ORIGINAL RESEARCH article
Azole-Resistance in Aspergillus terreus and Related Species: An Emerging Problem or a Rare Phenomenon?
- 1Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
- 2Servei de Microbiologia, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
- 3Microbiologia, Hospital Universitario Miguel Servet, IIS Aragon, Universidad de Zaragoza, Zaragoza, Spain
- 4Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
- 5Microbiology Division, Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
- 6Unit of Mycology, Department of Clinical Microbiology, Statens Serum Institute, Copenhagen University, Rigshospitalet, Copenhagen, Denmark
- 7Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
- 8University of Texas MD Anderson Cancer Center, Houston, TX, United States
- 9National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- 10Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- 11Unità Operativa Complessa di Microbiologia e Virologia, Dipartimento di Patologia e Diagnostica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- 12Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- 13Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
- 14Microbiology Institute, ASST Papa Giovanni XXIII, Bergamo, Italy
- 15Infectious Diseases Research Laboratory, 4th Department of Internal Medicine, ATTIKON University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- 16Laboratorio Centrale di Analisi Chimico Cliniche e Microbiologia, IRCCS Foundation, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- 17Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- 18Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
- 19Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
- 20Mycology Reference Laboratory, Public Health England, Bristol, United Kingdom
- 21Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- 22National Reference Medical Mycology Laboratory, Faculty of Medicine, Institute of Microbiology and Immunology, University of Belgrade, Belgrade, Serbia
- 23Department I of Internal Medicine, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Clinical Trials Centre Cologne, Center for Integrated Oncology (CIO Köln-Bonn), German Centre for Infection Research, University of Cologne, Cologne, Germany
- 24Clinical Microbiology Laboratory, National Kapodistrian University of Athens, ATTIKON University Hospital Athens, Athens, Greece
- 25Department of Hygiene and Medical Microbiology, Klinikum Wels-Grieskirchen, Wels, Austria
- 26Department of Public Health and Pediatrics, Microbiology Division, Turin, Italy
- 27Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- 28German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
- 29A.O.U. Policlinico Vittorio Emanuele Catania, Biometec–University of Catania, Catania, Italy
- 30Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi, University of Bologna, Bologna, Italy
- 31Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- 32Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- 33Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czechia
- 34Clinical Microbiology, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain
- 35Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- 36Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey
- 37Division of Mycology, Department of Medial Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- 38Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
- 39Departmento de Micología, Instituto de Medicina Regional, Universidad Nacional del Nordeste, CONICET, Resistencia, Argentina
- 40Division of Clinical Mycology, Department of Microbiology, Vall d'Hebron University Hospital, Barcelona, Spain
- 41Department of Medical Mycology and Parasitology, Invasive Fungi Research Center, Mazandaran University of Medical Sciences, Sari, Iran
- 42School of Medicine, European University Cyprus, Nicosia, Cyprus
- 43Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, Saint Petersburg, Russia
- 44Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- 45Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Medical School, Ankara, Turkey
- 46Department of Medical Mycology and Parasitology, School of Medicine, Iran University of Medical Science, Tehran, Iran
- 47Department of Dermatology, Hospital Ernest Lluch Martin, Zaragoza, Spain
- 48Department Applied and Industrial Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands
Objectives: Invasive mold infections associated with Aspergillus species are a significant cause of mortality in immunocompromised patients. The most frequently occurring aetiological pathogens are members of the Aspergillus section Fumigati followed by members of the section Terrei. The frequency of Aspergillus terreus and related (cryptic) species in clinical specimens, as well as the percentage of azole-resistant strains remains to be studied.
Methods: A global set (n = 498) of A. terreus and phenotypically related isolates was molecularly identified (beta-tubulin), tested for antifungal susceptibility against posaconazole, voriconazole, and itraconazole, and resistant phenotypes were correlated with point mutations in the cyp51A gene.
Results: The majority of isolates was identified as A. terreus (86.8%), followed by A. citrinoterreus (8.4%), A. hortai (2.6%), A. alabamensis (1.6%), A. neoafricanus (0.2%), and A. floccosus (0.2%). One isolate failed to match a known Aspergillus sp., but was found most closely related to A. alabamensis. According to EUCAST clinical breakpoints azole resistance was detected in 5.4% of all tested isolates, 6.2% of A. terreus sensu stricto (s.s.) were posaconazole-resistant. Posaconazole resistance differed geographically and ranged from 0% in the Czech Republic, Greece, and Turkey to 13.7% in Germany. In contrast, azole resistance among cryptic species was rare 2 out of 66 isolates and was observed only in one A. citrinoterreus and one A. alabamensis isolate. The most affected amino acid position of the Cyp51A gene correlating with the posaconazole resistant phenotype was M217, which was found in the variation M217T and M217V.
