Importancia Clínica Resistencia MicelialesEn enfermos oncohematológicos
Manuel Cuenca Estrella Febrero, 2015
Conflict of interest disclosure• In the past 5 years, M.C.E. has received grant support
from Astellas Pharma, bioMerieux, Gilead Sciences, Merck Sharp and Dohme, Pfizer, Schering Plough, Soria Melguizo SA, Ferrer International
• He has been an advisor/consultant to the Panamerican Health Organization, Astellas Pharma, Gilead Sciences, Merck Sharp and Dohme, Pfizer, and Schering Plough.
• He has been paid for talks on behalf of Gilead Sciences, Merck Sharp and Dohme, Pfizer, Astellas Pharma and Schering Plough.
Relevant Mycoses. Global burdenAccording to LIFE and GAFFI (www.life-worldwide.org)
Perfil de actividad en miceliales
EspeciesAntifúngicos
ANF FC FLC ITC VRC POS EQUIN
A. fumigatus S R R S S S S
Aspergillus flavus
S R R S S S S
Aspergillus terreus
I-R R R S S S S
Aspergillus niger S R R S-I-R** S S S
Fusarium spp. S-I-R** R R R S-I-R** S-I-R** R
Scedosporium spp.
S-I-R** R R R S-I-R** S-I-R** R
Mucorales S-I-R** R R R R S-I-R** R
• EORTC criteria: Probable aspergillosis (50-80% in last clinical trials)
• Proven aspergillosis (50-75%) by microscopic examination only. No ID of species
• Low performance of cultures• Laboratory contaminants
• EORTC criteria: Probable aspergillosis (50-80% in last clinical trials)
• Proven aspergillosis (50-75%) by microscopic examination only. No ID of species
• Low performance of cultures• Laboratory contaminants
Epidemiology of aspergillosis and other mold infections is tough, because…………..
Epidemiology of aspergillosis and other mold infections is tough, because…………..
• Population-based survey• Molds isolated from deep samples
(including respiratory ones)• Two months (spring and fall)• 30 Spanish hospitals• Molecular ID and AST
• Population-based survey• Molds isolated from deep samples
(including respiratory ones)• Two months (spring and fall)• 30 Spanish hospitals• Molecular ID and AST
Results from SpainFILPOP_2012
AAC 2013; 57:3380
Epidemiology of mouldsEpidemiology of moulds
Hematological patients SOT
Neofytos CID’09
Pagano CID’07
Marr CID’02
Husain CID’03
Aspergillus 80% 94.5% 77.3% 69.8%
Zygomycetes
9.7% 1.1% 8.6% 5.6%
Fusarium 2.2% 3.2% 9.2% 3.7%
Scedosporium
--- 1.1% 2.9% 5.6%
Other 9.2% --- 1.78% 15%
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Results from Spain. FILPOP. Population-based survey.
325 isolates
Aspergillus spp. (sensu stricto)
N %
TOTAL 27785% (4 cases
per 100,000 pop)
A. fumigatus 156 48%
A. flavus 26 8%
A. terreus 26 8%
A. tubingensis (section Nigri)
22 6.8%
A. niger 21 6.5%
A. nidulans 8 2.5%
Aspergillus cryptic species
Alastruey-Izquierdo et al. AAC 2013Balajee et al, JCM 2009
Alastruey-Izquierdo et al. ANYAS 2012
FILPOP
11% cryptic species
15% cryptic species
Cryptic Species
n AMB ICZ VCZ PCZ CPF MCF ANF
A. lentulus 26 3 2.3 3.4 0.23 1.6 0.1 0.1
N. hiratsukae 9 1.7 0.9 1.1 0.16 0.11 0.03 0.03
N. pseudofischerii 6 0.25 4 2.51 0.22 0.86 0.03 0.03
A. fumigatiaffiinis 6 4.8 5 3.1 0.4 0.22 0,03 0,03
N. udagawae 5 2 0.6 2.3 0.25 0.3 0.03 0.03
A. viridinutans 3 0,7 16 4 0,25 5,66 0,06 0,09
A. tubingensis 22 0.11 0.42 0.76 0.09 0.3 0.05 0.03
A. calidoustus 19 0.9 8.6 6.2 6.8 0.5 0.04 0.04
A. insuetus 2 0.7 11.3 8 2.8 5.6 1.4 0.9
A. keveii 1 0,25 16 16 16 16 16 16
A. alliaceus 30 19.25 0.2 0.5 0.11 12.15 3.8 1.9
By Alastruey-Izquierdo
World Surveys on A. fumigatus complex resistance.
