Publications by authors named "Birgit Willinger"

63 Publications

State of Medical Mycology at German Academic Medical Centres: A Survey of the German-Speaking Mycological Society (DMYKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG).

Mycoses 2021 Oct 7;64(10):1177-1182. Epub 2021 Jul 7.

Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), and German Centre for Infection Research (DZIF) Partner Site Bonn-Cologne, University of Cologne, Cologne, Germany.

Background: Little is known about the infrastructure to translate advances in the management of patients at risk to develop invasive opportunistic fungal diseases. To assess the current state of Medical Mycology support in Germany, we conducted a survey among all 36 academic medical centres.

Methods: The survey consisted of a 3-pages questionnaire sent out in the first half of 2019. Information included details of infrastructure, education and teaching; consultation services and interdisciplinary conferences; research activities and participation in network groups; radiology, microbiology and pharmacology support; publication activity; and European Confederation for Medical Mycology (ECMM) Excellence Center designation, if assigned.

Results: Information was returned from 24 centres (67%). Thirteen institutions (54%) reported an independent infectious disease, and two a separate Medical Mycology department (8%); a Medical Mycology working group was reported for nine institutions (38%). An infectious disease consultation service was existent in 16 institutions (67%) and a multidisciplinary conference in 13 (54%). Fifteen institutions reported a separate study office with activities in infectious disease studies (63%). Laboratory capability for fungal identification and susceptibility testing was confirmed by all 24 institutions; testing of galactomannan by 23 (96%), cryptococcal antigen by 21 (88%), ß-D-Glucan by 9 (38%), and panfungal and Pneumocystis PCR by 21 and 22 (88% and 92%), respectively. Therapeutic drug monitoring of voriconazole was reported to be available in 15 (63%) institutions with a turnaround of ≤24 h during weekdays in 10 (42%). Two of the 24 University hospitals (8%) reported ECMM Diamond Excellence Status.

Conclusions: The results of this survey document the continuing need to improve the availability of specialised Medical Mycology support in German academic medical centres.
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http://dx.doi.org/10.1111/myc.13346DOI Listing
October 2021

Emerging Fungi and Diagnosis of Fungal Infections: Current Knowledge and New Developments.

Authors:
Birgit Willinger

J Fungi (Basel) 2021 Apr 19;7(4). Epub 2021 Apr 19.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.

I would like to thank all the authors contributing to this Special Issue [...].
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http://dx.doi.org/10.3390/jof7040316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074204PMC
April 2021

Vulvovaginal Candidosis (Excluding Mucocutaneous Candidosis): Guideline of the German (DGGG), Austrian (OEGGG) and Swiss (SGGG) Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry Number 015/072, September 2020).

Geburtshilfe Frauenheilkd 2021 Apr 14;81(4):398-421. Epub 2021 Apr 14.

Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe, Wuppertal, Germany.

The aim of this official guideline, published and coordinated by the German (DGGG), Austrian (OEGGG) and Swiss (SGGG) Societies of Gynecology and Obstetrics in collaboration with the DMykG, DDG and AGII societies, was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnosis, treatment and management of women with vulvovaginal candidosis. This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the above-mentioned societies. This guideline gives recommendations for the diagnosis, management, counseling, prophylaxis and screening of vulvovaginal candidosis.
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http://dx.doi.org/10.1055/a-1345-8793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046514PMC
April 2021

Paracoccidioidomycosis Diagnosed in Europe-A Systematic Literature Review.

J Fungi (Basel) 2021 Feb 23;7(2). Epub 2021 Feb 23.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.

Paracoccidioidomycosis is a systemic mycosis that is endemic in geographical regions of Central and South America. Cases that occur in nonendemic regions of the world are imported through migration and travel. Due to the limited number of cases in Europe, most physicians are not familiar with paracoccidioidomycosis and its close clinical and histopathological resemblance to other infectious and noninfectious disease. To increase awareness of this insidious mycosis, we conducted a systematic review to summarize the evidence on cases diagnosed and reported in Europe. We searched PubMed and Embase to identify cases of paracoccidioidomycosis diagnosed in European countries. In addition, we used Scopus for citation tracking and manually screened bibliographies of relevant articles. We conducted dual abstract and full-text screening of references yielded by our searches. To identify publications published prior to 1985, we used the previously published review by Ajello et al. Overall, we identified 83 cases of paracoccidioidomycosis diagnosed in 11 European countries, published in 68 articles. Age of patients ranged from 24 to 77 years; the majority were male. Time from leaving the endemic region and first occurrence of symptoms considerably varied. Our review illustrates the challenges of considering systemic mycosis in the differential diagnosis of people returning or immigrating to Europe from endemic areas. Travel history is important for diagnostic-workup, though it might be difficult to obtain due to possible long latency period of the disease.
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http://dx.doi.org/10.3390/jof7020157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926554PMC
February 2021

Guideline: Vulvovaginal candidosis (AWMF 015/072, level S2k).

Mycoses 2021 Jun 27;64(6):583-602. Epub 2021 Feb 27.

Deutsches Zentrum fuer Infektionen in Gynaekologie und Geburtshilfe, Wuppertal, Germany.

