing of clinically relevant isolates has been strongly recommended in the ESCMID-EFISG aspergillosis guidelines. Furthermore, mixed azole-susceptible and azole-resistant (isogenic as well as non-isogenic) infections have been reported to occur, which implies that colonies of clinical cultures may harbour various phenotypes of azole susceptibility. OBJECTIVES The EUCAST-AFST (European Committee on Antimicrobial Susceptibility Testing Subcommittee on Antifungal Susceptibility Testing) has released a new screening method document (E.Def 10.1) for the detection of azole-resistant A. fumigatus isolates and updated the QC tables for antifungal susceptibility testing with associated QC endpoints. This review described in detail how to perform the screening test. SOURCES This "How to document" is based on the EUCAST azole agar screening method document E.Def 10.1 and the QC tables for antifungal susceptibility testing document, v 2.0 (available at http://www.eucast.org/ast_of_fungi/qcafsttables/) CONTENTS: The method is based on the inoculation of azole-containing and azole-free agars and visual determination of fungal growth after one and two days of incubation. It can easily be implemented in routine laboratories of clinical microbiology and has been validated for simultaneous testing of up to five A. fumigatus colonies using itraconazole and voriconazole (mandatory), and posaconazole (optional). IMPLICATIONS This easy-to-use screening procedure for the detection of azole resistance in clinical A. fumigatus isolates will allow rapid testing in the daily routine of the microbiology laboratory and thus facilitate earlier appropriate therapy.
Collapse
Affiliation(s)
- J Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de enfermedades respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
| | - J Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - J W Mouton
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - F Barchiesi
- Dipartimento di Scienze Biomediche e Sanità Pubblica, Clinica Malattie Infettive, Università Politecnica delle Marche, Ancona, Italy
| | - M C Arendrup
- Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark.
| |
Collapse
|
41
|
Delfino E, Del Puente F, Briano F, Sepulcri C, Giacobbe DR. Respiratory Fungal Diseases in Adult Patients With Cystic Fibrosis. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2019; 13:1179548419849939. [PMID: 31205434 PMCID: PMC6537484 DOI: 10.1177/1179548419849939] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/18/2019] [Indexed: 12/20/2022]
Abstract
Clinical manifestations of respiratory fungal diseases in adult cystic fibrosis (CF) patients are very heterogeneous, ranging from asymptomatic colonization to chronic infections, allergic disorders, or invasive diseases in immunosuppressed CF patients after lung transplantation. In this narrative review, mainly addressed to clinicians without expertise in CF who may nonetheless encounter adult CF patients presenting with acute and chronic respiratory syndromes, we briefly summarize the most representative clinical aspects of respiratory fungal diseases in adult CF patients.
Collapse
Affiliation(s)
- Emanuele Delfino
- Clinica Malattie Infettive e Tropicali, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Filippo Del Puente
- Clinica Malattie Infettive e Tropicali, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Federica Briano
- Clinica Malattie Infettive e Tropicali, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Chiara Sepulcri
- Clinica Malattie Infettive e Tropicali, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Clinica Malattie Infettive e Tropicali, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| |
Collapse
|
42
|
Nasri E, Fakhim H, Vaezi A, Khalilzadeh S, Ahangarkani F, Laal Kargar M, Abtahian Z, Badali H. Airway colonisation by Candida and Aspergillus species in Iranian cystic fibrosis patients. Mycoses 2019; 62:434-440. [PMID: 30681747 DOI: 10.1111/myc.12898] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 12/20/2022]
Abstract
Cystic fibrosis (CF) is associated with increased rates of morbidity and mortality due to fungal and bacterial colonisation of the airways or respiratory infections. The prevalence of fungi in Iranian CF population has been underestimated. Therefore, the current study was conducted to define the frequency of fungi in respiratory specimens obtained from Iranian CF patients based on conventional and molecular assays. Furthermore, in vitro antifungal susceptibility testing was performed on the obtained isolates according to the guidelines from the Clinical and Laboratory Standards Institute. A cohort of 42 CF patients, including 29 males and 13 females, were categorised according to the referenced diagnostic criteria. Candida albicans (n = 24, 80%), C. dubliniensis (n = 2, 6.6%), C. parapsilosis (n = 2, 6.6%), C. tropicalis (n = 1, 3.3%), C. glabrata (n = 1, 3.3%) and Meyerozyma caribbica (n = 1, 3.3%) were isolated from 73.8% of the CF patients. Aspergillus terreus (n = 3, 42.8%) was identified as the most common Aspergillus species, followed by A. fumigatus (n = 2, 28.5%), A. oryzae (n = 1, 14.2%) and A. flavus (n = 1, 14.2%). Bacterial and fungal co-colonisation was detected in 7 (16.6%) and 22 (52.3%) samples that were positive for Aspergillus and Candida species, respectively. However, Scedosporium species and Exophiala dermatitidis never were detected. In terms of geometric mean (GM) minimum inhibitory concentrations (MICs), posaconazole (0.018 μg/mL) and caspofungin (0.083 μg/mL) exhibited the highest antifungal activities against all Candida species. In addition, posaconazole exhibited the lowest MIC range (0.008-0.063 μg/mL) against all Aspergillus species, followed by caspofungin (0.016-0.125 μg/mL) and voriconazole (0.125-0.25 μg/mL). To conclude, it is essential to adopt a consistent method for the implementation of primary diagnosis and determination of treatment regimen for the CF patients. However, further studies are still needed to better define the epidemiology of fungal organisms in CF patients from the Middle East and the clinical significance of their isolation.
