Azole Resistance and CYP51A/B Mutations in Aspergillus Clinical Isolates Before and During the COVID-19 Pandemic: A Molecular Surveillance Study
-
Mohammadrafi Khorgami
,
Shirin Sayyahfar
,
Negar Omidi
,
Maryam Moradian
,
Nikta Aliabadi
,
Pegah Tamimi
,
Aliasghar Ghaderi
,
Hengameh Soudi
,
Fatemeh Naderi
,
Mahsa Fattahi
,
Fatemeh Omidi
Abstract
We conducted a cross-sectional study to (I) determine the relative frequency of antifungal-resistant Aspergillus clinical isolates, (II) address changes in susceptibility to available antifungals in patients infected with Aspergillus spp. with COVID-19, and (III) determine mutations in the CYP51A and CYP51B genes of Aspergillus spp. Isolated from the clinical specimens. A total of 30 fungal species were enrolled in the study. The antifungal activities of itraconazole and voriconazole were assessed using azole-containing agar media in Petri dishes. After identifying resistance in the isolates, the CYP51A and CYP51B gene regions were sequenced using the designed primers, and mutations were identified. To amplify CYP51A and CYP51B, primers with the specified sequences were used. Genomic DNA from 22 azole-resistant Aspergillus isolates was amplified using the CYP51-A and CYP51-B gene primers. 12/22 (54.54%) azole-resistant A. flavus isolates with the Tandem Repeat (TR34)/L98H (leucine-to-histidine substitution) mutation, MICs above the CLSI Epidemiological Cutoff Value. One carried the F46Y /TR34. 5/22 azole non-WT A. fumigatus isolates, CYP51-A analysis revealed that M220I, S297T/ TR34/L98H mutations, 4 A.orezea isolates had C498T/TR34 at a CYP51-B gene. Antifungal susceptibility testing should be performed when possible, and efficient systems must be implemented to monitor the evolution of newly introduced azole-resistant Aspergillus spp. In addition, these data are useful for clinicians to understand the incidence of azole resistance, enabling optimal management of affected patients and helping choose the right solution for infection management.
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14. Zakaria A, Osman M, Dabboussi F, Rafei R, Mallat H, Papon N, et al. Recent trends in the epidemiology, diagnosis, treatment, and mechanisms of resistance in clinical Aspergillus species: a general review with a special focus on the Middle Eastern and North African region. J Infect Public Health 2020;13:1-10.
15. Lestrade PPA, Meis JF, Melchers WJG, Verweij PE. Triazole resistance in Aspergillus fumigatus: recent insights and challenges for patient management. Clin Microbiol Infect 2019;25:799-806.
16. Garcia-Rubio R, Alcazar-Fuoli L, Monteiro MC, Monzon S, Cuesta I, Pelaez T, et al. Insight into the significance of Aspergillus fumigatus cyp51A polymorphisms. Antimicrob Agents Chemother 2018;62:e02000-17.
17. Hagiwara D, Watanabe A, Kamei K, Goldman GH. Epidemiological and genomic landscape of azole resistance mechanisms in Aspergillus fungi. Front Microbiol 2016;7:1382.
18. Badali H, Vaezi A, Haghani I, Yazdanparast SA, Hedayati MT, Mousavi B, et al. Environmental study of azole-resistant Aspergillus fumigatus with TR34/L98H mutations in the cyp51A gene in Iran. Mycoses 2013;56:659-63.
19. Erami M, Hashemi SJ, Raiesi O, Fattahi M, Getso MI, Momen-Heravi M, et al. COVID-19-associated pulmonary aspergillosis in Iranian patients admitted with severe COVID-19 pneumonia. Infection 2022;50:1-8.
20. Alanio A, Dellière S, Fodil S, Bretagne S, Mégarbane B. Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19. Lancet Respir Med 2020;8:e48-9.
21. Chen P, Liu J, Zeng M, Sang H. Exploring the molecular mechanism of azole resistance in Aspergillus fumigatus. J Mycol Med 2020;30:100915.
22. Dudakova A, Spiess B, Tangwattanachuleeporn M, Sasse C, Buchheidt D, Weig M, et al. Molecular tools for the detection and deduction of azole antifungal drug resistance phenotypes in Aspergillus species. Clin Microbiol Rev 2017;30:1065-91.
23. Clinical and Laboratory Standards Institute. Reference method for broth dilution antifungal susceptibility testing of yeasts. CLSI document M27-A2. Wayne, PA: CLSI; 2002.
24. Pham CD, Reiss E, Hagen F, Meis JF, Lockhart SR. Passive surveillance for azole-resistant Aspergillus fumigatus, United States, 2011–2013. Emerg Infect Dis 2014;20:1498-501.
25. Van der Linden J, Arendrup M, Warris A, Lagrou K, Pelloux H, Hauser P, et al. Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus. Emerg Infect Dis 2015;21:1041-4.
26. Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016;47:45-68.
27. Romero M, Messina F, Marin E, Arechavala A, Depardo R, Walker L, et al. Antifungal resistance in clinical isolates of Aspergillus spp.: when local epidemiology breaks the norm. J Fungi 2019;5:41.
28. Meijer EF, Dofferhoff AS, Hoiting O, Buil JB, Meis JF. Azole-resistant COVID-19-associated pulmonary aspergillosis in an immunocompetent host: a case report. J Fungi 2020;6:79.
29. Ghelfenstein-Ferreira T, Saade A, Alanio A, Bretagne S, de Castro RA, Hamane S, et al. Recovery of a triazole-resistant Aspergillus fumigatus in respiratory specimen of COVID-19 patient in ICU: a case report. Med Mycol Case Rep 2021;31:15-8.
30. Mohamed A, Hassan T, Trzos-Grzybowska M, Thomas J, Quinn A, O'Sullivan M, et al. Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 coinfection: a lethal combination. Med Mycol Case Rep 2021;31:11-4.
31. Chen Y, Li Z, Han X, Tian S, Zhao J, Chen F, et al. Elevated MIC values of imidazole drugs against Aspergillus fumigatus isolates with TR34/L98H/S297T/F495I mutation. Antimicrob Agents Chemother 2018;62:e01549-17.
32. Pontes L, Beraquet CAG, Arai T, Pigolli GL, Lyra L, Watanabe A, et al. Aspergillus fumigatus clinical isolates carrying CYP51A with TR34/L98H/S297T/F495I substitutions detected after four-year retrospective azole resistance screening in Brazil. Antimicrob Agents Chemother 2020;64:e02059-19.
33. Kemoi E, Bii C, Nyerere A. Azole-resistant Aspergillus fumigatus with TR34/L98H mutation from clinical isolates in Kenya. East Afr Med J 2023;100:5832-7.
2. Rawson TM, Moore LS, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis 2020;71:2459-68.
3. Hoenigl M. Invasive fungal disease complicating coronavirus disease 2019: when it rains, it spores. Clin Infect Dis 2021;72:e1645-8.
4. Lansbury L, Lim B, Baskaran V, Lim WS. Coinfections in people with COVID-19: a systematic review and meta-analysis. J Infect 2020;81:266-75.
5. Koehler P, Cornely OA, Böttiger BW, Dusse F, Eichenauer DA, Fuchs F, et al. COVID-19 associated pulmonary aspergillosis. Mycoses 2020;63:528-34.
6. Verweij PE, Gangneux JP, Bassetti M, Brüggemann RJ, Cornely OA, Koehler P, et al. Diagnosing COVID-19-associated pulmonary aspergillosis. Lancet Microbe 2020;1:e53-5.
7. Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2021;21:e149-62.
8. Dellière S, Dudoignon E, Fodil S, Voicu S, Collet M, Oillic PA, et al. Risk factors associated with COVID-19-associated pulmonary aspergillosis in ICU patients: a French multicentric retrospective cohort. Clin Microbiol Infect 2021;27:790.e1-5.
9. Marr KA, Platt A, Tornheim JA, Zhang SX, Datta K, Cardozo C, et al. Aspergillosis complicating severe coronavirus disease. Emerg Infect Dis 2021;27:18-25.
10. Benedetti MF, Alava KH, Sagardia J, Cadena RC, Laplume D, Capece P, et al. COVID-19 associated pulmonary aspergillosis in ICU patients: report of five cases from Argentina. Med Mycol Case Rep 2021;31:24-8.
11. Machado M, Valerio M, Álvarez-Uría A, Olmedo M, Veintimilla C, Padilla B, et al. Invasive pulmonary aspergillosis in the COVID-19 era: an expected new entity. Mycoses 2021;64:132-43.
12. Latgé JP. Aspergillus fumigatus and aspergillosis. Clin Microbiol Rev 1999;12:310-50.
13. Rudramurthy SM, Paul RA, Chakrabarti A, Mouton JW, Meis JF. Invasive aspergillosis by Aspergillus flavus: epidemiology, diagnosis, antifungal resistance, and management. J Fungi 2019;5:1-15.
14. Zakaria A, Osman M, Dabboussi F, Rafei R, Mallat H, Papon N, et al. Recent trends in the epidemiology, diagnosis, treatment, and mechanisms of resistance in clinical Aspergillus species: a general review with a special focus on the Middle Eastern and North African region. J Infect Public Health 2020;13:1-10.
15. Lestrade PPA, Meis JF, Melchers WJG, Verweij PE. Triazole resistance in Aspergillus fumigatus: recent insights and challenges for patient management. Clin Microbiol Infect 2019;25:799-806.
