Antifungal susceptibility testing practices in mycology laboratories in France, 2018.

A survey of mycology laboratories for antifungal susceptibility testing (AFST) was undertaken in France in 2018, to better understand the difference in practices between the participating centers and to identify the difficulties they may encounter as well as eventual gaps with published standards and guidelines. The survey captured information from 45 mycology laboratories in France on how they perform AFST (number of strains tested, preferred method, technical and quality aspects, interpretation of the MIC values, reading and interpretation difficulties). Results indicated that 86% of respondents used Etest as AFST method, with a combination of one to seven antifungal agents tested. Most of the participating laboratories used similar technical parameters to perform their AFST method and a large majority used, as recommended, internal and external quality assessments. Almost all the participating mycology laboratories (98%) reported difficulties to interpret the MIC values, especially when no clinical breakpoints are available. The survey highlighted that the current AFST practices in France need homogenization, particularly for MIC reading and interpretation.

[Main parasitic skin disorders]. / Principales parasitoses cutanées : mise au point.

Cutaneous parasitic skin diseases are frequent in human pathology. There are few reliable epidemiological data on the prevalence and/or incidence of such diseases. Skin parasites are cosmopolitan but their global distribution is heterogenous; prevalence is especially high in subtropical and tropical countries. They are mainly due to arthropods (insects and mites). Many species of parasites are involved, explaining the diversity of their clinical signs. The most common are caused by ectoparasites such as scabies or pediculosis (head lice, body lice and pubic lice). Clinical signs may be related to the penetration of the parasite under the skin, its development, the inoculation of venom or allergic symptoms. Diagnosis can be easy when clinical signs are pathognomonic (e.g. burrows in the interdigital web spaces in scabies) or sometimes more difficult. Some epidemiological characteristics (diurnal or nocturnal bite, seasonality) and specific clinical presentation (single or multiple bites, linear or grouped lesions) can be a great diagnostic help. Modern non-invasive tools (dermoscopy or confocal microscopy) will play an important role in the future but the eye and experience of the specialist (dermatologist, parasitologist, infectious disease specialist or entomologist) remains for the time the best way to guide or establish a diagnosis. For most skin parasites, therapeutic proposals are rarely based on studies of high level of evidence or randomized trials but more on expert recommendations or personal experience.

Prevalences of scabies and pediculosis corporis among homeless people in the Paris region: results from two randomized cross-sectional surveys (HYTPEAC study).

BACKGROUND: Dermatological infections constitute the most common health problem in the homeless population. OBJECTIVES: To estimate the prevalences of scabies and pediculosis corporis and to identify associated factors in the homeless population. METHODS: Two randomized cross-sectional surveys were performed, one on the homeless population sleeping in public places in Paris, and the other on the homeless population in various shelters in the Ile-de-France administrative region. Overall 341 and 667 people, respectively, were interviewed about sociodemographic characteristics, lifestyle and hygiene practices, and were examined by a nurse. RESULTS: In individuals sleeping in public places the prevalence of scabies was estimated at 6·5% [95% confidence interval (CI) 0·5-12·5] and for pediculosis corporis at 5·4% (95% CI 1·7-9·1). For those sleeping in shelters these values were 0·4% (95% CI 0·1-1·8) and 0·15% (95% CI 0·0-9·7), respectively (P < 0·01 in both cases). In public places, after multivariate analysis, being a woman, citing squats among the three main types of accommodation and not possessing a sleeping bag were significantly associated with diagnosis of scabies. Likewise, begging, a history of pubic lice, and not taking showers in municipal baths were associated with pediculosis corporis in public places. CONCLUSIONS: Firstly, this study highlights the real existence of two distinct subpopulations having different sociodemographic characteristics, with specific lifestyles and practices, and with different prevalences of ectoparasitism. Secondly, the results of the multivariate analyses will help the implementation of specific actions targeting the group of people who sleep in public places.

Sarcoptes scabiei mites in humans are distributed into three genetically distinct clades.

