Prospective multicentre study on azole resistance in Aspergillus isolates from surveillance cultures in haematological patients in Italy.

OBJECTIVES: This study was conducted to assess the prevalence of azole resistance in Aspergillus isolates from patients with haematological malignancies or who were undergoing haematopoietic stem cell transplantation and to identify the molecular mechanism of resistance. METHODS: In this 28-month prospective study involving 18 Italian centres, Aspergillus isolates from surveillance cultures were collected and screened for azole resistance, and mutations in the cyp51A gene were identified. Resistant isolates were genotyped by microsatellite analysis, and the allelic profiles were compared with those of resistant environmental and clinical isolates from the same geographical area that had been previously genotyped. RESULTS: There were 292 Aspergillus isolates collected from 228 patients. The isolates belonged mainly to the section Fumigati (45.9%), Nigri (20.9%), Flavi (16.8%) and Terrei (4.8%). Three isolates showed itraconazole resistance: Aspergillus fumigatus sensu stricto, Aspergillus lentulus (section Fumigati) and Aspergillus awamori (section Nigri). The itraconazole resistance rates were 1% and 1.48% considering all Aspergillus spp. isolates and the Aspergillus section Fumigati, respectively. The prevalence of azole resistance among all the patients was 1.3%. Among patients harbouring A. fumigatus sensu stricto isolates, the resistance rate was 0.79%. The A. fumigatus isolate, with the TR34/L98H mutation, was genotypically distant from the environmental and clinical strains previously genotyped. CONCLUSIONS: In this study, the Aspergillus azole resistance rate was 1% (3/292). In addition to A. fumigatus sensu stricto, A. lentulus and A. awamori azole-resistant isolates were identified. Therefore, it is important have a correct identification at the species level to address a rapid therapy better, quickly understand the shift towards cryptic species and have an updated knowledge of the local epidemiology.

Evolution of fungemia in an Italian region.

BACKGROUND: Fungemia represents a public health concern. Knowing aetiology and activity of the antifungals is critical for the management of bloodstream infections. Therefore, surveillance on local/international levels is desirable for a prompt administration of appropriate therapy. METHODS: Data on fungi responsible for fungemia and antifungal susceptibility profiles were collected from a laboratory-based surveillance over 2016-2017 in 12 hospitals located in Lombardia, Italy. The trend of this infection in twenty years was analysed. RESULTS: A total of 1024 episodes were evaluated. Rate of candiaemia progressively increased up to 1.46/1000 admissions. C.albicans was the most common species (52%), followed by C. parapsilosis (15%) and C glabrata (13%). As in the previous surveys the antifungal resistance is rare (echinocandins<2%, fluconazole 6%, amphotericin B 0.6%). Fungi other than Candida were responsible for 18 episodes: Cryptococcus neoformans (5 cases), Fusarium spp. (4), Magnusiomyces clavatus (3), Saccharomyces cerevisiae (3), Rhodotorula spp. (2), Exophiala dermatitidis (1). All fungi, except S.cerevisiae, were intrinsically resistant to echinocandins. Some isolates showed also elevated azole MIC. CONCLUSIONS: No particular changes in terms of species distribution and antifungal susceptibility patterns was noted. However, surveillance programs are needed to monitor trends in antifungal resistance, steer stewardship activities, orient empirical treatment.

Muon-Electron Scattering at Next-To-Next-To-Leading Order: The Hadronic Corrections.

The standard model prediction for muon-electron scattering beyond leading order requires the inclusion of QCD contributions which cannot be computed perturbatively. At next-to- and next-to-next-to-leading order, they arise from one- and two-loop diagrams with hadronic vacuum polarization insertions in the photon propagator. We present their evaluation using the dispersive approach with hadronic e^{+}e^{-} annihilation data and estimate their uncertainty. We find that these corrections are crucial for the analysis of future high-precision muon-electron scattering data, like those of the recently proposed MUonE experiment at CERN.

Method-Dependent Epidemiological Cutoff Values for Detection of Triazole Resistance in Candida and Aspergillus Species for the Sensititre YeastOne Colorimetric Broth and Etest Agar Diffusion Methods.

