Manuel Cuenca Estrella

Presentación del tema: "Manuel Cuenca Estrella"— Transcripción de la presentación:

1 Manuel Cuenca Estrella
Importancia Clínica Resistencia Miceliales En enfermos oncohematológicos Manuel Cuenca Estrella Febrero, 2015

2 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.

3 Relevant Mycoses. Global burden According to LIFE and GAFFI (www
Relevant Mycoses. Global burden According to LIFE and GAFFI (

4 Perfil de actividad en miceliales
Especies Antifúngicos ANF FC FLC ITC VRC POS EQUIN A. fumigatus S R Aspergillus flavus Aspergillus terreus I-R Aspergillus niger S-I-R** Fusarium spp. Scedosporium spp. Mucorales

5 Low performance of cultures Laboratory contaminants
Epidemiology of aspergillosis and other mold infections is tough, because………….. 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 To know the epidemiology of moulds is tough because many reasons. As most of them are opportunistic infections in immunocompromised patients a system for classified them as proven or probable has been decided. However, only those cases with a culture positive from a sterile sample are valid for epidemiology purposes and those cases are a minority due to the low rate of sterile samples that can be obtained from patients and also the high rate of false negative results of culture procedures. Besides, identification to level species of moulds are not possible by means of microscopy examination of sterile material or indirect tests. Finally, blood cultures, the gold standard for yeasts epidemiology are not useful for moulds.

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7 Results from Spain FILPOP_2012 Population-based survey Molds isolated from deep samples (including respiratory ones) Two months (spring and fall) 30 Spanish hospitals Molecular ID and AST

8 AAC 2013; 57:3380

9 Epidemiology 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 --- 2.9% Other 1.78% 15% Let’s start with epidemiology. In all works collected the most frequent genera causing IMIs is Aspergillus. Then, there are geographical differences. In some places, Zygomycetes are the second most frequent family and in other the genera Fusarium. Besides, Scedosporium is another genera involved in IMIS but in some places a miscellaneous number of species cause significant number of cases.

10 No patients with a +ve culture % patients with azole R isolates
Now the second situation with A. fumigatus that is the mergence of secondary resistance to azole drugs. In the chart the evolution of resistance to azole in the Netherlands is shown. Since 2000 an increase in the detection of resistant isolates have been detected while the number of isolates analyzed is not very different 10

11 This finding has been also found in other settings as in UK
This finding has been also found in other settings as in UK. In 2007, 17% of isolates received in the Regional Mycology Laboratory of Manchester were resistant to azole drugs but the most worrisome finding was the increase of isolates showing cross resistance to all azole drugs available 11

12 Results from Spain. FILPOP. Population-based survey.
325 isolates Aspergillus spp. (sensu stricto) N % TOTAL 277 85% (4 cases per 100,000 pop) A. fumigatus 156 48% A. flavus 26 8% A. terreus A. tubingensis (section Nigri) 22 6.8% A. niger 21 6.5% A. nidulans 8 2.5%

13 Aspergillus cryptic species
FILPOP 11% cryptic species 15% cryptic species Balajee et al, JCM 2009 Alastruey-Izquierdo et al. AAC 2013 Alastruey-Izquierdo et al. ANYAS 2012

14 Cryptic Species n AMB ICZ VCZ PCZ CPF MCF ANF A. lentulus 26 3 2.3 3.4
0.23 1.6 0.1 N. hiratsukae 9 1.7 0.9 1.1 0.16 0.11 0.03 N. pseudofischerii 6 0.25 4 2.51 0.22 0.86 A. fumigatiaffiinis 4.8 5 3.1 0.4 0,03 N. udagawae 2 0.6 0.3 A. viridinutans 0,7 16 0,25 5,66 0,06 0,09 A. tubingensis 22 0.42 0.76 0.09 0.05 A. calidoustus 19 8.6 6.2 6.8 0.5 0.04 A. insuetus 0.7 11.3 8 2.8 5.6 1.4 A. keveii 1 A. alliaceus 30 19.25 0.2 12.15 3.8 1.9 By Alastruey-Izquierdo

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16 World Surveys on A. fumigatus complex resistance.
Rates of resistance according to ECOFFs Journals and Congresses Country Itraconazole Voriconazole Posaconazole Spain Cuenca-Estrella et al 8% 4.5% 4.4% USA Diekema et al 7% 1% France Bretagne et al 2% Holland Snelders et al 12.8% 10% United Kingdom Howard et al 17%

17 Haematologica. 2012;97(7):963-5.

18 Aguado et al. Clin Infect Dis. 2014;Oct 21. pii: ciu833

19 PCRAGA STUDY P=0.027 Aguado et al. Clin Infect Dis. 2014;Oct 21. pii: ciu833

20 ABC Azole Strain with low MIC           Cyp51A Cyp51B

21 Mutations in Cyp51A ABC Strain with high MIC Azole Cyp51A Cyp51B

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23 UP regulation of Cyp51A ABC Strain with high MIC Azole Cyp51A Cyp51B

24 34-bp sequence in the promoter
Gen Cyp51A in a resistant strain Duplication of 34-bp sequence in the promoter Cyp51A L98H TR-R-ITC x 8 237

25 New mechanisms of resistance in Aspergillus
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 Arendrup et al, Denning et al, Mellado et al, Verweij et al

26 No patients with a +ve culture % patients with azole R isolates
Now the second situation with A. fumigatus that is the mergence of secondary resistance to azole drugs. In the chart the evolution of resistance to azole in the Netherlands is shown. Since 2000 an increase in the detection of resistant isolates have been detected while the number of isolates analyzed is not very different 26

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28 This finding has been also found in other settings as in UK
This finding has been also found in other settings as in UK. In 2007, 17% of isolates received in the Regional Mycology Laboratory of Manchester were resistant to azole drugs but the most worrisome finding was the increase of isolates showing cross resistance to all azole drugs available 28

29 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

30 Descripción en muchos países
JCM 2012;50:2531

31 30% resistencia en paciente hematológico y 88% mortalidad

32 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)

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34 PCR in tissues. Proven IFI

35 84 patients were analyzed. 68/84 (81%) were cultured
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%

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37 Sequencing and analysis

38 Table 1. Current situation of the antifungal susceptibility testing field by antifungal agent, by species and by stages of standardization process Antifungal agents Fungal species Availability 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. YES NO  NO Azoles IN PROGRESS NO NO Echinocandins YES  FILPOP 2, In progress