1
|
Santana DJ, Anku JAE, Zhao G, Zarnowski R, Johnson CJ, Hautau H, Visser ND, Ibrahim AS, Andes D, Nett JE, Singh S, O'Meara TR. A Candida auris-specific adhesin, Scf1 , governs surface association, colonization, and virulence. Science 2023; 381:1461-1467. [PMID: 37769084 DOI: 10.1126/science.adf8972] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/23/2023] [Indexed: 09/30/2023]
Abstract
Candida auris is an emerging fungal pathogen responsible for health care-associated outbreaks that arise from persistent surface and skin colonization. We characterized the arsenal of adhesins used by C. auris and discovered an uncharacterized adhesin, Surface Colonization Factor (Scf1), and a conserved adhesin, Iff4109, that are essential for the colonization of inert surfaces and mammalian hosts. SCF1 is apparently specific to C. auris, and its expression mediates adhesion to inert and biological surfaces across isolates from all five clades. Unlike canonical fungal adhesins, which function through hydrophobic interactions, Scf1 relies on exposed cationic residues for surface association. SCF1 is required for C. auris biofilm formation, skin colonization, virulence in systemic infection, and colonization of inserted medical devices.
Collapse
Affiliation(s)
- Darian J Santana
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Juliet A E Anku
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
- West African Centre for Cell Biology of Infectious Pathogens (WACCBIP), Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Accra, Ghana
| | - Guolei Zhao
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Robert Zarnowski
- Department of Medicine, University of Wisconsin, Madison, WI, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI, USA
| | - Chad J Johnson
- Department of Medicine, University of Wisconsin, Madison, WI, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI, USA
| | - Haley Hautau
- Division of Infectious Disease, The Lundquist Institute for Biomedical Innovation at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
| | - Noelle D Visser
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Ashraf S Ibrahim
- Division of Infectious Disease, The Lundquist Institute for Biomedical Innovation at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - David Andes
- Department of Medicine, University of Wisconsin, Madison, WI, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI, USA
| | - Jeniel E Nett
- Department of Medicine, University of Wisconsin, Madison, WI, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI, USA
| | - Shakti Singh
- Division of Infectious Disease, The Lundquist Institute for Biomedical Innovation at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Teresa R O'Meara
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
2
|
Zhu Y, Hager KM, Manjari SR, Banavali NK, Chaturvedi V, Chaturvedi S. Development and Validation of TaqMan Chemistry Probe-Based Rapid Assay for the Detection of Echinocandin-Resistance in Candida auris. J Clin Microbiol 2023; 61:e0176722. [PMID: 36975998 PMCID: PMC10117040 DOI: 10.1128/jcm.01767-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/14/2023] [Indexed: 03/29/2023] Open
Abstract
Candida auris is a multidrug-resistant yeast pathogen causing outbreaks in health care facilities worldwide, and the emergence of echinocandin-resistant C. auris is a concern. Currently used Clinical and Laboratory Standards Institute (CLSI) and commercial antifungal susceptibility tests (AFST) are phenotype-based, slow, and not scalable, limiting their effectiveness in the surveillance of echinocandin-resistant C. auris. The urgent need for accurate and rapid methods of assessment of echinocandin resistance cannot be overstated, as this class of antifungal drugs is preferred for patient management. We report the development and validation of a TaqMan chemistry probe-based fluorescence melt curve analysis (FMCA) following asymmetric polymerase chain reaction (PCR) to assess mutations within the hot spot one (HS1) region of FKS1, the gene responsible for encoding 1,3-β-d-glucan synthase that is a target for echinocandins. The assay correctly identified F635C, F635Y, F635del, F635S, S639F or S639Y, S639P, and D642H/R645T mutations. Of these mutations, F635S and D642H/R645T were not involved in echinocandin resistance, while the rest were, as confirmed by AFST. Of 31 clinical cases, the predominant mutation conferring echinocandin resistance was S639F/Y (20 cases) followed by S639P (4 cases), F635del (4 cases), F635Y (2 cases), and F635C (1 case). The FMCA assay was highly specific and did not cross-react with closely and distantly related Candida and other yeast and mold species. Structural modeling of the Fks1 protein, its mutants, and docked conformations of three echinocandin drugs suggest a plausible Fks1 binding orientation for echinocandins. These findings lay the groundwork for future evaluations of additional FKS1 mutations and their impact on the development of drug resistance. The TaqMan chemistry probe-based FMCA would allow rapid, high throughput, and accurate detection of FKS1 mutations conferring echinocandin resistance in C. auris.