Scabies is an ectoparasitic infestation caused by the mite Sarcoptes scabiei. Currently, S. scabiei is taxonomically divided into different varieties on the basis of host origin. Genetics-based research on scabies has been conducted, but the data on genetic diversity of populations of this mite in humans in Europe are lacking. We evaluated the genetic diversity of populations of S. scabiei. A large series of mites obtained from humans in France and the data of mites from various hosts and geographical areas retrieved from GenBank were included to investigate whether mites are divided into distinct populations. The study of cytochrome c oxidase subunit 1 gene polymorphisms were found to be best suited for phylogenetic analysis. S. scabiei mites were distributed into three genetically distinct clades, with most mites clustering in clades B and C. The Fst value and the Nm value calculated for mites included in clades B and C indicated a strong population structure and a very low gene flow between mites of those clades. The results of the present study not only support the rejection of the hypothesis of panmixia for S. scabiei in humans but also suggest that mites belonging to different clades are genetically isolated. Moreover, the results suggest that the subdivision of S. scabies in varieties according to animal or human hosts is not warranted. In conclusion, S. scabiei mites in humans do not constitute a homogeneous population. Further investigations are now required to assess whether different clinical forms of scabies are associated with particular haplotypes or clades.

Prospective evaluation of azole resistance in Aspergillus fumigatus clinical isolates in France.

OBJECTIVES: Several studies, especially in Europe, have recently reported the emerging phenomenon of azole resistance in Aspergillus fumigatus, but very few data are available in France. Our study aimed to determine the resistance prevalence in A. fumigatus isolates recovered from clinical samples over a 1-year period in two university hospital centers. METHODS: All A. fumigatus isolates were screened for azole resistance using RPMI agar plates supplemented with itraconazole and voriconazole. Resistance was then confirmed by the EUCAST method. A part of the beta-tubulin gene was amplified for resistant isolates to confirm the A. fumigatus species, and the Cyp51A gene and its promoter were afterward sequenced to detect mutations potentially responsible for this resistance. RESULTS: One hundred sixty-five A. fumigatus isolates were recovered from 134 patients. Three isolates recovered from three patients were found resistant with MICs of >8 mg/l, 4 mg/l, and 1 mg/l for itraconazole, voriconazole, and posaconazole, respectively. The TR34/L98H mutation, previously and largely described in other countries, was detected in the three isolates. CONCLUSION: Our study demonstrated the occurrence of azole resistance among unselected A. fumigatus clinical isolates, with an overall prevalence of 1.8%.

Contribution of (1,3)-beta-D-glucan to diagnosis of invasive candidiasis after liver transplantation.

Invasive candidiasis (IC) causes high morbidity and mortality rates after liver transplantation, in part due to delayed diagnosis. The fungal cell wall component (1,3)-beta-d-glucan (BG) could be an early biomarker of IC. This preliminary prospective study was designed to evaluate the contribution of BG measurements to the diagnosis of IC after liver transplantation. All consecutive patients who underwent liver transplantation at Henri Mondor Hospital in France between January and June 2013 were enrolled prospectively in the study. They were monitored weekly for colonization by Candida, and colonization index values were calculated. Serum samples were tested for BG (Fungitell; Cape Cod Inc.) at least weekly between liver transplantation and discharge from the hospital. A total of 52 patients (including 39 male patients) were enrolled, with a median age of 55 years (range, 31 to 69 years). The median Model for End-Stage Liver Disease (MELD) score was 27 (range, 6 to 40). Cultures from 42 patients (81%) yielded Candida spp., with the most common Candida species isolated being Candida glabrata (47%). Six cases of documented IC were found for four of the 52 patients. On the day the clinical diagnosis of IC was made, analysis based on combining two sequential BG-positive samples (>146 pg/ml) and a colonization index of ≥0.5 revealed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) results of 83%, 89%, 50%, and 97.6%, respectively. The detection of BG associated with Candida colonization may be a promising tool based on a high NPV that can rule out IC among high-risk patients.

Candida vascular complication in a liver transplant recipient due to yeast contamination of preservation solution.

Infections remain a major cause of morbidity and mortality after liver transplantation. One possible cause of infection is preservation fluid contamination. Donor-derived pathogens, such as Candida albicans, have occasionally produced life-threatening complications in organ recipients, already described in renal transplantation. In the present case, we report the loss of a liver graft secondary to vascular complications because of C. albicans found in the preservation fluid. Our case report raises the question of implementing procedures, similar to those in renal transplantation, including early antifungal treatment and repeated radiological monitoring for the prevention and detection of vascular complications.

Molecular survey of knockdown resistance to pyrethroids in human scabies mites.

There are growing concerns about the emergence of resistance of Sarcoptes scabiei to permethrin and other pyrethroid derivatives. Sarcoptes scabiei mites collected from 40 patients visiting two hospitals near Paris, France, were genotypically characterized considering two parts of their voltage-sensitive sodium channel gene. No nucleotide polymorphism resulting in a codon change at codon 733 or other positions associated with knockdown resistance in other arthropods has been identified. These data may establish a reference line for future surveys of the susceptibility of S. scabiei in the area.

