Pilar Escribano

In Vitro Acquisition of Secondary Azole Resistance in Aspergillus fumigatus Isolates after Prolonged Exposure to Itraconazole: Presence of Heteroresistant Populations

ABSTRACT Secondary resistance to azoles in Aspergillus fumigatus isolates from patients taking long-term itraconazole therapy has been described. We studied the acquisition of secondary azole resistance in 20 A. fumigatus isolates with no mutations at codon 54, 98, 138, 220, 432, or 448 in the cyp51A gene. Adjusted conidium inocula (3 × 107 CFU/ml) of each isolate were prepared and progressively or directly exposed to increasing itraconazole concentrations, ranging from 0.5 μg/ml to 16 μg/ml. Itraconazole, voriconazole, and posaconazole MICs were determined using the CLSI M38-A2 procedure before (MICinitial) and after (MICfinal) exposure to itraconazole. In both procedures, the MICfinal was significantly higher than the MICinitial. However, after progressive exposure to itraconazole, the MICs of the three azoles were higher than after direct exposure. No mutations were found at codon 54, 98, 138, 220, 432, or 448 in the cyp51A gene of isolates growing at the highest concentration of itraconazole. More concentrated conidium inocula (2 × 109 CFU/ml) plated in itraconazole at 4 μg/ml revealed the presence of heteroresistant populations in two initially wild-type isolates. These isolates became resistant to itraconazole and posaconazole only after use of the concentrated inoculum. These heteroresistant isolates harbored a mutation at codon G54, and the MICs of itraconazole and posaconazole were >16 μg/ml. In all procedures, A. fumigatus short tandem repeat (STRAf) typing was used to demonstrate that the genotype did not change before or after exposure to itraconazole.

Risk factors for late recurrent candidaemia. A retrospective matched case–control study

Incidence, risk factors and clinical significance of late recurrent (LR) candidaemia (>1 month between episodes) remains unclear. The 1219 episodes of candidaemia detected from January 1985 to December 2014 were reviewed. We selected all cases with more than one episode separated by at least 30 days after clinical resolution in the interim (cases) and compared each of them with two controls (patients with single episodes of candidaemia). Clinical strains were genotyped to differentiate relapses from re-infection. Eighteen patients (1.48%) had 36 episodes of LR candidaemia (median 4 months). Independent risk factors for recurrence in the multivariate analysis were: underlying gastrointestinal disease (OR 67.16; 95% CI 5.23-861.71; p 0.001) and fungaemia due to Candida parapsilosis (OR 9.10; 95% 1.33-62.00; p 0.02). All episodes of LR candidaemia diagnosed during the first 3 months were due to an intravascular source of infection, whereas in those occurring after 3 months the main source of the disease was the abdomen, followed by endocarditis, and urinary tract. Molecular typing showed that 42.9% of LR candidaemias were relapses and 57.1% were re-infections. Neither time of recurrence nor clinical origin could predict type of recurrence. LR candidaemia is a relatively rare event that is more frequent in patients who have an initial episode of candidaemia due to C.xa0parapsilosis or an underlying gastrointestinal disease. Episodes of LR candidaemia that occur within the first 3 months should prompt an attempt to exclude an intravascular source of infection, whereas those occurring later point to an intra-abdominal origin.

Aspergillus citrinoterreus, a New Species of Section Terrei Isolated from Samples of Patients with Nonhematological Predisposing Conditions

ABSTRACT The use of molecular identification techniques has revealed an increasing number of new species within Aspergillus section Terrei. We phenotyped a set of 26 clinical isolates that showed genetic differences from Aspergillus terreus sensu stricto by analyzing sequences from PCR-amplified β-tubulin and calmodulin genes and the internal transcribed spacer region. Since the isolates were phylogenetically and morphologically different from all of the members of Aspergillus section Terrei, they are described here as a new species, Aspergillus citrinoterreus, so named because it produces a diffusible yellowish pigment in agar. A. citrinoterreus isolates were significantly more susceptible to itraconazole, voriconazole, and posaconazole than A. terreus sensu stricto isolates were; in contrast, the amphotericin B MICs for both species were high. A. citrinoterreus was found in clinical samples from patients with proven or probable invasive aspergillosis and colonized patients, none of whom had hematological malignancies as predisposing conditions. However, they did have other underlying conditions such as chronic obstructive pulmonary disease, cirrhosis, and cancer or had received a solid organ transplants and presented not only with invasive pulmonary aspergillosis but also with mediastinitis. A. citrinoterreus isolates were detected for the first time in 2002. In all cases of invasive aspergillosis, A. citrinoterreus was found to be a copathogen, mostly with A. fumigatus.

Alta incidencia de bacteriemia por bacilos gramnegativos en pacientes con hipertensión pulmonar tratados con treprostinil por vía intravenosa

