MixInYest: a multicenter survey on mixed yeast infections in Europa

Transcription

1 MixInYest: a multicenter survey on mixed yeast infections in Europa COORDINATORS: - Ana Alastruey-Izquierdo, Mycology Reference Laboratory, National Centre for Microbiology, Spain - Cornelia Lass-Flörl, Division of Hygiene und Medical Microbiology, Medical University of Innsbruck, Austria - Sevtap Arikan-Akdagli, Hacettepe University Medical School, Dept. of Medical Microbiology, Ankara,Turkey PARTICIPANTS The project will be opened to all European Microbiology Laboratories and others. 1

2 Content Abstract... 3 Background... 4 Objectives... 5 Research plan:... 6 Data collection... 7 Collaborators... Error! Marcador no definido. Expected outcomes... 7 Ethical Considerations and Data Privacy Protection... 8 Authorship Policy... 8 Contact Information... 8 References... 9 Annex I:

3 Abstract Background: Candida species are a main source of morbidity and mortality in human infections. Mixed infections due to more than one species of yeasts can be associated with higher mortality rate and are probably underestimated in current reports. Within the context of a mixed yeast infection, the co-existence of a yeast species which is putatively resistant to antifungal drug(s) in clinical use is of uppermost significance in terms of guidance of antifungal therapy and successful clinical outcome. Therefore, all causative agents of a mixed fungal infection need to be isolated and identified at species level. Aim: To study the epidemiology, clinical and microbiological characteristics of mixed fungal infections in different centers in Europe and beyond. Methods: Standard laboratory procedures including chromogenic agar will be used to detect mixed infections caused by two or more yeast species. Strains will be prospectively collected, identified to species level and sent to a central laboratory. Main clinical data will also be recorded. In the referral laboratory, strains will be identified by means of sequencing informative targets and their antifungal susceptibility profiles will be determined by EUCAST methodology. Expected results: With this study we will gather information of mixed infections in different centers. Clinical, epidemiological and microbiological data will be analyzed in order to gain more knowledge of mixed infections of yeast. 3

4 Background Candida species are the most common cause of healthcare-associated bloodstream infections (BSI) (1) and are associated with significant mortality. Although Candida albicans remains the most frequent yeast isolated from human samples, the number of non-albicans species has progressively increased in the last years (2-4). Importantly some of these species are more difficult-to-treat because of the higher level of antifungal resistance (5). In addition, polymicrobial BSIs have been associated with higher mortality than monomicrobial episodes (6). Previous studies indicate that up to 25% of Candida BSI can be associated with more than one pathogen (7). A population based survey conducted in 30 Spanish hospitals (CANDIPOP study) detected 159 polymicrobial infections, a bacterial strain was identified in 145 (19.3%) and two different Candida species were simultaneously isolated in 14 (1.9%) out of 752 episodes of candidemia (8). TRANSNET (Transplant-Associated Infection Surveillance Network) study analyzed invasive Candida infections among organ transplant recipients in the United States and found that >10% of cases included infection with two or more Candida species (2). Other surveillance studies have found rates of mixed infections in candidemia between 1.2 to 6% (9-15). However, although tools for detecting mixed infections have been available for years, current standard procedures may miss to detect them and therefore these numbers are probably underestimated. Sample processing in clinical laboratories usually involves plating the sample onto agar media and after incubation, a single colony is picked and analyzed. While examination of inter-species differences in colony morphology are very helpful in differentiating and thus processing all species grown in the sample, this evaluation needs expertise and growth of sufficient number of colonies of each species on the inoculated agar medium. Thus, mixed infections may remain undetected. Chromogenic agars are cheap and simple tools that allow the distinction of the most frequent species of Candida. Differences in enzymatic activities are used to identify a number of species by producing a characteristic colony color in these media (Figure 1). The most common species of Candida implicated in human infections are thus differentiated by this method enabling the detection of mixed infections. However, other methods are also possible (i.e. PNA-FISH). 4