Collapse
Affiliation(s)
- Elahe Nasri
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Fakhim
- Department of Medical Parasitology and Mycology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.,Cellular and Molecular Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Afsane Vaezi
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Soheila Khalilzadeh
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Ahangarkani
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Melika Laal Kargar
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zahra Abtahian
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Badali
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Invasive Fungi Research Center, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|
43
|
Zhang J, Snelders EE, Zwaan BJ, Schoustra SE, Kuijper EJ, Arendrup MC, Melchers WJG, Verweij PE, Debets AJM. Relevance of heterokaryosis for adaptation and azole-resistance development in Aspergillus fumigatus. Proc Biol Sci 2019; 286:20182886. [PMID: 30963936 PMCID: PMC6408600 DOI: 10.1098/rspb.2018.2886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/21/2019] [Indexed: 12/27/2022] Open
Abstract
Aspergillus fumigatus causes a range of diseases in humans, some of which are characterized by fungal persistence. Aspergillus fumigatus, being a generalist saprotroph, may initially establish lung colonization due to its physiological versatility and subsequently adapt through genetic changes to the human lung environment and antifungal treatments. Human lung-adapted genotypes can arise by spontaneous mutation and/or recombination and subsequent selection of the fittest genotypes. Sexual and asexual spores are considered crucial contributors to the genetic diversity and adaptive potential of aspergilli by recombination and mutation supply, respectively. However, in certain Aspergillus diseases, such as cystic fibrosis and chronic pulmonary aspergillosis, A. fumigatus may not sporulate but persist as a network of fungal mycelium. During azole therapy, such mycelia may develop patient-acquired resistance and become heterokaryotic by mutations in one of the nuclei. We investigated the relevance of heterokaryosis for azole-resistance development in A. fumigatus. We found evidence for heterokaryosis of A. fumigatus in patients with chronic Aspergillus diseases. Mycelium from patient-tissue biopsies segregated different homokaryons, from which heterokaryons could be reconstructed. Whereas all variant homokaryons recovered from the same patient were capable of forming a heterokaryon, those from different patients were heterokaryon-incompatible. We furthermore compared heterokaryons and heterozygous diploids constructed from environmental isolates with different levels of azole resistance. When exposed to azole, the heterokaryons revealed remarkable shifts in their nuclear ratio, and the resistance level of heterokaryons exceeded that of the corresponding heterozygous diploids.
