Antifungal Resistance and auris Infections

George R. Thompson III, MD, FIDSA Associate Professor Division of Infectious Diseases Department of Internal Medicine Department of Medical Micro and Immunology University of California-Davis DISCLOSURES

Name of Organization Relationship

Pfizer, Merck, Astellas, Wako, Research Support Scynexis, Cidara, Vical, T2, F2G & Astellas, Vical, Mayne Consulting Key Questions

Resistance in fungi?

. Candida auris ….and other Candida spp . . Changes in and “cryptic” . Cryptococcus . Other moulds . Other Mortality Due to Invasive Mycoses

Overall Pathogen Mortality Candida spp. 40%1,2

Aspergillus spp. 62->90%3 Invasive moulds (e.g. Bipolaris, , ~80%4 )

Resistant fungi (e.g. 100%4 Lomentospora prolificans*)

1. Pappas PG, et al. Clin Infect Dis. 2003;37:634-643. 2. Wisplinghoff H, et al. Clin Infect Dis. 2004;39:309-317. 3. Perfect J, et al. Clin Infect Dis. 2001;33:1824-1833. 4. Marr KA, et al. Clin Infect Dis. 2002;34:909-917. *formerly Scedosporium prolificans Invasive Candida Infections 1. Is Candida susceptibility performed “in-house” at your center?

A. Yes B. No C. I don’t know : Risk Factors

. IV catheters Quantitative or . TPN Barrier qualitative neutrophil disruption dysfunction . Post-procedure Neutropenia Central venous catheters . Broad-spectrum Chemotherapy (mucositis) antibiotics . Colonization Exposures Deficits in cell-mediated immunity Change in microbiome . Chemotherapy HIV, hereditary syndromes . Transplant Metabolic

Horn DL, Clin Infect Dis. (2009) 48 (12): 1695-1703. Pappas PG et al. Clin Infect Dis. 2010. 15;50(8):1101-11

PATH alliance database: . 2019 patients (peds and adult) – 2004-08 . Incidence of non-C. albicans species > C. albicans . Those with prior therapy . Crude mortality ~35%

 C. krusei = intrinsically FLU resistant  C. glabrata = ? incidence of FLU resistance

Horn DL, et al. Clin Infect Dis 2009;48:1695-703. Pfaller MA, et al. PLoS One. 2014 Jul 3;9(7):e101510. Rapid emergence of C. auris

South S. Africa Pakistan India Japan Korea Kenya Venezuela Kuwait Israel, U.K 2009 2010 2011 2012 2013 2014 2015

Satoh K, et al. Microbiol Immunol. 2009 Jan;53(1):41-4. Changes afoot?

. C. auris outbreak in U.K. hospital . 9 C. auris bloodstream infections . >40 patients colonized . Clear patient to patient transmission . CDC alert in June 2016 to look for cases in U.S. . Almost uniformly resistant, also resistant to and amphotericin B in selected cases . C. auris persists for > 4 weeks on plastic surfaces . Quaternary ammonium compounds inadequate for disinfection

. Early in outbreak misidentified as other Candida spp, Saccharomyces cerevisiae . MALDI-TOF identifies correctly as does PCR Where did it come from?

• Separate independent emergence

 C. auris in U.S. is closely related to other global isolates.  All appeared to have emerged independently https://www.cdc.gov/fungal/diseases/candidiasis/tracking-c-auris.html Accessed 16 Jan 2018.

Emerging problems in more common Candida species as well… Increase in Resistance

. Breakpoints have changed! . 2007: MIC <2 μg/mL . Clinical failures with mutations in FKS1 and FKS2, MICs of these isolates remained below 2 μg/mL

. 2011: now species specific Fluconazole C. albicans C. glabrata C. parapsilosis

Caspo (μg/mL) <0.25 ≤ 0.12 <2

Mica (μg/mL) <0.25 ≤ 0.06 <2 Echinocandins Anidula (μg/mL) <0.25 ≤ 0.12 <2

These have been questioned Lepak et al AAC Trends in C. glabrata resistance: 2001-2010 2012;56(11):5875-82.