Although the Sensititre Yeast-One (SYO) and Etest methods are widely utilized, interpretive criteria are not available for triazole susceptibility testing of Candida or Aspergillus species. We collected fluconazole, itraconazole, posaconazole, and voriconazole SYO and Etest MICs from 39 laboratories representing all continents for (method/agent-dependent) 11,171 Candida albicans, 215 C. dubliniensis, 4,418 C. glabrata species complex, 157 C.guilliermondii (Meyerozyma guilliermondii), 676 C. krusei (Pichia kudriavzevii), 298 C.lusitaniae (Clavispora lusitaniae), 911 C.parapsilosissensu stricto, 3,691 C.parapsilosis species complex, 36 C.metapsilosis, 110 C.orthopsilosis, 1,854 C.tropicalis, 244 Saccharomyces cerevisiae, 1,409 Aspergillus fumigatus, 389 A.flavus, 130 A.nidulans, 233 A.niger, and 302 A.terreus complex isolates. SYO/Etest MICs for 282 confirmed non-wild-type (non-WT) isolates were included: ERG11 (C. albicans), ERG11 and MRR1 (C. parapsilosis), cyp51A (A. fumigatus), and CDR2 and CDR1 overexpression (C. albicans and C. glabrata, respectively). Interlaboratory modal agreement was superior by SYO for yeast species and by the Etest for Aspergillus spp. Distributions fulfilling CLSI criteria for epidemiological cutoff value (ECV) definition were pooled, and we proposed SYO ECVs for S. cerevisiae and 9 yeast and 3 Aspergillus species and Etest ECVs for 5 yeast and 4 Aspergillus species. The posaconazole SYO ECV of 0.06 µg/ml for C. albicans and the Etest itraconazole ECV of 2 µg/ml for A. fumigatus were the best predictors of non-WT isolates. These findings support the need for method-dependent ECVs, as, overall, the SYO appears to perform better for susceptibility testing of yeast species and the Etest appears to perform better for susceptibility testing of Aspergillus spp. Further evaluations should be conducted with more Candida mutants.

Fungemia due to Kodamaea ohmeri: First isolating in Italy. Case report and review of literature.

Kodamaea ohmeri, also known as Pichia ohmeri, is a yeast belonging to the Saccharomycetes family. In 2012, our hospital has recorded the first case of fungemia caused by K. ohmeri in an 80-year-old male, admitted to intensive care following an acute anterior-lateral myocardial infarction. K. ohmeri grew in blood cultures. Biochemical identification was confirmed using Matrix-Assisted Laser Desorption Ionization-Time of Flight (MALDI-TOF) mass spectrometry and molecular sequencing. Antifungal susceptibility has been performed by broth dilution technique. This case confirms that K. ohmeri is an emergent pathogen even though rarely isolated in human disease. Permanent catheterization is a risk factor and may cause the persistence of a K. ohmeri infection, as well as support treatments (mechanical ventilation, tracheotomy, dialysis). Our therapeutic strategy has been empirical and based exclusively on tested antifungals MIC because EUCAST recommendations does not indicate breakpoints.

Cardiovascular changes during SCUBA diving: an underwater Doppler echocardiographic study.

AIM: Body immersion induces blood redistribution (from peripheral to intrathoracic vessels) and is a powerful autonomic stimulus (activating both parasympathetic and sympathetic systems). For these reasons, concerns have been raised about the safety of diving for subjects with previous heart disease. The aim of this study was to evaluate cardiovascular changes occurring during recreational SCUBA diving, as assessed by underwater Doppler echocardiography. METHODS: Eighteen healthy experienced divers underwent a 2D Doppler echocardiography basally, during two 15' steps of still SCUBA diving at different depths (10 m followed by 5 m) and shortly after the end of immersion. RESULTS: During dive, left ventricular (LV) diastolic volume and early left ventricular filling significantly increased (5 m vs. basal: P < 0.05 and P < 0.01, respectively), while both deceleration time of the early filling rate and late diastolic filling velocity significantly decreased (5 m and 10 m dive vs. basal: P < 0.01). LV volume increase and diastolic filling changes persisted at postdive evaluation, where a significant decrease in heart rate was also observed (P < 0.01 as compared to basal, 5-m and 10-m dive). CONCLUSION: This study documents that shallow-depth SCUBA diving induces LV enlargement and diastolic dysfunction. Direct underwater evaluation by Doppler echocardiography could be an appropriate tool for unmasking subjects at risk for underwater-related accidents.

