Screening for triazole resistance in clinically significant Aspergillus species; report from Pakistan

Abstract

Background: Burden 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. Methods: A 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 itraconazole, voriconazole and posaconazole against 41 isolates, a subset of the collection, were tested and interpreted according to the Clinical and Laboratory Standards Institute broth microdilution method. Results: All the isolates were triazole-susceptible on agar screening. MICs of all 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 two weeks. Conclusion: Triazole resistance could not be detected amongst clinical Aspergillus isolates from Karachi. 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. Keywords: Aspergillosis, Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger, Aspergillus terreus, itraconazole, voriconazole and posaconazole.