Pfaller MA, et al. Drug Res Update. 2011;14(3):164–176 Alexander BD, et al. Clin Infect Dis. 2013;56(12):1724–32 Species Fluconazole Echinocandin Amphotericin C. albicans S S S C. glabrata S – DD S (emerging R) S C. krusei R S S C. parapsilosis S S – elevated S MICs Meyerozyma S S – elevated S guillermondii* MICs

C. lusitanea S S R C. auris R S to R S to R

*formerly Candida guillermondii Tremendous taxonomic changes in mycology

Borman and Johnson. J Clin Micro Ahead of print 2. What pathogen is responsible for the majority of AIDS-associated deaths in Africa ?

A. Schistosomiasis B. Malaria C. Tuberculosis D. Cryptococcus E. Ebola Cryptococcus spp.

Caused by two spp. . C. neoformans . C. gattii Cryptococcus

. Antigenemia precedes symptomatic disease

. CRAG positivity precedes symptoms of CM by median of 22 days (range, 5-234)

. Treatment during this time significantly improves mortality

Kozel TR, Expert Opin Med Diagn. 2012 May;6(3):245-51. French N, et al. AIDS 2002, 16:1031-38. Global burden of Cryptococcus

Incidence Deaths ______Malaria 360 million 1.15 million TB 1.6 million 350,000 Crypto 1 – 2 million 0.5 – 1 million

◦ 25 million in Sub-Saharan Africa with HIV . 4-12% infected with Cryptococcus spp . Responsible for 50% of HIV-related mortality

Chiller T, 2007. WHO Burden of Disease Estimates C. gattii

. Australian Aborigines . Vancouver island . Recent increase in U.S. cases . Washington → TX, NM, NC, FL . Morbidity differences? . Susceptibility differences?

Hoang Med Microbiol. 2004;53:935-40. Thompson et al Antimicrob Agents Chemo 2009;53:309-11. Susceptibility Differences

*Species in Cryptococcus are currently in taxonomic debate

Thompson GR et al. Antimicrob Agents Chemo. 2008 52(8):2959-61 Thompson GR et al. Antimicrob Agents Chemo. 2009 53(1):309-11. Thompson GR et al. Mycopathologia. 2010 170(5):291-313. Espinel-Ingroff A, Thompson GR et al Antimicrob Agents Chemo. 2014 Heteroresistance in fungi: Cell Death: Lethal genomic events Stress: . Antifungal . Free radical . Etc

Advantageous Aneuploidy Wild copy number change

Cell Death: No change in resistance mechanisms Mechanism of Resistance?

. Target enzyme modification - NO . Ergosterol pathway - NO . Efflux pump….

. 2 major efflux pumps: . MDR1 and PDR11 WM178 WT mdr1Δ MDR1 . Knockouts and reconstituted isolates constructed . PDR11 major factor for Resistance WM178 WT pdr11Δ PDR11 3. When do you request susceptibility testing for aspergillosis?

A. Routinely at initial isolation B. In patients with prior exposure to antifungal agents C. In patients with progressive infection D. Never—clinical correlation is limited E. Uncertain due to limited evidence Global Emergence of Resistance in Aspergillus

New reports (especially with TR/mutations): Italy, Tanzania, Sweden, Kuwait, Poland, Japan, France, China, Germany, Australia, & US! Wiederhold NP, et al. TIMM 2015. Map courtesy Matthew Kneal and David Denning Continent/Country Percent Resistance Isolate Source

Europe (G54, M222, G448S, G138, TR34/L98H, TR46/Y121F/T289A, TR53) Belgium 5.7% Clinical France 0.9 – 10.6% Clinical Germany 1.1 – 12 % Clinical & Environmental Netherlands 2.1 – 20% Clinical & Environmental Poland 2.3% Clinical Spain 1.8% Clinical Turkey 10.2% Clinical United Kingdom 6.6 – 28% Clinical

North & South America (G54, M222, G448S, G138, TR34/L98H, TR46/Y121F/T289A, TR53) United States 0.6 – 11.8% Clinical

Colombia (TR53) 3.3% Environmental

Africa (TR34/L98H, TR46/Y121F/T289A) Tanzania 13.9% Environmental

Asia & Australia (G54, M222, G448S, TR34/L98H, TR46/Y121F/T289A) Australia 2.6% Clinical China, India, Iran, Japan, Kuwait, Pakistan 1.9 – 11.1% Clinical & Environmental

Rivero-Menendez J Fungi 2016;21; doi:10.3390/jof2030021. Slide adopted from Nathan Wiederhold. Antifungal Activity vs. A. fumigatus

