Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline.

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Serious fungal infections in Canada.

There are currently no nationwide epidemiological data on fungal infections in Canada. We estimated the burden of serious fungal diseases using literature review and modeling, as per a methodology previously described by the LIFE program ( http://www.LIFE-worldwide.org ). Among the population of Canada (35.5 million in 2014), it was estimated that approximately 1.8% are affected by a serious fungal infection. Recurrent vulvovaginal candidiasis, severe asthma with fungal sensitization, and allergic bronchopulmonary aspergillosis are the most frequent infections, with population prevalences of 498,688 (1403/100,000), 73,344 (206/100,000), and 61,854 (174/100,000) cases, respectively. Over 3000 invasive fungal infections are estimated to occur annually, with incidences of 2068 cases (5.8/100,000) of invasive candidiasis, 566 cases (1.6/100,000) of invasive aspergillosis, 252 cases (0.71/100,000) of Pneumocystis pneumonia, 99 cases (0.28/100,000) of endemic mycoses, and 63 cases (0.18/100,000) of cryptococcosis. These estimates warrant validation through more formal epidemiological studies in Canada.

Invasive Saccharomyces cerevisiae in a liver transplant patient: case report and review of infection in transplant recipients.

Saccharomyces cerevisiae, an ascosporogenous yeast commonly used in the production of food, is an emerging infection in immunocompromised patients. We report the case of a 60-year-old man whose orthotopic liver transplant was complicated by S. cerevisiae fungemia and peritoneal abscess, successfully treated with caspofungin and drainage. We also review the literature of invasive saccharomycoses in recipients of hematologic and solid organ transplants.

Improvement in the outcome of invasive fusariosis in the last decade.

Invasive fusariosis (IF) has been associated with a poor prognosis. Although recent series have reported improved outcomes, the definition of optimal treatments remains controversial. The objective of this study was to evaluate changes in the outcome of IF. We retrospectively analysed 233 cases of IF from 11 countries, comparing demographics, clinical findings, treatment and outcome in two periods: 1985-2000 (period 1) and 2001-2011 (period 2). Most patients (92%) had haematological disease. Primary treatment with deoxycholate amphotericin B was more frequent in period 1 (63% vs. 30%, p <0.001), whereas voriconazole (32% vs. 2%, p <0.001) and combination therapies (18% vs. 1%, p <0.001) were more frequent in period 2. The 90-day probabilities of survival in periods 1 and 2 were 22% and 43%, respectively (p <0.001). In period 2, the 90-day probabilities of survival were 60% with voriconazole, 53% with a lipid formulation of amphotericin B, and 28% with deoxycholate amphotericin B (p 0.04). Variables associated with poor prognosis (death 90 days after the diagnosis of fusariosis) by multivariable analysis were: receipt of corticosteroids (hazard ratio (HR) 2.11, 95% CI 1.18-3.76, p 0.01), neutropenia at end of treatment (HR 2.70, 95% CI 1.57-4.65, p <0.001), and receipt of deoxycholate amphotericin B (HR 1.83, 95% CI 1.06-3.16, p 0.03). Treatment practices have changed over the last decade, with an increased use of voriconazole and combination therapies. There has been a 21% increase in survival rate in the last decade.

Endemic human blastomycosis in Quebec, Canada, 1988-2011.

Blastomycosis is a systemic fungal infection found in various parts of the world. A review of literature for Quebec, Canada revealed only few case reports with the most recent one dating back to 1993. However, whether Quebec represents an important endemic region for blastomycosis in North America is unknown. In this work we reviewed 158 cases of human blastomycosis documented in Quebec during 1988-2011 using microbiological records available from the provincial public health laboratory. The estimated annual incidence of blastomycosis in the province is was ~0·133 cases per 100 000 individuals with the highest rates of 0·79 and 0·46 cases per 100 000 recorded in South-eastern and South-western Quebec. Moreover, the annual incidence rate significantly increased over the past 20 years. This study for the first time establishes Quebec as an important endemic region for Blastomyces dermatitidis.

Concentration of antifungal agents within host cell membranes: a new paradigm governing the efficacy of prophylaxis.

Posaconazole prophylaxis has proven highly effective in preventing invasive fungal infections, despite relatively low serum concentrations. However, high tissue levels of this agent have been reported in treated patients. We therefore hypothesized that the intracellular levels of antifungal agents are an important factor in determining the success of fungal prophylaxis. To examine the effect of host cell-associated antifungals on the growth of medically important molds, we exposed cells to antifungal agents and removed the extracellular drug prior to infection. Epithelial cells loaded with posaconazole and its parent molecule itraconazole, but not other antifungals, were able to inhibit fungal growth for at least 48 h and were protected from damage caused by infection. Cell-associated posaconazole levels were 40- to 50-fold higher than extracellular levels, and the drug was predominantly detected in cellular membranes. Fungistatic levels of posaconazole persisted within epithelial cells for up to 48 h. Therefore, the concentration of posaconazole in mammalian host cell membranes mediates its efficacy in prophylactic regimens and likely explains the observed discrepancy between serum antifungal levels and efficacy.

