<Emphasis Type="Italic">Candida auris</Emphasis>: Antifungal Multi-Resistant Emerging Yeast

Purpose of Review

The purpose of this review is to contribute to the knowledge about the existence of Candida auris as an emerging pathogenic fungus, multi-resistant to antifungal, and causing health care-associated infections (HCAI).

Recent Findings

C. auris emerges as yeast with clonal transmission resistance to three families of commonly used antifungals, mainly azoles (fluconazole and voriconazole), diminishing therapeutic options for the treatment of fungal infections. In 2009, C. auris was isolated for the first time in Japan and by the time of this review, it has been reported in different countries in Africa, America, Asia, and Europe.

Summary

It is important to identify yeasts of the Candida genus up to species, to perform susceptibility tests and to implement surveillance, prevention, and control measures, to minimize the global spread of this fungus, due to its impact on public health.

     

Fungal Eye Infections: New Hosts,Novel Emerging Pathogens but No New Treatments?

Purpose of Review

We sought to explore the current incidence and associated risk factors associated with fungal eye infections. We also reviewed new diagnostic strategies and recent clinical studies exploring the use of topical and oral antifungal agents.

Recent Findings

Incidence and associated risks continue to vary with geographic region, and access to timely healthcare. Nosocomial fungal endophthalmitis can result from minor surgical procedures to the eye. Molecular methods offer increasing diagnostic utility. Clinical treatment studies have mainly focussed on the treatment of fungal keratitis and have been conducted in South Asia. Topical natamycin remains superior to topical reconstituted voriconazole and remains the preferred therapy including for Fusarium eye infections. Neither adjunctive oral ketoconazole nor oral voriconazole has been shown to have added clear benefit to topical treatment.

Summary

Larger international studies with more heterogenous populations are required for future clinical studies which should include patients with contact lens fungal keratitis and those with fungal endophthalmitis. Basic science studies exploring the immunology of fungal eye infections and drug levels to understand the differences in clinical outcomes are encouraged.

     

Clinical Implications of <Emphasis Type="Italic">Candida</Emphasis> Biofilms

Purpose of Review

In this review, we will assess what is currently known about Candida biofilms, its epidemiology and impact on clinical practice, and the biology underlying biofilm-related antifungal drug resistance. We also review potential antifungal lock therapies and discuss what avenues are available for future discoveries for the prevention and eradication of fungal biofilms.

Recent Findings

There is a multitude of in vitro tests of agents against Candida biofilms, but many of these studies have not demonstrated their utility against other Candida species and/or their efficacy in in vivo systems. This makes it particularly difficult to translate these findings for use in the clinical setting.

Summary

Research has helped us to understand the complexity of biofilms and its inherent antifungal resistance. The extracellular matrix remains a significant barrier for most antifungal therapy, and thus it stands to reason that agents directed at disrupting this protective barrier could be useful in antifungal lock therapies.

     

Emergence of Resistance to Fluconazole in <Emphasis Type="Italic">Candida albicans</Emphasis> Isolated From Vaginal Discharge

Purpose of Review

To provide information about the emergence of fluconazole resistance in Candida albicans isolated from vaginal discharge, in a global context, and to update the in vitro susceptibility profile of this species from Argentina.

Recent Findings

Vulvovaginal candidiasis is the second most common vaginal infection after vaginal bacteriosis. C. albicans remains the prevalent etiological yeast species, and despite antifungal treatment, the rate of recurrence remains high, which may be associated to antifungal resistance.

Summary

Data here presented were obtained from the study of C. albicans strains isolated from patients with clinical signs of vulvovaginal candidiasis from 1996 to 2017. Data obtained could represent the susceptibility profile of C. albicans strains circulating in Argentina and could be of potential usefulness to monitor and guide therapy, and also suggests the need for greater surveillance programs to detect fluconazole resistance over time.

