Abstract
BackgroundBurden of aspergillosis is reported to be significant from developing countries including those in South Asia. The estimated burden in Pakistan is also high on the background of tuberculosis and chronic lung diseases. There is concern for management of aspergillosis with the emergence of azole resistant Aspergillus species in neighbouring countries in Central and South Asia.Hence the aim of this study was to screen significant Aspergillus species isolates at the Microbiology Section of Aga Khan Clinical Laboratories, Pakistan, for triazole resistance.MethodsA descriptive cross-sectional study, conducted at the Aga Khan University Laboratories, Karachi, from September 2016–May 2019. One hundred and fourteen, clinically significant Aspergillus isolates [A. fumigatus (38; 33.3%), A. flavus (64; 56.1%), A. niger (9; 7.9%) A. terreus (3; 2.6%)] were included. The clinical spectrum ranged from invasive aspergillosis (IA) (n = 25; 21.9%), chronic pulmonary aspergillosis (CPA) (n = 58; 50.9%), allergic bronchopulmonary aspergillosis (ABPA) (n = 4; 3.5%), severe asthma with fungal sensitization (SAFS) (n = 4; 3.5%), saprophytic tracheobronchial aspergillosis (n = 23; 20.2%). Screening for triazole resistance was performed by antifungal agar screening method. The minimum inhibitory concentration (MIC) of 41 representative isolates were tested and interpreted according to the Clinical and Laboratory Standards Institute broth microdilution method.ResultsAll the isolates were triazole-susceptible on agar screening. MICs of three azole antifungals for 41 tested isolates were found to be ≤1 ml/L; all isolates tested were categorized as triazole-susceptible, including 4 isolates from patients previously on triazole therapy for more than 2 weeks. The minimum inhibitory concentration required to inhibit the growth of 90% organisms (MIC90) of itraconazole, voriconazole and posaconazole of the representative Aspergillus isolates was 1 mg/L, 1 mg/L and 0.5 mg/L, respectively.ConclusionTriazole resistance could not be detected amongst clinical Aspergillus isolates from the South of Pakistan. However, environmental strains remain to be tested for a holistic assessment of the situation. This study will set precedence for future periodic antifungal resistance surveillance in our region on Aspergillus isolates.
Highlights
Burden of aspergillosis is reported to be significant from developing countries including those in South Asia
One had Invasive pulmonary aspergillosis (IPA) with A. fumigatus (Fig. 1), and three suffered from allergic bronchopulmonary aspergillosis (ABPA) (A. flavus, A. fumigatus, A. terreus) two of whom improved on itraconazole
The minimum inhibitory concentration required to inhibit the growth of 90% organisms (MIC90) of itraconazole, voriconazole and posaconazole of the representative Aspergillus isolates was 1 MIC range itraconazole (mg/L), 1 mg/L and 0.5 mg/L respectively (Tables 2 and 3)
Summary
Burden of aspergillosis is reported to be significant from developing countries including those in South Asia. The estimated burden in Pakistan is high on the background of tuberculosis and chronic lung diseases. There is concern for management of aspergillosis with the emergence of azole resistant Aspergillus species in neighbouring countries in Central and South Asia. Aspergillus species have emerged as an important cause of morbidity and mortality in the immunocompromised patients with a wide spectrum of aspergillosis requiring systemic antifungal therapy [1]. The clinical spectrum of aspergillosis requiring systemic therapy is very wide, ranging from fulminant invasive disease in patients with no immune defenses to slowly progressing fibrosing disease as seen in CFPA and severe asthma with fungal sensitization (SAFS) or allergic bronchopulmonary aspergillosis (ABPA). Infections prevailing in our country project a high fungal burden and an estimate has been drawn for the major fungal burden with the help of data from neighboring countries like India [4]
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