Collapse
Affiliation(s)
- YanChun Zhu
- Mycology Laboratory, Division of Infectious Diseases, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Kelli M. Hager
- Mycology Laboratory, Division of Infectious Diseases, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Swati R. Manjari
- Division of Translational Medicine, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Nilesh K. Banavali
- Division of Translational Medicine, Wadsworth Center, New York State Department of Health, Albany, New York, USA
- Department of Biomedical Sciences, University at Albany, Albany, New York, USA
| | - Vishnu Chaturvedi
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Sudha Chaturvedi
- Mycology Laboratory, Division of Infectious Diseases, Wadsworth Center, New York State Department of Health, Albany, New York, USA
- Department of Biomedical Sciences, University at Albany, Albany, New York, USA
| |
Collapse
|
3
|
Li X, Muñoz JF, Gade L, Argimon S, Bougnoux ME, Bowers JR, Chow NA, Cuesta I, Farrer RA, Maufrais C, Monroy-Nieto J, Pradhan D, Uehling J, Vu D, Yeats CA, Aanensen DM, d’Enfert C, Engelthaler DM, Eyre DW, Fisher MC, Hagen F, Meyer W, Singh G, Alastruey-Izquierdo A, Litvintseva AP, Cuomo CA. Comparing genomic variant identification protocols for Candida auris. Microb Genom 2023; 9:mgen000979. [PMID: 37043380 PMCID: PMC10210944 DOI: 10.1099/mgen.0.000979] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/09/2023] [Indexed: 04/13/2023] Open
Abstract
Genomic analyses are widely applied to epidemiological, population genetic and experimental studies of pathogenic fungi. A wide range of methods are employed to carry out these analyses, typically without including controls that gauge the accuracy of variant prediction. The importance of tracking outbreaks at a global scale has raised the urgency of establishing high-accuracy pipelines that generate consistent results between research groups. To evaluate currently employed methods for whole-genome variant detection and elaborate best practices for fungal pathogens, we compared how 14 independent variant calling pipelines performed across 35 Candida auris isolates from 4 distinct clades and evaluated the performance of variant calling, single-nucleotide polymorphism (SNP) counts and phylogenetic inference results. Although these pipelines used different variant callers and filtering criteria, we found high overall agreement of SNPs from each pipeline. This concordance correlated with site quality, as SNPs discovered by a few pipelines tended to show lower mapping quality scores and depth of coverage than those recovered by all pipelines. We observed that the major differences between pipelines were due to variation in read trimming strategies, SNP calling methods and parameters, and downstream filtration criteria. We calculated specificity and sensitivity for each pipeline by aligning three isolates with chromosomal level assemblies and found that the GATK-based pipelines were well balanced between these metrics. Selection of trimming methods had a greater impact on SAMtools-based pipelines than those using GATK. Phylogenetic trees inferred by each pipeline showed high consistency at the clade level, but there was more variability between isolates from a single outbreak, with pipelines that used more stringent cutoffs having lower resolution. This project generated two truth datasets useful for routine benchmarking of C. auris variant calling, a consensus VCF of genotypes discovered by 10 or more pipelines across these 35 diverse isolates and variants for 2 samples identified from whole-genome alignments. This study provides a foundation for evaluating SNP calling pipelines and developing best practices for future fungal genomic studies.