Collapse
Affiliation(s)
- Jianhua Zhang
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Eveline E. Snelders
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Bas J. Zwaan
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Sijmen E. Schoustra
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| | - Ed J. Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maiken C. Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Willem J. G. Melchers
- Department of Medical Microbiology and Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology and Centre of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
| | - Alfons J. M. Debets
- Laboratory of Genetics, Wageningen University, Droevendaalsesteeg 1, 6708 PB Wageningen, The Netherlands
| |
Collapse
|
44
|
Engel TGP, Slabbers L, de Jong C, Melchers WJG, Hagen F, Verweij PE, Merkus P, Meis JF. Prevalence and diversity of filamentous fungi in the airways of cystic fibrosis patients - A Dutch, multicentre study. J Cyst Fibros 2018; 18:221-226. [PMID: 30514613 DOI: 10.1016/j.jcf.2018.11.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 11/14/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Progressive lung injury in Cystic Fibrosis (CF) patients can lead to chronic colonization with bacteria and fungi. Fungal colonization is obtained from the environment which necessitates locally performed epidemiology studies. We prospectively analyzed respiratory samples of CF patients during a 3-year period, using a uniform fungal culture protocol, focusing on filamentous fungi and azole resistance in Aspergillus fumigatus. METHODS Over a 3-year period, all respiratory specimens collected from CF patients in 5 Dutch CF centers, were analyzed. Samples were inoculated onto the fungal culture media Sabouraud dextrose agar (SDA) and Medium B+. All fungal isolates were collected and identified in one centre, using Amplified Fragment Length Polymorphism (AFLP) fingerprinting, rDNA PCR and ITS, calmodulin and β-tubulin sequencing. Azole resistance was assessed for all A. fumigatus using a qPCR assay followed by phenotypic confirmation. RESULTS Filamentous fungi were recovered from 699 patients from at least one respiratory sample, corresponding with 3787 cultured fungal species. A. fumigatus was cultured most often with a mean prevalence of 31.7%, followed by Penicillium species (12.6%), non-fumigatus Aspergillus species (5.6%), Scedosporium species (4.5%) and Exophiala dermatitidis and Cladosporium species (1.1% each). In total 107 different fungal species were identified, with 39 Penicillium species and 15 Aspergillus species. Azole resistance frequency in A. fumigatus was 7.1%, with TR34/L98H being the dominant resistance mechanism. CONCLUSION A vast diversity of filamentous fungi was demonstrated, dominated by Aspergillus and Penicillium species. We observed a mean azole resistance prevalence of 7.1% of A. fumigatus culture positive patients.
Collapse
Affiliation(s)
- Tobias G P Engel
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands; Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.
| | - Lydie Slabbers
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carmen de Jong
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands; Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands; Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Peter Merkus
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacques F Meis
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | | |
Collapse
|
45
|
Tracy MC, Moss RB. The myriad challenges of respiratory fungal infection in cystic fibrosis. Pediatr Pulmonol 2018; 53:S75-S85. [PMID: 29992775 DOI: 10.1002/ppul.24126] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/21/2018] [Indexed: 12/27/2022]
Abstract
Fungal infection in cystic fibrosis (CF) is a recognized challenge, with many areas requiring further investigation. Consensus definitions exist for allergic bronchopulmonary aspergillus in CF, but the full scope of clinically relevant non-allergic fungal disease in CF-asymptomatic colonization, transient or chronic infection localized to endobronchial mucus plugs or airway tissue, and invasive disease-is yet to be clearly defined. Recent advances in mycological culture and non-culture identification have expanded the list of both potential pathogens and community commensals in the lower respiratory tract. Here we aim to outline the current understanding of fungal presence in the CF respiratory tract, risk factors for acquiring fungi, host-pathogen interactions that influence the role of fungi from bystander to pathogen, advances in the diagnostic approaches to isolating and identifying fungi in CF respiratory samples, challenges of classifying clinical phenotypes of CF patients with fungi, and current treatment approaches. Development and validation of biomarkers characteristic of different fungal clinical phenotypes, and controlled trials of antifungal agents in well-characterized target populations, remain central challenges to surmount and goals to be achieved.