     

Invasive Fungal Infection in Primary Immunodeficiencies Other Than Chronic Granulomatous Disease

Purpose of review

We aimed to review invasive fungal infections complicating primary immunodeficiencies (PID).

Recent findings

Several PID predisposing to fungal infections were recently deciphered. CARD9 deficiency selectively predisposes to fungal infections including candidiasis, aspergillosis, deep dermatophytosis, and phaeohyphomycosis, with frequent central nervous system location, especially after Candida infection. Patients with heterozygous STAT1 gain-of-function mutations are mostly predisposed to chronic mucocutaneous candidiasis but may also display, even though less frequently, invasive fungal infections. Aspergillosis complicating STAT3 deficiency is also a major concern in patients with lung cavities. Antifungal prophylaxis is recommended in this first group of patients. Previously well-reported PID are known to predispose to fungal infections, such as genetic defects impairing the IL-12/IFN-γ axis can predispose to cryptococcosis, and dimorphic fungal infections.

Summary

Patients developing invasive fungal infections including candidiasis, aspergillosis, cryptococcosis, phaeohyphomycosis, pneumocystosis, or disseminated infections caused by dimorphic fungi, without known underlying risk factors, should be explored immunogenetically in order to diagnose primary immunodeficiencies, even in the absence of previous other infectious episodes.

     

Epidemiology and Management of Candidiasis in Solid Organ Transplant Recipients

Purpose of Review

Invasive candidiasis (IC) is the leading cause of fungal infections in solid organ transplant recipients (SOT). In this article, we aim to review the epidemiology, risk factors, presentation, and management of IC in this population.

Recent Findings

Certain risk factors have been associated with IC in SOT recipients. Targeted antifungal prophylaxis for SOT recipients at the highest risk of infection is currently recommended although the choice and duration of antifungal agents remain controversial. Early diagnosis and monitoring of IC in SOT recipients are critical to achieve better outcomes and prevent serious complications. Non-culture-based diagnostic modalities have been introduced to aid in earlier and more accurate diagnosis.

Summary

The use of azoles for prophylaxis or treatment in SOT recipients allowed for selection of resistance and increased the incidence of non-albicans Candida. Drug–drug interactions, cost, and risk of resistance are to be considered when using more potent or newer antifungal agents.

     

Antifungal Dosing Strategies for Critically Ill Patients

Purpose of review

This article provides updates on antifungals, dosing strategies for safe and effective therapy in the critically ill, including special populations, and the understanding of resistance over the last 5 years.

Recent findings

Reports of adverse effects with echinocandins have risen while antifungal resistance to this class has increased, especially in Candida glabrata. New formulations of posaconazole and isuvaconazole have been developed. Alternative dosing strategies including combination therapy are being evaluated for difficult to treat fungal infections. Other highlights include additional data on dosing patients with severe organ dysfunction, including those on continuous renal replacement therapy, and new breakpoints for individual Candida species being established for the echinocandins and triazole classes.

Summary

Increasing resistance in Candida spp. has made susceptibility testing a standard of care for critically ill patients. New formulations of the triazole antifungals have made prevention and treatment of mold infections more of a reality. There are many implications that must be considered when treating critically ill patients due to alterations in pharmacokinetics and pharmacodynamics in order to ensure adequate treatment. This article exposes the need for further clinical research in treating invasive infections in this patient population.

     

Impact of New Diagnostic Approaches for Invasive Candidiasis on Antifungal Stewardship

Background

Invasive candidiasis (IC) including candidemia and deep-seated candidiasis is associated with up to 50 % overall mortality and up to $80,000 in attributable cost (2015 US$). Rapid diagnostic tests (RDTs) for Candida have been developed. However, whether RDTs along with real-time decision support translate to better attainment of stewardship goals—improve clinical outcomes, minimize unintended consequences of antifungal use, and reduce healthcare costs—is unknown. The purpose of this systematic review was to provide an up-to-date review of recently published studies that have assessed how RDTs for IC impact attainment of these goals.