Approximately 70-75% of women will have vulvovaginal candidosis (VVC) at least once in their lifetime. In premenopausal, pregnant, asymptomatic and healthy women and women with acute VVC, Candida albicans is the predominant species. The diagnosis of VVC should be based on clinical symptoms and microscopic detection of pseudohyphae. Symptoms alone do not allow reliable differentiation of the causes of vaginitis. In recurrent or complicated cases, diagnostics should involve fungal culture with species identification. Serological determination of antibody titres has no role in VVC. Before the induction of therapy, VVC should always be medically confirmed. Acute VVC can be treated with local imidazoles, polyenes or ciclopirox olamine, using vaginal tablets, ovules or creams. Triazoles can also be prescribed orally, together with antifungal creams, for the treatment of the vulva. Commonly available antimycotics are generally well tolerated, and the different regimens show similarly good results. Antiseptics are potentially effective but act against the physiological vaginal flora. Neither a woman with asymptomatic colonisation nor an asymptomatic sexual partner should be treated. Women with chronic recurrent Candida albicans vulvovaginitis should undergo dose-reducing maintenance therapy with oral triazoles. Unnecessary antimycotic therapies should always be avoided, and non-albicans vaginitis should be treated with alternative antifungal agents. In the last 6 weeks of pregnancy, women should receive antifungal treatment to reduce the risk of vertical transmission, oral thrush and diaper dermatitis of the newborn. Local treatment is preferred during pregnancy.
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http://dx.doi.org/10.1111/myc.13248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248160PMC
June 2021

Do Isolates with Borderline Resistant Micafungin MICs Always Harbor Hot Spot Mutations?

J Fungi (Basel) 2021 Jan 28;7(2). Epub 2021 Jan 28.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria.

Antifungal susceptibility testing is important in guiding patient therapy due to an increasing number of resistant isolates. In the clinical strain collection of the Austrian resistance report (AURES), a high number of micafungin-resistant isolates (18.2% 49/269) was detected in seven different centres in Austria from 2011-2016. Most of these isolates showed a micafungin MIC value that was just above the clinical breakpoint (CB) established by EUCAST (0.016 mg/L). The aim of this study was to analyse whether strains showing a micafungin MIC value of 1-2 dilutions above the CB (0.032 mg/L and 0.064 mg/L) are associated with mutations in hotspot (HS) regions. 115 candidemia strains showing a micafungin MIC one or two dilutions above the EUCAST CB (0.032 mg/L and 0.064 mg/L) were categorized as borderline resistant and screened for mutations in HS1, HS2, and HS3 regions, which are known locations for the development of echinocandin resistance. For this purpose, we implemented targeted resequencing utilizing a next generation sequencing technology. No missense mutations could be detected in HS1, HS2, and HS3 in any of the 115 isolates, which indicated that resistance conferred by alteration of seems unlikely.
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http://dx.doi.org/10.3390/jof7020093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911425PMC
January 2021

Lessons from low seroprevalence of SARS-CoV-2 antibodies in schoolchildren: A cross-sectional study.

Pediatr Allergy Immunol 2021 05 15;32(4):762-770. Epub 2021 Feb 15.

Department of Pediatrics and Adolescent Medicine, Klinik Ottakring, Vienna, Austria.

Background: Children are discussed as hidden SARS-CoV-2 virus reservoir because of predominantly mild or even asymptomatic course of disease. The objective of this cross-sectional study in May-July 2020 was to assess the prevalence of SARS-CoV-2 antibodies and virus RNA in schoolchildren, consistent with previous infection by contact tracing.

Methods: School authorities approached parents for voluntary participation. Interested families were contacted by the study team. A nasal and oropharyngeal swab, a blood sample, and a questionnaire were employed. Primary endpoint was the frequency of SARS-CoV-2 real-time PCR (RT-PCR) and antibody-positive children. Antibody positivity was assessed by a highly sensitive first-line ELISA, and a neutralization assay and two other immunoassays as confirmatory assays.

Results: Of 2069 children (median age 13 years, IQR 10-15), 2 cases (0.1%) tested positive for SARS-CoV-2 RNA and 26 cases (1.3%) tested positive for specific antibodies. SARS-CoV-2-specific antibodies exhibited detectable virus-neutralizing activity in 92% (24 of 26 samples). Seropositivity was associated with a history of mild clinical symptoms in 14 children (53.8%), while 12 children (46.2%) remained asymptomatic. Among 13 seropositive children being tested concomitantly with their siblings, only one pair of siblings was seropositive. Contact tracing revealed adult family members and school teachers as potential index cases.

Conclusion: In schoolchildren, the infection rate with SARS-CoV-2 is low and associated with a mild or asymptomatic course of disease. Virus spreading seemed to occur more likely in intergenerational contacts than among siblings in the same household. The presence of neutralizing SARS-CoV-2 antibodies in children may reflect protective adaptive immunity.
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http://dx.doi.org/10.1111/pai.13459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013685PMC
May 2021

Filamentous Fungal Infections in a Tertiary Care Setting: Epidemiology and Clinical Outcome.

