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Candida auris was first described as a yeast pathogen in 2009. Since then, the species has emerged worldwide. In contrast to most other Candida spp., C. auris frequently exhibits multi-drug resistance and is readily transmitted in hospital settings. While most detections so far are from colonised patients, C. auris does cause superficial and life-threatening invasive infections. During management of the first documented C. auris transmission in a German hospital, experts from the National Reference Centers for Invasive Fungal Infections (NRZMyk) and the National Reference Center for Surveillance of Nosocomial Infections screened available literature and integrated available knowledge on infection prevention and C. auris epidemiology and biology to enable optimal containment. Relevant recommendations developed during this process are summarised in this guidance document, intended to assist in management of C. auris transmission and potential outbreak situations. Rapid and effective measures to contain C. auris spread require a multi-disciplinary approach that includes clinical specialists of the affected unit, nursing staff, hospital hygiene, diagnostic microbiology, cleaning staff, hospital management and experts in diagnostic mycology / fungal infections. Action should be initiated in a step-wise process and relevant interventions differ between management of singular C. auris colonised / infected patients and detection of potential C. auris transmission or nosocomial outbreaks.
Candida lusitaniae is a rare cause of candidemia that is known for its unique capability to rapidly acquire resistance to amphotericin B. We report the case of an adolescent with grade IV graft-vs.-host disease after hematopoietic cell transplantation who developed catheter-associated C. lusitaniae candidemia while on therapeutic doses of liposomal amphotericin B. We review the epidemiology of C. lusitaniae bloodstream infections in adult and pediatric patients, the development of resistance, and its role in breakthrough candidemia. Appropriate species identification, in vitro susceptibility testing, and source control are pivotal to optimal management of C. lusitaniae candidemia. Initial antifungal therapy may consist of an echinocandin and be guided by in vitro susceptibility and clinical response.
Candida dubliniensis ist eine 1995 erstmals beschriebene pathogene Hefespezies mit enger phylogenetischer Verwandtschaft zu Candida albicans. Sie wird mittels routinemäßig angewendeter Verfahren nicht von C. albicans unterschieden, weil sie als einzige Spezies im Genus Candida neben C. albicans Chlamydosporen ausbilden kann. C. dubliniensis ist bisher vor allem aus dem Oropharynx HIV-positiver Patienten isoliert worden. PHR1 und PHR2 sind funktionell homologe, pH-abhängig exprimierte Gene von C. albicans, deren Produkte essentiell für die Verknüpfung von b-1,3- und b-1,6-Glukan in der Zellwand sind. Die Deletion jedes dieser Gene führt zu einem pH-abhängigen Phänotyp mit aberranter Morphogenese in vitro und reduzierter Virulenz im Tiermodell. In dieser Arbeit werden PHR homologe Gene im Genom von C. dubliniensis charakterisiert. CdPHR1 weist eine Homologie von 90,5 Prozent zu PHR1 und CdPHR2 eine Homologie von 91,7 Prozent zu PHR2 auf. Wie PHR1 wird auch CdPHR1 nur unter neutralen und alkalischen Bedingungen exprimiert, während sich CdPHR2 Transkript, wie das von PHR2, nur unter sauren Bedingungen nachweisen lässt. Die funktionelle Homologie von CdPHR1 zu PHR1 wird durch Komplementation des Phänotyps einer C. albicans phr1 Mutante mit CdPHR1 gezeigt. Dabei erweist sich der native Promoter von CdPHR1 als funktional in C. albicans. Im Modellorganismus Saccharomyces cerevisiae wird CdPHR1 unter Kontrolle seines nativen Promotors dagegen pH-unabhängig exprimiert. Auch die zusätzliche Einführung eines mutierten, dominant aktiven Allels von RIM101, das in C. albicans für die pH-abhängige Genexpression verantwortlich ist, hat darauf keinen Einfluss. In C. glabrata und Aspergillus nidulans findet sich keine Expression von CdPHR1. Basierend auf Sequenzunterschieden zwischen PHR1 und CdPHR1 wird ein PCR-Schnelltest zur Speziesunterscheidung entwickelt. Dieser wird in einer epidemiologischen Studie mit 133 chlamydosporenpositiven klinischen Isolaten evaluiert. 