Methods

Three electronic bibliographic databases were searched using a pre-defined search strategy evaluating the impact of RDTs for IC on attainment of antifungal stewardship goals. Quality assessments were performed by two reviewers using established study methodology metrics.

Results and Conclusions

Eight studies were identified of which five had sufficient information to be included in the review. Despite the limitations of the various studies and the different methodologies employed, the studies all produced similar conclusions. Compared to conventional methods and baseline stewardship activities, the integration of RDTs for IC and real-time decision support, mainly through antifungal stewardship, was associated with decreased mortality, more optimal use of antifungals, and reduced healthcare costs. However, larger clinical studies are needed to confirm these trends.

     

Candidemia in Adults at a Tertiary Hospital in China: Clinical Characteristics,Species Distribution,Resistance, and Outcomes

Background

Candidemia is one of the most common nosocomial bloodstream infections. Early diagnosis and antifungal treatment improve clinical outcomes in some studies but not all, with diverse data reported from different institutions. Similarly, antifungal resistance is more common in the USA than in Europe, but there is little data regarding the microbiology and clinical course of candidemia in adult patients in Asia.

Aims

(1) To capture species distribution and drug resistance rates among Candida bloodstream isolates, (2) to describe clinical features of candidemia, and (3) to identify factors associated with all-cause mortality, with emphasis on early initiation of antifungal treatment, at a large tertiary University Hospital in China.

Methods

In this single-center retrospective study, we identified all patients with candidemia, between 2008 and 2014. Demographic and clinical characteristics, microbiological information, details of antifungal therapy and clinical outcomes were collected.

Results

We studied 166 patients. 71 (42.8%) had cancer. Candida albicans was the most frequent species (37.3%), followed by C. parapsilosis (24.1%), C. tropicalis (22.8%), and C. glabrata (14.5%). Antifungal resistance was more frequent in non-albicans strains and especially C. glabrata. Twenty patients received inappropriate treatment with all-cause mortality of 35%. The remaining 146 patients had significantly lower mortality (21.9%, P?=?0.045). Among patients who received antifungal treatment, mortality rate increased with time to appropriate antifungal therapy (AAT): 13.7%, for?<?24 h, 21.1% for 24–48 h, 23.1% for?>?48 h, and 32.4% among patients who received no AT (χ² for trend P?=?0.039). Initiating AAT more than 24 h after blood culture collection was an independent risk factor for mortality, after adjustment for other confounders (OR 7.1, 95% CI 1.3–39.4, P?=?0.024).

Conclusions

Candida albicans was the most frequent cause of candidemia at a large tertiary hospital in China, but antifungal resistance is a growing concern among non-albicans Candida species. The mortality rate of patients treated with ineffective antifungal agents based on in vitro susceptibilities was similar to that of patients who received no treatment at all, and delayed initiation of antifungal treatment was associated with increased risk of death.

     

Lateral Flow Assays for the Diagnosis of Invasive Aspergillosis: Current Status

Purpose of Review

Diagnosis during early stages of invasive aspergillosis (IA) and targeted antifungal treatment has the potential to improve survival significantly. Despite advances in the diagnostic arsenal, invasive mold infections remain difficult to diagnose—especially at early stages before typical radiological signs develop. Varying availability and time-to-results are important limitations of current approved biomarkers and molecular assays for diagnosis of IA. Here, we will give an update on the Aspergillus-specific lateral-flow device (LFD) test. We further review promising findings on feasibility of point-of-care (POC) detection of urinary excreted fungal galactomannan-like antigens.

Recent Findings

POC LFD assays for detection of Aspergillus antigens are currently in development. The Aspergillus-specific LFD test, which is based on the JF5 antibody (Ab), detects an extracellular glycoprotein antigen secreted during active growth of Aspergillus spp. The test has shown promising results in various studies. In addition, a monoclonal Ab476-based LFD for POC detection of urinary excreted fungal galactomannan-like antigens has been developed but needs further validation.