Collapse
Affiliation(s)
- Xiao Li
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - José F. Muñoz
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA, 30329, USA
| | - Silvia Argimon
- Centre for Genomic Pathogen Surveillance, Big Data Institute, University of Oxford, Oxford, UK
| | - Marie-Elisabeth Bougnoux
- Institut Pasteur, Université Paris Cité, INRAE, USC2019, Unité Biologie et Pathogénicité Fongiques, Paris, France
- Université Paris Cité, Hôpital Necker-Enfants-Malades, Unité de Parasitologie-Mycologie, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Jolene R. Bowers
- Translational Genomics Research Institute, Pathogen and Microbiome Division, Flagstaff, AZ 86005, USA
| | - Nancy A. Chow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA, 30329, USA
| | - Isabel Cuesta
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Rhys A. Farrer
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, EX4 4PY, UK
| | - Corinne Maufrais
- Institut Pasteur, Université Paris Cité, INRAE, USC2019, Unité Biologie et Pathogénicité Fongiques, Paris, France
- Institut Pasteur, Université Paris Cité, CNRS USR 3756, Hub de Bioinformatique et Biostatistique, Paris, France
| | - Juan Monroy-Nieto
- Translational Genomics Research Institute, Pathogen and Microbiome Division, Flagstaff, AZ 86005, USA
| | - Dibyabhaba Pradhan
- All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Jessie Uehling
- Botany and Plant Pathology, Oregon State University, Corvallis, OR 97330, USA
| | - Duong Vu
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584CT, Utrecht, Netherlands
| | - Corin A. Yeats
- Centre for Genomic Pathogen Surveillance, Big Data Institute, University of Oxford, Oxford, UK
| | - David M. Aanensen
- Centre for Genomic Pathogen Surveillance, Big Data Institute, University of Oxford, Oxford, UK
| | - Christophe d’Enfert
- Institut Pasteur, Université Paris Cité, INRAE, USC2019, Unité Biologie et Pathogénicité Fongiques, Paris, France
| | - David M. Engelthaler
- Translational Genomics Research Institute, Pathogen and Microbiome Division, Flagstaff, AZ 86005, USA
| | - David W. Eyre
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Matthew C. Fisher
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584CT, Utrecht, Netherlands
- Institute for Biodiversity and Ecosystem Dynamics (IBED), University of Amsterdam, Amsterdam, Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wieland Meyer
- Sydney Medical School, University of Sydney, Sydney, NSW 2050, Australia
| | - Gagandeep Singh
- All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Anastasia P. Litvintseva
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA, 30329, USA
| | | |
Collapse
|
4
|
Abstract
Antifungal resistance mediated by overexpression of ABC transporters is one of the primary roadblocks to effective therapy against Candida infections. Thus, identification and characterization of the ABC transporter repertoire in Candida species are of high relevance. The method described in the chapter is based on our previously developed bioinformatic pipeline for identification of ABC proteins in Candida species. The methodology essentially involves the utilization of a hidden Markov model (HMM) profile of the nucleotide-binding domain (NBD) of ABC proteins to mine these proteins from the proteome of Candida species. Further, a widely used tool to predict membrane protein topology is exploited to identify the true transporter candidates out of the ABC proteins. Even though the chapter specifically focuses on a method to identify ABC transporters in Candida auris , the same can also be applied to any other Candida species.
Collapse
Affiliation(s)
- Atanu Banerjee
- Amity Institute of Biotechnology and Amity Institute of Integrative Sciences and Health, Amity University Haryana, Gurugram, India.
| | - Poonam Vishwakarma
- School of Computational and Integrative Sciences, Jawaharlal Nehru University, New Delhi, India
- DSIMB Laboratory, Faculty of Sciences and Technology, University of Reunion Island, Saint Denis, France
| | - Naveen Kumar Meena
- School of Computational and Integrative Sciences, Jawaharlal Nehru University, New Delhi, India
| | - Andrew M Lynn
- School of Computational and Integrative Sciences, Jawaharlal Nehru University, New Delhi, India.
| | - Rajendra Prasad
- Amity Institute of Biotechnology and Amity Institute of Integrative Sciences and Health, Amity University Haryana, Gurugram, India.
| |
Collapse
|
5
|
Bagal UR, Phan J, Welsh RM, Misas E, Wagner D, Gade L, Litvintseva AP, Cuomo CA, Chow NA. MycoSNP: A Portable Workflow for Performing Whole-Genome Sequencing Analysis of Candida auris. Methods Mol Biol 2022; 2517:215-228. [PMID: 35674957 DOI: 10.1007/978-1-0716-2417-3_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Candida auris is an urgent public health threat characterized by high drug-resistant rates and rapid spread in healthcare settings worldwide. As part of the C. auris response, molecular surveillance has helped public health officials track the global spread and investigate local outbreaks. Here, we describe whole-genome sequencing analysis methods used for routine C. auris molecular surveillance in the United States; methods include reference selection, reference preparation, quality assessment and control of sequencing reads, read alignment, and single-nucleotide polymorphism calling and filtration. We also describe the newly developed pipeline MycoSNP, a portable workflow for performing whole-genome sequencing analysis of fungal organisms including C. auris.