Collapse
Affiliation(s)
- Michael C Tracy
- Center for Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Richard B Moss
- Center for Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| |
Collapse
|
46
|
Delhaes L, Touati K, Faure-Cognet O, Cornet M, Botterel F, Dannaoui E, Morio F, Le Pape P, Grenouillet F, Favennec L, Le Gal S, Nevez G, Duhamel A, Borman A, Saegeman V, Lagrou K, Gomez E, Carro ML, Canton R, Campana S, Buzina W, Chen S, Meyer W, Roilides E, Simitsopoulou M, Manso E, Cariani L, Biffi A, Fiscarelli E, Ricciotti G, Pihet M, Bouchara JP. Prevalence, geographic risk factor, and development of a standardized protocol for fungal isolation in cystic fibrosis: Results from the international prospective study "MFIP". J Cyst Fibros 2018; 18:212-220. [PMID: 30348610 DOI: 10.1016/j.jcf.2018.10.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/07/2018] [Accepted: 10/01/2018] [Indexed: 01/18/2023]
Affiliation(s)
| | - Kada Touati
- University & CHU of Lille, F-59000 Lille, France
| | - Odile Faure-Cognet
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Muriel Cornet
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | | | | | | | | | | | | | | | | | | | | | - Veroniek Saegeman
- University of Leuven, National Reference center for Mycosis, Belgium
| | - Katrien Lagrou
- University of Leuven, National Reference center for Mycosis, Belgium
| | - Elia Gomez
- Hosital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Madrid, Spain
| | - Maiz-Luis Carro
- Hosital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Madrid, Spain
| | - Rafael Canton
- Hosital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Madrid, Spain
| | | | | | - Sharon Chen
- Molecular Mycology Research Laboratory, Marie Bashir Institute for Biosecurity and Emerging Infections, University of Sydney, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Marie Bashir Institute for Biosecurity and Emerging Infections, University of Sydney, Australia
| | | | | | | | - Lisa Cariani
- Microbiology and Cystic Fibrosis Microbiology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Italy
| | - Arianna Biffi
- Microbiology and Cystic Fibrosis Microbiology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Italy
| | | | | | | | | |
Collapse
|
47
|
Güngör Ö, Sampaio-Maia B, Amorim A, Araujo R, Erturan Z. Determination of Azole Resistance and TR 34/L98H Mutations in Isolates of Aspergillus Section Fumigati from Turkish Cystic Fibrosis Patients. Mycopathologia 2018; 183:913-920. [PMID: 30187246 DOI: 10.1007/s11046-018-0297-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/24/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Aspergillus fumigatus is the species section Fumigati most frequently isolated from the respiratory tract of cystic fibrosis (CF) patients. Recent studies suggest that mutations in the Cyp51 gene, particularly TR34/L98H, are responsible for azole resistance. OBJECTIVES AND METHODS The focus of this study was on section Fumigati isolates isolated from the respiratory tract samples of CF patients. More specifically, the goal was to detect A. fumigatus isolates, test their antifungal susceptibility to itraconazole, voriconazole and posaconazole, and finally determine the presence of TR34/L98H and other mutations in the isolates Cyp51A gene. RESULTS AND CONCLUSIONS A set of 31 isolates of Aspergillus section Fumigati were obtained from the sputum samples of 6 CF patients and subsequently identified to species level by microsatellite genotyping. All isolates were determined as A. fumigatus and involved 14 different genotypes. The minimal inhibitory concentrations to the three azoles were determined by the E-test method, and the Cyp51A gene was sequenced. One of the genotypes was found to be resistant to all azoles but no mutations were detected in the Cyp51A gene, especially the TR34/L98H mutation. Therefore, mutations in genes other than Cyp51A or other distinct mechanisms may be responsible for this reported multiazole resistance found in a Turkish CF patient.
Collapse
Affiliation(s)
- Özge Güngör
- Istanbul Medical Faculty, Department of Medical Microbiology, Istanbul University, 34093, Capa, Istanbul, Turkey.
| | - Benedita Sampaio-Maia
- Faculty of Dental Medicine, University of Porto, Porto, Portugal
- INEB, Instituto Nacional de Engenharia Biomédica da Universidade do Porto, Porto, Portugal
- i3S, Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Antonio Amorim
- i3S, Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Faculdade de Ciências, Universidade do Porto, Porto, Portugal
| | - Ricardo Araujo
- i3S, Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
- Department of Medical Biotechnology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Zayre Erturan
- Istanbul Medical Faculty, Department of Medical Microbiology, Istanbul University, 34093, Capa, Istanbul, Turkey
| |
Collapse
|
48
|
High prevalence of triazole resistance in clinical Aspergillus fumigatus isolates in a specialist cardiothoracic centre. Int J Antimicrob Agents 2018; 52:637-642. [PMID: 30103005 DOI: 10.1016/j.ijantimicag.2018.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/10/2018] [Accepted: 08/04/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the prevalence of triazole-resistant Aspergillus fumigatus and common molecular cyp51A polymorphisms amongst clinical isolates in a specialised cardiothoracic centre in London, UK. METHODS All A. fumigatus isolates were prospectively analysed from April 2014 to March 2016. Isolates were screened with a four-well VIPcheck™ plate to assess triazole susceptibility. Resistance was confirmed with a standard microbroth dilution method according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. Triazole-resistant A. fumigatus isolates were subjected to a mixed-format real time polymerase chain reaction (RT-PCR) assay (AsperGenius®) to detect common cyp51A alterations. RESULTS We identified 167 clinical A. fumigatus isolates from 135 patients. Resistance to at least one azole antifungal drug was confirmed in 22/167 (13.2%) of isolates from 18/135 (13.3%) patients, including 12/74 (16.2%) patients with cystic fibrosis (CF). The highest detection rate of azole-resistant A. fumigatus was among the 11- to 20-y age group. All triazole-resistant isolates (n = 22) were resistant to itraconazole, 18 showed cross-resistance to posaconazole and 10 displayed reduced susceptibility to voriconazole. No pan-azole-resistant A. fumigatus was identified. TR34/L98H was identified in 6/22 (27.3%) of azole-resistant isolates and detectable in 5/12 (42%) patients with CF. CONCLUSIONS In our specialist cardiothoracic centre, the prevalence of triazole-resistant A. fumigatus is alarmingly high (13.2%). The majority of azole-resistant isolates were from patients with CF. We found a higher prevalence of the environmentally driven mutation TR34/L98H in our A. fumigatus isolates than in published UK data from other specialist respiratory centres, which may reflect differing patient populations managed at these institutions.
