[Phenotypic and Genotypic Evaluation of Azole Resistance in Aspergillus fumigatus Isolates from Clinical and Environmental Specimens]. / ÜKlinik ve Çevresel Örneklerden Elde Edilen Aspergillus fumigatus Izolatlarinda Azol Direncinin Fenotipik ve Genotipik Olarak Degerlendirilmesi.

Aspergillus fumigatus can cause different clinical manifestations including chronic pulmonary infections, as well as invasive aspergillosis which is highly mortal in the immunocompromised host. Azole antifungal drugs, voriconazole in particular, are the first-line recommended therapeutic regimen. Azoles inhibit 14-α demethylase enzyme encoded by the cyp51A gene. In recent years, increased azole resistance is observed among environmental and clinical A.fumigatus isolates. Two different mechanisms have been proposed for the development of resistance. The first one is the triggering of resistance as a result of long-term clinical azole use. Point mutations in cyp51A gene are generally responsible for this type of azole resistance. The second mechanism is incidental environmental azole exposure due to the use of azoles as agricultural fungicides. Contact with azoles for extended periods and at varying concentrations causes selective pressure and mutations on sporulating A.fumigatus. Since the resistant strains may persist in nature, susceptible individuals may be infected by acquisition of these strains from the environment. When genotypically examined, the cyp51A gene of the resistant isolates of environmental origin specifically presents with a tandem repeat in the promoter region in addition to the point mutation in codon 98 (TR34/L98H). The aim of this study was to investigate azole resistance rates in A.fumigatus strains isolated from clinical specimens and landscaping areas around Hacettepe University Faculty of Medicine Hospital by phenotypical and genotypical methods. Agar screening test was used as the initial test to detect azole resistance in isolates identified as A.fumigatus sensu stricto according to thermotolerance test results. For all strains that grew on any of the azole containing plates in agar screening test, minimum inhibitory concentration (MIC) values were determined by "European Committee on Antimicrobial Susceptibilitiy Testing" reference microdilution method for the confirmation of the resistance. In addition, cyp51A gene sequence was investigated in selected isolates and mutation analysis was performed. A total of 483 clinical and 65 environmental A.fumigatus sensu stricto isolates were included in the study. The first group of clinical isolates consisted of 215 strains isolated in 1997-2015, revived from stock and tested. The second group consisted of 268 strains belonging to the time period of 2016-2018, during which routine azole agar screening tests were performed for A.fumigatus isolates. When all isolates (n= 483) were evaluated together, 11 isolates (1 before 2015 and 10 between 2016-2018), were found to be resistant to itraconazole (2.3%). None of the mutations previously reported to be associated with azole resistance in Aspergillus strains that were detected in cyp51A sequence analysis, However, polymorphisms which are not (yet) fully elucidated in relation to the resistance (Y46F, G89G, V172M, T248N, E255D, L358L, K427E, C454C, Y431D and Q141H in one strain) were shown to exist in resistant isolates. These results have shown that the rate of azole resistance among clinical A.fumigatus isolates was low (2.3%) in our center. Further studies are required to demonstrate the possible role of the detected polymorphisms on azole resistance and to clarify other mechanisms related with high azole MIC values. In addition, since high azole resistance has been reported from one region in our country, it has been concluded that multicenter studies are required to determine the azole resistance status and the range for the azole resistance ratio in different regions and to reveal resistance mutations that may be specific to our country.