Journal Article

Aspergillosis due to Voriconazole Highly Resistant Aspergillus fumigatus and Recovery of Genetically Related Resistant Isolates From Domiciles

Camps, Simone M. T., Arends, Jan P. A., Zoll, J., Kampinga, Greetje A., Varga, János, van der Linden, Jan W. M., Karawajczyk, Anna, Melchers, Willem J. G., Verweij, Paul E., van Tiel, Frank H., Debets-Ossenkopp, Yvette J., Haas, Pieter J. A., Rijnders, Bart J. A., Kujiper, Ed J.

2013

Overview

Background. Azole resistance is an emerging problem in Aspergillus fumigatus and complicates the management of patients with Aspergillus-related diseases. Selection of azole resistance may occur through exposure to azole fungicides in the environment. In the Netherlands a surveillance network was used to investigate the epidemiology of resistance selection in A. fumigatus. Methods. Clinical A. fumigatus isolates were screened for azole resistance in 8 university hospitals using azole agar dilution plates. Patient information was collected using an online questionnaire and azole-resistant A. fumigatus isolates were analyzed using gene sequencing, susceptibility testing, and genotyping. Air sampling was performed to investigate the presence of resistant isolates in hospitals and domiciles. Results. Between December 2009 and January 2011, 1315 A. fumigatus isolates from 921 patients were screened. A new cyp51A-mediated resistance mechanism (TR 46 /Y121F/T289A) was observed in 21 azole-resistant isolates from 15 patients in 6 hospitals. TR 46 /Y121F/T289A isolates were highly resistant to voriconazole (minimum inhibitory concentration ≥16 mg/L). Eight patients presented with invasive aspergillosis due to TR 46 /Y121F/T289A, and treatment failed in all 5 patients receiving primary therapy with voriconazole. TR 46 /Y121F/T289A Aspergillus fumigatus was recovered from 6 of 10 sampled environmental sites. Conclusions. We describe the emergence and geographical migration of a voriconazole highly resistant A. fumigatus that was associated with voriconazole treatment failure in patients with invasice aspergillosis. Recovery of TR 46 /Y121F/T289A from the environment suggests an environmental route of resistance selection. Exposure of A. fumigatus to azole fungicides may facilitate the emergence of new resistance mechanisms over time, thereby compromising the use of azoles in the management of Aspergillus-related diseases.

• Publisher: Oxford University Press
• Subject: Agar / Aged / Air Microbiology / Air sampling / Antibiotics. Antiinfectious agents. Antiparasitic agents / Antifungal agents / Antifungal Agents - pharmacology / Antifungal Agents - therapeutic use / ARTICLES AND COMMENTARIES / Aspergillosis / Aspergillosis - diagnosis / Aspergillosis - drug therapy / Aspergillosis - microbiology / Aspergillus / Aspergillus fumigatus / Aspergillus fumigatus - classification / Aspergillus fumigatus - drug effects / Aspergillus fumigatus - genetics / Aspergillus fumigatus - isolation & purification / Azoles / Biological and medical sciences / Child / Disease management / Drug resistance / Drug Resistance, Fungal / Environmental health / Epidemiology / Female / Fungi / Fungicides / Genes, Fungal / Genotype / Genotype & phenotype / Hospitals / Human mycoses / Humans / Infections / Infectious diseases / Male / Medical sciences / Microbiology / Middle Aged / Miscellaneous mycoses / Molecular Typing / Mycological Typing Techniques / Mycoses / Netherlands / Pharmacology. Drug treatments / Prescription drugs / Pyrimidines - pharmacology / Pyrimidines - therapeutic use / Residence Characteristics / Resistance mechanisms / Selection, Genetic / Sequence Analysis, DNA / Surveys and Questionnaires / Treatment Failure / Triazoles / Triazoles - pharmacology / Triazoles - therapeutic use / Trucks / Voriconazole / Young Adult