V2O3(0001) surface termination: phase equilibrium.

Complementary but independent medium-energy and low-energy ion scattering studies of the (0001) surfaces of V(2)O(3) films grown on Pd(111), Au(111) and Cu(3)Au(100) reveal a reconstructed full O(3)-layer termination creating a VO(2) surface trilayer. This structure is fully consistent with previous calculations based on thermodynamic equilibrium at the surface during growth, but contrasts with previous suggestions that the surface termination comprises a complete monolayer of vanadyl (V=O) species.

Interactions of Aspergillus fumigatus with vascular endothelial cells.

Invasive aspergillosis is characterized by two different types of angioinvasion. During pulmonary aspergillosis, hyphae are initially outside of the pulmonary vasculature and they invade the endothelial cell lining of the blood vessels by passing from the abluminal to the luminal surface. Some of these hyphal fragments can break off and circulate in the bloodstream. In severely immunocompromised hosts, these blood-borne hyphal fragments adhere to the luminal surface of the endothelial cells and they penetrate the endothelial cell lining of the vasculature by passing from the luminal to the abluminal surface. We have set up in vitro models of luminal and abluminal endothelial cell invasion by Aspergillus fumigatus. Luminal invasion by hyphae results in both endothelial cell damage and stimulation of tissue factor expression. Abluminal invasion causes less endothelial cell damage than luminal invasion, but greater induction of endothelial cells genes encoding cytokines, leukocyte adhesion molecules and tissue factor. These differences in the endothelial cell response to luminal versus abluminal infection may indicate significant differences in the pathogenesis of hematogenously disseminated versus locally invasive versus aspergillosis.

Comparison of three methodologies for the determination of pulmonary fungal burden in experimental murine aspergillosis.

Quantitative culture, quantitative PCR and the galactomannan enzyme immunoassay (EIA) were compared for their ability to determine the pulmonary fungal burden in a murine model of invasive aspergillosis. Quantitative culture of specimens containing hyphae under-represented the absolute fungal burden in established infection when compared with the two other methods. The best correlation was observed between the two non-culture methods. Higher variability was observed with the galactomannan EIA when compared with quantitative PCR. Collectively, these data suggest that quantitative PCR is the preferred method for determination of the pulmonary fungal burden in experimental aspergillosis.

Effects of ploidy and mating type on virulence of Candida albicans.

Candida albicans is the most common fungal pathogen of humans. The recent discovery of sexuality in this organism has led to the demonstration of a mating type locus which is usually heterozygous, although some isolates are homozygous. Tetraploids can be formed between homozygotes of the opposite mating type. However, the role of the mating process and tetraploid formation in virulence has not been investigated. We describe here experiments using a murine model of disseminated candidiasis which demonstrate that in three strains, including CAI-4, the most commonly used strain background, tetraploids are less virulent than diploids and can undergo changes in ploidy during infection. In contrast to reports with other strains, we find that MTL homozygotes are almost as virulent as the heterozygotes. These results show that the level of ploidy in Candida albicans can affect virulence, but the mating type configuration does not necessarily do so.

Risk factors for nosocomial candiduria due to Candida glabrata and Candida albicans.

The aims of this study were to analyze the clinical characteristics and risk factors associated with catheter-associated candiduria due to Candida glabrata and due to Candida albicans and to compare patients with candiduria due to C. glabrata or C. albicans (cases) with controls. Controls were a randomly chosen sample of inpatients with Foley catheters for whom urine cultures were negative for Candida species. Univariate and multivariate analyses were performed. There were 40 cases of C. glabrata candiduria and 289 cases of C. albicans candiduria. Factors strongly associated with both C. albicans candiduria and C. glabrata candiduria were female gender (P <. 05) and being in the intensive care unit (P <. 01). Fluconazole use (adjusted odds ratio, 4.37; P <. 01) and quinolone use (adjusted odds ratio, 3.16; P <. 01) were specifically associated with C. glabrata candiduria but not with C. albicans candiduria. In conclusion, patients receiving fluconazole treatment are at risk of developing C. glabrata candiduria.

Entamoeba histolytica and Entamoeba dispar: epidemiology and comparison of diagnostic methods in a setting of nonendemicity.