5 Figure 1. Different colonies of Candida species on Chromogenic agar. Picture obtained from: Objectives The aim of this work is to study mixed yeast infections in different centers and to broaden the knowledge on epidemiology, on clinical courses of mixed yeast infections. Main objectives are to: - determine the rate of mixed infections - determine the epidemiology of mixed infections - analyze possible risk factors for mixed infections - evaluate the associated mortality - evaluate the antifungal susceptibility profile of the isolates 5

6 Research plan: The prevalence of mixed yeast infections will be investigated by screening prospectively the presence of two or more species of yeast in sterile clinical samples. The screening will be performed by plating the sample on chromogenic agars or by other routine standard procedures (equivalent replacement to chromogenic agar). For samples which were cultivated for bacterial isolation initially and then turn out to grow yeasts, it will not be possible to use the chromogenic media at the very initial primary isolation step (but may be used only after isolation of yeasts and as a medium to subculture). The following sampling is possible: 1) Processed for bacterial cultures initially but yielded yeast colonies on bacteriological media. At least five colonies need to be sub-cultured for further processing. Different colony morphologies if present will be considered as mixed infections and will be further investigated. 2) Processed for fungal cultures at the very initial step for which using chromogenic agar media as the primary isolation medium will be possible. 3) Processed by a method equivalent to chromogenic agar (needs to be specified in detail). Samples to be included: all sterile clinical samples, processed at the microbiology department for 6 months. Timeline - April-September 2018 sampling period - October- December 2018 complete data of CRF and send strains - January-June 2019 (depending on the number of samples) AFST and id. - July-December 2019 analysis report and draft paper 6

7 Data collection Data to be collected: - Centre - Date of isolation - Strain identification numbers (one per species isolated in the same sample) - Underlying disease(s) - Origin of the sample - Ward - Type of infection - Tentative identification - Identification method* If possible, these variables will also be recorded: - Antifungal drug use at the time of isolation - Outcome of the patient - AFST (If performed) - Method for AFST * The identification of the strains must rely on a more specific identification method, such as morphology + assimilation profiles, other automated systems (i.e. Sensititre, Vitek), MALDI-TOF, molecular identification, etc. Patient characteristics, epidemiological data, and antifungal treatment (if possible) will be collected through an online questionnaire using online platform. At the end of the study the center will need to provide the total number of samples that yielded yeast growth (mixed + single species) during the study period. The strains will be referred to Ana Alastruey-Izquierdo, Mycology Reference Laboratory, National Centre for Microbiology, Spain to: - Confirm identification to species level by sequencing informative targets - Antifungal susceptibility profile by EUCAST method The isolates will be available to any group member. Expected outcomes - Abstract for ECCMID 7

8 - Manuscript Ethical Considerations and Data Privacy Protection In the current study 2 aspects have to be considered separately: 1 Documentation of clinical data 2 Work with isolates of Candida species There is no interventional aspect to this study. Therefore, there are neither associated risks nor benefits for the patient when participating in the study. The documentation of the clinical data will take place in an anonymized fashion. There will also be no pseudonyms which would make a retrospective re-identification of the patient possible. Clinical data collected refers only to underlying condition and treatment modalities in medical care, such that no re-identification of the individual case on the basis of these data will be possible. Under these circumstances, we consider an informed consent of the patient not necessary. Regular data backup, hierarchized management of rights and authentication protocols ensure the protection of data from unauthorized access and loss. All clinical data fall under medical confidentiality, and results will be stored for at least 10 years after publication of results. To ensure anonymity, the results of microbiological examinations will only be communicated to the treating physician and entered into the database along with the clinical data in one session by the treating physician. Authorship Policy Authorship will be restricted to those centers contributing clinical/microbiological data. For each contributing center, there will be authorship positions available. This will extend to a maximum of two: one clinician, and one microbiologist/medical mycologist, if applicable. Contact Information Ana Alastruey-Izquierdo, Mycology Reference Laboratory, National Centre for Microbiology, Spain. anaalastruey@isciii.es Phone:

