Supplementary Materials to the Manuscript: Polymorphisms in TNF-α Increase Susceptibility to

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1 Supplementary Materials to the Manuscript: Polymorphisms in TNF-α Increase Susceptibility to Intra-abdominal Candida Infection in High Risk Surgical ICU Patients A. Wójtowicz, Ph.D. 1, F. Tissot, M.D. 1, F. Lamoth, M.D. 1, C. Orasch, M.D. 1,4, P. Eggimann, M.D. 2, M. Siegemund, M.D. 3, S. Zimmerli, M.D. 5, U. Flueckiger, M.D 4,6, J. Bille, M.D. 7, T. Calandra, M.D., Ph.D. 1, O. Marchetti, M.D. 1,*, P.-Y. Bochud, M.D. 1,* and the Fungal Infection Network of Switzerland (FUNGINOS) Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland Adult Intensive Care Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland Intensive Care Unit, Basel University Hospital, Basel, Switzerland Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine, Basel University Hospital, Basel, Switzerland Institute for Infectious Diseases, University of Bern, Bern, Switzerland Hirslanden Klink, Aarau, Switzerland Institute of Microbiology, Department of Laboratories, Lausanne University Hospital (CHUV), Lausanne, Switzerland * Equal contributions 1

2 Complementary Methods Study design (as described in [1]). This observational FUNGINOS cohort study was conducted in ICUs of two Swiss University Hospitals (Basel, Lausanne). Consecutive patients with abdominal surgery or acute pancreatitis admitted to ICU 72h were screened (August 1, 2007-January 31, 2010). Based on previous observations, those with recurrent GI tract perforation (anastomotic leakage, ischemic necrosis, recurrent GI surgery for other local complications) or acute necrotizing pancreatitis (Balthazar grade D-E) not receiving antifungal agents were included and prospectively studied until two weeks after ICU discharge. Demographic, clinical, and microbiological data were recorded. Institutional Ethical Committees approved the study. Written informed consent was obtained from the patients or their legal representatives. Monitoring and definition of Candida colonization (as described in [1]). Samples from at least three non-sterile sites (mouth, urine, stools, skin and/or respiratory tract) were cultured twice weekly for monitoring Candida colonization, defined by recovery of Candida spp. from at least one site and graded by semi-quantitative cultures as light (growth on the first of the three inoculation quadrants), moderate (growth on the first and second of the three inoculation quadrants) and heavy (growth on all three inoculation quadrants) according to prior reports [2] The corrected colonization index (CCI=number of colonized sites/number of cultured sites (i.e. colonization index) x number of heavily colonized sites/number of colonized sites) was calculated at inclusion and twice weekly during the study: the threshold 0.4 indicating a heavy colonization was used as previously described [3]. Diagnosis and management of Candida infection (as described in [1]). Two sets of blood cultures were drawn according to institutional guidelines at onset of fever/suspected infection and in persistent fever/signs of infection despite antibacterial therapy (automated system Bactec 9240, BACTEC Plus aerobic/f and Lytic anaerobic/f bottles, Becton Dickinson, Sparks, MD, USA). Candidemia was defined as at least one blood culture positive for Candida spp. in presence of clinical symptoms/signs of infection. Intra-abdominal abscess 2

3 or peritonitis was classified as IAC according to one of the following culture results from specimens obtained at surgery: i) monomicrobial growth of Candida spp., ii) growth in any amount of Candida spp. within a mixed-flora abscess, iii) moderate or heavy growth of Candida spp. in mixed-flora peritonitis treated with appropriate antibacterial therapy according to susceptibility testing. Initiation of antifungal therapy was based on international guidelines: i) documented Candida infection (see above), ii) pre-emptive therapy for suspected invasive Candida infection in patients colonized at 2 non-sterile sites and with severe sepsis/septic shock or persistent signs of infection despite >48h of appropriate antibacterial therapy. Antifungal prophylaxis was not recommended, regardless of presence/absence of Candida colonization. Blood sampling for genetic testing. EDTA blood samples were drawn at study inclusion. SNP selection. Candidate SNPs were extracted from the literature by using the keywords SNP, candidiasis, candidemia, colonization, aspergillosis for a search strategy in PubMed. References 1. Tissot, F., et al., Beta-Glucan Antigenemia Anticipates Diagnosis of Blood Culture- Negative Intra-Abdominal Candidiasis. Am J Respir Crit Care Med, Calandra, T., et al., Clinical significance of Candida isolated from peritoneum in surgical patients. Lancet, (8677): p Pittet, D., et al., Candida colonization and subsequent infections in critically ill surgical patients. Ann Surg, (6): p