Conclusions: Aspergillus terreus was most prevalent, followed by A. citrinoterreus. Posaconazole was the most potent drug against A. terreus, but 5.4% of A. terreus sensu stricto showed resistance against this azole. In Austria, Germany, and the United Kingdom posaconazole-resistance in all A. terreus isolates was higher than 10%, resistance against voriconazole was rare and absent for itraconazole.
In the last decade, the taxonomy and nomenclature of the previously morphologically defined genus Aspergillus changed, mainly due to comprehensive molecular phylogenetic studies and the introduction of the single name nomenclature (Samson et al., 2011, 2014; Alastruey-Izquierdo et al., 2013). With the introduction of molecular identification methods morphologically similar species were split into several cryptic species (Balajee et al., 2009a,b; Samson et al., 2011; Gautier et al., 2014). Samson et al. (2011) recognized 13 species in section Terrei: A. terreus sensu stricto (s.s.), A. alabamensis, A. allahabadii, A. ambiguus, A. aureoterreus, A. carneus, A. floccosus, A. hortai, A. microcysticus, A. neoafricanus, A. neoindicus, A. niveus, and A. pseudoterreus. In 2015, Guinea et al. (2015) described A. citrinoterreus as a new species of the section Terrei and subsequently A. bicephalus and A. iranicus were introduced (Arzanlou et al., 2016; Crous et al., 2016), resulting in a total of 16 accepted species.
Aspergillus terreus s.s., an important cause of fungal infections in immunocompromised patients, is reported as second or third most common pathogen of invasive aspergillosis (Baddley et al., 2003; Lass-Flörl et al., 2005; Blum et al., 2008). Treatment of infections caused by A. terreus s.s. and other section Terrei species (Walsh et al., 2003; Risslegger et al., 2017) may be difficult because of intrinsic amphotericin B resistance (Sutton et al., 1999; Escribano et al., 2012; Hachem et al., 2014; Risslegger et al., 2017). In addition, the emergence of A. terreus sensu lato (s.l.) isolates with reduced azole-susceptibility was reported (Arendrup et al., 2012; Won et al., 2017). Azole resistance in A. terreus s.s. and A. fumigatus is associated with mutations and alterations of the lanosterol-14-α steroldemethylase gene (Cyp51A), a key protein in the ergosterol biosynthesis pathway (Chowdhary et al., 2015, 2017). However, aside from mutations in the primary target gene, also other less known mechanisms (e.g., efflux pumps, overexpression of cyp51) were found to be involved in azole resistance (Arendrup, 2014; Rivero-Menendez et al., 2016).
The aim of this study was to evaluate the frequency of A. terreus s.s. and phenotypically similar (cryptic) species in a global set of clinical isolates and to screen for the presence of azole resistance.
Materials and Methods
During an international A. terreus survey (Risslegger et al., 2017) various A. terreus sensu lato (s.l.) isolates were sent to and collected at the Medical University of Innsbruck by members of the ISHAM-ECMM-EFISG TerrNet Study group (www.isham.org/working-groups/aspergillus-terreus). Isolates were from Europe (n = 390), Middle East (n = 70), South America (n = 10), North America (n = 7), and South Asia (n = 19). A total of 498 strains, including isolates collected in Innsbruck within the last years, were analyzed (Supplementary Figure S1 and Supplementary Table S1), 495 were of clinical and 3 of environmental origin. For two isolates, the source is unknown. Isolates were cultured on Sabouraud's agar (Becton Dickinson, France), incubated at 37°C and stored in Sabouraud's broth with glycerin at −20°C.
Antifungal Susceptibility Testing
Susceptibility to itraconazole, posaconazole, and voriconazole was determined by using reference broth microdilution according to EUCAST (www.EUCAST.org) and ETest® (bioMérieux, France). ETest® MICs were rounded to the next higher EUCAST concentrations and isolates displaying high MICs (≥0.25 mg/L for posaconazole, ≥2.0 mg/L for each, voriconazole and itraconazole) with ETest® were evaluated according to EUCAST. MIC50 and MIC90 were calculated for all studied section Terrei strains and each individual species. EUCAST clinical breakpoints (CBP) for Aspergillus fumigatus (see Table 3) were applied for wild typ and non-wildtyp categorization, as CBP for Aspergillus terreus are not available.