Rates of resistance according to ECOFFsJournals and Congresses
Country Itraconazole
Voriconazole Posaconazole
SpainCuenca-Estrella et al
8% 4.5% 4.4%
USADiekema et al
7% 1% 8%
FranceBretagne et al
2% 1% 2%
HollandSnelders et al
12.8% 10% 10%
United KingdomHoward et al
17% 8% 10%
Haematologica. 2012;97(7):963-5.
Aguado et al. Clin Infect Dis. 2014;Oct 21. pii: ciu833
PCRAGA STUDY
Aguado et al. Clin Infect Dis. 2014;Oct 21. pii: ciu833
P=0.027
Cyp51A Cyp51B
Azole
ABC
Strain with low MIC
ABC
Mutations in Cyp51AMutations in Cyp51A
Cyp51A Cyp51B
Azole
Strain with high MIC
ABC
UP regulation of Cyp51A
Cyp51A Cyp51B
Azole
Strain with high MIC
x 8
TR-R-ITC
Cyp51A
237
L98H
Duplication of 34-bp sequence in the promoter
Gen Cyp51A in a resistant strain
Gen Cyp51A in a resistant strain
• The azole target cyp51A is a hotspot for mutations that confer phenotypic resistance, but in an increasing number of resistant isolates the underlying mechanism remains unknown. (TR46/Y121F/T289A)
• Increase of expression and mutations related to efflux pumps
• Mutation in the CCAAT-binding transcription factor complex subunit HapE. A P88L substitution in HapE. Camps et al Plos One 2012
New mechanisms of resistance in Aspergillus
New mechanisms of resistance in Aspergillus
Arendrup et al, Denning et al, Mellado et al, Verweij et al
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Figure 3
3D Representation of three aligned structures of CYP51 with the ligands in their active site, constructed by using the Yasara software. Snelders Plos One 2012
Figure 3
3D Representation of three aligned structures of CYP51 with the ligands in their active site, constructed by using the Yasara software. Snelders Plos One 2012
JCM 2012;50:2531
Descripción en muchos paísesDescripción en muchos países
30% resistencia en paciente hematológico y 88% mortalidad
Epidemiología de la EFI• La resistencia clínica en hongos filamentosos es
relevante si la prevalencia de Mucorales, Scedosporium y Fusarium es elevada (tratamiento empírico y primera línea)
• La resistencia a azoles en España en Aspergillus se mantiene por debajo del 10%
• Parece estar más asociadas a especies crípticas aunque ya hay casos en A. fumigatus
• Los casos con cepas resistentes son difíciles de tratar (90% mortalidad en paciente hematológico)
• Problemas para hacer estudios representativos:– Cepas ambientales– Pruebas moleculares– Estudios con medios suplementados con itraconazol en
muestras respiratorias (FILPOP 2)
PCR in tissues. Proven IFI
•84 patients were analyzed. 68/84 (81%) were cultured. 56% of sensitivity (38/68 cases)•PCR-based technique detected fungal DNA in 75/84 patients (89.3%)
Species Nb of cases Rate
Aspergillus 50/75 66.6%
Mucorales 9/75 12%
Candida 11/75 14.6%
Sequencing and analysis
Antifungal agents
Fungal speciesAvailability of
reference procedures
Breakpoint setting
Extension of AST in clinical
practice
Molecular description of
resistance
Prevention and control strategies
Amphotericin B Candida spp.Aspergillus spp.
YESYES
YESYES
YESYES
NO
NONONO
Azoles Candida spp.Aspergillus spp.
YESYES
YES YES
YESYES
IN PROGRESSIN PROGRESS
NONO
Echinocandins Candida spp.Aspergillus spp.
YES
YESYES NO
YESIN PROGRESS
IN PROGRESSNO
NONO
Table 1. Current situation of the antifungal susceptibility testing field by antifungal agent, by species and by stages of standardization process
FILPOP 2, In progress