Travelers with cutaneous leishmaniasis cured without systemic therapy.

BACKGROUND: Cutaneous leishmaniasis (CL) is a disfiguring but not life-threatening disease. Because antileishmanial drugs are potentially toxic, the World Health Organization (WHO) recommends simple wound care or local therapy as first-line treatment, followed or replaced by systemic therapy if local therapy fails or cannot be performed. METHODS: To determine the feasibility and impact of the recommended approach, we analyzed the results of a centralized referral treatment program in 135 patients with parasitologically proven CL. RESULTS: Infections involved 10 Leishmania species and were contracted in 29 different countries. Eighty-four of 135 patients (62%) were initially treated without systemic therapy. Of 109 patients with evaluable charts, 23 of 25 (92%) treated with simple wound care and 37 of 47 (79%) treated with local antileishmanial therapy were cured by days 42-60. In 37 patients with large or complex lesions, or preexisting morbidities, or who had not been cured with local therapy, the cure rate with systemic antileishmanial agents was 60%. Systemic adverse events were observed in 15 patients, all receiving systemic therapy. CONCLUSIONS: In this population of CL patients displaying variable degrees of complexity and severity, almost two-thirds of patients could be initially managed without systemic therapy. Of these, 60 were cured before day 60. The WHO-recommended stepwise approach favoring initial local therapy therefore resulted in at least 44% of all patients being cured without exposure to the risk of systemic adverse events. Efforts are needed to further simplify local therapy of CL and to improve the management of patients with complex lesions and/or preexisting comorbidities.

Yeast contamination of kidney, liver and cardiac preservation solutions before graft: need for standardisation of microbial evaluation.

Contamination of preservation solution (PS) with yeasts during solid organ recovery can lead to life-threatening complications in the recipients. The prevalence of such a contamination needs to be established. From January 2004 to December 2008, we prospectively investigated the potential fungal contamination of all the PSs collected in our institution using a standardised procedure consisting in centrifugation of 10 mL PS and incubation of the pellet seeded on fungal-specific medium for 15 days at 30 degrees C. During the study period, 728 transplantations (397 kidneys, 262 livers and 69 hearts) were performed for which 659 PSs (90.5%) were available. The yeast contamination rate was 0% (0/62), 3.1% (11/356) and 4.1% (10/241) for heart, kidney and liver transplants, respectively. We identified 10 Candida albicans, five C. glabrata, two C. krusei, one C. tropicalis, one C. valida, one Pichia etchelsii and one Rhodorula sp. Routine bacterial analysis identified only five of these 21 fungal contaminations. Twenty recipients were alive after at least one year of follow-up and one died from meningeal carcinomatosis at seven months. Three patients were found to have the same species of Candida from their surgical drains but did not develop any infection or abnormalities upon ultrasound investigation. Fourteen patients received antifungal drugs. Yeast contamination occurred in 3.4% of all kidney and liver PSs tested. Its clinical consequences and therapeutic management remain to be defined. Our study also suggests that optimisation/standardisation of microbiological procedures is warranted, including analysis of large PS volume, seeding of fungal-specific medium and prolonged incubation.

Two unusual occurrences of trichomoniasis: rapid species identification by PCR.

PCR analysis in two unusual occurrences of trichomoniasis, trichomonal empyema due to Trichomonas tenax and Trichomonas vaginalis in an infant urine sample, allowed us to obtain rapid and accurate trichomonad species identification. The weak sensitivity of wet preparations and the low viability of the flagellates can be remedied by the PCR method.

Nosocomial dermatitis caused by Dermanyssus gallinae.

The mite Dermanyssus gallinae may cause pruritic dermatitis in humans. We describe a case of nosocomial infestation with D. gallinae from an abandoned pigeon nest suspended on the front wall of the Hôpital Henri Mondor near a window. Close surveillance and regular destruction of pigeon nests could prevent these incidents of infection in humans.

[Frequency of plantar dermatophytosis. A retrospective study 2002-2003]. / Estimation de la fréquence des atteintes plantaires à dermatophytes.