Genomic DNA was extracted by a method using CTAB (Lackner et al., 2012), and partial β-tubulin gene was amplified using bt2a/bt2b as previously described (Balajee et al., 2009a; Kathuria et al., 2015). KAPA2G Robust HotStart ReadyMix PCR Kit (Kapa Biosystems, USA) was used as master mix and PCR products were cleaned with ExoSAP-IT. For sequencing the BigDye XTerminator purification kit (Applied Biosystems, USA) was used. Sequencing was performed with the 3500 Genetic Analyzer (Applied Biosystems, USA) and data were analyzed with Bionumerics 6.6. Software (Applied Maths, Belgium). Generated sequences were compared with an in-house database of the Westerdijk Institute containing all available Aspergillus reference sequences.
Sequencing of Lanosterol 14-α Sterol Demethylase Gene (cyp51A)
Azole-resistant isolates (Table 3) and a control set of susceptible isolates (Supplementary Table S2) underwent Cyp51A sequencing. Cyp51A genes were amplified by PCR, using KAPA2G Robust HotStart ReadyMix PCR Kit (Kapa Biosystems, USA) and in-house designed primers described by Arendrup et al. (2012). In short, PCR conditions were as follows: initial denaturation at 95°C for 5 min, followed by 35 cycles of 95°C for 1 min, 58°C for 1 min, 72°C for 2 min 30 s, and a final elongation step of 72°C for 10 min. Primers used for Cyp51A sequencing are provided in Supplementary Table S3. PCR products were cleaned with ExoSAP-IT and for sequencing the BigDye XTerminator purification kit was used. Sequencing was performed with the 3500 Genetic Analyzer and data were analyzed with Bionumerics 6.6. Software and Geneious 8 (Biomatters Limited).
Results and Discussion
Epidemiology of Cryptic Species
Reports on cryptic species within the genus Aspergillus are on the rise (Balajee et al., 2009b; Alastruey-Izquierdo et al., 2013; Negri et al., 2014; Masih et al., 2016) and display variabilities in antifungal susceptibility (Risslegger et al., 2017). Negri et al. (2014) observed an increase of cryptic Aspergillus species causing fungal infections, and others calculated a prevalence of 10–15% of cryptic Aspergillus species in clinical samples (Balajee et al., 2009b; Alastruey-Izquierdo et al., 2013).
The present study analyzed a large number of isolates (n = 498) collected from Europe, Middle East, South America, North America, and South Asia (Supplementary Table S1 and Supplementary Figure S2) and identified A. terreus (n = 432), A. citrinoterreus (n = 42), A. alabamensis (n = 8), A. hortai (n = 13), A. floccosus (n = 1), and A. neoafricanus (n = 1). As previously reported (Risslegger et al., 2017) one isolate failed to be associated with any existing species, but clustered most closely to A. alabamensis (Supplementary Figure S1).
Our study showed limitations due to the unknown source and date of some clinical isolates. A differentiation between isolates from superficial and deep seeded infections was not made, therefore, source-variable resistance rates cannot be excluded. Number of studied isolates varied per country and might also introduce a bias to resistance rates.
Aspergillus terreus s.s. was the most prevalent species (86.8%), followed by A. citrinoterreus (8.4%), A. hortai (2.6%), and A. alabamensis (1.6%). This is in agreement with other authors (Balajee et al., 2009a; Neal et al., 2011; Escribano et al., 2012; Kathuria et al., 2015) showing that A. terreus s.s. is the most common species of section Terrei in clinical and environmental samples. In addition, we detected A. floccosus and A. neoafricanus. We did not identify A. allahabadii, A. ambiguus, A. aureoterreus, A. bicephalus, A. carneus, A. iranicus, A. microcysticus, A. neoindicus, A. niveus, and A. pseudoterreus. The reason for this might be that these species are less common in clinical samples and the environment. Our species distribution is in line with Kathuria et al. (2015), who reported for the first time a probable invasive aspergillosis and aspergilloma case due to A. hortai, which was found to occur in a prevalance of 1.4% of all section Terrei isolates. A multicenter study by Balajee et al. (2009a) observed a high frequency (33% of all clinical A. terreus s.l. isolates were A. alabamensis) of A. alabamensis. Other studies (Neal et al., 2011; Gautier et al., 2014; Risslegger et al., 2017) reported a lower prevalence of A. alabamensis isolates (up to 4.3%).