J Fungi (Basel) 2021 Jan 9;7(1). Epub 2021 Jan 9.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.

Information on the distribution of filamentous fungal pathogens, which cause potential life-threatening invasive infections mostly in immunocompromised persons, is of great importance. The aim of this study was to evaluate the epidemiology and clinical outcome in patients with infections due to filamentous fungi at the University Hospital of Vienna, Austria. We conducted a retrospective observational study and consecutively included patients of any age with filamentous fungal infections between 2009 and 2017. The classification for probable and proven invasive filamentous fungal infections was based on the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC) criteria or the expert opinion of an experienced clinical mycologist. We included 129 patients (median age: 52 years; 47.3% female) with episodes of 101 proven and probable invasive and 35 localized filamentous fungal infections (16 sinus, 14 eye, one ear, and four deep cutaneous). alone accounted for 50.3% of the fungi, which was followed by the Mucorales group (13.7%) and spp. (8.5%). Diagnosis was mainly based on culture findings. The lung was the most frequent site of infection. The 30-day and 90-day overall mortality of invasive fungal infections was 30.2% and 42.7%, respectively. We observed a high all-cause mortality among patients with invasive filamentous fungal infections. Prospective data collection in a nationwide registry would be necessary to provide important information on surveillance to clinicians and other decision-makers.
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http://dx.doi.org/10.3390/jof7010040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827224PMC
January 2021

Human Pathogenic Species Respond Distinctively to Lactic Acid Stress.

J Fungi (Basel) 2020 Dec 8;6(4). Epub 2020 Dec 8.

Department of Applied Genetics and Cell Biology (DAGZ), Institute of Microbial Genetics, University of Natural Resources and Life Sciences, Vienna (BOKU), 3430 Tulln an der Donau, Austria.

Several species are opportunistic human fungal pathogens and thrive in various environmental niches in and on the human body. In this study we focus on the conditions of the vaginal tract, which is acidic, hypoxic, glucose-deprived, and contains lactic acid. We quantitatively analyze the lactic acid tolerance in glucose-rich and glucose-deprived environment of five species: and . To characterize the phenotypic space, we analyzed 40-100 clinical isolates of each species. Each species had a very distinct response pattern to lactic acid stress and characteristic phenotypic variability. and were best to withstand high concentrations of lactic acid with glucose as carbon source. A glucose-deprived environment induced lactic acid stress tolerance in all species. With lactate as carbon source the growth rate of is even higher compared to glucose, whereas the other species grow slower. may use lactic acid as carbon source in the vaginal tract. Stress resistance variability was highest among strains. In conclusion, each spp. is adapted differently to cope with lactic acid stress and resistant to physiological concentrations.
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http://dx.doi.org/10.3390/jof6040348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762603PMC
December 2020

Education of medical personnel optimizes filling volume of blood culture bottles without negatively affecting microbiology testing.

BMC Health Serv Res 2020 Dec 1;20(1):1105. Epub 2020 Dec 1.

Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: Anemia is a risk factor for adverse outcomes, which can be aggravated by unnecessary phlebotomies. In blood culture testing, up to 30 ml of blood can be withdrawn per sample, even though most manufacturers recommend blood volumes of 10 ml or less. After assessing the filling volume of blood culture bottles at our institution, we investigated whether an educational intervention could optimize filling volume of blood culture bottles without negatively affecting microbiology testing.

Methods: We weighed 10,147 blood cultures before and 11,806 blood cultures after a six-month educational intervention, during which employees were trained regarding correct filling volume via lectures, handouts, emails, and posters placed at strategic places.

Results: Before the educational intervention, only 31% of aerobic and 34% of anaerobic blood cultures were filled correctly with 5-10 ml of blood. The educational intervention increased the percentage of correctly filled bottles to 43% (P < 0.001) for both aerobic and anaerobic samples without negatively affecting results of microbiologic testing. In addition, sample volume was reduced from 11.0 ± 6.5 to 9.4 ± 5.1 ml (P < 0.001) in aerobic bottles and from 10.1 ± 5.6 to 8.8 ± 4.8 ml (P < 0.001) in anaerobic bottles.

Conclusion: Education of medical personnel is a simple and effective way to reduce iatrogenic blood loss and possibly moderate the extent of phlebotomy-induced anemia.
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http://dx.doi.org/10.1186/s12913-020-05959-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704116PMC
December 2020

Molecular Methods for the Diagnosis of Invasive Candidiasis.

J Fungi (Basel) 2020 Jul 6;6(3). Epub 2020 Jul 6.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria.

Invasive infections caused by members of the genus are on the rise. Especially patients in intensive care units, immunocompromised patients, and those recovering from abdominal surgery are at risk for the development of candidemia or deep-seated candidiasis. Rapid initiation of appropriate antifungal therapy can increase survival rates significantly. In the past, most of these infections were caused by , a species that typically is very susceptible to antifungals. However, in recent years a shift towards infections caused by non-albicans species displaying various susceptibly patterns has been observed and the prompt diagnosis of the underlying species has become an essential factor determining the therapeutic outcome. The gold standard for diagnosing invasive candidiasis is blood culture, even though its sensitivity is low and the time required for species identification usually exceeds 48 h. To overcome these issues, blood culture can be combined with other methods, and a large number of tests have been developed for this purpose. The aim of this review was to give an overview on strengths and limitations of currently available molecular methods for the diagnosis of invasive candidiasis.
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http://dx.doi.org/10.3390/jof6030101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558065PMC
July 2020

Clinical Usefulness of Susceptibility Breakpoints for Yeasts in the Treatment of Candidemia: A Noninterventional Study.