BACKGROUND: Plantar dermatophytosis frequently goes unnoticed and can cause relapse or re-infestation at other sites. The purpose of this study was to evaluate the incidence of plantar dermatophytosis in association with onyxis and intertrigo involving dermatophytes. PATIENTS AND METHODS: This was a retrospective study in patients seen at mycology consultations between January 2002 and December 2003 and for whom culture revealed dermatophytes on the soles, interdigital spaces and/or toe nails. Gender, age and culture data were record from the laboratory workbooks. RESULTS: 716 patients were included, giving 1291 samples. The sex ratio M/F was 1.5 with a mean age of 48 years. Samples of toe nail were obtained from 591 patients, with plantar samples from 433 patients and intertrigo samples from 267 patients. Plantar dermatophytosis was seen in 66.6% of patients with interdigital-plantar signs, in 75.1% of those with ungual involvement and in 73.9% of cases involving both. T. rubrum was the most frequently isolated dermatophyte. DISCUSSION: Combine involvement of the sole, nail and/or interdigital space was seen in more than 2/3 of cases. Despite the retrospective nature of our study and the evident bias, our results suggest that plantar dermatophytosis is common and should be sought. The sensitivity and specificity of clinical screening methods merit investigation in a prospective study.

Microsatellite marker analysis as a typing system for Candida glabrata.

Candida glabrata is one of the most important causes of nosocomial fungal infection. We investigated, using a multiplex PCR, three polymorphic microsatellite markers, RPM2, MTI, and ERG3, in order to obtain a rapid genotyping method for C. glabrata. One set of primers was designed for each locus, and one primer of each set was dye labeled to read PCR signals using an automatic sequencer. Eight reference strains including other Candida species and 138 independent C. glabrata clinical isolates were tested. The clinical isolates were collected from different anatomical sites of adult patients either hospitalized in different wards of two different hospitals or not hospitalized. Since C. glabrata is haploid, one single PCR product for each PCR set was obtained and assigned to an allele. The numbers of different alleles were 5, 7, and 15 for the RPM2, MTI, and ERG3 loci, respectively. The number of allelic associations was 21, leading to a discriminatory power of 0.84. The markers were stable after 25 subcultures, and the amplifications were specific for C. glabrata. A factorial correspondence analysis did not indicate any correlation between the 21 multilocus genotypes and the clinical data (source, sex, ward, anatomical sites). Microsatellite marker analysis is a rapid and reliable technique to investigate clinical issues concerning C. glabrata. However, its discriminatory power should be improved by testing other polymorphic microsatellite loci.

[Recommended techniques for obtaining nail specimens and mycologic diagnosis of onychomycosis]. / Prélèvements et diagnostics mycologiques des onychomycoses.

The diagnosis of onychomycosis requires an assessment of both clinical and laboratory features. The laboratory diagnosis is essential to confirm the fungal origin of the onyxis. Various types of onychomycosis need different methods to obtain a nail specimen. It requires a direct examination to confirm the presence of fungi, and a fungal culture to identify the specific genus and species of the pathogen. A good interpretation of these results is necessary to adapt the therapeutics.

[Profuse scabies: kinetic curves of parasitologic cure with an association of benzyl benzoate and sulfiram]. / Gale profuse: cinétique de guérison parasitologique avec l'association benzoate de benzyl et sulfiram.

BACKGROUND: In vitro exposure to benzyl benzoate (25 p. 100) kills Sarcoptes scabiei within three hours. The aim of our study was to determine in vivo elimination of Sarcopte scabiei with a benzyl benzoate-sulfiram association. METHODS: Medical charts of patients hospitalized for disseminated scabies from 1993 to 1999 were reviewed retrospectively. The diagnosis of scabies was confirmed by microscopic determination. Parasitological examinations were conducted every day or every two days until negative results. Patients were treated by successive applications of benzyl benzoate until parasitological cure. RESULTS: Twenty patients were included in the study. The median delay of parasitological cure was seven days. After 15 days, 95 p. 100 of patients were cured. Two cutaneous side-effects were reported. DISCUSSION: Despite immediate in vitro efficacy, benzyl benzoate action is delayed in vivo. The time of parasitological negativation after one application of benzyl benzoate is unknown. Therefore, it is not currently possible to determine whether our therapeutic regimen was excessive or not.

Real-time PCR for diagnosis and follow-up of Toxoplasma reactivation after allogeneic stem cell transplantation using fluorescence resonance energy transfer hybridization probes.

Toxoplasma reactivation is a life-threatening complication of allogeneic stem cell transplantation. A poor prognosis is probably linked to a difficult diagnosis, based on the detection of evidence of parasites in tissue. We developed a real-time PCR test using fluorescence resonance energy transfer hybridization probes to detect and quantify Toxoplasma gondii DNA in serum. This PCR test gave reproducible quantitative results over a dynamic range of from 0.75 x 10(6) to 0.75 parasites per PCR mixture. Serial samples from four patients with toxoplasma reactivation were evaluated. Three patients had several consecutive PCR-positive samples which corresponded to