Little is known about the geographical distribution of cryptic species of section Terrei in clinical specimens. A. terreus s.s. was exclusively found in France, Portugal, Serbia, India, and Sweden (Supplementary Table S1). Spain, Italy, Texas and Germany showed highest species diversity (Figure 1 and Supplementary Table S1). In Spain, the prevalent cryptic species were A. citrinoterreus (18.2%), A. alabamensis (2.3%), A. hortai (2.3%), and A. neoafricanus (1.1%), in Italy A. citrinoterreus and A. hortai (4.9%), together with one A. alabamensis (2.4%) and one unknown Terrei species (2.4%). In Germany A. citrinoterreus (7.8%) was followed by A. hortai (3.9%), and A. alabamensis (2.0%). In Texas 80.0% were A. terreus s.s. followed by 10% A. alabamensis and 10.0% A. hortai. Percentage of A. citrinoterreus was highest in Iran accounting 36.36% of all isolates (Figure 1).
Figure 1. Epidemiological distribution of species (circles) and relative percentage of posaconazole resistance (according to EUCAST clinical breakpoints, see Table 2) isolates per country (blue numbers in blue circles) in respect to all investigated isolates. In France, Portugal, Serbia, and Sweden all collected isolates were identified as A. terreus sensu stricto (small dots in magenta). Azole-resistance percentage per countries are given in blue circled numbers. Species distribution in non-EU countries were as follows: India 100% A. terreus s.s.; Israel 84.85% A. terreus s.s. 12.12% A. citrinoterreus 3.03% A. hortai; Texas 80% A. terreus s.s. 10% A. alabamensis 10% A. hortai; Qatar: 83.34% A. terreus s.s. 16.66% A. citrinoterreus; Iran 63.64% A. terreus s.s. 36.36% A. citrinoterreus; and Brazil 85.71% A. terreus s.s., 14.29% A. hortai. All isolates from Iran, Israel, India, Brazil, Texas, and Qatar were susceptible to all azoles tested. For detailed information see Table 4.
Azole Resistance Among Studied Section Terrei Isolates
Proposed epidemiological cut off values (ECOFF) values by EUCAST for A. terreus s.s. were 0.25 μg/mL for posaconazole, 2 μg/mL each for voriconazole and itraconazole. Antifungal susceptibility results (MICs) for A. terreus s.s. and cryptic species of the section Terrei are reported in Table 1 and Figure 2. Posaconazole had the lowest MICs for section Terrei isolates (MIC50, 0.032 μg/mL Etest® and 0.250 μg/mL EUCAST), followed by itraconazole (MIC50, 0.125 μg/mL Etest® and 0.500 μg/mL EUCAST), and voriconazole (MIC50, 0.064 μg/mL Etest® and 0.500 μg/mL EUCAST) (Figure 2). Lass-Flörl et al. (2009) observed similar MIC values for posaconazole among clinical isolates of A. terreus s.l. Astvad et al. (2017) tested A. terreus species complex isolates against voriconazole and observed slightly higher MIC ranges of 0.250–8.000 μg/mL.
Figure 2. MIC distribution of posaconazole, itraconazole, voriconazole, and posaconazoleintraconazole against Aspergillus section Terrei, obtained by ETest® (A-C) and EUCAST method (D-F). MIC, minimum inhibitory concentration; MIC50 and MIC90, MIC for 50 and 90% of tested population; CBP EUCAST clinical breakpoint (see Table 2).
No major differences in azole susceptibility profiles for A. terreus s.s. and cryptic species were observed (Table 2). Posaconazole and itraconazole MIC ranges for A. terreus were only slightly higher when compared to cryptic species. As shown in Table 2, MICs50 obtained with Etest® are equal among A. terreus s.s. isolates and cryptic species for posaconazole (0.032 μg/mL) and voriconazole (0.064 μg/mL). No significant differences in MIC90 values were observed among A. terreus s.s. isolates and cryptic species for itraconazole and posaconazole. Voriconazole MICs90 were somewhat higher among cryptic species (0.500 μg/mL) when compared to A. terreus s.s. (0.250 μg/mL). In general, all cryptic A. terreus species were per trend more susceptible to posaconazole and itraconazole than A. terreus s.s. The two most common cryptic species in our study, A. citrinoterreus, and A. alabamensis, showed highest MICs for voriconazole (range: 0.016–2.000 and 0.023–2.000 μg/mL).