J Fungi (Basel) 2020 Jun 2;6(2). Epub 2020 Jun 2.

Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria.

This prospective noninterventional study evaluated whether antifungal susceptibility data (MIC) provided for clinical isolates on the basis of recently established breakpoints are taken into account by clinicians to guide their treatment decision making process, and assessed the response in MIC- and non-MIC-based treatment groups. During a six month period, the usage of systemic antifungals was recorded in detail and compared with mycological data ( species and MICs) in candidemia patients. Patients were assigned to a susceptible or resistant infection group based on European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints; treatment decisions were under the professional discretion of the treating physicians. 123 patients were evaluated with accounting for 59%, for 19%, for 15%, for 4% and for 3%. Antifungal treatment correlated with species and MICs in 80% ( = 99 patients), high MICs and species-dependent guideline recommendations were ignored in 20% ( = 24 patients); the overall outcome of candidemia cases in our study population was excellent, as by day 14, all patients were cleared from fungal blood stream infection (mean 5.6 days, range 2-12). The current variability in antifungal usage and the delay in initiating appropriate therapy indicate a need for antifungal stewardship to improve the management of invasive fungal infections.
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http://dx.doi.org/10.3390/jof6020076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7345773PMC
June 2020

Calculated parenteral initial treatment of bacterial infections: Microbiology.

GMS Infect Dis 2020 26;8:Doc18. Epub 2020 Mar 26.

Klinisches Institut für Labormedizin, Medizinische Universität Wien, Vienna, Austria.

This is the second chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2 updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Preliminary microbiological findings regarding the patient and their immediate environment are crucial for the calculation of treatment with antibiotics in each case, as well as the resistance situation of the ward on which the patient is being cared for. If such data is not available, regional or supra-regional data can be used as a fallback. This chapter describes the methods of susceptibility testing, informs about the resistance situation in Germany and describes the main resistance mechanisms of bacterial pathogens against antibiotics. Further, the chapter informs about collateral damage of antibiotics as well as medical measures against increasing resistance.
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http://dx.doi.org/10.3205/id000062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186810PMC
March 2020

Pharyngeal carriage rates of Neisseria meningitidis in health care professionals at a tertiary university pediatric hospital.

Eur J Clin Microbiol Infect Dis 2020 Sep 24;39(9):1703-1709. Epub 2020 Apr 24.

Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropediatrics, Medical University of Vienna, Vienna, Austria.

Pharyngeal carriage is the reservoir for Neisseria meningitidis in the population and the first step in disease transmission. Especially in young infants and adolescents, N. meningitidis can cause serious invasive infection with high fatality rates and high rates of long-term sequelae among survivors. The aim of this study was to determine N. meningitidis colonization rates in asymptomatic health care professionals at a tertiary university pediatric hospital and to identify risk factors for carriage. This cross-sectional meningococcal carriage survey was conducted between April and October 2018 at the Medical University of Vienna. Individuals working as nurses, pediatricians, or medical students were enrolled. Oropharyngeal swabs were directly plated onto selective agar plates and conventional culture was used for bacterial identification. Meningococcal isolates were further characterized using whole-genome sequencing. A total of 437 oropharyngeal specimens were collected. Overall, meningococcal carriage prevalence was 1.14% (5/437), with 0.7% (3/437) for capsular genotype B, and 0.5% (2/437) for capsular genotype W. Mean age of carriers was significantly lower than of non-carriers (24.2 vs. 35.8; p = 0.004). The highest carriage rate of 4.4% (4/91) was found in the age group 18-25. Carriage was negatively associated with age and timespan working in pediatrics. This is the first study evaluating the prevalence of Neisseria meningitidis carriage in health care professionals working in Pediatrics and Adolescent Medicine. Carriage was in general lower than expected for all age groups, implicating a low risk of meningococcal transmission via this population.
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http://dx.doi.org/10.1007/s10096-020-03894-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427699PMC
September 2020

Clinical evaluation of an in-house panfungal real-time PCR assay for the detection of fungal pathogens.

Infection 2020 Jun 12;48(3):345-355. Epub 2020 Feb 12.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.

Purpose: Due to an increasing incidence of invasive fungal infections, the availability of reliable diagnostic tools for the fast detection of a wide spectrum of fungal pathogens is of vital importance. In this study, we aimed to conduct an extensive clinical evaluation of a recently published in-house panfungal PCR assay on samples from suspected invasive fungal infections.

Methods: Overall 265 clinical samples from 232 patients with suspected invasive fungal disease (96 deep airway samples, 60 sterile fluids, 50 tissue biopsies, and 59 blood samples) were included. All samples underwent standard culture-based diagnostics and were additionally analyzed with our panfungal PCR assay.

