A report published in August in the Journal of Antimicrobial Chemotherapy, documents how many countries do not have life-saving antifungal therapies resulting in 1.6 million per year dying from lack of treatment of serious fungal infections. That number is equivalent to the populations of Philadelphia, Kampala or Prague.
GAFFI (The Global Action Fund for Fungal Infections) has published the largest survey ever undertaken from 159 countries and found that a pair of critical antifungal medicines for AIDS patients are not available in over 95 countries. One of these antifungals has been available since the 1950’s and the other since the 1970’s.
- One of the critical drugs for fungal meningitis (amphotericin B) is not available in 42 countries.
- The other key drug for fungal meningitis, flucytosine is not licensed in and is unavailable in 89 of 125 (71.2%) and 95 of 125 (76.0%) countries, respectively, representing an unserved population of 2898 million. The daily price of flucytosine varied from $4.60 to $1409.
Yet both amphotericin B and flucytosine have been available in Europe and the US for over 40 years. The World Health Organisation recommends they are used together to bring down mortality from 100% to 25%. (Fungal meningitis is the commonest form of meningitis in sub-sarahan Africa because of AIDS).
- The 25 year old drug, fluconazole is available in all countries and itraconazole is unavailable in just five countries. However, being available is not enough – cost matters as patients pay for their care in many countries. The daily cost of fluconazole varied from <$1 to $31 and itraconazole from <$1 to $102.
In South Africa, which has the largest AIDS burden in the world and a massive TB problem, itraconazole costs about £11.60 per day – unaffordable for most people there.
Flucytosine world availability map
More information. Full article
Molecular methods for the diagnosis of chronic fungal rhinosinusitis
Chronic rhinitis, sometimes with nasal polyps, is a common disorder affecting an estimated 0–17% of all people and many cases are attributable to fungi called chronic fungal rhinosinusitis or CFRS The sensitivity of testing for the presence of fungi by fungal cultures from mucus is known to be low and the specificity from nasal wash or swab is also poor, as fungi are commonly cultured from the nose because it acts as an air filter. The epidemiology of CFRS is likely to be under estimated because of the lack of a sensitive detection method. this article sets out to establish the sensitivity of molecular diagnosis CFRS in 61 patients with CRS.
Molecular detection by ITS1/2 proved far superior to both culture (51% sensitivity) and histology (48% senstitivity). The molecular ITS1/2/method had the advantage over conventional diagnostic tests of identifying the fungal species in 46/47 samples. Aspergillus was the most commonly identified (37/47) of which 31 were A. fumigatus, whilst A. nidulans, Cladosporium cladosporoides, & Scedosporium spp. were found equally in 8.5 % of samples each. This study demonstrates that molecular tools such as PCR are important for establishing a diagnosis of FCRS and for it's aetiology.
Cryptococcal meningitis persists despite 90-90-90 Botswana experience
At the EMBO Mycoses in AIDS meeting in Cape Town, Dr Joe Jarvis working in Gabarone, Botswana questioned the value of 90-90-90 in reducing cryptococcal meningitis.
Botswana's record in rolling out 90-90-90 antiretroviral therapy was published in Lancet HIV in July. Botswana achieved: 83·3% individuals knew their HIV status, among these 87·4%, were receiving ART and 96·5%, had a viral load of <400 copies per mL - 70·2% with virological suppression, close to the UNAIDS target of 73%. This performance is probably the best in Africa and exceeds performance for most countries across the world, with the exception of several European countries.
Fig: Change in cryptococcal meningitis observed (red line)
Despite this the rate of cryptococcal meningitis has not changed The majority of patients with cryptococcal meningitis were patients in care, not newly presenting patients with a new diagnosis of AIDS.
Dr Jarvis commented; “Cryptococcal meningitis is not going away any time soon. If Botswana, with its strong HIV treatment program, still has a continuing problem with cryptococcal meningitis, the situation across sub-Saharan Africa must be worse. Cryptococcal meningitis requires a rethink – only 40% of these patients are still alive at 12 months.”
Global emergence of multidrug- resistant yeast Candida auris.
Many of the world's Public Health agencies including the CDC and the UK's PHE is alerting healthcare facilities to be on the lookout for Candida auris in their patients having received reports from international healthcare facilities, that this emerging multidrug resistant yeast is causing invasive infections with high mortality.
There is particular concern because as it is often multidrug resistant, it is difficult to identify with standard laboratory methods and it has already caused outbreaks in hospital settings.
C. auris can enter the bloodstream and spread throughout the body, causing serious invasive infections & often does not respond to commonly used antifungal drugs, making infections difficult to treat. Some strains of C. auris have elevated minimum inhibitory concentrations (MICs) to the three major classes of antifungals, severely limiting treatment options. No MIC breakpoints exist for C. auris, but testing of an international collection of isolates demonstrated that they were nearly all highly resistant to fluconazole, more than half were voriconazole resistant. In addition one third of isoaltes were amphotericin B resistant and a few resistant to echinocandins. Alarmingly some isolates showed elevated MICs to all three major classes of antifungals. Read more
Now the first outbreak of C. auris in South America has been reported. Bloodstream isolates of C. auris were obtained from 18 critically ill patients admitted to a medical centre in Maracaibo, Venezuela over a 16 month period. Read More
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