Collapse
|
49
|
Garcia-Rubio R, Escribano P, Gomez A, Guinea J, Mellado E. Comparison of Two Highly Discriminatory Typing Methods to Analyze Aspergillus fumigatus Azole Resistance. Front Microbiol 2018; 9:1626. [PMID: 30079058 PMCID: PMC6062602 DOI: 10.3389/fmicb.2018.01626] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
Aspergillus fumigatus molecular typing has become increasingly more important for detecting outbreaks as well as for local and global epidemiological investigations and surveillance. Over the years, many different molecular methods have been described for genotyping this species. Some outstanding approaches are based on microsatellite markers (STRAf assay, which is the current gold standard), or based on sequencing data (TRESP typing improved in this work with a new marker and was renamed TRESPERG). Both methodologies were used to type a collection of 212 A. fumigatus isolates that included 70 azole resistant strains with diverse resistance mechanisms from different geographic locations. Our results showed that both methods are totally reliable for epidemiological investigations showing similar stratification of the A. fumigatus population. STRAf assay offered higher discriminatory power (D = 0.9993) than the TRESPERG typing method (D = 0.9972), but the latter does not require specific equipment or skilled personnel, allowing for a prompt integration into any clinical microbiology laboratory. Among azole resistant isolates, two groups were differentiated considering their resistance mechanisms: cyp51A single point mutations (G54, M220, or G448), and promoter tandem repeat integrations with or without cyp51A modifications (TR34/L98H, TR46/Y121F/A289T, or TR53). The genotypic differences were assessed to explore the population structure as well as the genetic relationship between strains and their azole resistance profile. Genetic cluster analyses suggested that our A. fumigatus population was formed by 6–7 clusters, depending on the methodology. Also, the azole susceptible and resistance population showed different structure and organization. The combination of both methodologies resolved the population structure in a similar way to what has been described in whole-genome sequencing works.
Collapse
Affiliation(s)
- Rocio Garcia-Rubio
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Pilar Escribano
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Gomez
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jesus Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Emilia Mellado
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
50
|
Kemoi EK, Nyerere A, Bii CC. Triazole-Resistant Aspergillus fumigatus from Fungicide-Experienced Soils in Naivasha Subcounty and Nairobi County, Kenya. Int J Microbiol 2018; 2018:7147938. [PMID: 30046310 PMCID: PMC6038473 DOI: 10.1155/2018/7147938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/06/2017] [Accepted: 05/03/2018] [Indexed: 11/18/2022] Open
Abstract
The mainstay in prevention and treatment of aspergillosis is the use triazole drugs. In Kenya, the use of agricultural azole is one of the predisposing factors in development of resistance. One hundred fifty-six (156) experienced soils were collected from agricultural farms and cultured on Sabouraud DextroseAagar. The study isolated 48 yielded Aspergillus fumigatus and 2 A. flavus. All the isolates were subjected to antifungal susceptibility testing against three triazoles: posaconazole, voriconazole, and itraconazole. Out of the isolates, 3 had MIC of 32 and 1 had MIC of 16 against itraconazole, and 1 isolate had MIC of 32 against posaconazole. CYP51A gene was sequenced, and TR34/L98H mutation was identified. Triazole resistance existing in Kenya calls for rational use of azole-based fungicides in agriculture over concerns of emerging antifungal resistance in clinical practice.
Collapse
Affiliation(s)
- Edson K. Kemoi
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- University of Kabianga, Kericho, Kenya
| | - Andrew Nyerere
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | |
Collapse
|