Results: Overall, 55.1% of agreement between culture and the panfungal PCR was observed; in 17% of all samples partial concordance was noted, while results between culture and our PCR assay were not in agreement in 27.9%. Our panfungal assay performed better in samples from normally sterile sites, while samples from the deep airways yielded the highest rate of discordant (39.6%) results. In two tissue and three blood samples an invasive pathogen was only detected by PCR while cultures remained negative.

Conclusion: In combination with routine methods, our panfungal PCR assay is a valuable diagnostic tool. Patients at risk for invasive fungal infections might profit from the reduced time to pathogen identification.
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http://dx.doi.org/10.1007/s15010-020-01395-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256020PMC
June 2020

Detection of Species in Clinical Specimens by Probe-Based Real-Time PCR.

J Fungi (Basel) 2019 Nov 12;5(4). Epub 2019 Nov 12.

Department for Internal Medicine II, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany.

The mold is a ubiquitous fungus causing plant, animal and human infections. In humans, spp. are the major cause of eye infections in patients wearing contact lenses or after local trauma. Systemic infections by spp. mainly occur in immunosuppressed patients and can disseminate throughout the human body. Due to high levels of resistance to antifungals a fast identification of the causative agent is an urgent need. By using a probe-based real-time PCR assay specific for the genus we analysed several different clinical specimens detecting spp. commonly found in clinical samples in Germany. Also, a large collection of lung fluid samples of haematological patients was analysed ( = 243). In these, two samples (0.8%) were reproducibly positive, but only one could be confirmed by sequencing. For this case of probable invasive fungal disease (IFD) culture was positive for species. Here we describe a rapid, probe-based real-time PCR assay to specifically detect DNA from a broad range of species and its application to clinically relevant specimens.
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http://dx.doi.org/10.3390/jof5040105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958410PMC
November 2019

Augmenting Analytics Software for Clinical Microbiology by Man-Machine Interaction.

Stud Health Technol Inform 2019 Aug;264:1243-1247

Medexter Healthcare GmbH, Vienna, Austria.

In the present study, we intended to solve identification problems in analyzing the results of microbiology by proactive man-machine interaction. We modified the analytics software MOMO so that it flags laboratory results containing textual elements unknown to the thesaurus, and a human expert assigns the elements to the respective existing thesaurus elements or creates new ones. In 773,309 laboratory results, roughly 2.6% contained unassigned elements and would have been ignored in thesaurus-based analyses for purposes other than simply reporting microbiological findings to physicians. In current use, the thesaurus is kept up to date with synonyms, syntactic deviations, misspellings, and entries not contained earlier, with man-machine interaction of 2-3 hours per week. This approach helps to accommodate both up-to-date clinical reporting for immediate patient care as well as up-to-date queries for infection surveillance and epidemiology, outbreak management, quality control and benchmarking, and antimicrobial stewardship.
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http://dx.doi.org/10.3233/SHTI190425DOI Listing
August 2019

Matched-paired analysis of patients treated for invasive mucormycosis: standard treatment versus posaconazole new formulations (MoveOn).

J Antimicrob Chemother 2019 11;74(11):3315-3327

University of Cologne, Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Cologne, Germany.

Background: First-line antifungal treatment for invasive mucormycosis (IM) consists of liposomal amphotericin B. Salvage treatment options are limited and often based on posaconazole oral suspension. With the approval of posaconazole new formulations, patients could benefit from improved pharmacokinetics, safety and tolerability.

Objectives: Our aim was to assess the effectiveness of posaconazole new formulations for IM treatment.

Methods: We performed a case-matched analysis with proven or probable IM patients from the FungiScope® Registry. First-line posaconazole new formulations (1st-POSnew) and first-line amphotericin B plus posaconazole new formulations (1st-AMB+POSnew) cases were matched with first-line amphotericin B-based (1st-AMB) treatment controls. Salvage posaconazole new formulations (SAL-POSnew) cases were matched with salvage posaconazole oral suspension (SAL-POSsusp) controls. Each case was matched with up to three controls (based on severity, haematological/oncological malignancy, surgery and/or renal dysfunction).

Results: Five patients receiving 1st-POSnew, 18 receiving 1st-AMB+POSnew and 22 receiving SAL-POSnew were identified. By day 42, a favourable response was reported for 80.0% (n = 4/5) of patients receiving 1st-POSnew, for 27.8% (n = 5/18) receiving 1st-AMB+POSnew and for 50.0% (n = 11/22) receiving SAL-POSnew. Day 42 all-cause mortality of patients receiving posaconazole new formulations was lower compared with controls [20.0% (n = 1/5) in 1st-POSnew versus 53.3% (n = 8/15) in 1st-AMB; 33.3% (n = 6/18) in 1st-AMB+POSnew versus 52.0% (n = 26/50) in 1st-AMB; and 0.0% (n = 0/22) in SAL-POSnew versus 4.4% (n = 2/45) in SAL-POSsusp].

