Trichophyton isolates with reduced susceptibility to antifungals are now increasingly reported worldwide. We therefore studied the molecular epidemiology and the in vitro antifungal susceptibility patterns of Greek Trichophyton isolates over the last 10 years with the newly released EUCAST reference method for dermatophytes. Literature was reviewed to assess the global burden of antifungal resistance in Trichophyton spp. The in vitro susceptibility of 112 Trichophyton spp. molecularly identified clinical isolates (70 T. rubrum, 24 T. mentagrophytes, 12 T. interdigitale and 6 T. tonsurans) was tested against terbinafine, itraconazole, voriconazole and amorolfine (EUCAST E.DEF 11.0). Isolates were genotyped based on the internal transcribed spacer (ITS) sequences and the target gene squalene epoxidase (SQLE) was sequenced for isolates with reduced susceptibility to terbinafine. All T. rubrum, T. interdigitale and T. tonsurans isolates were classified as wild-type (WT) to all antifungals, whereas 9/24 (37.5%) T. mentagrophytes strains displayed elevated terbinafine MICs (0.25–8 mg/L) but not to azoles and amorolfine. All T. interdigitale isolates belonged to ITS Type II, while T. mentagrophytes isolates belonged to ITS Type III* (n = 11), VIII (n = 9) and VII (n = 4). All non-WT T. mentagrophytes isolates belonged to Indian Genotype VIII and harbored Leu393Ser (n = 5) and Phe397Leu (n = 4) SQLE mutations. Terbinafine resistance rates ranged globally from 0–44% for T. rubrum and 0–76% for T. interdigitale/T. mentagrophytes with strong endemicity. High incidence (37.5%) of terbinafine non-WT T. mentagrophytes isolates (all belonging to ITS Type VIII) without cross-resistance to other antifungals was found for the first time in Greece. This finding must alarm for susceptibility testing of dermatophytes at a local scale particularly in non-responding dermatophytoses.

Updated information on the epidemiology of candidemia, particularly during severe socioeconomic events, is important for proper management of these infections. A systematic literature review on candidemia in Greece and a retrospective surveillance study were conducted in a tertiary university hospital during the years of the recent financial crisis (2009 to 2018) in order to assess changes in incidence rates, patient characteristics, species distribution, antifungal susceptibilities, and drug consumption. The average annual incidence of 429 candidemic episodes was 2.03/10,000 bed days, with 9.88 in adult intensive care units (ICUs), 1.74 in surgical wards, and 1.81 in internal medicine wards, where a significant increase was observed (1.15, 1.85, and 2.23/10,000 bed days in 2009 to 2011, 2012 to 2014, and 2015 to 2018, respectively; P = 0.004). Candida albicans was the most common species (41%), followed by Candida parapsilosis species complex [SC] (37%), Candida glabrata SC (11%), Candida tropicalis (7%), Candida krusei (1%), and other rare Candida spp. (3%). Mixed infections were found in 20/429 (4.7%) cases, while 33 (7%) cases were due to non-Candida spp. Overall, 44/311 (14%) isolates were resistant/non-wild type (WT) to the nine antifungals tested, with 23/113 (20%) C. parapsilosis SC and 2/34 (6%) C. glabrata SC isolates being resistant to fluconazole (1 panechinocandin and 2 panazole resistant). All isolates were susceptible/WT to amphotericin B and flucytosine. While the overall consumption of antifungals diminished (P = 0.02), with a mean of 17.93 defined daily doses (DDD)/100 bed days, increased micafungin use was correlated with the rise in C. parapsilosis SC (P = 0.04). A significant increase of candidemia in internal medicine wards and of C. parapsilosis SC infections was found during the years of financial crisis. Although resistance rates remain low (<14%), fluconazole-resistant C. parapsilosis SC and multidrug-resistant C. glabrata SC isolates are of major concern.

