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LIFE Newsletter - Leading International Fungal Education

September 2015

Antifungal resistance in both candidemia and aspergillosis in Asia

Invasive Candida infection is the 3rd commonest infection in intensive care units and has a high mortality rate (35-67%). A study from China has just been published (Liao et al 2015) and indicates that 41% of infected patients in ICUs had fluconazole resistant candidemia. A potential risk factor for resistance was identified as the length of time spent in time in ICU prior to testing positive for Candida sp. The longer the interval the more chance of resistance developing. This study indicated it is therefore inadvisable to treat long stay ICU patients with fluconazole as a first-line drug before testing isolates for drug sensitivity.

In Taiwan an investigation into the status of azole resistance in A. fumigatus (38 clinical isolates over a 3 yr interval) has been published (Wu et al 2015). Three isolates obtained from respiratory samples of two azole-naïve patients with pulmonary aspergillosis were found to display multi-azole resistance and cross resistance to agricultural azole fungicides, and all carried TR34 /L98H mutations in cyp51A gene. The prevalence rates of azole resistance were 7.9% and 6.5% based on isolates and patients respectively. Phylogenetic analysis suggested genetic diversity of the TR34 /L98H isolates, including a unique genotype distinct from strains outside Taiwan. The result underlines the emergence of such isolates in Taiwan as well, emphasising the importance of further surveillance for azole-resistant A. fumigatus and implementation of strategies that prevent fungicide-driven resistance selection.

Antimicrobial resistance (AMR) has been a subject of intense interest over the last 2 years with major governmental efforts to address the growing issues. A report commissioned by the UK government and lead by economist Lord Jim O’Neill predicts increasing deaths attributable to AMR from 700,000 in 2015 to 10 million by 2050, and an increasing cost from 1 trillion US dollars a year in 2025 to $8 trillion a year by 2050 (total >$100 trillion), if not addressed. O'Neill report 


NEWS

Guatemala to have life-saving fungal diagnosis for HIV patients

Guatemala could soon be leading the way in providing better fungal diagnostic services for HIV patients in Central America, thanks to a partnership between the Asociación de Salud Integral (ASI), and Global Action Fund for Fungal Infections (GAFFI). Amongst a population of 14.7 million, an estimated 58,000 people are HIV infected, but only 15,136 patients currently attend the country’s HIV comprehensive care units and late HIV diagnosis is common. Only 53 per cent of the HIV population receive anti-retroviral therapy but HIV infected patients tend to present very late because of denial and stigma, and early death is the biggest problem. Guatemala is an excellent global location to both make big improvements in healthcare and demonstrates the value of combined fungal diagnostic availability and enhanced clinical training. At the end of the program, the country will have the first national reference laboratory specialized in mycology providing diagnostic services to HIV patients in Central America.
More information; News item in Spanish

New inhaled anti-infective to treat fungal infections in cystic fibrosis

Pulmatrix, Inc. have announced a new drug candidate, PUR1900,which is an inhaled anti-infective to treat fungal infections associated with cystic fibrosis (CF). Pulmatrix is strategically focused on developing innovative, first-in-class inhaled therapies for rare pulmonary diseases. Fungal lung infections are difficult to treat, so methods for safely delivering effective agents directly to the lung address an important un-met medical need. More information

Disseminated histoplamosis in India is not so rare in immunocompetent patients

Histoplasma exists in mycelial form at soil temparatures, but switches to the yeast form at normal human body temparatures (37C). Histoplasmosis with PAs stainThe fungus persists in soil particularly where bird faeces are present. De & Nath from Kolkata describe a small study of 7 patients with disseminated histoplasmosis - none of whom had immunocompromised status. Only one patient gave positive cultures from a swab, diagnosis was from either bone marrow aspiration or biopsy. Most patients responded well to amphotericin B or itraconazole. Clinicians should be aware of disseminated histoplasmosis, which is similar to visceral leishmaniasis, in India. More information

 