Conclusions: Posaconazole new formulations were effective in terms of treatment response and associated mortality of IM. While posaconazole new formulations may be an alternative for treatment of IM, the limited sample size of our study calls for a cautious interpretation of these observations.
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http://dx.doi.org/10.1093/jac/dkz344DOI Listing
November 2019

Antifungal susceptibility of yeast bloodstream isolates collected during a 10-year period in Austria.

Mycoses 2019 Apr 20;62(4):357-367. Epub 2019 Feb 20.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.

Background: Candida-associated infections put a significant burden on western healthcare systems. Development of (multi-)resistant fungi can become untreatable and threaten especially vulnerable target groups, such as the immunocompromised.

Objectives: We assessed antifungal susceptibility and explored possible influence factors of clinical Candida isolates collected from Austrian hospitals between 2007 and 2016.

Methods: Thousand three hundred and sixty clinical Candida spp. isolated from blood cultures were subjected to antifungal susceptibility testing (AFST) in a liquid-handling aided continuous microdilution assay. We tested against fluconazole, voriconazole, posaconazole, itraconazole, isavuconazole, anidulafungin, caspofungin and micafungin according to EUCAST with additional recording of growth curves. We performed rigid quality control on each assay via growth curve assessment and included two standard reference strains. Minimal inhibitory concentrations (MIC) were quantified according to EUCAST guideline E.DEF 7.3.1, and susceptibility was evaluated using EUCAST clinical breakpoints.

Results: The isolate collection consisted of Candida albicans (59%), C. glabrata (19%), C. parapsilosis (9%), C. tropicalis (5%) and C. krusei (3%) and few other Candida species and fungi (5%). During the observed time period, species abundance and antifungal resistance rates remained constant. Multi-resistance was rare and we found no single isolate which was resistant to both azoles and echinocandins. Within the antifungal resistance profile of our strain collection, we observed clusters along species boundaries.

Conclusions: Over the last decade, the distribution of Candida species and its level of antifungal resistance remained constant in Austria. Our data compare well with other European countries. Principal component analysis of the susceptibility profile of this collection revealed species-specific clusters and substantial intra-species variation, especially for C. glabrata.
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http://dx.doi.org/10.1111/myc.12892DOI Listing
April 2019

Analysis of antifungal resistance genes in Candida albicans and Candida glabrata using next generation sequencing.

PLoS One 2019 10;14(1):e0210397. Epub 2019 Jan 10.

Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria.

Introduction/objectives: An increase in antifungal resistant Candida strains has been reported in recent years. The aim of this study was to detect mutations in resistance genes of azole-resistant, echinocandin-resistant or multi-resistant strains using next generation sequencing technology, which allows the analysis of multiple resistance mechanisms in a high throughput setting.

Methods: Forty clinical Candida isolates (16 C. albicans and 24 C. glabrata strains) with MICs for azoles and echinocandins above the clinical EUCAST breakpoint were examined. The genes ERG11, ERG3, TAC1 and GSC1 (FKS1) in C. albicans, as well as ERG11, CgPDR1, FKS1 and FKS2 in C. glabrata were sequenced.

Results: Fifty-four different missense mutations were identified, 13 of which have not been reported before. All nine echinocandin-resistant Candida isolates showed mutations in the hot spot (HS) regions of FKS1, FKS2 or GSC1. In ERG3 two homozygous premature stop codons were identified in two highly azole-resistant and moderately echinocandin-resistant C. albicans strains. Seven point mutations in ERG11 were determined in azole-resistant C. albicans whereas in azole-resistant C. glabrata, no ERG11 mutations were detected. In 10 out of 13 azole-resistant C. glabrata, 12 different potential gain-of-function mutations in the transcription factor CgPDR1 were verified, which are associated with an overexpression of the efflux pumps CDR1/2.

Conclusion: This study showed that next generation sequencing allows the thorough investigation of a large number of isolates more cost efficient and faster than conventional Sanger sequencing. Targeting different resistance genes and a large sample size of highly resistant strains allows a better determination of the relevance of the different mutations, and to differentiate between causal mutations and polymorphisms.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210397PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328131PMC
October 2019

Competition of Candida glabrata against Lactobacillus is Hog1 dependent.

Cell Microbiol 2018 Dec 7;20(12):e12943. Epub 2018 Sep 7.

Department of Applied Genetics and Cell Biology (DAGZ), University of Natural Resources and Life Sciences, Vienna (BOKU), Tulln, Austria.

Candida glabrata is a common human fungal commensal and opportunistic pathogen. This fungus shows remarkable resilience as it can form recalcitrant biofilms on indwelling catheters, has intrinsic resistance against azole antifungals, and is causing vulvovaginal candidiasis. As a nosocomial pathogen, it can cause life-threatening bloodstream infections in immune-compromised patients. Here, we investigate the potential role of the high osmolarity glycerol response (HOG) MAP kinase pathway for C. glabrata virulence. The C. glabrata MAP kinase CgHog1 becomes activated by a variety of environmental stress conditions such as osmotic stress, low pH, and carboxylic acids and subsequently accumulates in the nucleus. We found that CgHog1 allows C. glabrata to persist within murine macrophages, but it is not required for systemic infection in a mouse model. C. glabrata and Lactobacilli co-colonise mucosal surfaces. Lactic acid at a concentration produced by vaginal Lactobacillus spp. causes CgHog1 phosphorylation and accumulation in the nucleus. In addition, CgHog1 enables C. glabrata to tolerate different Lactobacillus spp. and their metabolites when grown in co-culture. Using a phenotypic diverse set of clinical C. glabrata isolates, we find that the HOG pathway is likely the main quantitative determinant of lactic acid stress resistance. Taken together, our data indicate that CgHog1 has an important role in the confrontation of C. glabrata with the common vaginal flora.
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http://dx.doi.org/10.1111/cmi.12943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283251PMC
December 2018