According to EUCAST breakpoints 5.4% of all section Terrei isolates are posaconazole resistant. This is a relatively high frequency in comparison to A. fumigatus. A prospective multicenter international surveillance study (van der Linden et al., 2015) showed a prevalence of azole-resistance of 3.2% in A. fumigatus. As shown in Table 3, only mono-azole resistance was observed (posaconazole, MICs ranged from 0.500 to 1.000 μg/mL). Azole resistance was more frequently observed among A. terreus s.s. isolates and was rare among cryptic species. One A. citrinoterreus isolate was resistant against posaconazole (0.500 μg/mL). Posaconazole resistant strains were detected from Germany (13.7%) followed by the United Kingdom (12.5%), Austria (10.5%), France (9.1%), Italy (4.9%), and Spain (2.3%) (Tables 3, 4 and Figure 1). In Turkey, Greece, Serbia, Iran, Israel, India, Brazil, Texas, and Qatar all isolates were susceptible against all azoles tested. However, resistance rates per countries might be influenced by multiple factors such as specimen handling and sampling, and investigated patient cohorts.
Table 4. Posaconazole resistance per country relative to (1) all studied isolates and (2) A. terreus s.s. only (also see Figure 1).
Posaconazole showed to be the most effective azole against A. terreus s.s. and related (cryptic) species. However, a high frequency of posaconazole resistant isolates was detected and it was shown that the occurrence of azole resistance differed geographically. Posaconazole resistance among cryptic species was rare when compared to A. terreus s.s.
SNPs in the Cyp51A Gene
Mutations at the position M217 were reported to be associated with reduced susceptibility against itraconazole (MICs of 1.0–2.0 μg/mL), voriconazole (MICs of 1.0–4.0 μg/mL), and posaconazole (MICs of 0.25–0.5 μg/mL) (Arendrup et al., 2012), however the substituting amino acids varied from the one found in our study. Our isolates carried the mutations M217T (nucleic acid change T650C) or M217V (nucleic acid change A649G) (Table 3) and were exclusively resistant against posaconazole, when applying the EUCAST clinical breakpoints. Strains carrying the point mutation M217I in the study from Arendrup et al. (2012) were isolated from cystic fibrosis patients receiving long-term azole therapy and showed a pan-azole resistant phenotype. Another posaconazole resistant isolate (T153) carried an amino acid substitution at position A221V, a mutation, which was also previously reported by Arendrup et al. (2010), but was not associated with posaconazole resistance. Hence, functional studies in mutant strains are needed to evaluate the role of the mutations M217V, M217I, M217T, and A221V, which are all located in close proximity to the hot spot mutation M220I of A. fumigatus. Understanding the impact of mutations at the position M217 on the protein folding pattern and subsequently on binding capacities of azoles is the key to evaluate its role as azole-resistance markers. Other hotspot mutations, which were linked to acquired azole-resistance in A. fumigatus, are G54, L98, and M220 (Arendrup et al., 2010). None of them were found in our resistant isolates, suggesting different mechanisms of acquired azole-resistance than in A. fumigatus. The role of the other coding mutations within A. terreus s.s. isolates E19G (nucleic acid substitution A956G) and D344N (nucleic acid substitution C662T) remains to be studied. Voriconazole resistant A. citrinoterreus carried the amino acid changes I23T, R163H, E202D, Q270R (Table 3), which need to be analyzed in detail.
Aspergillus terreus s.s. was most prevalent, followed by A. citrinoterreus. Posaconazole was the most potent azole against the investigated isolates and species. Approximately 5% of all tested A. terreus s.s. isolates were resistant against posaconazole in vitro. In Austria, Germany and the UK posaconazole resistance was higher than 10% in all A. terreus s.s. isolates. Resistance against itraconazole and voriconazole was rare.