9 References 1. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13): Andes DR, Safdar N, Baddley JW, Alexander B, Brumble L, Freifeld A, et al. The epidemiology and outcomes of invasive Candida infections among organ transplant recipients in the United States: results of the Transplant-Associated Infection Surveillance Network (TRANSNET). Transpl Infect Dis Guinea J, Zaragoza O, Escribano P, Martin-Mazuelos E, Peman J, Sanchez-Reus F, et al. Molecular identification and antifungal susceptibility of yeast isolates causing fungemia collected in a population-based study in Spain in 2010 and Antimicrob Agents Chemother. 2014;58(3): Falagas ME, Roussos N, Vardakas KZ. Relative frequency of albicans and the various nonalbicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review. Int J Infect Dis. 2010;14(11):e Pfaller MA, Messer SA, Moet GJ, Jones RN, Castanheira M. Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-icu settings in the SENTRY Antimicrobial Surveillance Program ( ). Int J Antimicrob Agents. 2011;38(1): Weinstein MP, Reller LB, Murphy JR. Clinical importance of polymicrobial bacteremia. Diagn Microbiol Infect Dis. 1986;5(3): Klotz SA, Chasin BS, Powell B, Gaur NK, Lipke PN. Polymicrobial bloodstream infections involving Candida species: analysis of patients and review of the literature. Diagn Microbiol Infect Dis. 2007;59(4): Puig-Asensio M, Padilla B, Garnacho-Montero J, Zaragoza O, Aguado JM, Zaragoza R, et al. Epidemiology and predictive factors for early and late mortality in Candida bloodstream infections: a population-based surveillance in Spain. Clin Microbiol Infect. 2014;20(4):O Arendrup MC, Bruun B, Christensen JJ, Fuursted K, Johansen HK, Kjaeldgaard P, et al. National surveillance of fungemia in Denmark (2004 to 2009). J Clin Microbiol. 2011;49(1): Chen S, Slavin M, Nguyen Q, Marriott D, Playford EG, Ellis D, et al. Active surveillance for candidemia, Australia. Emerg Infect Dis. 2006;12(10): Cuenca-Estrella M, Rodriguez D, Almirante B, Morgan J, Planes AM, Almela M, et al. In vitro susceptibilities of bloodstream isolates of Candida species to six antifungal agents: results from a population-based active surveillance programme, Barcelona, Spain, J Antimicrob Chemother. 2005;55(2): Lockhart SR, Iqbal N, Cleveland AA, Farley MM, Harrison LH, Bolden CB, et al. Species identification and antifungal susceptibility testing of Candida bloodstream isolates from population-based surveillance studies in two U.S. cities from 2008 to J Clin Microbiol. 2012;50(11): Lortholary O, Desnos-Ollivier M, Sitbon K, Fontanet A, Bretagne S, Dromer F, et al. Recent exposure to caspofungin or fluconazole influences the epidemiology of candidemia: a prospective multicenter study involving 2,441 patients. Antimicrob Agents Chemother. 2011;55(2): Sandven P, Bevanger L, Digranes A, Haukland HH, Mannsaker T, Gaustad P, et al. Candidemia in Norway (1991 to 2003): results from a nationwide study. J Clin Microbiol. 2006;44(6): Tortorano AM, Biraghi E, Astolfi A, Ossi C, Tejada M, Farina C, et al. European Confederation of Medical Mycology (ECMM) prospective survey of candidaemia: report from one Italian region. J Hosp Infect. 2002;51(4):

10 16. Sahand IH, Moragues MD, Eraso E, Villar-Vidal M, Quindos G, Ponton J. Supplementation of CHROMagar Candida medium with Pal's medium for rapid identification of Candida dubliniensis. J Clin Microbiol. 2005;43(11):

11 Annex I: MixInYeast: A multicenter survey on mixed yeast infections in Europe Case Report Form Data to be collected: - Centre - Date of isolation - Strain identification numbers (one per species isolated in the same sample) - Underlying disease(s) - Origin of the sample - Ward - Type of infection - Tentative identification - Identification method* If possible, these variables will also be recorded: - Antifungal drug use at the time of isolation - Outcome of the patient - AFST (If performed) - Method for AFST In addition, at the end of the study period the centers will need to provide the total number of samples processed to calculate incidence of mix infections. 11