Isolation of Candida auris from Ear of Otherwise Healthy Patient, Austria, 2018.

Emerg Infect Dis 2018 08;24(8):1596-1597

The emerging pathogen Candida auris is isolated mostly from hospitalized patients and often shows multidrug resistance. We report on the isolation of this yeast in Austria from an outpatient's auditory canal. The isolate showed good susceptibility against antifungals except for echinocandins; the patient was treated successfully with topical administration of nystatin.
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http://dx.doi.org/10.3201/eid2408.180495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056136PMC
August 2018

Invasive Fungal Infection Caused by Exophiala dermatitidis in a Patient After Lung Transplantation: Case Report and Literature Review.

Mycopathologia 2019 Feb 11;184(1):107-113. Epub 2018 Jun 11.

Division of Clinical Microbiology, Department of Laboratory Medicine, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria.

This report describes a case of invasive Exophiala dermatitidis infection after double lung transplantation in a 76-year-old man. After thoracotomy, the patient's wound showed dehiscence with purulent secretion. The black yeast was isolated from cultures taken from the wound, and species identification was confirmed by sequence analysis of the internal transcribed spacer (ITS-S2) region. The results of the susceptibility testing showed voriconazole as the most active drug. Despite adaptation of the antifungal therapy the clinical condition worsened, and the patient died. In addition, we evaluated the fungicidal activity of antiseptics towards E. dermatitidis and aimed to provide a brief literature review of previously reported infections caused by this rare fungus. To the best of our knowledge, this is the first report of a rapidly progressing invasive fungal infection with E. dermatitidis originating from a colonized wound after lung transplantation.
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http://dx.doi.org/10.1007/s11046-018-0275-4DOI Listing
February 2019

Azole-Resistance in and Related Species: An Emerging Problem or a Rare Phenomenon?

Front Microbiol 2018 28;9:516. Epub 2018 Mar 28.

Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany.

Invasive mold infections associated with species are a significant cause of mortality in immunocompromised patients. The most frequently occurring aetiological pathogens are members of the section followed by members of the section . The frequency of and related (cryptic) species in clinical specimens, as well as the percentage of azole-resistant strains remains to be studied. A global set ( = 498) of 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 gene. The majority of isolates was identified as (86.8%), followed by (8.4%), (2.6%), (1.6%), (0.2%), and (0.2%). One isolate failed to match a known sp., but was found most closely related to . According to EUCAST clinical breakpoints azole resistance was detected in 5.4% of all tested isolates, 6.2% of 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 and one isolate. The most affected amino acid position of the gene correlating with the posaconazole resistant phenotype was M217, which was found in the variation M217T and M217V. was most prevalent, followed by . Posaconazole was the most potent drug against , but 5.4% of showed resistance against this azole. In Austria, Germany, and the United Kingdom posaconazole-resistance in all isolates was higher than 10%, resistance against voriconazole was rare and absent for itraconazole.
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http://dx.doi.org/10.3389/fmicb.2018.00516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5882871PMC
March 2018

A Retrospective Assessment of Four Antigen Assays for the Detection of Invasive Candidiasis Among High-Risk Hospitalized Patients.

Mycopathologia 2018 Jun 22;183(3):513-519. Epub 2018 Jan 22.

Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Währinger Gürtel 18-20/5P, A-1090, Vienna, Austria.

Because of their high mortality rates and non-specific symptoms, invasive Candida infections pose a huge diagnostic and therapeutic challenge. In this study, we evaluated the three mannan antigen assays Platelia, Platelia Plus and Serion, and the (1-3)-β-D-glucan assay Fungitell in a group of high-risk (hematological and surgical) patients. Test results of 305 patients hospitalized at the Vienna General Hospital and the University Hospital of Innsbruck were retrospectively analyzed. We assessed the test accuracy by means of descriptive statistics. Nine (2.95%) patients were affected by invasive candidiasis (IC), and 25 (8.2%) patients had a probable/possible infection. The majority of patients (271; 88.9%) showed no signs of infection. The Platelia and Serion mannan assays had a low sensitivity (65% and 52%, respectively), but high specificity (98% for both tests). The newer version of the Platelia assay, the Platelia Plus, had a higher sensitivity (85%) but a lower specificity (89%). The sensitivity of the Fungitell assay was high (100%), while its specificity was low (58%). The positive predictive values were 0.48 for the Platelia and 0.41 for the Serion assay, 0.26 for the Platelia Plus and 0.09 for the Fungitell assay. Our limited, retrospective study suggests the efficacy of mannan assays as screening (Platelia Plus) and confirmatory (Serion) tests, while the Fungitell assay can be used to exclude invasive Candida infections.
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http://dx.doi.org/10.1007/s11046-017-0238-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958149PMC
June 2018

Detection of fungal pathogens by a new broad range real-time PCR assay targeting the fungal ITS2 region.