4 Supplementary tables Table S1. Patients demographic and clinical characteristics (N=89). Variable N (%) Age, median years (range) 61 (22-86) Sex M/F 59 / 30 (66 / 34) Inclusion criteria Recurrent gastrointestinal perforation 68 (76) Acute necrosing pancreatitis 21 (24) Primary diagnosis at ICU admission Intra-abdominal tumor 23 (26) Intestinal ischemic disorder 20 (22) Acute necrotizing pancreatitis 20 (22) Gastro-intestinal perforation 10 (11) Gastro-intestinal bleeding 5 (6) Ruptured aneurysm of abdominal aorta 4 (4) Others 7 (8) Clinical severity at inclusion SAPS II : median (range) 51 (13-87) APACHE II : median (range) 23 (5-37) Severe sepsis or septic shock 50 (56) Mortality 15 (17) Hospital stay : median days (range) 44.5 (9-176) ICU stay : median days (range) 13 (3-74) Risk factors for Candida infection at inclusion Central venous catheter 87 (98) Proton pump inhibitors 86 (97) Urinary catheter 86 (97) Total parenteral nutrition 84 (94) Antibacterial therapy 77 (87) Invasive mechanical ventilation > 24h 61 (69) Antifungal therapy None 45 (51) Pre-emptive therapy for suspected IAC 18 (20) Therapy for documented infection 26 (29) Heavy Candida colonization a CCI b 0.4 : Week 1, Week 2, Week 3, Week 4 12 / 27 / 34 / 42 Intra-abdominal candidiasis (IAC) a Week 1 11 Week 2 21 Week 3 25 Week 4 27 Candida species IAC (N=29) C. albicans 23 (79) C. tropicalis 5 (17) C. glabrata 3 (10) C. kefyr 1 (3) Other non-albicans Candida species 1 (3) a Time of occurrence during the period at high risk Corrected colonization index 4

5 Table S2. Association of genetic polymorphisms with heavy Candida colonization (CCI 0.4) and intra-abdominal candidiasis (IAC) in high-risk surgical ICU patients. Gene (nt aa change) rs number TLR1 (S602I) rs TLR1 (R80T) rs TLR3 (L412F) rs TLR4 (D299G) rs TLR9 (-1237 C/T) rs CARD9 (9243 G/C) rs Dectin-1 (Y238X) rs MBL (G54D) rs TNF-α (-308 G/A) rs IL-1β (-31 T/C) rs IL-1α (-889 C/T) rs IL-4 (-589 T/C) rs CXCL10 (1642G/C) rs3921 IL-10 (-1082 A/G) rs IL-10 (-819 C/T) rs SP-A2 (A91P) rs PLG (D472N) rs DEFB1 (-44 C/G) rs a MAF (HWE) 0.41 (0.4) (0.6) (0.8) 0.08 (0.08) (0.3) 0.28 (0.3) (0.8) (0.2) (0.8) 0.13 (0.6) Endpoint Univariate log-rank test P a Candida colonization b 0.6 IAC c 0.2 IAC c 0.8 Candida colonization b 0.5 IAC c 0.08 Candida colonization b 0.04 IAC c 0.4 Candida colonization b 0.7 IAC c 0.5 Candida colonization b 0.2 IAC c 0.2 IAC c 1.0 Candida colonization b 0.4 IAC c 0.1 Candida colonization b 0.8 IAC c 0.001* IAC c 0.8 Candida colonization b 0.7 IAC c 0.6 Candida colonization b 0.7 IAC c 0.9 Candida colonization b 0.1 IAC c 0.4 Candida colonization b 0.4 IAC c 0.6 Candida colonization b 1.0 IAC c 0.6 Candida colonization b 0.03 IAC c 0.1 IAC c 0.3 Candida colonization b 0.1 IAC c 0.09 P value was assessed by log-rank test, dominant mode (patients homo- and heterozygous for the rare allele are compared to the others). b Heavy Candida colonization defined by a corrected colonization index (CCI) 0.4. c Patients who received a preemptive treatment for suspected IAC were excluded from the analyses (N=18). * Significant after correction for multiple testing (18 tests; P=0.02). Abbreviations: CARD9: caspase recruitment domain-9; CI: confidence interval; CLEC7A: C-type lectin domain 7; CXCL10: CXC-chemokine ligand-10; DEFB1: human beta-defensin 1; HR: hazard ratio; IAC: intra-abdominal candidiasis; IL: interleukin; MBL: mannose binding lectin; MAF: minor allele frequency; PLG: plasminogen; SP-A2: surfactant protein A2; TLR: toll-like receptor; TNF: tumor necrosis factor. 5

6 Table S3. Allelic frequencies for significant SNPs in high-risk surgical patients. Gene (nt aa change) rs number N (%) Genotype Case Control Candida colonization (N=89) a TLR4 (D299G) b rs SP-A2 (A91P) c rs AA 35 (83%) 43 (94%) GG or GA 7 (17%) 3 (6%) GG 25 (62%) 33 (81%) CG or CC 15 (38%) 8 (19%) TNF-α (-308 G/A) e rs DEFB1 (-44 C/G) f rs Intra-abdominal candidiasis (N=69) d GG 13 (50%) 32 (80%) GA or AA 13 (50%) 8 (20%) CC 17 (63%) 34 (85%) CG or GG 10 (37%) 6 (15%) a Heavy Candida colonization assessed by a corrected colonization index (CCI) 0.4. b Genotype missing in 1/89 patients c Genotype missing in 8/89 patients d Patients who received a preemptive treatment for suspected IAC were excluded from the analyses (N=18). e Genotype missing in 3/69 patients f Genotype missing in 2/69 patients Abbreviations: DEFB1: human beta-defensin1; SP-A2: surfactant protein A2; TLR: toll-like receptor; TNF: tumor necrosis factor. 6