21 oropharyngeale Isolate von 14 HIV-positiven Patienten können so retrospektiv als C. dubliniensis klassifiziert werden, dies entspricht einer Prävalenz von C. dubliniensis in diesem Kollektiv von 30 Prozent. Die Ergebnisse der PCR werden durch Sequenzierung ribosomaler Gene (V3, ITS1, ITS2) bestätigt. Parallel werden phänotypische Tests zur Identifizierung von C. dubliniensis auf ihre diagnostische Validität getestet. Während sich die Chlamydosporenmorphologie der Isolate und die Koloniefärbung auf dem Farbindikatormedium CHROMagar Candida als unzulänglich für die Unterscheidung erweisen und das für C. dubliniensis beschriebene Wachstumsdefizit bei 45°C zwar sensitiv, nicht aber spezifisch für die Identifizierung dieser Spezies ist, korreliert die Koloniemorphologie auf Staib-Agar zu 100 Prozent mit den molekularen Daten. Alle C. dubliniensis Isolate werden in einem biochemischen Assay (Micronaut RC) untersucht, dabei zeigt der Test auf b-Glukosidase Aktivität hohes diskriminatorisches Potenzial. In Resistenztestungen zeigen sich die C. dubliniensis Isolate sensibler als die oropharyngealen C. albicans Isolate gegen gebräuchliche Antimykotika. In dieser Studie kann gezeigt werden, dass C. dubliniensis und C. albicans auf teilweise austauschbare Mechanismen zur Reaktion auf Alterationen des pH-Milieus verfügen. Die pH-abhängige Regulation zellwandassoziierter Gene ist dabei eng mit morphogenetischen Prozessen verbunden. Trotz dieser Ähnlichkeit ist C. dubliniensis nicht nur weniger virulent als C. albicans, sondern zeigt auch ein unterschiedliches epidemiologisches Spektrum, das durch eine Spezialisierung auf oropharyngeale Kolonisation und Infektion bei HIV-positiven Patienten gekennzeichnet ist. Um die Gründe für diese Unterschiede aufzeigen zu können, ist eine verlässliche Identifizierung von C. dubliniensis notwendig. Dazu stellen die präsentierten Daten einerseits einen schnellen und verlässlichen PCR Test, andererseits eine sorgfältige Evaluierung derzeit gebräuchlicher phänotypischer Verfahren vor. Phänotypisch und genotypisch exzellent charakterisierte Isolate beider Spezies stehen für weitere Untersuchungen zur Verfügung.
Murine infection models are widely used to study systemic candidiasis caused by C. albicans. Whole-blood models can help to elucidate host-pathogens interactions and have been used for several Candida species in human blood. We adapted the human whole-blood model to murine blood. Unlike human blood, murine blood was unable to reduce fungal burden and more substantial filamentation of C. albicans was observed. This coincided with less fungal association with leukocytes, especially neutrophils. The lower neutrophil number in murine blood only partially explains insufficient infection and filamentation control, as spiking with murine neutrophils had only limited effects on fungal killing. Furthermore, increased fungal survival is not mediated by enhanced filamentation, as a filament-deficient mutant was likewise not eliminated. We also observed host-dependent differences for interaction of platelets with C. albicans, showing enhanced platelet aggregation, adhesion and activation in murine blood. For human blood, opsonization was shown to decrease platelet interaction suggesting that complement factors interfere with fungus-to-platelet binding. Our results reveal substantial differences between murine and human whole-blood models infected with C. albicans and thereby demonstrate limitations in the translatability of this ex vivo model between hosts.