Collapse
Affiliation(s)
- Ujwal R Bagal
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Phan
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rory M Welsh
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elizabeth Misas
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Christina A Cuomo
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Nancy A Chow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| |
Collapse
|
6
|
Iyer KR, Kim SH, Robbins N, Cowen LE. Downregulation of Essential Genes in the Fungal Pathogen Candida auris. Methods Mol Biol 2022; 2517:111-126. [PMID: 35674949 PMCID: PMC11016342 DOI: 10.1007/978-1-0716-2417-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The recent global emergence of the fungal pathogen Candida auris has caused significant concern given that this pathogen often exhibits resistance to multiple antifungal drug classes. In order to effectively combat C. auris infections, there is a dire need to expand our current antifungal arsenal. Essential proteins often serve as targets for antimicrobial compounds, and thus being able to study essential genes in a pathogen of interest is a critical first step in drug development. To identify and characterize essential genes in microorganisms, researchers must be able to manipulate microbial genomes using a variety of molecular biology techniques. Given the haploid genome of C. auris, genetic alterations have largely been achieved by gene deletion through homologous recombination using a drug resistance marker. However, this approach is not feasible to study essential gene function. Here, we describe a method for the study of essential genes using a tetracycline-repressible promoter replacement system, which can be used to genetically repress essential genes in C. auris and, thus, study their function. This method provides a powerful approach to assess and characterize essential gene function in an emerging fungal pathogen.
Collapse
Affiliation(s)
- Kali R Iyer
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Sang Hu Kim
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Nicole Robbins
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Leah E Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
7
|
Ennis CL, Hernday AD, Nobile CJ. A Markerless CRISPR-Mediated System for Genome Editing in Candida auris Reveals a Conserved Role for Cas5 in the Caspofungin Response. Microbiol Spectr 2021; 9:e0182021. [PMID: 34730409 PMCID: PMC8567271 DOI: 10.1128/spectrum.01820-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 12/26/2022] Open
Abstract
Candida auris is a multidrug-resistant human fungal pathogen that has recently emerged worldwide. It can cause life-threatening disseminated infections in humans, with mortality rates upwards of 50%. The molecular mechanisms underlying its multidrug resistance and pathogenic properties are largely unknown. Few methods exist for genome editing in C. auris, all of which rely on selectable markers that limit the number of modifications that can be made. Here, we present a markerless CRISPR/Cas9-mediated genome editing system in C. auris. Using this system, we successfully deleted genes of interest and subsequently reconstituted them at their native loci in isolates across all five C. auris clades. This system also enabled us to introduce precision genome edits to create translational fusions and single point mutations. Using Cas5 as a test case for this system, we discovered a conserved role for Cas5 in the caspofungin response between Candida albicans and C. auris. Overall, the development of a system for precise and facile genome editing in C. auris that can allow edits to be made in a high-throughput manner is a major step forward in improving our understanding of this important human fungal pathogen. IMPORTANCE Candida auris is a recently emerged multidrug-resistant fungal pathogen capable of causing life-threatening systemic infections in humans. Few tools are available for genome editing in C. auris. Here, we present a markerless genome editing system for C. auris that relies on CRISPR/Cas9 technology and works to modify the genomes of all known C. auris clades. Using this system, we discovered a conserved role for Cas5 in the caspofungin response between C. albicans and C. auris. Overall, the development of a system for facile genome editing in C. auris is a major step forward in improving our understanding of this important human fungal pathogen.
Collapse
Affiliation(s)
- Craig L. Ennis
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, California, USA
- Quantitative and Systems Biology Graduate Program, University of California, Merced, California, USA
- Health Sciences Research Institute, University of California, Merced, California, USA
| | - Aaron D. Hernday
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, California, USA
- Health Sciences Research Institute, University of California, Merced, California, USA
| | - Clarissa J. Nobile
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, California, USA
- Health Sciences Research Institute, University of California, Merced, California, USA
| |
Collapse
|
8
|
Rybak JM, Sharma C, Doorley LA, Barker KS, Palmer GE, Rogers PD. Delineation of the Direct Contribution of Candida auris ERG11 Mutations to Clinical Triazole Resistance. Microbiol Spectr 2021; 9:e0158521. [PMID: 34878305 PMCID: PMC8653815 DOI: 10.1128/spectrum.01585-21] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/28/2021] [Indexed: 11/27/2022] Open
Abstract