A 1-year prospective survey of candidemia in Italy and changing epidemiology over one decade.

PURPOSE: The aim of this study was to assess the epidemiology of candidemia and antifungal susceptibility profiles of Candida isolates in Italy through a prospective surveillance study and to evaluate changes compared to a previous survey performed in one Italian region (Lombardy) in 1997-1999. METHODS: A prospective laboratory-based surveillance of candidemia was performed in Italy from January to December 2009. For each case a questionnaire was filled in, and the first isolate was collected and tested for in vitro antifungal susceptibility. RESULTS: During our 12-month survey, 467 episodes of candidemia were reported from 34 centres (30 located in Lombardy) and 464 isolates collected. Candida albicans was the predominant species (overall incidence 50.4 %), but the proportion varied considerably from 52.1 % in Lombardy hospitals to 45.2 % hospitals located outside this region. The second most frequent species was C. glabrata in Lombardy and C. parapsilosis in other regions. Comparison of the 1997-1999 and 2009 data on episodes of candidemia in Lombardy revealed a threefold increase in incidence (from 0.38 to 1.19 per 1,000 admissions), aging of infected patients, decline in crude mortality (from 35 to 27.1 %) and an increased proportion of C. glabrata etiology (from 12.8 to 20.3 %). Susceptibility testing confirmed the broad activity of amphotericin B and echinocandins. Decreased susceptibility to fluconazole was found in 24.9 % of the tested isolates. CONCLUSIONS: The results of this latest survey confirm the high rate of candidemia in Italy and show changes in some of the epidemiological tracts, such as aging of infected patients, increased proportion of C. glabrata infections, increased diagnosis in medical wards, and improvement in patients' survival.

Comparative study of the in vitro activity of various antifungal drugs against Scedosporium spp. in aerobic and hyperbaric atmosphere versus normal atmosphere.

INTRODUCTION: Scedosporium spp. have been observed with increasing frequency over the last decade in immunocompromised patients and trauma patients. This mould is often multi-drug resistant and its mortality rate remains very high. AIM: The primary goal of this study was to obtain data concerning the in vitro susceptibility of 13 Scedosporium strains comparing the in vitro incubation in aerobic versus hyperbaric conditions. MATERIALS AND METHODS: Chemosensitivity of thirteen Scedosporium strains was evaluated after a 72h-incubation in a normoxic (21% O2) normobaric (1 ATA) atmosphere versus a hyperoxic (100% O2) hyperbaric (2-3 ATA), and after a re-incubation at room temperature for an additional 72h. RESULTS: All S. apiospermum and S. prolificans strains showed no growth after incubation in hyperbaric hyperoxic atmosphere. However, when plates were then maintained at room temperature in aerobic conditions, growth was systematically observed from 36 to 96h, and Minimal inhibitory concentration (MIC) values were the same obtained after incubation in aerobic conditions. CONCLUSIONS: These results suggest impressive in vitro fungistatic activity of the hyperoxic hyperbaric atmosphere, even if its effect is strictly time-dependent. This preliminary in vitro study has potential clinical relevance because it focuses on examining in vitro combination therapy using hyperoxic hyperbaric conditions plus a single antifungal agent, rather than using combinations of different antifungal drugs, to potentially increase the antifungal activity.

Time course of carbon monoxide transfer factor after breath-hold diving.

Breath-hold divers may experience haemoptysis during diving. Central pooling of blood as well as compression of pulmonary gas content can damage the integrity of the blood-gas barrier, resulting in alveolar hemorrhage. The single-breath carbon monoxide test (DL,CO) was used to investigate the blood-gas barrier following diving. The study population consisted of 30 divers recruited from a training course. DL,CO levels were measured before diving and at 2, 10 and 25 min after the last of a series of four dives to depths of 10, 15, 20 and 30 m. When compared to pre-diving values, DL,CO values increased significantly at 2 min following diving in all subjects except one. Thereafter values progressively decreased toward baseline at 10 and 25 min in all subjects but one, while in four divers DL,CO values decreased below baseline. The early but transient increase in DL,CO levels shortly after diving supports the persistence of capillary pooling of red blood cells following emersion. Persistence at 25 min of high DL,CO values in one subject could be attributed by lung CT to extravasation of blood into the alveoli. Early or late DL,CO values >10% below baseline values suggest the presence of pulmonary edema. The relatively high prevalence of DL,CO alterations found suggests caution on the safety of breath-hold diving activities.