U.S. Clinical Isolates Parameter Itraconazole Posaconazole MIC Range <0.03 – >16 μg/ml 0.06 - >16 μg/ml <0.03 – >16 μg/ml MIC50 0.5 μg/ml 0.5 μg/ml 0.25 μg/ml MIC90 1 μg/ml 1 μg/ml 0.5 μg/ml GM MIC 0.537 μg/ml 0.586 μg/ml 0.191 μg/ml

Wiederhold et al. Advances Against Aspergillosis 2014. Resistance in Aspergillus

. Itraconazole R - first described in 1997 . Specific mutations in CYP51A (azole target) – Global emergence of point mutations with TR in promoter region (TR34/L98H & TR46/Y121F/T289A)—environmental – Specific “hot-spots”: G54, L98, G138, M220, G448 Problematic for PCR – . Over expression of CYP51B, CDR1B, AfuMDR1 vs phenotype . Efflux pump: cdr1B, atrF and a number of novel mechanisms . “Pan” azole resistant isolates now described – cavitary disease, also in azole naïve patients

G54 Vori and Isa lower MICs

M220 variable

Buied A, et al. J Antimicrob Chemother. 2010 Oct;65(10):2116-8. Fraczek MG, et al. J Antimicrob Chemother. 2013 Jul;68(7):1486-96. Buied A, et al. J Antimicrob Chemother. 2013 Mar;68(3):512-4. Gregson L, et al. Antimicrob Agents Chemother. 2013;57(11):5778-5780 Invasive Aspergillosis in Patients Admitted to ICU with COVID19 or Severe Influenza

. Retrospective cohort study in Belgium/Netherlands 2009-2016 . IA dx in 83 (19%) of 432 patients with influenza; median 3 days after admission . Immunocompromised: 32% (38 of 117) . Non-immunocompromised: 14% (45 of 315) . Controls: 5% (16 of 315) . 90 d mortality: 51% with IA vs 28% no IA . Risk factors for mortality: influenza (OR 5.19), higher APACHE score, male, corticosteroids

Thompson GR, et al. Open Forum Infect Dis 2020 ahead of print Schauwvliegh A, Rijnders B, et al Lancet Resp Med 2018;ePub July 31 Recommendations for Management of Multi-Drug Resistant (MDR) Candidiasis: C. auris

. Echinocandins recommended for use in most patients pending susceptibility testing . Consideration for use of liposomal AmB for echinocandin resistant isolates or with persistent . Recommendation for susceptibility testing for all C. auris bloodstream isolates . Susceptibility testing from non-sterile sites if: clinically indicated, colonization/infection in facility/unit, prior admission to international healthcare facility with transmission . Evidence limited but strong recommendation (Strong recommendation, low-quality evidence)

Pappas PG, et al. Clin Infect Dis 2016;62:e1-50; Arendrup MC, Patterson TF, J Infect Dis 2017;216(S3):S445–51 https://www.cdc.gov/fungal/candida-auris/c-auris- treatment.html 4. How are moulds identified to species level at your center?

A. Phenotypic methods B. Genomic sequencing in-house C. Send-out to other lab D. Not sure E. Need more coffee Cryptic Aspergillus Species

Leading causes of IA: A. niger A. terreus . A. fumigatus (45% – 60%) A. flavus 10% 12% 12% . A. flavus (6% – 10%) A. nidulans 3% . A. terreus (4% – 10%) A. ustus 2% . A. niger (2% - 9%) A. sydowii 2% A. versicolor . Molecular tools led to description of new 2% species . Cryptic or sibling species – difficult to differentiate by classic means (phenotype/morphology alone) A. fumigatus 57% . TRANSNET (U.S.: 2001 – 2006) 11% cryptic species among 218 Aspergillus isolates . A. lentulus (1.8%), A. udagawae (1.4%), A. tubingensis (2.8%), A. calidoustus (2.8%) . FILPOP (Spain: Oct. 2010 & May 2011) – 14.5% cryptic species among 323 Aspergillus isolates .A. lentulus (1.1%), A. alliaceus (1.1%), A. tubingensis (7.9%), A. calidoustus (1.4%)

Rivero-Menendez J Fungi 2016;21. Balajee et al. J Clin Microbiol 2009;47:3138-3141. Kontoyiannis et al. Clin Infect Dis 2010;50:1091-1100. Pappas et al. Clin Infect Dis 2010;50:1101-1111. Alastruey-Izquierdo et al. Antimicrob Agents Chemother 2013;57:3380-3387. Other fungi of interest 5. Which of these fungi cannot become resistant to ?