TZ: manuscript writing, Etest susceptibility testing, data analysis and interpretation, discussion of results, DNA extraction, sequencing; BS: wrote parts of the manuscript (M&M), DNA extraction, sequencing, nucleic acid alignments, and amino acid alignments; LS: EUCAST susceptibility testing, DNA extraction; JH: BLAST comparison of sequences, molecular species identification; BR: culturing of isolates, subcultivation of isolates, morphological identification, data management; CL-F: manuscript writing, discussion of results, clinical background, funding, coordination of the TerrNet study group, isolate recruitment; ML: manuscript writing, data analysis, study design, supervising TZ, BS, and LS; MA, FS-R, AR, AnC, ST-A, MA, SO, DK, AA-I, KL, GL, JM, WB, CF, MD-A, AG, AT, BW, AH, EJ, LK, VA-A, OC, JM, WP, VT, J-JV, LT, RL, ES, P-MR, PH, MR-I, ER, SA-A, ArC, ALC, MF, MM-G, HB, GP, NK, SH, OU, MR, SdlF are members of the EFISG-ISHAM-ECMM TerrNet Study group: providing strains and data.
This work was supported by ECMM, ISHAM, and EFISG and in part by an unrestricted research grant through the Investigator Initiated Studies Program of Astellas, MSD, and Pfizer. This study was fundet by the Christian Doppler Laboratory for invasive fungal infections.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The handling Editor declared a past co-authorship with several of the authors BS, KL, JM, BW, VA-A, OC, J-JV, P-MR, CL-F, and ML. The handling Editor declared a shared affiliation, and co-authorship, with one of the authors WB.
The authors thank Katharina Rosam, Sandra Leitner, and Caroline Hörtnagl for technical assistance. The authors also thank the EFISG-ISHAM-ECMM TerrNet Study group for providing strains and data.
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmicb.2018.00516/full#supplementary-material
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Keywords: cryptic species, Aspergillus section Terrei, susceptibility profiles, azoles, Cyp51A alterations
Citation: Zoran T, Sartori B, Sappl L, Aigner M, Sánchez-Reus F, Rezusta A, Chowdhary A, Taj-Aldeen SJ, Arendrup MC, Oliveri S, Kontoyiannis DP, Alastruey-Izquierdo A, Lagrou K, Cascio GL, Meis JF, Buzina W, Farina C, Drogari-Apiranthitou M, Grancini A, Tortorano AM, Willinger B, Hamprecht A, Johnson E, Klingspor L, Arsic-Arsenijevic V, Cornely OA, Meletiadis J, Prammer W, Tullio V, Vehreschild J-J, Trovato L, Lewis RE, Segal E, Rath P-M, Hamal P, Rodriguez-Iglesias M, Roilides E, Arikan-Akdagli S, Chakrabarti A, Colombo AL, Fernández MS, Martin-Gomez MT, Badali H, Petrikkos G, Klimko N, Heimann SM, Uzun O, Roudbary M, de la Fuente S, Houbraken J, Risslegger B, Lass-Flörl C and Lackner M (2018) Azole-Resistance in Aspergillus terreus and Related Species: An Emerging Problem or a Rare Phenomenon? Front. Microbiol. 9:516. doi: 10.3389/fmicb.2018.00516
Received: 19 January 2018; Accepted: 06 March 2018;
Published: 28 March 2018.
Edited by:Martin Hoenigl, University of California, San Diego, United States
Reviewed by:Murat Akova, Hacettepe University School of Medicine, Turkey
Taissa Vila, University of Maryland, Baltimore, United States
Copyright © 2018 Zoran, Sartori, Sappl, Aigner, Sánchez-Reus, Rezusta, Chowdhary, Taj-Aldeen, Arendrup, Oliveri, Kontoyiannis, Alastruey-Izquierdo, Lagrou, Cascio, Meis, Buzina, Farina, Drogari-Apiranthitou, Grancini, Tortorano, Willinger, Hamprecht, Johnson, Klingspor, Arsic-Arsenijevic, Cornely, Meletiadis, Prammer, Tullio, Vehreschild, Trovato, Lewis, Segal, Rath, Hamal, Rodriguez-Iglesias, Roilides, Arikan-Akdagli, Chakrabarti, Colombo, Fernández, Martin-Gomez, Badali, Petrikkos, Klimko, Heimann, Uzun, Roudbary, de la Fuente, Houbraken, Risslegger, Lass-Flörl and Lackner. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
†These authors have contributed equally to this work.