INTRODUCTIONnAn excessive risk for bacteremia has recently been reported in patients with pulmonary arterial hypertension (PAH) treated with intravenous treprostinil. We aimed to assess this association in a cohort of patients from a Spanish referral center.nnnPATIENTS AND METHODSnWe performed a retrospective cohort study that included 55 patients diagnosed with PAH who received a continuous intravenous infusion of a prostanoid (epoprostenol or treprostinil) for ≥1month at our center between January 1991 and December 2011. The risk factors associated with the incidence of bacteremia were analyzed with the log-rank test.nnnRESULTSnAfter a total follow-up of 64,453 treatment days, we found 12 episodes of bacteremia: Staphylococcus aureus (5 episodes), non-fermenting gram-negative bacilli (4 episodes), other gram-positive cocci (2 episodes), and Enterobacter cloacae (one episode). The incidence of bacteremia was 0.118 episodes per 1,000 treatment days in patients receiving epoprostenol versus 0.938 episodes per 1,000 treatment-days in patients receiving treprostinil (P=.0037). All episodes of bacteremia due to Gram-negative bacilli were diagnosed in patients on treprostinil. In the univariate analysis the treatment with intravenous treprostinil was associated with the incidence of bacteremia (hazard ratio: 4.09; 95% confidence interval: 1.24-14.53), although the low number of events prevented us from performing a multivariate analysis.nnnCONCLUSIONSnTherapy with intravenous treprostinil is associated with a higher risk for bacteremia, especially due to non-fermenting Gram-negative bacilli. This association should be taken in consideration when choosing empirical antibiotic therapy for patients with PAH and sepsis.

The distribution of the obstruction in the pulmonary arteries modifies pulsatile right ventricular afterload in pulmonary hypertension

a Heart Failure, Heart Transplantation and PulmonaryHypertensionUnit, Department of Cardiology, 12 deOctubre University Hospital,Madrid, Spain, and Cardiovascular ResearchNetwork (RIC), Spain b Department of Pulmonary Medicine, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona Spain and Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain c Department of Pneumonoloy, Hospital Universitario, Leon, Spain d Department of Cardiology, Hospital Virgen Salud, Toledo, Spain

Microsatellite (STRAf) Genotyping Cannot Differentiate between Invasive and Colonizing Aspergillus fumigatus Isolates

ABSTRACT We studied whether short tandem repeats of Aspergillus fumigatus (STRAf) can differentiate between invasive and colonizing genotypes of A. fumigatus. Of the 395 genotypes detected (n = 1,373 isolates), 50 were clusters and 24 (6% of all genotypes) involved the patients with invasive aspergillosis and those colonized with A. fumigatus, indicating that genotyping cannot discriminate between invasive and colonizing isolates.

Genotyping of Aspergillus fumigatus Reveals Compartmentalization of Genotypes in Disseminated Disease after Invasive Pulmonary Aspergillosis

Invasive pulmonary aspergillosis (IPA) disseminated to distant organs (IPAd) is uncommon ([1][1], [2][2]) and has traditionally been considered a monomicrobial infection caused by a single Aspergillus fumigatus clone present both in the lower respiratory tract and at distant sites ([3][3], [4][4]).

The Etest Performed Directly on Blood Culture Bottles Is a Reliable Tool for Detection of Fluconazole-Resistant Candida albicans Isolates

ABSTRACT We assessed the ability of the Etest performed directly on positive blood cultures (ETDIR) to detect fluconazole susceptibility in 6 fluconazole-resistant and 12 fluconazole-susceptible Candida albicans isolates, according to CLSI M27-A3 and EUCAST EDef 7.2 procedures. Categorical agreement between ETDIR and broth microdilution was 100% when the trays were incubated at 25°C and trailing effect was ruled out. ETDIR is a reliable procedure when screening for the presence of fluconazole resistance in C. albicans.

Composite hemodynamic method of pulsatile and steady right ventricular afterload predicts early outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

predicts early outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension☆ Maria J. Ruiz-Cano ⁎, J.C. Grignola , J. Cortina , C. Jimenez , M.T. Velazquez , M.A. Gomez-Sanchez , J. Delgado , P. Escribano a a Heart Failure, Heart Transplantation and Pulmonary Hypertension Unit, Cardiology Dept. 12 de Octubre University Hospital, Madrid, Spain b Dept Fisiopatologia, Hospital de Clinicas, Universidad de laRepublica, Montevideo, Uruguay c Cardio-thoracic Surgery Dept. 12 de Octubre University Hospital, Madrid, Spain

Is biofilm production a prognostic marker in adults with candidaemia

OBJECTIVESnThe role of biofilm production in the outcome of candidaemia remains under discussion. Current evidence relies on variable biofilm detection methods while evaluating distinct clinical end points. We aimed to determine the impact of biofilm production measured by metabolic activity (MA) and biomass (BM) on the prognosis of adults with candidaemia.nnnMETHODSnRetrospective cohort including 280 adults with candidaemia admitted from 2010 to 2016. BM was assessed using crystal violet binding stain and the XTT reduction assay was used to detect MA. Strains were classified as high and moderate-low biofilm producers according to published cut-offs. The primary outcome was overall mortality within 7 and 30xa0days. The secondary outcome was unfavourable prognosis defined as metastatic infection, admission to an intensive care unit due to the severity of candidaemia, or death within 30xa0days.nnnRESULTSnHigh BM and high MA were detected in 90 (32.1%) and 114 (40.7%) of the 280 isolates, respectively. Comparison of high and moderate-low biofilm forming isolates revealed no correlation between biofilm production and 7-day mortality (BM high 15/90 (16.7%) versus moderate-low 24/190 (12.6%); MA high 12/114 (10.5%) versus moderate-low 27/166 (16.3%)), 30-day mortality (BM high 34/90 (37.8%) versus moderate-low 61/190 (32.1%); MA high 33/114 (28.9%) versus moderate-low 62/166 (37.3%)), or unfavourable prognosis (BM high 45/90 (50.0%) versus moderate-low 73/190 (38.4%); MA high 41/114 (36.0%) versus moderate-low 77/166 (46.4%)).nnnCONCLUSIONSnBiofilm production was not a predictor of mortality or of unfavourable prognosis in adults with candidaemia.