A. Mucorales – (Rhizopus, Mucor etc) B. Scedosporium/Lomentospora C. D. Cryptococcus E. Candida Coccidioides Susceptibility

. Large scale susceptibility testing >400 isolates

. >1/3 of isolates with FLC MICs > 16 µg/mL

. 22 isolates with FLC MICs > 64 In vitro susceptibility of Coccidioides isolates to AMB, triazoles and echinocandins ITC > 2, 1.0% VOR >2, 1.2%; POS >1, 1.1% AMB > 2, 2.8%

Biased? – isolates sent to reference lab Prior literature – animal models and one clinical trial suggest mould active azoles more favorable response – has this played a role in prior studies of 1o disease?

Thompson GR et al. Antimicrob Agents Chemother. 2017 – ahead of print Epidemiology

Affects approximately 150,000 yearly (CDC estimates 400-500K) . ½ to 1/3 are subclinical . Almost universal protection from reinfection

Cause of CAP in 17-29% of patients in endemic areas!

No definitive recommendations for testing in IDSA or IDSA/ATS CAP guidelines

Vugia DJ,et al. MMWR Morb Mortal Wkly Rep. 2009;58:105–9 Brown J, Thompson et al. Clin Epidemiol. 2013 Jun 25;5:185-97. Primary Coccidioidal Pneumonia

. Presentation: . Fever . Cough . Chills . Pleuritic chest pain . Erythema nodosum/rash . Eosinophilia

Indistinguishable from CAP!!

Vugia DJ,et al. MMWR Morb Mortal Wkly Rep. 2009;58:105–9 Sunenshine RH et al. Ann N Y Acad Sci. 2007;1111:96–102. Antifungal agents

. Fluconazole: cheap, high doses needed . Itraconazole: diss. disease, TDM . Posaconazole: absorption?, TDM . Voriconazole: drug interactions, TDM . Amphotericin B: toxicity, IV only . Echinocandins: ONLY as combination . Other (IFN-γ, etc): cases/in vitro

Thompson GR et al. Clin Chest Med. 2009 Jun;30(2):203-15. Levy ER, et al. Clin Infect Dis. 2013 Jun;56(11):1573-8. Posaconazole & Itraconazole

. Association with hypertension and hypokalemia . Multiple recent patients with diagnosed apparent mineralocorticoid excess syndrome (AME) . Diagnosis: . ↓ Renin . ↓ Aldosterone . ↑ 11-deoxycortisol . ↑ cortisol:cortisone ratio . ↑ Estradiol

Itraconazole induced inhibition of 11β-HSD2 (11β-hydroxysteroid dehydrogenase type 2) results in a build-up of precursor hormones causing the apparent mineralocorticoid excess syndrome. 11 β -HSD1 is unaffected

Thompson GR et al. Antimicrob Agents Chemo 2017 Hoffman et al Mycoses 2017 Difficult fungal pathogens Mucormycoses

Risk Factors . Neutropenia . Chemotherapy . T-cell immunosuppression . Transplantation . DKA . Trauma

Cunninghamella Rhizomucor Lichtheimia Saksenaea

Mucorales and trauma

. Mucormycoses following natural disasters (blast injury and tornado, etc) . Rhizopus spores . Static culture (controls) . Shear challenge via centrifugation (tornado) . Shear challenge + calcineurin inhibitor . Flies inoculated with high shear stress with high mortality compared to static (p<0.001) . In presence of tacrolimus virulence returned to that of control group Conclusion: shear stress prior to infection = increased virulence

Tatara A, et al. Fungal Mechanobiology: High Shear Forces Increase Rhizopus Virulence. IDWeek 2017. Poster 277. Conclusions

Resistant fungi carry increased mortality rate! . Candida auris and other Candida spp emerging as significant concern . Aspergillus . Changes in taxonomy and “cryptic” species more resistant . Cryptococcus . Other moulds – Mucorales, Lomentospora, Fusarium present unique challenges . New agents in development with novel mechanisms Thank You!

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