Recent studies suggest that stool antigen assays are more sensitive and specific than microscopy for the diagnosis of Entamoeba histolytica infection. One hundred twelve patients presenting at 3 centers with symptoms or risk factors of E. histolytica infection were prospectively enrolled in this study to evaluate new diagnostic tests for infections with E. histolytica and Entamoeba dispar. Four ELISA-based stool antigen kits for detecting E. histolytica or E. dispar were blindly compared with stool microscopy. Amebic serology was assessed by indirect hemagglutination. When antigen assays were used as the reference standard, microscopy performed at referral centers was more specific (68.4% vs. 9.5%) but less sensitive (70.4% vs. 92.1%) than microscopy performed in community laboratories. Diagnosis with the E. histolytica test and Merlin Optimun S ELISA indicated that only 3 (4.2%) of 72 coproantigen-positive stools were positive for E. histolytica. Indirect hemagglutination was a good predictor of E. histolytica infection when titers of antibody to ameba were >/=1:512.

Simple strategy for direct identification of medically important yeast species from positive blood culture vials.

We compared direct inoculation of the Auxacolor yeast identification system from positive blood culture vials to standard identification with the API 20C AUX (API 20C), using 44 prospectively collected clinical specimens and 25 seeded blood culture vials. Direct inoculation of the Auxacolor system was accurate and more rapid than standard identification with the API 20C.

Streptococcus pneumoniae transmission in chronic-care facilities: description of an outbreak and review of management strategies.

We report an outbreak of invasive Streptococcus pneumoniae disease in a chronic-care facility with a documented immunization rate of only 2.5%. We describe and discuss the infection control strategies used in prevention and management of such outbreaks, highlighting the role of immunization and presumptive chemotherapy.

Evaluation of the auxacolor system for biochemical identification of medically important yeasts.

We compared the Auxacolor yeast identification system (Sanofi Diagnostics Pasteur) with the API 20C Aux (bioMerieux-Vitek) using 105 isolates of medically important yeasts. The Auxacolor system provided more rapid, accurate results and displayed less interobserver variability than the API 20C Aux.

Onset of resistance to fenvalerate, a pyrethroid insecticide in Argentine horn flies (Diptera: Muscidae).

Haematobia irritans (L.) horn flies recently have immigrated into Argentina from Brazil or Paraguay. Bioassays were conducted with fenvalerate to develop baseline information on pyrethroid susceptibility. Four populations tested in 1994 and 1995 were more susceptible than a laboratory strain of horn fly not exposed to insecticides since 1970, but 3 populations from Corrientes Province tested in 1996 were moderately resistant to fenvalerate, with resistance ratios ranging from 3 to 26. Argentine horn fly populations were exposed to pyrethroid treatments of pour-on, spray, and dip formulations for 4 yr before developing resistance. Horn flies in the United States developed pyrethroid resistance after 2 yr of treatment with pyrethroid ear tags.

High levels of pyrethroid resistance in horn flies (Diptera: Muscidae) selected with cyhalothrin.

Lambdacyhalothrin cattle ear tags controlled horn fly, Haematobia irritans (L.), for 14 wks or longer during 1986-1988 in Georgia, USA. In 1989 and 1990, control of < 50 horn flies per side of cow was achieved for < or = 4 wk because of high levels of pyrethroid resistance in horn flies selected with lambdacyhalothrin. The highest resistance ratios (RRs) were seen in 1989. These were 498 for lambdacyhalothrin; 92,000 for fenvalerate; and 54 for permethrin. RRs for cypermethrin as high as 8,800 were estimated in 1990 when the RR for fenvalerate was only 1,060. No cross-resistance to diazinon was detected. These high levels of pyrethroid resistance seem to have a large component of metabolic resistance. Synergistic coefficients as high as 3,600 were determined by addition of nonlethal amounts of piperonyl butoxide. Resistance development in a no-pyrethroid-use area indicates movements of > or = 3km by sufficient numbers of horn flies can significantly change the RR.

Effect of temperature on toxicity of three pyrethroids to horn flies.

Predictive models describing best-fit regression equations for per cent mortality of horn flies as a function of temperature were determined for each of three pyrethroid insecticides (fenvalerate, flucythrinate and permethrin) over the temperature range 20-35 degrees C. Susceptible horn flies, Haematobia irritans (L.), were exposed to c. an LC70 dose of each pyrethroid using a residue-on-glass method. This technique used confined exposure in chambers with temperatures of 20, 25, 30 and 35 degrees C. Within this range, mortality was greatest at 25 degrees C with all three insecticides. Estimated temperature-mortality equations for each pyrethroid revealed different responses of horn flies to each of these insecticides. Horn flies exposed to flucythrinate demonstrated a linear mortality response that varied inversely with temperature. The response to permethrin was described by a quadratic equation, while the response to fenvalerate was best fitted by a cubic equation.