Summary

Important advances have been made in the development of LFD assays for IA. Most promising is the Aspergillus-specific LFD test; commercial availability is still pending, however. The search for reliable POC tests for other molds, including mucorales, continues.

     

PCR-Based Methods for the Diagnosis of Invasive Candidiasis: Are They Ready for Use in the Clinic?

Purpose of Review

We review the performance of Candida PCR and the T2Candida panel (T2Biosystems, Lexington, MA) in diagnosing invasive candidiasis, consider how these tests may be incorporated into patient care, and determine if they are ready to be used in the clinic.

Recent Findings

PCR and T2Candida sensitivity/specificity for diagnosing candidemia are ~?90%/90% and ~?90%/98%, respectively. Limited data for intra-abdominal candidiasis suggest PCR sensitivity of ~?85–90%, but specificity has varied from 33 to 97%. T2Candida data are lacking for infections other than candidemia.

Summary

PCR and T2Candida will have the greatest value if their use is restricted to cases in which positive and negative predictive values differ in a clinically meaningful way from the pre-test likelihood. Studies are needed to establish that patient care and stewardship strategies incorporating Candida PCR or T2Candida improve patients’ outcomes, reduce unnecessary antifungal usage, limit emergence of resistance, and are cost-effective. The development and validation of standardized PCR assays is a top priority.

     

Candidiasis of the Central Nervous System in Neonates and Children With Primary Immunodeficiencies

Purpose of review

Candida infections of the central nervous system (CNS) are a life-threatening complication of invasive infections that most often affect vulnerable groups of patients, including neonates and children with primary immunodeficiency disorders (PID). Here, we review the currently known risk factors for CNS candidiasis, focusing predominantly on the PID caused by biallelic mutations in CARD9.

Recent findings

How the CNS is protected itself against fungal invasion is poorly understood. CARD9 promotes neutrophil recruitment and function, and is the only molecule shown to be critical for protection against CNS candidiasis in humans thus far.

Summary

Fundamental insights into the pathogenesis of CNS candidiasis gained from studying rare CARD9-deficient patients has significant implications for other patients at risk for this disease, such as CARD9-sufficient neonates. These findings will be important for the development of adjunctive immune-based therapies, which are urgently needed to tackle the global burden of invasive fungal diseases.

     

Fungi as a source of marker compounds for the control of illicit use of drugs: mesterolone as a case study

Introduction

Anabolic steroids are frequently misused for performance enhancement during sports competitions. One of the major bottlenecks in the confident analysis of steroids and their metabolites is the non-availability/cost of standard reference compounds.

Objective

The study objective was to identify the common metabolites of prohibited anabolic steroids that are produced in both fungi and human and thus can be synthesized in bulk using fungal cultures. Mesterolone is used as a case study.

Methods

The study was conducted in three steps; we first studied the fungal transformation of mesterolone. In the second step, these metabolites were used as references to detect in human urine after the oral use of mesterolone using LC-ESI-QqQ-MS/MS. In the third step, 12 fungal cultures were screened to evaluate their potential to produce reference markers.

Results

This led to the detection of two metabolites, 6α-hydroxymesterolone (M1) and 7α-hydroxymesterolone (M2) that were found to be common in both, fungal cultures and human urine samples. Moreover, Rhizopus stolonifer and Beauveria bassiana can be considered as good candidates to produce M1 and M2 metabolites, respectively.

Conclusion

This approach can be employed for the synthesis of marker compounds of other prohibited anabolic steroids thus can be detected efficiently during national and international sports competitions.

     

Metabolic response of porcine colon explants to in vitro infection by <Emphasis Type="Italic">Brachyspira hyodysenteriae</Emphasis>: a leap into disease pathophysiology

Introduction

Swine dysentery caused by Brachyspira hyodysenteriae is a production limiting disease in pig farming. Currently antimicrobial therapy is the only treatment and control method available.

