title: New therapeutic strategies for invasive aspergillosis in the era of azole resistance: how should the prevalence of azole resistance be defined?
abstract: Given reports showing a high prevalence of azole resistance in Aspergillus fumigatus, alternatives to azole therapy are discussed when a threshold of 10% of azole-resistant environmental isolates is reached. This raises the issue of calculation of this threshold, either on the prevalence of azole-resistant isolates as a whole or on the prevalence of azole-resistant cases in populations at risk of invasive aspergillosis (IA). For isolate evaluation, there are high disparities in routine microbiological procedures for the isolation of A. fumigatus and azole resistance detection. There are also huge differences between the microbiological work-up for diagnosing IA. Some centres rely on galactomannan detection alone without actively trying to culture appropriate samples, which affects reliability of the figures on the prevalence of resistance and thus the threshold of resistance. Moreover, reports from the laboratory could mix up figures from completely different patient populations: frequent azole-resistant isolates from pneumology patients and rare azole-resistant isolates from haematology patients. Therefore, to sum isolates from different specimens and different wards can lead to erroneous calculations for the restricted populations at risk of developing IA. In conclusion, assessing the incidence of azole resistance in A. fumigatus should be based on harmonized consensual microbiological methods and reports should be restricted to IA episodes in identified populations at risk of IA when the issue is to define an operational threshold for modifying recommendations.
authors: Laboratoire de Parasitologie-Mycologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France Paris Diderot, Sorbonne Paris Cité University, Paris, France Institut Pasteur, Molecular Mycology Unit, National Reference Centre of Invasive Mycoses and Antifungals, CNRS URA 3012, Paris, France.
authors: Alexandre
authors: A
authors: Alanio
authors: Service de Maladie Infectieuses et tropicales, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France.
authors: Blandine
authors: B
authors: Denis
authors: Laboratoire de Parasitologie-Mycologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France.
authors: Samia
authors: S
authors: Hamane
authors: Service d'Hématologie adulte, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France.
authors: Emmanuel
authors: E
authors: Raffoux
authors: Paris Diderot, Sorbonne Paris Cité University, Paris, France Service d'Hématologie-Greffe de Moelle, AP-HP, Groupe hospitalier Lariboisière-Saint Louis, Paris, France.
authors: Régis
authors: R
authors: Peffault de la Tour
authors: Service de Pharmacie, AP-HP, Groupe hospitalier Lariboisière-Saint Louis, Paris, France.
authors: Sophie
authors: S
authors: Touratier
authors: Paris Diderot, Sorbonne Paris Cité University, Paris, France Service de Pneumologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France.
authors: Anne
authors: A
authors: Bergeron
authors: Laboratoire de Parasitologie-Mycologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Paris, France Paris Diderot, Sorbonne Paris Cité University, Paris, France Institut Pasteur, Molecular Mycology Unit, National Reference Centre of Invasive Mycoses and Antifungals, CNRS URA 3012, Paris, France stephane.bretagne@aphp.fr.
authors: Stéphane
authors: S
authors: Bretagne
mesh_terms: D000935:Antifungal Agents / Q000494:pharmacology* / Q000627:therapeutic use*; D001232:Aspergillus fumigatus / Q000187:drug effects* / Q000302:isolation & purification*; D001393:Azoles / Q000494:pharmacology*; D025141:Drug Resistance, Fungal; D006801:Humans; D015994:Incidence; D055744:Invasive Pulmonary Aspergillosis / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology; D008826:Microbial Sensitivity Tests / Q000379:methods; D015995:Prevalence
chemical_list: D000935:Antifungal Agents; D001393:Azoles