Blastomycosis in Indiana over 30 years

Blastomycosis is not currently a reportable disease in many US states including Indiana. Cases can be mild but blastomycosis can lead to severe sequelae including disseminated infection, especially in immunocompromised individuals. There is new evidence of a rise in blastomycosis in endemic areas.  Dr Chadi Hage, Dr Marwan Azar and colleagues describe characteristics of 114 patients seen with blastomycosis in 4 hospitals in the endemic Marion County over a 30 year period.  Their report provides insights into the difficulty in diagnosis and treatment of very ill patients requiring ICU admission and those with meningitis, as well as the more typical ambulant patients. The introduction of a highly-sensitive and commercially-available assay for the detection of Blastomyces dermatitidis antigen in 2004 could be the reason for the higher incidence in Marion County. More information; Article

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Featured LIFE website section: Tinea capitis

Tinea capitis appears as hair loss (alopecia) with little apparent inflammation. Well defined patches Tinea capitis kerionof hair loss start small and increase in size. One type is ‘black dot’ tinea capitis in hair breaks just above the scalp, and diffuse swollen black dots appear. The clinical diagnosis requires the presence of broken hairs accompanied by scaling on the scalp, but can be difficult. Kerion is an inflammatory mass of hair, exudate, fungus and granulation tissue that can mimic a squamous cell carcinoma. Historically, kerion was thought to occur in 1-2% of children with Tinea capitis, but a recent study from Tunisia suggests that as many as 13.7%of children had kerion compared to a figure of 1.8% in 1998 (article)T. capitis has a global presence of 200 million cases and malnourished and deprived children are at greatest risk. Diagnosis is by microscopy of hair roots and by culture.

LIFE website. Tinea Capitis Guidelines (2015)


Top Diagnostic Tip

Candida diagnosis from blood smear

Although the gold standard for candidaemia is blood culture, yeast with buds, pseudohyphae, or that have been phagocytosed by white blood cells in peripheral blood smears can be visible microscopically. This is rare, but obviously useful if found. The ‘usual' fungus seen in white blood cells in blood is Histoplasma capsulatum, often in the context of severe infection in AIDS. Talaromyces (Penicillium) marneffei and Cryptococcus neoformans have also been reported. In a mouse model Trichosporon could be visualised in a blood smear, appearing as box-like structures; More usually these structures are seen in blood culture bottles on gram stain.
Articles (Hirai et al 2015); (Mo et al 2002)

 

Best practice diagnostic recommendations for serious fungal infections (BSMM 2015) the BSMM have publishesd 43 key recommendations for the appropriate use of microbiological, histological, and radiological diagnostic methods for the diagnosis of invasive fungal diseases.


Really Important Reviews

Dermatophytosis, trends in epidemiology and diagnostic approach (Hayette & Sacheli 2015)
Dermatophytes are one of the commonest fungal agents causing skin infections. The epidemiology
of dermatophytosis has changed during the last century and Trichophyton rubrum and Microsporum canis have become the most frequent species worldwide causing tinea infections. In cities and urban areas however, the occurrence of anthrophilic dermatophytes causing tinea capitis in the young is causing epidemics and public health concerns. This review summarises the current state of dermatophyte infection and an overview of molecular methods used for diagnosis.

Article


Books

 
Edited by: Alix T. Coste and Patrick Vandeputte
Caister Academic Press
A timely overview of current antifungal research with chapters written from a molecular and genomic perspective. read more

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Courses

 

The 2nd Veterinary Mycology course will be organised in Turin, Italy on the 26-30th October 2015 by the ISHAM Working Group Veterinary Mycology. More information.

Moving Antimicrobial Stewardship Forward in Special Population Settings. Being held in Ferney-Voltaire, France on the 5-6th November 2015More information.

Microbiology for Diagnosis of Infectious Diseases: ABC and XYZ, being held in Beijing, China. 20- 22nd November 2105  More information.

ECMM Educational Symposium dedicated to 'Ecology and Mycology: from the Environment to the Patient's Bed' will be held in Tel Aviv, Israel, 14-16 February 2016. The program can be seen here

More courses


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We are looking for volunteers to assist with estimating the burden of fungal infection in the following countries:
Angola, Bolivia, Bulgaria, Bosnia, Burkina Faso, Cambodia, Central African Rep., Chad, DRC, Costa Rica, Gabon, Honduras, Laos Mali, Myanmar, Nicaragua, Panama, Papua New Guinea, Poland, Slovak Republic, Tunisia.
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