Objective

The aim of this study was to characterize the metabolic response of porcine colon explants to infection by B. hyodysenteriae.

Methods

Porcine colon explants exposed to B. hyodysenteriae were analyzed for histopathological, metabolic and pro-inflammatory gene expression changes.

Results

Significant epithelial necrosis, increased levels of l-citrulline and IL-1α were observed on explants infected with B. hyodysenteriae.

Conclusions

The spirochete induces necrosis in vitro likely through an inflammatory process mediated by IL-1α and NO.

     

Arbuscular mycorrhizal fungi can shift plant-soil feedback of grass-endophyte symbiosis from negative to positive

Background and aims

Variations in root-associated fungal communities contribute to the so-called ‘crop rotation benefit’ on soil productivity. We assessed the effects of chickpea, lentil, and pea in wheat-based rotations, as compared to wheat monoculture, on the structure of root-associated fungal communities, and described the legacy of pulses on a following wheat crop.

Methods

The internal transcribed spacer (ITS) and 18S rRNA gene markers, and 454 amplicon pyrosequencing were used to describe the fungal communities of crop roots and rhizosphere soil in a field experiment and agronomic data were collected.

Results

Pulses influenced only the structure of the non-mycorrhizal fungal community of roots. Fusarium tricinctum, Clonostachys rosea, Fusarium redolens, and Cryptococcus sp. were specific to certain crops. Despite the absence of selective effects of pulses on their associated arbuscular mycorrhizal (AM) fungal community, pea had a legacy effect on the structure of the AM fungal community associated with the roots of the following wheat crop, in one of the two year/sites examined. Species of Mortierella, Cryptococcus, and Paraglomus in wheat rhizosphere soil may benefit yield, whereas species of Fusarium, Davidiella, Lachnum, Sistotrema and Podospora may reduce yield.

Conclusion

The effect of pulse crops on root fungal communities varied with rotation crop species. Pulses had various effects on the physiology of the following wheat crop, including increased productivity.

     

Correction to: Neighbourhood stories: role of neighbour identity,spatial location and order of arrival in legume and non-legume initial interactions

Background and aims

We characterized fungal endophytes of seeds of invasive, non-native Phragmites from three sites in the Great Lakes region to determine if fungal symbiosis could contribute to invasiveness through their effects on seed germination and seedling growth.

Methods

Field-collected seeds were surface sterilized and plated on agar to culture endophytes for ITS sequencing. Prevalence of specific endophytes from germinated and non-germinated seeds, and from seedlings, was compared.

Results

One-third of 740 seeds yielded endophyte isolates. Fifteen taxa were identified with Alternaria sp. representing 54% of all isolates followed by Phoma sp. (21%) and Penicillium corylophilum (12%). Overall germination of seeds producing an isolate (36%) was significantly higher than seeds not producing an isolate (20%). Penicillium in particular was strongly associated with increased germination of seeds from one site. Sixty-three isolates and 11 taxa were also obtained from 30 seedlings where Phoma, Penicillium and Alternaria respectively were most prevalent. There was a significant effect of isolating an endophyte from the seed on seedling growth.

Conclusions

These results suggest that many endophyte taxa are transmitted in seeds and can increase seed germination and seedling growth of invasive Phragmites. The role of fungal endophytes in host establishment, growth and invasiveness in nature requires further research.

     

Role of Serological Tests in the Diagnosis of Mold Infections

Purpose of Review

To understand the role of antibody detection in the diagnosis of infections caused by filamentous fungi (molds). Rapid and accurate profiling of infection-causing fungal pathogens remains a significant challenge in modern health care. Classical fungal culture and serology continue to be relevant even though over the past few decades, antigen (biomarker) assays such as ELISA and lateral flow devices have been developed and validated.