16. Garcia-Rubio R, Alcazar-Fuoli L, Monteiro MC, Monzon S, Cuesta I, Pelaez T, et al. Insight into the significance of Aspergillus fumigatus cyp51A polymorphisms. Antimicrob Agents Chemother 2018;62:e02000-17.
17. Hagiwara D, Watanabe A, Kamei K, Goldman GH. Epidemiological and genomic landscape of azole resistance mechanisms in Aspergillus fungi. Front Microbiol 2016;7:1382.
18. Badali H, Vaezi A, Haghani I, Yazdanparast SA, Hedayati MT, Mousavi B, et al. Environmental study of azole-resistant Aspergillus fumigatus with TR34/L98H mutations in the cyp51A gene in Iran. Mycoses 2013;56:659-63.
19. Erami M, Hashemi SJ, Raiesi O, Fattahi M, Getso MI, Momen-Heravi M, et al. COVID-19-associated pulmonary aspergillosis in Iranian patients admitted with severe COVID-19 pneumonia. Infection 2022;50:1-8.
20. Alanio A, Dellière S, Fodil S, Bretagne S, Mégarbane B. Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19. Lancet Respir Med 2020;8:e48-9.
21. Chen P, Liu J, Zeng M, Sang H. Exploring the molecular mechanism of azole resistance in Aspergillus fumigatus. J Mycol Med 2020;30:100915.
22. Dudakova A, Spiess B, Tangwattanachuleeporn M, Sasse C, Buchheidt D, Weig M, et al. Molecular tools for the detection and deduction of azole antifungal drug resistance phenotypes in Aspergillus species. Clin Microbiol Rev 2017;30:1065-91.
23. Clinical and Laboratory Standards Institute. Reference method for broth dilution antifungal susceptibility testing of yeasts. CLSI document M27-A2. Wayne, PA: CLSI; 2002.
24. Pham CD, Reiss E, Hagen F, Meis JF, Lockhart SR. Passive surveillance for azole-resistant Aspergillus fumigatus, United States, 2011–2013. Emerg Infect Dis 2014;20:1498-501.
25. Van der Linden J, Arendrup M, Warris A, Lagrou K, Pelloux H, Hauser P, et al. Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus. Emerg Infect Dis 2015;21:1041-4.
26. Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016;47:45-68.
27. Romero M, Messina F, Marin E, Arechavala A, Depardo R, Walker L, et al. Antifungal resistance in clinical isolates of Aspergillus spp.: when local epidemiology breaks the norm. J Fungi 2019;5:41.
28. Meijer EF, Dofferhoff AS, Hoiting O, Buil JB, Meis JF. Azole-resistant COVID-19-associated pulmonary aspergillosis in an immunocompetent host: a case report. J Fungi 2020;6:79.
29. Ghelfenstein-Ferreira T, Saade A, Alanio A, Bretagne S, de Castro RA, Hamane S, et al. Recovery of a triazole-resistant Aspergillus fumigatus in respiratory specimen of COVID-19 patient in ICU: a case report. Med Mycol Case Rep 2021;31:15-8.
30. Mohamed A, Hassan T, Trzos-Grzybowska M, Thomas J, Quinn A, O'Sullivan M, et al. Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 coinfection: a lethal combination. Med Mycol Case Rep 2021;31:11-4.
31. Chen Y, Li Z, Han X, Tian S, Zhao J, Chen F, et al. Elevated MIC values of imidazole drugs against Aspergillus fumigatus isolates with TR34/L98H/S297T/F495I mutation. Antimicrob Agents Chemother 2018;62:e01549-17.
32. Pontes L, Beraquet CAG, Arai T, Pigolli GL, Lyra L, Watanabe A, et al. Aspergillus fumigatus clinical isolates carrying CYP51A with TR34/L98H/S297T/F495I substitutions detected after four-year retrospective azole resistance screening in Brazil. Antimicrob Agents Chemother 2020;64:e02059-19.
33. Kemoi E, Bii C, Nyerere A. Azole-resistant Aspergillus fumigatus with TR34/L98H mutation from clinical isolates in Kenya. East Afr Med J 2023;100:5832-7.
| Files | ||
| Issue | Vol 63 No 6 (2025) | |
| Section | Original Articles | |
| DOI | https://doi.org/10.18502/acta.v63i6.20673 | |
| Keywords | ||
| Antifungal resistance COVID-19 Aspergillus Cytochromes P 51 gene (CYP51 gene) | ||
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How to Cite
1.
Khorgami M, Sayyahfar S, Omidi N, Moradian M, Aliabadi N, Tamimi P, Ghaderi A, Soudi H, Naderi F, Fattahi M, Omidi F. Azole Resistance and CYP51A/B Mutations in Aspergillus Clinical Isolates Before and During the COVID-19 Pandemic: A Molecular Surveillance Study. Acta Med Iran. 2025;63(6):324-329.