Resistance to fluconazole is one of clinical characteristics most frequently challenging the treatment of invasive Candida auris infections, and is observed among >90% of all characterized clinical isolates. In this work, the native C. auris ERG11 allele in a previously characterized fluconazole-susceptible clinical isolate was replaced with the ERG11 alleles from three highly fluconazole-resistant clinical isolates (MIC ≥256 mg/L), encoding the amino acid substitutions VF125AL, Y132F, and K143R, using Cas9-ribonucleoprotein (RNP) mediated transformation system. Reciprocally, the ERG11WT allele from the same fluconazole-susceptible clinical isolate, lacking any resistance-associated mutation, was introduced into a previously characterized fluconazole-resistant clinical isolate, replacing the native ERG11K143R allele, using the same methods. The resulting collection of strains was subjected to comprehensive triazole susceptibility testing, and the direct impact each of these clinically-derived ERG11 mutations on triazole MIC was determined. Introduction of each of the three mutant ERG11 alleles was observed to increase fluconazole and voriconazole MIC by 8- to 16-fold. The MIC for the other clinically available triazoles were not significantly impacted by any ERG11 mutation. In the fluconazole-resistant clinical isolate background, correction of the K143R encoding mutation led to a similar 16-fold decrease in fluconazole MIC, and 8-fold decrease in voriconazole MIC, while the MIC of other triazoles were minimally changed. Taken together, these findings demonstrate that mutations in C. auris ERG11 significantly contribute to fluconazole and voriconazole resistance, but alone cannot explain the substantially elevated MIC observed among clinical isolates of C. auris. IMPORTANCE Candida auris is an emerging multidrug-resistant and health care-associated pathogen of urgent clinical concern. The triazoles are the most widely prescribed antifungal agents worldwide and are commonly utilized for the treatment of invasive Candida infections. Greater than 90% of all C. auris clinical isolates are observed to be resistant to fluconazole, and nearly all fluconazole-resistant isolates of C. auris are found to have one of three mutations (encoding VF125AL, Y132F, or K143R) in the gene encoding the target of the triazoles, ERG11. However, the direct contribution of these mutations in ERG11 to fluconazole resistance and the impact these mutations may have the susceptibility of the other triazoles remains unknown. The present study seeks to address this knowledge gap and potentially inform the future application the triazole antifungals for the treatment of infections caused by C. auris.
Collapse
Affiliation(s)
- Jeffrey M. Rybak
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Cheshta Sharma
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Laura A. Doorley
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Katherine S. Barker
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Glen E. Palmer
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - P. David Rogers
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
9
|
Munhoz da Rocha IF, Martins ST, Amatuzzi RF, Zamith-Miranda D, Nosanchuk JD, Rodrigues ML, Alves LR. Cellular and Extracellular Vesicle RNA Analysis in the Global Threat Fungus Candida auris. Microbiol Spectr 2021; 9:e0153821. [PMID: 34908466 PMCID: PMC8672890 DOI: 10.1128/spectrum.01538-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/03/2021] [Indexed: 12/18/2022] Open
Abstract
Emerging and reemerging pathogens are a worldwide concern, and it is predicted that these microbes will cause severe outbreaks. Candida auris affects people with weakened immune systems, particularly those who are hospitalized or are in health care facilities. Extracellular vesicles (EVs) are lipid bilayer structures released by organisms from all domains of life. EVs can deliver functional molecules to target cells, including proteins and nucleic acids, especially RNA molecules. EVs from several pathogenic fungi species play diverse biological roles related to cell-cell communication and pathogen-host interaction. In this study, we describe a data set which we produced by sequencing the RNA content of EVs from C. auris under normal growth conditions and in the presence of the antifungal caspofungin, a first-line drug to treat this fungus. To generate a more complete data set for future comparative studies, we also sequenced the RNA cellular content of EVs under the same conditions. This data set addresses a previously unexplored area of fungal biology regarding cellular small RNA and EV RNA. Our data will provide a molecular basis for the study of the aspects associated with antifungal treatment, gene expression response, and EV composition in C. auris. These data will also allow the exploration of small RNA content in the fungal kingdom and might serve as an informative basis for studies on the mechanisms by which molecules are directed to fungal EVs. IMPORTANCE Candida auris, a relevant emerging human-pathogenic yeast, is the first fungus to be called a global public health threat by the WHO. This is because of its rapid spread on all inhabited continents, together with its extremely high frequency of drug and multidrug resistance. In our study, we generated a large data set for 3 distinct strains of C. auris and obtained cellular small RNA fraction as well as extracellular vesicle RNA (EV-RNA) during normal growth conditions and after treatment with caspofungin, the first-line drug used to treat C. auris infection.