The fungal cell wall is essential for the maintenance of cellular integrity and mediates interactions of the cells with the environment. It is a highly flexible organelle whose composition and organization is modulated in response to changing growth conditions. In the pathogenic yeast Candida albicans, a network of signaling pathways regulates the structure of the cell wall, and mutants with defects in these pathways are hypersensitive to cell wall stress. By harnessing a library of genetically activated forms of all C. albicans zinc cluster transcription factors, we found that a hyperactive Czf1 rescued the hypersensitivity to cell wall stress of different protein kinase deletion mutants. The hyperactive Czf1 induced the expression of many genes with cell wall-related functions and caused visible changes in the cell wall structure. C. albicans czf1Δ mutants were hypersensitive to the antifungal drug caspofungin, which inhibits cell wall biosynthesis. The changes in cell wall architecture caused by hyperactivity or absence of Czf1 resulted in an increased recognition of C. albicans by human neutrophils. Our results show that Czf1, which is known as a regulator of filamentous growth and white-opaque switching, controls the expression of cell wall genes and modulates the architecture of the cell wall.
Bloodstream infections by the human-pathogenic fungi Candida albicans and Candida glabrata increasingly occur in hospitalized patients and are associated with high mortality rates. The early immune response against these fungi in human blood comprises a concerted action of humoral and cellular components of the innate immune system. Upon entering the blood, the majority of fungal cells will be eliminated by innate immune cells, i.e., neutrophils and monocytes. However, recent studies identified a population of fungal cells that can evade the immune response and thereby may disseminate and cause organ dissemination, which is frequently observed during candidemia. In this study, we investigate the so far unresolved mechanism of fungal immune evasion in human whole blood by testing hypotheses with the help of mathematical modeling. We use a previously established state-based virtual infection model for whole-blood infection with C. albicans to quantify the immune response and identified the fungal immune-evasion mechanism. While this process was assumed to be spontaneous in the previous model, we now hypothesize that the immune-evasion process is mediated by host factors and incorporate such a mechanism in the model. In particular, we propose, based on previous studies that the fungal immune-evasion mechanism could possibly arise through modification of the fungal surface by as of yet unknown proteins that are assumed to be secreted by activated neutrophils. To validate or reject any of the immune-evasion mechanisms, we compared the simulation of both immune-evasion models for different infection scenarios, i.e., infection of whole blood with either C. albicans or C. glabrata under non-neutropenic and neutropenic conditions. We found that under non-neutropenic conditions, both immune-evasion models fit the experimental data from whole-blood infection with C. albicans and C. glabrata. However, differences between the immune-evasion models could be observed for the infection outcome under neutropenic conditions with respect to the distribution of fungal cells across the immune cells. Based on these predictions, we suggested specific experimental studies that might allow for the validation or rejection of the proposed immune-evasion mechanism.
Background
PCR testing is considered the gold standard for SARS-CoV-2 diagnosis but its results are earliest available hours to days after testing. Rapid antigen tests represent a diagnostic tool enabling testing at the point of care. Rapid antigen tests have mostly been validated by the manufacturer or in controlled laboratory settings only. External validation at the point of care, particularly in general practice where the test is frequently used, is needed. Furthermore, it is unclear how well point of care tests are accepted by the practice staff.
Methods
In this prospective multicenter validation study in primary care, general practitioners included adult individuals presenting with symptoms suggesting COVID-19. Each patient was tested by the general practitioner, first with a nasopharyngeal swab for the point of care test (Roche SARS-CoV-2 Rapid Antigen Test) and then with a second swab for PCR testing. Using the RT-PCR result as a reference, we calculated specificity, sensitivity, positive predictive value and negative predictive value, with their 95% confidence intervals. General practitioners and medical assistants completed a survey to assess feasibility and usefulness of the point of care tests.
Results
In 40 practices in Würzburg, Germany, 1518 patients were recruited between 12/2020 and 06/2021. The point of care test achieved a sensitivity of 78.3% and a specificity of 99.5% compared to RT-PCR. With a prevalence of 9.5%, the positive predictive value was 93.9% and the negative predictive value was 97.8%. General practitioners rated the point of care test as a helpful tool to support diagnostics in patients with signs and symptoms suggestive for infection, particularly in situations where decision on further care is needed at short notice.
