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Trends in Aspergillus species
distribution and resistance pattern
Global Vs. Indian scenario
Shivaprakash M Rudramurthy Additional Professor, Mycology Division
Center of Advanced Research in Medical Mycology, National Culture Collection of Pathogenic Fungi
& WHO Collaborating Center
Postgraduate Institute of Medical Education & Research
Chandigarh – 160012, India
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Introduction
• Invasive aspergillosis (IA) remains a difficult to
manage infectious disease.
• Outcome is largely determined by the
persistence of the underlying disease or
immunosuppression
• Factors related to the fungus also play a role.
• The taxonomy of Aspergillus is evolving.
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Introduction
• Aspergillus is a large genus comprised of more
than 250 species
• Polyphasic taxonomy has a major impact on the
species concept of the genus Aspergillus
• New sibling species described – variable
susceptibility profiles.
• Aspergillus sections including Fumigati , Flavi ,
Terrei ,Nidulanti and Nigri
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Aspergillus section Fumigati
29 –Neosartorya
14 - Aspergillus
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Pathogenic species in Aspergillus
section Fumigati
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Pathogenic species in Aspergillus
section flavi
•Second most common cause of IA
•ability to survive at higher temperatures
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Aspergillus Section Terrei
• Until recently A. terreus was the only
recognized species in this section
• Presence of several cryptic species
• in vivo conidia formation - a role in
haematogenous dissemination
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Aspergillus section Nidulanti
• reported in patients with chronic
granulomatous disease
• A. nidulans
• Emericella quadrilineata anamorph Aspergillus
tetrazonus
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Aspergillus section Usti • A. ustus, A. puniceus ,A. granulosus, A. pseudodeflectus, A.
calidoustus , A. insuetus A. keveii sp.
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Aspergillus section Nigri
• A. niger, A. tubingensis
• Mainly cause otomycoses.
• Third leading cause of IPA aspergillosis
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Aspergillus species isolated from
immunocompromised patients in USA
1980-1997
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A. fumigatus complex
139 (93.9%) - A. Fumigatus
4 (2.7%) - A. Lentulus
3 (2.0%) - A. Udagawae
1- Neosartorya pseudofischeri
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Aspergillus spp 2012 & 2013
• Total -445
– 223 isolates from pus and tissue sample
– 169 isolates from respiratory samples
– 53 isolates from eye samples (from 2013 only)
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Respiratory samples
Isolates /
Samples
A. flavus
(90)
A. fumigatus
(57)
A.
terreus
(2)
Aspergillus
spp.
(20)
Total
Sputum
(77)
41/77 24/77 1/77 11/77 77
ETA
(45)
22/45 18/45 1/45 4/45 45
BAL
(30)
20/30
7/30
- 3/30
30
Others*
(17)
7/17 8/17 - 2/17 17
No of Isolates
/(percentage)
90/169
(53.25%)
57/169
(33.72)
2/169
(1.18%)
20/169
(11.83%)
169
* Majority of the samples were from pleural fluid and Gastric aspirates
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Pus / Tissue samples
Isolates /
samples
A. flavus
(204)
A. fumigatus
(11)
A.spp
(8)
Total
Fungal muck/
nasal tissue
173/186 7/186 6/187 186
Other samples* 31/37 4/37 2/37 37
No of Isolates
/(percentage)
204/223
(91.47%)
11/223
(4.93%)
8/223
(3.58%)
223
* Includes deep tissue samples, aneurysmal wall, brain tissue/ abscess, pus
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Eye sample (2013)
• Total - Aspergillus spp isolated- 53
• Aspergillus flavus- 47
• Aspergillus fumigatus- 3
• Aspergillus niger-3
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Aspergillus keratitis – Aravind eye
hospital
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Aspergillus keratitis – Aravind eye
hospital
Manikandan et al Mycoses 2012
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Aspergillus species sent for
identification to NCCPF
STRAINS DATE NCCPF NO.
A.niger 15/11/2012 790039
A.niger 15/03/2013 790038
A.niger 01-10-2013 790037
A.versicolor 23/3/2012 820016
A.versicolor 19/9/2012 820017
A.versicolor 19/9/2012 820018
A.versicolor 19/9/2012 820019
A.versicolor 19/9/2012 820020
A.versicolor 17/4/2012 820021
A.tetrazonous 06-07-2012 840010
A.tetrazonous 28/12/2012 840011
A.terreus 03-01-2012 860030
A.terreus 05-05-2012 860031
A.terreus 06-07-2012 860032
A.terreus 28/12/2012 860033
A.terreus 28/2/2013 860034
A.terreus 25/6/2013 860035
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Aspergillus in our hospital
Months Aspergillus Other Hyalo Mucor Dematiaceous Unidentified
AC
NON-
AC AC
NON-
AC AC
NON-
AC AC
NON-
AC AC
NON-
AC
Jan 37 64 13 4 2 2 17 10 0 0
Mar 94 133 0 0 38 2 9 0 0 0
Apr 9 65 0 5 3 0 58 162 3 5
May 48 115 0 0 0 0 10 0 0 0
June 84 90 0 0 6 10 0 0 0 0
July 47 89 0 0 6 10 3 0 0 0
Aug 100 178 16 4 0 6 0 0 0 0
Sept 45 76 0 0 0 0 16 8 0 2
Oct 34 118 2 4 2 0 70 28 8 4
Nov 38 54 13 42 0 0 9 0 3 0
Dec 50 44 0 6 0 2 0 0 6 0
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Aspergillus in our hospital
0
10
20
30
40
50
60
70
80
Jan March April May June July Aug Sept Oct Nov Dec
A. flavus A. fumigatus A. niger
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Epidemiology of antifungal resistance in Aspergillus
• Current treatment options of Aspergillus diseases
include three classes of antifungal agents
– polyenes (amphotericin B), echinocandins
(caspofungin) and azoles.