Collapse
Affiliation(s)
| | - Sharon T. Martins
- Gene Expression Regulation Laboratory, Carlos Chagas Institute, Fiocruz Paraná, Curitiba, Brazil
| | - Rafaela F. Amatuzzi
- Gene Expression Regulation Laboratory, Carlos Chagas Institute, Fiocruz Paraná, Curitiba, Brazil
| | - Daniel Zamith-Miranda
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Joshua D. Nosanchuk
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marcio L. Rodrigues
- Gene Expression Regulation Laboratory, Carlos Chagas Institute, Fiocruz Paraná, Curitiba, Brazil
- Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lysangela R. Alves
- Gene Expression Regulation Laboratory, Carlos Chagas Institute, Fiocruz Paraná, Curitiba, Brazil
| |
Collapse
|
10
|
Lara-Aguilar V, Rueda C, García-Barbazán I, Varona S, Monzón S, Jiménez P, Cuesta I, Zaballos Á, Zaragoza Ó. Adaptation of the emerging pathogenic yeast Candida auris to high caspofungin concentrations correlates with cell wall changes. Virulence 2021; 12:1400-1417. [PMID: 34180774 PMCID: PMC8244764 DOI: 10.1080/21505594.2021.1927609] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Candida auris has emerged as a fungal pathogen that causes nosocomial outbreaks worldwide. Diseases caused by this fungus are of concern, due to its reduced susceptibility to several antifungals. C. auris exhibits paradoxical growth (PG; defined as growth at high, but not intermediate antifungal concentrations) in the presence of caspofungin (CPF). We have characterized the cellular changes associated with adaptation to CPF. Using EUCAST AFST protocols, all C. auris isolates tested showed PG to CPF, although in some isolates it was more prominent. Most isolates also showed a trailing effect (TE) to micafungin and anidulafungin. We identified two FKS genes in C. auris that encode the echinocandins target, namely β-1,3-glucan synthase. FKS1 contained the consensus hot-spot (HS) 1 and HS2 sequences. FKS2 only contained the HS1 region which had a change (F635Y), that has been shown to confer resistance to echinocandins in C. glabrata. PG has been characterized in other species, mainly C. albicans, where high CPF concentrations induced an increase in chitin, cell volume and aggregation. In C. auris CPF only induced a slight accumulation of chitin, and none of the other phenomena. RNAseq experiments demonstrated that CPF induced the expression of genes encoding several GPI-anchored cell wall proteins, membrane proteins required for the stability of the cell wall, chitin synthase and mitogen-activated protein kinases (MAPKs) involved in cell integrity, such as BCK2, HOG1 and MKC1 (SLT2). Our work highlights some of the processes induced in C. auris to adapt to echinocandins.
Collapse
Affiliation(s)
- Violeta Lara-Aguilar
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Cristina Rueda
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Irene García-Barbazán
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| | - Sarai Varona
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Sara Monzón
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Pilar Jiménez
- Genomics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Isabel Cuesta
- Bioinformatics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Ángel Zaballos
- Genomics Unit, Core Scientific and Technical Units, Instituto De Salud Carlos III, Madrid, Spain
| | - Óscar Zaragoza
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto De Salud Carlos III, Madrid, Spain
| |
Collapse
|
11
|
Karmarkar EN, O'Donnell K, Prestel C, Forsberg K, Gade L, Jain S, Schan D, Chow N, McDermott D, Rossow J, Toda M, Ruiz R, Hun S, Dale JL, Gross A, Maruca T, Glowicz J, Brooks R, Bagheri H, Nelson T, Gualandi N, Khwaja Z, Horwich-Scholefield S, Jacobs J, Cheung M, Walters M, Jacobs-Slifka K, Stone ND, Mikhail L, Chaturvedi S, Klein L, Vagnone PS, Schneider E, Berkow EL, Jackson BR, Vallabhaneni S, Zahn M, Epson E. Rapid Assessment and Containment of Candida auris Transmission in Postacute Care Settings-Orange County, California, 2019. Ann Intern Med 2021; 174:1554-1562. [PMID: 34487450 PMCID: PMC10984253 DOI: 10.7326/m21-2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Candida auris, a multidrug-resistant yeast, can spread rapidly in ventilator-capable skilled-nursing facilities (vSNFs) and long-term acute care hospitals (LTACHs). In 2018, a laboratory serving LTACHs in southern California began identifying species of Candida that were detected in urine specimens to enhance surveillance of C auris, and C auris was identified in February 2019 in a patient in an Orange County (OC), California, LTACH. Further investigation identified C auris at 3 associated facilities. OBJECTIVE To assess the prevalence of C auris and infection prevention and control (IPC) practices in LTACHs and vSNFs in OC. DESIGN Point prevalence surveys (PPSs), postdischarge testing for C auris detection, and assessments of IPC were done from March to October 2019. SETTING All LTACHs (n = 3) and vSNFs (n = 14) serving adult patients in OC. PARTICIPANTS Current or recent patients in LTACHs and vSNFs in OC. INTERVENTION In facilities where C auris was detected, PPSs were repeated every 2 weeks. Ongoing IPC support was provided. MEASUREMENTS Antifungal susceptibility testing and whole-genome sequencing to assess isolate relatedness. RESULTS Initial PPSs at 17 facilities identified 44 additional patients with C auris in 3 (100%) LTACHs and 6 (43%) vSNFs, with the first bloodstream infection reported in May 2019. By October 2019, a total of 182 patients with C auris were identified by serial PPSs and discharge testing. Of 81 isolates that were sequenced, all were clade III and highly related. Assessments of IPC identified gaps in hand hygiene, transmission-based precautions, and environmental cleaning. The outbreak was contained to 2 facilities by October 2019. LIMITATION Acute care hospitals were not assessed, and IPC improvements over time could not be rigorously evaluated. CONCLUSION Enhanced laboratory surveillance and prompt investigation with IPC support enabled swift identification and containment of C auris. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
Collapse
Affiliation(s)
- Ellora N Karmarkar
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia, and the California Department of Public Health, Richmond, California (E.N.K.)