Recent Findings

This article reviews the current antibody detection systems (serological tests) for the diagnosis of mold infections associated with pulmonary disease and introduces new developments. Classic and more recently developed serological techniques and their performance characteristics, including immunodiffusion, complement fixation, and ELISA.

Summary

The diseases covered are allergic bronchopulmonary aspergillosis, chronic pulmonary aspergillosis, invasive aspergillosis, mucormycosis, diseases caused by filamentous basidiomycetes, infection caused by Talaromyces marneffei and pythiosis. Serology remains a cornerstone for fungal diagnostic testing.

     

Iridoid and phenylethanoid/phenylpropanoid metabolite profiles of <Emphasis Type="Italic">Scrophularia</Emphasis> and <Emphasis Type="Italic">Verbascum</Emphasis> species used medicinally in North America

Introduction

Botanicals containing iridoid and phenylethanoid/phenylpropanoid glycosides are used worldwide for the treatment of inflammatory musculoskeletal conditions that are primary causes of human years lived with disability, such as arthritis and lower back pain.

Objectives

We report the analysis of candidate anti-inflammatory metabolites of several endemic Scrophularia species and Verbascum thapsus used medicinally by peoples of North America.

Methods

Leaves, stems, and roots were analyzed by ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) and partial least squares-discriminant analysis (PLS-DA) was performed in MetaboAnalyst 3.0 after processing the datasets in Progenesis QI.

Results

Comparison of the datasets revealed significant and differential accumulation of iridoid and phenylethanoid/phenylpropanoid glycosides in the tissues of the endemic Scrophularia species and Verbascum thapsus.

Conclusions

Our investigation identified several species of pharmacological interest as good sources for harpagoside and other important anti-inflammatory metabolites.

     

<Emphasis Type="Italic">massPix</Emphasis>: an R package for annotation and interpretation of mass spectrometry imaging data for lipidomics

Introduction

Mass spectrometry imaging (MSI) experiments result in complex multi-dimensional datasets, which require specialist data analysis tools.

Objectives

We have developed massPix—an R package for analysing and interpreting data from MSI of lipids in tissue.

Methods

massPix produces single ion images, performs multivariate statistics and provides putative lipid annotations based on accurate mass matching against generated lipid libraries.

Results

Classification of tissue regions with high spectral similarly can be carried out by principal components analysis (PCA) or k-means clustering.

Conclusion

massPix is an open-source tool for the analysis and statistical interpretation of MSI data, and is particularly useful for lipidomics applications.

     

The impact of <Emphasis Type="Italic">Carpobrotus</Emphasis> cfr. <Emphasis Type="Italic">acinaciformis</Emphasis> (L.) L. Bolus on soil nutrients,microbial communities structure and native plant communities in Mediterranean ecosystems

Background and aims

Carpobrotus spp. are amongst the most impactful and widespread plant invaders of Mediterranean habitats. Despite the negative ecological impacts on soil and vegetation that have been documented, information is still limited about the effect by Carpobrotus on soil microbial communities. We aimed to assess the changes in the floristic, soil and microbial parameters following the invasion by Carpobrotus cfr. acinaciformis within an insular Mediterranean ecosystem.

Methods

Within three study areas a paired-site approach, comparing an invaded vs. a non-invaded plot, was established. Within each plot biodiversity indexes, C and N soil content, pH and microbial biomass and structure (bacterial and fungal) were assessed.

Results

Invaded plots showed a decrease of α-species richness and diversity. The least represented plant species in invaded plots were those related to grassland habitats. In all invaded soils, a significant increase of carbon and nitrogen content and a significant decrease of pH were registered. Carpobrotus significantly increased bacterial and fungal biomass and altered soil microbial structure, particularly favoring fungal growth.

Conclusions

Carpobrotus may deeply impact edaphic properties and microbial communities and, in turn, these strong modifications probably increase its invasive potential and its ability to overcome native species, by preventing their natural regeneration.