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Epidemiology of antifungal resistance in Aspergillus
• Voriconazole is the recommended first choice
therapy for invasive aspergillosis.
• Itraconazole is used for the treatment of chronic
and allergic conditions
• Posaconazole is used prophylactic agent to
prevent IA in patients with certain hematologic
malignancies.
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Itraconazole Resistance
• The first cases of itraconazole resistance were reported in late
1980s
• Vast majority have been detected since the turn of the
millennium.
• The frequency is largely undefined
– many centres do not routinely perform AFST for Aspergillus
• Resistance has currently been reported in Belgium, Canada,
China, Denmark, France, Norway, Spain, Sweden, The
Netherlands, UK and the USA.
• The frequency in these reports (~ 5,000 isolates) ranged from
0 – 6%, with an arithmetic mean of 2%
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Epidemiology of ITZ Resistance in the A. fumigatus Isolates
Snelders E, van der Lee HAL, Kuijpers J, Rijs AJMM, et al. (2008) Emergence of Azole Resistance in Aspergillus fumigatus and Spread of a Single
Resistance Mechanism. PLoS Med 5(11): e219. doi:10.1371/journal.pmed.0050219
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050219
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Azole resistance in the A. fumigatus
• The frequencies in UK (Manchester) and The Netherlands (Nijmegen) is 5 and 6% respectively.
• Cross-resistance to other azoles are common – Among itraconazole resistant isolates -74% resistant to posaconazole
and 65% to voriconazole
Howard et al Emerg Infect Dis 2009
• Current data suggests azole resistance is acquired by two routes – In- situ within the lung (chronic aspergillosis cases on long term
therapy)
– Acquisition of a resistant A. fumigatus from the environment driven by agricultural use of 14α- demethylase inhibitors (DMI).
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• Study period 1315 A. fumigatus isolates from 921 patients screened for resistance.
• Prevalence of azole resistance was 6.8% (63 of 921 patients)
• TR34/L98H - 74.6% (47/63)
• TR46/Y121F/T289A –20.6% (13 patients)
• No mutation in Cyp51A - 3 patients
• Microsatellite genotypes of the clinical and environmental resistant
TR 46 /Y121F/T289A isolates, compared with TR 34/L98H and
wild-type controls
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Dendrogram of all 28 isolates with elevated triazole MIC values. Isolates with the TR/L98H mutation are marked with an asterisk
Survey of 497 A.
fumigatus
• Years 2008-2009
• Part of ARTEMIS global surveillance
study
28 isolates with high
triazole MICs
From: Brazil, China,
Czech Republic,
Portugal, USA
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2 isolates ( 1.9%) with high triazole MICs
Itra MIC: >16
Vori MIC: 2
Posa MIC: 2
Isavu MIC: 8
Isolates are from patients with chronic
respiratory disease who are azole-naive
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Transplant Associated Infection
Surveillance Network
Baddely et al JCM 2009
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Organism n Lip AMB
Range MIC50 MIC90
AMB
Range MIC50 MIC90
VOR
Range MIC50 MIC90
ITR
Range MIC50 MIC90
Aspergillus
species
37 0.06-2 0.25 0.5 0.5-4 1 1 0.125-4 0.25 0.5 0.125-
16
0.25 >16
A. flavus 23 0.06-
0.5
0.25 0.5 0.5-2 0.5 1 0.125-1 0.25 0.5 0.125-
16
0.125 >16
A. fumigatus 12 0.125-
0.25
0.125 0.5 0.5-1 1 1 0.125-
0.5
0.125 0.25 0.125-
0.5
0.25 0.5
A. oryzae 2 1-2 1-2 ND 2-4 2-4 ND 0.5-4 0.5-4 ND 0.5-4 0.125 ND
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Clin Infect Dis 2013
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ECDC TECHNICAL REPORT
on
Risk assessment on the impact of
environmental usage of triazoles on the
development and spread of resistance to
medical triazoles in Aspergillus species
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Use of triazoles and other sterol demethylation
inhibitor (DMI) fungicides in agriculture
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Use of triazole fungicides in the production of
selected crops/commodities in the United
Kingdom
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Non-agricultural use of triazole
fungicides
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Countries where A. fumigatus with the
TR34/L98H and percentage of agricultural
fungicide use
Stensvold et al, Curr Fungal Infect Rep 2012
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What happens if we do nothing?
• If left unchecked, azole resistance could
continue to spread in the environment
• development of novel resistance mechanisms
in the environment
• acquisition of an azole-resistant strain of
Aspergillus spp. will likely go unnoticed until
the patient fails initial treatment
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Recommendations
• Improve epidemiological surveillance through − Routi e triazole sus epti ilit testi g for li i al isolates − I reased a d o ti uous sur eilla e of triazole resista e i A.
fumigatus in each EU Member State
• Develop molecular methods to detect triazole resistance in culture-negative specimens and implement them in laboratory practice.
• Investigate the environmental origin through environmental and laboratory studies − Field studies ith differe t triazoles hi h are putati e resista e
generators
− E te si e a d o ti ued e iro e tal studies
− No -agricultural studies
− Studies o the re ersal of risi g resista e rates restri ti g ertai triazole applications
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