Sensititre YeastOne (YO) panels were assessed for in vitro susceptibility testing of echinocandins against 39 isolates of Aspergillus fumigatus, A. flavus, and A. terreus, including two echinocandin-resistant A. fumigatus strains, using different inocula (10 3 , 10 4 , and 10 5 CFU/ml), incubation times (16 to 48 h), and endpoints (first blue or purple well) and compared to CLSI M38-A2. The best agreement was found with an inoculum of 10 4 CFU/ml, incubation times of 20 h for A. flavus and of 30 h for A. fumigatus and A. terreus, and reading the first purple well. The reproducibility within Ϯ1 2-fold dilutions was 100% for all three echinocandins. YO color endpoints were 2 to 3 2-fold dilutions lower than CLSI minimum effective concentrations (MECs) of caspofungin and 1 to 2 2-fold dilutions higher than CLSI MECs of micafungin. For anidulafungin, off-scale YO color endpoints were observed. Nevertheless, A. fumigatus echinocandin-resistant isolates were detected after 24 h of incubation.KEYWORDS echinocandins, Aspergillus spp., Sensititre, antifungal susceptibility testing, MEC A spergillus isolates with reduced susceptibility to current antifungal agents have been increasingly reported, highlighting the importance of antifungal susceptibility testing in clinical microbiology laboratory routine (1). In vitro reduced susceptibility of Aspergillus fumigatus isolates to echinocandins can be developed via FKS-dependent and FKS-independent mechanisms (2). Although clinical resistance of Aspergillus to echinocandins is limited (3), breakthrough infections in patients treated with echinocandins has been reported (4), and non-wild-type clinical isolates with minimal effective concentrations (MECs) above the epidemiological cutoff value have been found (5). Sensititre YeastOne (YO) is an adapted susceptibility system of the microbroth CLSI method based on the M27-A3 standard for yeasts, which uses alamarBlue as a colorimetric indicator. Sensititre YeastOne has been extensively evaluated for yeasts. There are fewer studies for molds, demonstrating high levels of agreement with the reference methodology for amphotericin B and azoles with Aspergillus spp. (6-12), while limited data exist for echinocandins. Since Sensititre YeastOne is widely used in routine microbiology laboratories, the aim of the present study was to assess its performance for in vitro susceptibility testing of echinocandins against the three most commonly isolated Aspergillus spp. -A. fumigatus, A. flavus, and A. terreus-compared

Introduction: Invasive pulmonary aspergillosis is an emerging complication among intensive care unit (ICU) patients with COVID-19 (CAPA). In the present study, all CAPA cases during the first year of the pandemic were reviewed in critically ill patients at a 650-bed tertiary Greek COVID-19 reference hospital. Methods: Data regarding patients admitted to the ICU of Attikon Hospital in Athens, Greece, between 22 March 2020 and 28 February 2021 with a positive PCR for SARS-CoV-2 infection were reviewed. Clinical and microbiological records were analysed including demographic, clinical, laboratory and radiological features, treatment and outcomes. CAPA was determined according to the recent 2020 ECMM/ISHAM definitions. Results: A total of 179 patients were admitted in the ICU and 6 (3.3%) patients were diagnosed with CAPA (4 probable and 2 possible CAPA) with 5/6 with co-infection with multidrug-resistant (MDR) gram-negative pathogens. No patient had a history of immunosuppression. All suffered from acute respiratory distress syndrome. The median (range) time from intubation to diagnosis was 6 (1-14) days. Five patients had positive Aspergillus cultures in bronchial secretions (1 A. fumigatus, 1 A. flavus, 1A. fumigatus ? A. flavus, 1 A. fumigatus ? A. terreus and 1 A. terreus) while culture was negative in one patient. All isolates were susceptible to antifungal drugs. Serum galactomannan (GM), pan-Aspergillus PCR and (1,3)b-D-glucan (BDG) were positive in 4/6 (67%), 5/6 (83%, 3/5 in two consecutive samples) and 4/6 (67%, in consecutive samples) patients, respectively. GM and PCR positive bronchial secretions had GM indices [ 9.95 and PCR C t \ 34. All were treated with antifungal drugs with 5 out of 6 receiving isavuconazole. Mortality was 67% (4/6) with 1/4 attributed to CAPA (two died as a result of bacterial septic shock and one as a result of multiorgan failure). Conclusion:The incidence of CAPA in ICU patients was 3.3% and it was associated with approximately a 17% attributable mortality in the setting of MDR gram-negative pathogen coinfections.

BackgroundAcinetobacter baumannii is a leading cause of healthcare-associated infections worldwide, due to both its persistence in the hospital setting and ability to acquire high levels of antibiotic resistance. Carbapenem-resistant A. baumannii isolates (CRAB) limit the activity of current antimicrobial regimens and new alternatives or adjuncts to traditional antibiotics are urgently needed. Durlobactam is a novel broad-spectrum inhibitor of serine-type β-lactamases that restores sulbactam (SUL) activity against A. baumannii. The sulbactam-durlobactam (SD) combination has recently completed Phase 3 testing in the global ATTACK trial.ObjectivesThe aim of this study is to evaluate the in vitro activity of SD versus comparators against a representative nationwide collection of CRAB isolates.MethodsOne hundred ninety CRAB isolates were collected from clinical samples of patients hospitalized in 11 hospitals throughout Greece during 2015. In vitro activities of SD and comparators (SUL alone, amikacin, minocycline, imipenem, meropenem, colistin, SD and imipenem combined with SD) were determined by broth microdilution.ResultsDurlobactam restored sulbactam activity against the majority of the strains tested, with SD exhibiting the lowest MIC90 (8 μg/ml) relative to the other single comparators tested; 87.9% of the isolates had SD MICs ≤4/4 µg/ml. The most active comparator was colistin (MIC90 = 16 μg/ml). The addition of imipenem further lowered the MIC90 of SD by one two-fold dilution.ConclusionsThis study demonstrated the potential utility of SD for the treatment of infections caused by A. baumannii. If its clinical efficacy is confirmed, SD may be an important therapeutic option for CRAB infections.