Conclusion
The point of care test used in this study showed a sensitivity below the manufacturer’s specification (Sensitivity 96.25%) in the practice but high values for specificity and high positive predictive value and negative predictive value. Although widely accepted in the practice, measures for further patient management require a sensitive interpretation of the point of care test results.
Candida auris is an emerging pathogen with resistance to many commonly used antifungal agents. Infections with C. auris require rapid and reliable detection methods to initiate successful medical treatment and contain hospital outbreaks. Conventional identification methods are prone to errors and can lead to misidentifications. PCR-based assays, in turn, can provide reliable results with low turnaround times. However, only limited data are available on the performance of commercially available assays for C. auris detection. In the present study, the two commercially available PCR assays AurisID (OLM, Newcastle Upon Tyne, UK) and Fungiplex Candida Auris RUO Real-Time PCR (Bruker, Bremen, Germany) were challenged with 29 C. auris isolates from all five clades and eight other Candida species as controls. AurisID reliably detected C. auris with a limit of detection (LoD) of 1 genome copies/reaction. However, false positive results were obtained with high DNA amounts of the closely related species C. haemulonii, C. duobushaemulonii and C. pseudohaemulonii. The Fungiplex Candida Auris RUO Real-Time PCR kit detected C. auris with an LoD of 9 copies/reaction. No false positive results were obtained with this assay. In addition, C. auris could also be detected in human blood samples spiked with pure fungal cultures by both kits. In summary, both kits could detect C. auris-DNA at low DNA concentrations but differed slightly in their limits of detection and specificity.
Data on biomarker-assisted diagnosis of invasive aspergillosis (IA) in pediatric patients is scarce. Therefore, we conducted a cohort study over two years including 404 serum specimens of 26 pediatric patients after allogeneic hematopoietic stem cell transplantation (alloSCT). Sera were tested prospectively twice weekly for Aspergillus-specific DNA, galactomannan (GM), and retrospectively for (1→3)-β-D-glucan (BDG). Three probable IA and two possible invasive fungal disease (IFD) cases were identified using the European Organization for Research and Treatment of Cancer and the Mycoses Study Group (EORTC/MSGERC) 2019 consensus definitions. Sensitivity and specificity for diagnosis of probable IA and possible IFD was 80% (95% confidential interval (CI): 28–99%) and 55% (95% CI: 32–77%) for BDG, 40% (95% CI: 5–85%) and 100% (95% CI: 83–100%) for GM, and 60% (95% CI: 15–95%) and 95% (95% CI: 75–100%) for Aspergillus-specific real-time PCR. However, sensitivities have to be interpreted with great caution due to the limited number of IA cases. Interestingly, the low specificity of BDG was largely caused by false-positive BDG results that clustered around the date of alloSCT. The following strategies were able to increase BDG specificity: two consecutive positive BDG tests for diagnosis (specificity 80% (95% CI: 56–94%)); using an optimized cutoff value of 306 pg/mL (specificity 90% (95% CI: 68–99%)) and testing BDG only after the acute posttransplant phase. In summary, BDG can help to diagnose IA in pediatric alloSCT recipients. However, due to the poor specificity either an increased cutoff value should be utilized or BDG results should be confirmed by an alternative Aspergillus assay.
The mold Fusarium is a ubiquitous fungus causing plant, animal and human infections. In humans, Fusarium spp. are the major cause of eye infections in patients wearing contact lenses or after local trauma. Systemic infections by Fusarium spp. mainly occur in immunosuppressed patients and can disseminate throughout the human body. Due to high levels of resistance to antifungals a fast identification of the causative agent is an urgent need. By using a probe-based real-time PCR assay specific for the genus Fusarium we analysed several different clinical specimens detecting Fusarium spp. commonly found in clinical samples in Germany. Also, a large collection of lung fluid samples of haematological patients was analysed (n = 243). In these, two samples (0.8%) were reproducibly positive, but only one could be confirmed by sequencing. For this case of probable invasive fungal disease (IFD) culture was positive for Fusarium species. Here we describe a rapid, probe-based real-time PCR assay to specifically detect DNA from a broad range of Fusarium species and its application to clinically relevant specimens.