| | - Kathleen O'Donnell
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | - Christopher Prestel
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia (C.P., J.R., M.T.)
| | - Kaitlin Forsberg
- Centers for Disease Control and Prevention and IHRC, Atlanta, Georgia (K.F.)
| | - Lalitha Gade
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Seema Jain
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| | - Douglas Schan
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | - Nancy Chow
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Darby McDermott
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - John Rossow
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia (C.P., J.R., M.T.)
| | - Mitsuru Toda
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia (C.P., J.R., M.T.)
| | - Ryan Ruiz
- Washington State Public Health Laboratories, Shoreline, Washington (R.R., S.H., E.S.)
| | - Sopheay Hun
- Washington State Public Health Laboratories, Shoreline, Washington (R.R., S.H., E.S.)
| | - Jennifer L Dale
- Minnesota Department of Health Public Health Laboratory, St. Paul, Minnesota (J.L.D., A.G., P.S.V.)
| | - Annastasia Gross
- Minnesota Department of Health Public Health Laboratory, St. Paul, Minnesota (J.L.D., A.G., P.S.V.)
| | - Tyler Maruca
- Maryland Department of Health Laboratories Administration, Baltimore, Maryland (T.M., L.K.)
| | - Janet Glowicz
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Richard Brooks
- Centers for Disease Control and Prevention, Atlanta, Georgia, and the Maryland Department of Health, Infectious Disease Epidemiology and Outbreak Response Bureau, Baltimore, Maryland (R.B.)
| | - Hosniyeh Bagheri
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| | - Teresa Nelson
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| | - Nicole Gualandi
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Zenith Khwaja
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| | - Sam Horwich-Scholefield
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| | - Josh Jacobs
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | - Michele Cheung
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | - Maroya Walters
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Kara Jacobs-Slifka
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Nimalie D Stone
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Lydia Mikhail
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | | | - Liore Klein
- Maryland Department of Health Laboratories Administration, Baltimore, Maryland (T.M., L.K.)
| | - Paula Snippes Vagnone
- Minnesota Department of Health Public Health Laboratory, St. Paul, Minnesota (J.L.D., A.G., P.S.V.)
| | - Emily Schneider
- Washington State Public Health Laboratories, Shoreline, Washington (R.R., S.H., E.S.)
| | - Elizabeth L Berkow
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Brendan R Jackson
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Snigdha Vallabhaneni
- Centers for Disease Control and Prevention, Atlanta, Georgia (L.G., N.C., D.M., J.G., N.G., M.W., K.J., N.D.S., E.L.B., B.R.J., S.V.)
| | - Matthew Zahn
- Orange County Health Care Agency, Santa Ana, California (K.O., D.S., J.J., M.C., L.M., M.Z.)
| | - Erin Epson
- California Department of Public Health, Richmond, California (S.J., H.B., T.N., Z.K., S.H., E.E.)
