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Azole-Resistance in Aspergillus terreus and Related Species: An Emerging Problem or a Rare Phenomenon?
Tamara Zoran1, Bettina Sartori1, Laura Sappl1
1Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
Abstract:
Objectives: Invasive mold infections associated with Aspergillus species are a significant cause of mortality in immunocompromised patients. The most frequently occurring aetiological pathogens are members of the Aspergillus section Fumigati followed by members of the section Terrei. The frequency of Aspergillus terreus and related (cryptic) species in clinical specimens, as well as the percentage of azole-resistant strains remains to be studied. Methods: A global set (n = 498) of A. terreus and phenotypically related isolates was molecularly identified (beta-tubulin), tested for antifungal susceptibility against posaconazole, voriconazole, and itraconazole, and resistant phenotypes were correlated with point mutations in the cyp51A gene. Results: The majority of isolates was identified as A. terreus (86.8%), followed by A. citrinoterreus (8.4%), A. hortai (2.6%), A. alabamensis (1.6%), A. neoafricanus (0.2%), and A. floccosus (0.2%). One isolate failed to match a known Aspergillus sp., but was found most closely related to A. alabamensis. According to EUCAST clinical breakpoints azole resistance was detected in 5.4% of all tested isolates, 6.2% of A. terreus sensu stricto (s.s.) were posaconazole-resistant. Posaconazole resistance differed geographically and ranged from 0% in the Czech Republic, Greece, and Turkey to 13.7% in Germany. In contrast, azole resistance among cryptic species was rare 2 out of 66 isolates and was observed only in one A. citrinoterreus and one A. alabamensis isolate. The most affected amino acid position of the Cyp51A gene correlating with the posaconazole resistant phenotype was M217, which was found in the variation M217T and M217V. Conclusions:Aspergillus terreus was most prevalent, followed by A. citrinoterreus. Posaconazole was the most potent drug against A. terreus, but 5.4% of A. terreus sensu stricto showed resistance against this azole. In Austria, Germany, and the United Kingdom posaconazole-resistance in all A. terreus isolates was higher than 10%, resistance against voriconazole was rare and absent for itraconazole.
Insights
Invasive mold infections caused by Aspergillus species are a significant threat. This study found that while Aspergillus terreus is prevalent, 5.4% of strains show resistance to posaconazole, a key antifungal drug.
Area of Science:
- Mycology
- Infectious Diseases
- Antimicrobial Resistance
Background:
- Invasive mold infections, particularly those caused by Aspergillus species, are a major cause of mortality in immunocompromised individuals.
- Aspergillus section Fumigati and Terrei are the most frequent etiological agents, but the prevalence of Aspergillus terreus and related species, along with their azole resistance, requires further investigation.
Purpose of the Study:
- To determine the frequency of Aspergillus terreus and phenotypically related species in clinical isolates.
- To assess the antifungal susceptibility of these isolates to posaconazole, voriconazole, and itraconazole.
- To correlate azole resistance phenotypes with specific mutations in the cyp51A gene.
Main Methods:
- Molecular identification of 498 Aspergillus terreus and related isolates using beta-tubulin gene sequencing.
- Antifungal susceptibility testing against posaconazole, voriconazole, and itraconazole according to EUCAST clinical breakpoints.
- Genomic analysis to identify point mutations in the cyp51A gene associated with drug resistance.
Main Results:
- Aspergillus terreus was the predominant species (86.8%), followed by A. citrinoterreus (8.4%).
- Overall azole resistance was detected in 5.4% of isolates; 6.2% of A. terreus sensu stricto were posaconazole-resistant, with geographic variations.
- Posaconazole resistance was linked to M217T/V mutations in the cyp51A gene, while resistance to voriconazole was rare and itraconazole resistance was absent.
Conclusions:
- Aspergillus terreus and A. citrinoterreus are the most common species causing invasive infections.
- A significant proportion of A. terreus sensu stricto isolates exhibit posaconazole resistance, necessitating careful monitoring and treatment strategies.
- Antifungal resistance patterns vary geographically, highlighting the importance of regional surveillance for effective management of invasive aspergillosis.
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