Antifungal heteroresistance causes prophylaxis failure and facilitates breakthrough Candida parapsilosis infections Journal Article
| Authors: | Zhai, B.; Liao, C.; Jaggavarapu, S.; Tang, Y.; Rolling, T.; Ning, Y.; Sun, T.; Bergin, S. A.; Gjonbalaj, M.; Miranda, E.; Babady, N. E.; Bader, O.; Taur, Y.; Butler, G.; Zhang, L.; Xavier, J. B.; Weiss, D. S.; Hohl, T. M. |
| Article Title: | Antifungal heteroresistance causes prophylaxis failure and facilitates breakthrough Candida parapsilosis infections |
| Abstract: | Breakthrough fungal infections in patients on antimicrobial prophylaxis during allogeneic hematopoietic cell transplantation (allo-HCT) represent a major and often unexplained cause of morbidity and mortality. Candida parapsilosis is a common cause of invasive candidiasis and has been classified as a high-priority fungal pathogen by the World Health Organization. In high-risk allo-HCT recipients on micafungin prophylaxis, we show that heteroresistance (the presence of a phenotypically unstable, low-frequency subpopulation of resistant cells (~1 in 10,000)) underlies breakthrough bloodstream infections by C. parapsilosis. By analyzing 219 clinical isolates from North America, Europe and Asia, we demonstrate widespread micafungin heteroresistance in C. parapsilosis. Standard antimicrobial susceptibility tests, such as broth microdilution or gradient diffusion assays, which guide drug selection for invasive infections, fail to detect micafungin heteroresistance in C. parapsilosis. To facilitate rapid detection of micafungin heteroresistance in C. parapsilosis, we constructed a predictive machine learning framework that classifies isolates as heteroresistant or susceptible using a maximum of ten genomic features. These results connect heteroresistance to unexplained antifungal prophylaxis failure in allo-HCT recipients and demonstrate a proof-of-principle diagnostic approach with the potential to guide clinical decisions and improve patient care. © The Author(s), under exclusive licence to Springer Nature America, Inc. 2024. |
| Keywords: | controlled study; genetics; nonhuman; diffusion; antifungal agent; hematopoietic stem cell transplantation; drug effect; europe; allogeneic hematopoietic stem cell transplantation; world health organization; asia; drug therapy; microbiology; caspofungin; fluconazole; candidiasis; voriconazole; antifungal agents; graft recipient; micafungin; north america; prevention and control; copy number variation; adverse event; minimum inhibitory concentration; fungus isolation; machine learning; amphotericin b; anidulafungin; microbial sensitivity tests; drug resistance, fungal; antifungal resistance; tunicamycin; candida parapsilosis; humans; human; article; microbial sensitivity test; isavuconazole; breakthrough infection; aureobasidin a |
| Journal Title: | Nature Medicine |
| Volume: | 30 |
| Issue: | 11 |
| ISSN: | 1078-8956 |
| Publisher: | Nature Publishing Group |
| Date Published: | 2024-11-01 |
| Start Page: | 3163 |
| End Page: | 3172 |
| Language: | English |
| DOI: | 10.1038/s41591-024-03183-4 |
| PUBMED: | 39095599 |
| PROVIDER: | scopus |
| PMCID: | PMC11840754 |
| DOI/URL: | |
| Notes: | The MSK Cancer Center Support Grant (P30 CA008748) is acknowledge in the PDF -- Corresponding authors is MSK author: Tobias M. Hohl -- Source: Scopus |
