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