J Med Microbiol 2017 Oct 8;66(10):1383-1392. Epub 2017 Sep 8.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Währinger Gürtel 18-20/5P, A-1090 Vienna, Austria.

Purpose: The rise in the incidence of fungal infections and the expanding spectrum of fungal pathogens make early and broad detection of fungal pathogens essential. In the present study, a panfungal real-time PCR assay for the broad-range detection of fungal DNA (Fungi assay) in a wide variety of clinical specimens was developed.

Methodology: Our in-house, HybProbe real-time PCR assay targets the ITS2 region of fungal DNA. The applicability was evaluated by testing 105 clinical samples from 98 patients with suspected fungal infection. Samples included tissue biopsies, paraffin embedded tissues, aspirates, EDTA-anticoagulated blood, cerebrospinal fluids and bronchoalveolar lavages.

Results: Fungal pathogens were identified by the Fungi assay in 47 samples. In all of these cases, conventional methods and clinical data were also indicative for a fungal infection. Five samples were interpreted false negative. blast analyses of the amplicons derived from 11 samples revealed the presence of environmental fungal species while other tests and clinical data did not suggest a fungal infection. This fact might indicate contaminated samples. The remaining 42 samples were negative by the Fungi assay as well as the conventional methods and were therefore regarded as true negatives. Thus, sensitivity was 90.4 % and specificity 79.2 %.

Conclusion: The Fungi assay improved the targeted diagnosis of fungal infections allowing pathogen identification in samples that were histologically positive but culture negative. For reliable diagnosis, results have to be interpreted in context with conventional methods and clinical data.
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http://dx.doi.org/10.1099/jmm.0.000575DOI Listing
October 2017

SeptiFast versus blood culture in clinical routine - A report on 3 years experience.

Wien Klin Wochenschr 2017 Jun 27;129(11-12):427-434. Epub 2017 Feb 27.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

Background: In recent years a multiplex real-time PCR (SeptiFast) has been introduced, allowing detection of 25 common blood pathogens considerably faster than conventional blood culture.

Methods: SeptiFast was applied routinely in addition to blood culture in cases of critically ill patients with fever and other signs of severe systemic infections. In this study data of 470 episodes were retrospectively analysed to assess the impact of various parameters, such as clinical indications, assigning ward and antimicrobial treatment on test outcome using a multivariate logistic model.

Results: After exclusion of microorganisms classified as contaminants, the concordance between SeptiFast and blood culture was 85.5%. SeptiFast detected 98 out of 120, while blood culture merely found 63 out of 120 potential pathogens. In comparison to blood culture, SeptiFast showed considerably higher positivity rates in sepsis, pneumonia and febrile immunosuppression and a lower rate in endocarditis. The highest positivity and concordance between tests was shown in patients from the emergency room (P = 0.007).

Conclusions: The results obtained in this study are similar to those from prospective settings confirming the robustness of the SeptiFast assay in routine use. Our data suggest that SeptiFast is a valuable add-on to blood culture and may increase the diagnostic efficiency of a microbiological laboratory.
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http://dx.doi.org/10.1007/s00508-017-1181-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5486735PMC
June 2017

Chronic Paracoccidioidomycosis with adrenal involvement mimicking tuberculosis - A case report from Austria.

Med Mycol Case Rep 2016 Dec 2;14:12-16. Epub 2016 Dec 2.

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.

Paracoccidioidomycosis is a systemic fungal infection caused by and endemic in certain areas of Central and South America. We report a case of a 62-year-old-man with a complex history of tuberculosis and imaging findings of a cerebral lesion and bilateral adrenal enlargement. Biopsy of adrenal gland revealed . This case highlights the importance of travel history for diagnosis of paracoccidioidomycosis in non-endemic areas and emphasizes the clinical and histopathological similarities with tuberculosis.
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http://dx.doi.org/10.1016/j.mmcr.2016.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154971PMC
December 2016

Culture-Based Techniques.

Authors:
Birgit Willinger

Methods Mol Biol 2017 ;1508:195-207

Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Währinger Gürtel 18-20/5P, 1090, Vienna, Austria.

The detection of fungal elements and their characterization in patient specimens provides fundamental information. Culture-based methods, though often slow, may yield the specific etiological agent, and may allow susceptibility testing to be performed. Proper collection and transportation of the specimen is essential. Particularly, sterile materials are important for diagnosis of invasive fungal infections.Therefore, culture and direct microscopy should be performed on all suitable clinical specimens when fungal disease is suspected. Numerous different media for culturing and identifying fungi are available, and those important for diagnosing mycoses as well as the most important staining methods for direct microcopy are described.
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http://dx.doi.org/10.1007/978-1-4939-6515-1_10DOI Listing
January 2018
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