| |
Collapse
|
12
|
Hamad A, Chen Y, Khan MA, Jamshidi S, Saeed N, Clifford M, Hind C, Sutton JM, Rahman KM. Schiff bases of sulphonamides as a new class of antifungal agent against multidrug-resistant Candida auris. Microbiologyopen 2021; 10:e1218. [PMID: 34459551 PMCID: PMC8301596 DOI: 10.1002/mbo3.1218] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 11/11/2022] Open
Abstract
Invasive Candida infections in hospitalized and immunocompromised or critically ill patients have become an important cause of morbidity and mortality. There are increasing reports of multidrug resistance in several Candida species that cause Candidemia, including C. glabrata and C. auris, with limited numbers of antifungal agents available to treat patients with invasive Candida infections. Therefore, there is an urgent need to discover new antifungal agents that work against multidrug-resistant Candida species, particularly C. auris, which has been identified as an emerging global pathogen. In this article, we report a new class of antifungal agents, the Schiff bases of sulphonamides, that show activity against all Candida species tested, with an MIC range of 4-32 µg/ml. Compound 2b showed activity against C. glabrata and a panel of fluconazole-resistant C. auris strains, with MICs of 4-16 µg/ml. The drug-like nature of these Schiff bases offers opportunities to optimize these compounds with medicinal chemistry techniques to obtain more potent analogs that can be progressed toward pre-clinical evaluation.
Collapse
Affiliation(s)
- Asad Hamad
- Department of PharmacyThe Islamia University of BahawalpurBahawalpurPakistan
- Institute of Pharmaceutical ScienceKing's College LondonLondonUK
| | - Yiyuan Chen
- Institute of Pharmaceutical ScienceKing's College LondonLondonUK
| | - Mohsin A. Khan
- Department of PharmacyThe Islamia University of BahawalpurBahawalpurPakistan
| | - Shirin Jamshidi
- Institute of Pharmaceutical ScienceKing's College LondonLondonUK
| | - Naima Saeed
- Institute of Pharmaceutical ScienceKing's College LondonLondonUK
| | | | - Charlotte Hind
- Public Health EnglandNational Infections ServiceSalisburyUK
| | - J. Mark Sutton
- Public Health EnglandNational Infections ServiceSalisburyUK
| | | |
Collapse
|
13
|
Muñoz JF, Welsh RM, Shea T, Batra D, Gade L, Howard D, Rowe LA, Meis JF, Litvintseva AP, Cuomo CA. Clade-specific chromosomal rearrangements and loss of subtelomeric adhesins in Candida auris. Genetics 2021; 218:iyab029. [PMID: 33769478 PMCID: PMC8128392 DOI: 10.1093/genetics/iyab029] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/10/2021] [Indexed: 12/17/2022] Open
Abstract
Candida auris is an emerging fungal pathogen of rising concern due to global spread, the ability to cause healthcare-associated outbreaks, and antifungal resistance. Genomic analyses revealed that early contemporaneously detected cases of C. auris were geographically stratified into four major clades. While Clades I, III, and IV are responsible for ongoing outbreaks of invasive and multidrug-resistant infections, Clade II, also termed the East Asian clade, consists primarily of cases of ear infection, is often susceptible to all antifungal drugs, and has not been associated with outbreaks. Here, we generate chromosome-level assemblies of twelve isolates representing the phylogenetic breadth of these four clades and the only isolate described to date from Clade V. This Clade V genome is highly syntenic with those of Clades I, III, and IV, although the sequence is highly divergent from the other clades. Clade II genomes appear highly rearranged, with translocations occurring near GC-poor regions, and large subtelomeric deletions in most chromosomes, resulting in a substantially different karyotype. Rearrangements and deletion lengths vary across Clade II isolates, including two from a single patient, supporting ongoing genome instability. Deleted subtelomeric regions are enriched in Hyr/Iff-like cell-surface proteins, novel candidate cell wall proteins, and an ALS-like adhesin. Cell wall proteins from these families and other drug-related genes show clade-specific signatures of selection in Clades I, III, and IV. Subtelomeric dynamics and the conservation of cell surface proteins in the clades responsible for global outbreaks causing invasive infections suggest an explanation for the different phenotypes observed between clades.
Collapse
Affiliation(s)
- José F Muñoz
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Rory M Welsh
- Mycotic Diseases Branch, U.S. Department of Health and Human Services, Atlanta, GA, USA
| | - Terrance Shea
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Dhwani Batra
- Division of Scientific Resources, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA, USA
| | - Lalitha Gade
- Mycotic Diseases Branch, U.S. Department of Health and Human Services, Atlanta, GA, USA
| | - Dakota Howard
- Division of Scientific Resources, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA, USA
| | - Lori A Rowe
- Division of Scientific Resources, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA, USA
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | | | | |
Collapse
|