Cardiac function during breath-hold diving in humans: an echocardiographic study.

Breath-hold diving induces, in marine mammals, a reduction of cardiac output due to a decrease of both heart rate and stroke volume. Cardiovascular changes in humans during breath-hold diving are only partially known due to the technical difficulty of studying fully immersed subjects. Recently, a submersible echocardiograph has been developed, allowing a feasible assessment of cardiac anatomy and function of subjects during diving. Aim of the study was to evaluate, by Doppler-echocardiography, the cardiovascular changes inducedby breath-hold diving in humans. Ten male subjects were studied by Doppler echocardiography in dry conditions and during breath-hold diving at 3 m depth. In addition 14 male subjects were studied, using the same protocol, before and during breath-hold diving at 10 m depth. At 3 m depth significant reductions in heart rate (-17%), stroke volume (-17%), cardiac output (-29%), left atrial dimensions, and deceleration time of early diastolic transmitral flow (DTE) were observed. At 10 m depth similar but more pronounced changes occurred. In particular, increase in early transmitral flow velocity became significant (+33%), while DTE decreased by 34%. At both depths dimensions of right cardiac chambers remained unchanged. Breath-hold diving at shallow depth induced, in humans, cardiovascular changes qualitatively similar to those observed in natural divers such as seals. The reduced dimensions of left atrium associated to a left ventricular diastolic pattern resembling that of restrictive/constrictive heart disease, suggest that the hemodynamic effects of diving could be explained, at least in part, by a constriction exerted on the heart by the reduced chest volume and the increased blood content of the lungs. Finally, the absence of dimensional changes in the right chambers suggests that most of the pulmonary blood shift occurred before cardiac imaging.

Tinea capitis due to Trichophyton soudanense with a papular IDE reaction in Northern Italy.

A little boy from a Nigerian family who lives in a little industrialized village in the suburbs of Bergamo, (Northern Italy), has never been to his country but presented with tinea capitis and with a secondary papular pruritic eruption of the trunk. Fungal cultures analysis have shown the development of Trichophyton soudanense, an anthropophilic dermatophyte which is endemic in Africa, but only rarely reported in Italy and in other European countries. The growing racial mixing related to migratory movements is favoring, also in Italy, the integration of this strain with the species which are most commonly responsible for dermatophytoses and the appearance of papular IDE reactions which were only occasionally seen in the Italian children population.

Stress-induced changes in subendocardial tissue texture in hypertrophic cardiomyopathy: an echocardiographic videodensitometric study.

BACKGROUND: Myocardial ischemia changes myocardial acoustic properties, inducing increase of integrated backscatter and blunting of cyclic variation of backscatter. Stress-induced subendocardial underperfusion has been demonstrated in patients with hypertrophic cardiomyopathy (HCM). AIM: To evaluate the potential of a videodensitometric approach in assessing transmural ultrasonic tissue changes in HCM during dipyridamole infusion. METHODS: Twenty-two patients (13 males, 50+/-12 years) with HCM underwent dipyridamole echo testing (DET). Myocardial gray levels amplitude was calculated off-line on digitized images in the left subendocardial (LV-endo), right subendocardial (RV-endo) region of the interventricular septum and posterior wall (long axis parasternal view). RESULTS: The thickness of the interventricular septum and posterior wall was 1.9+/-0.3 and 1.17+/-2.1 cm, respectively. In the LV-endo layer, the cyclic variation was blunted during DET (rest = 37+/-14 vs. DET 27+/-20%, p < 0.02). In the RV-endo layer and posterior wall, no changes occurred. In the LV-endo layer of the septum, blunting of cyclic variation was more pronounced in the 10 patients with than in the 12 without ST-segment depression during DET (21.2+/-14.7% vs. 43.8+/-15.8, p < 0.01). CONCLUSIONS: In HCM patients, DET induced blunting of cyclic variation without the evidence of wall motion abnormalities. This reduction was more pronounced when electrocardiographic signs of ischemia were simultaneously elicited by DET.