# 9th Trends in Medical Mycology Held on 11-14 October 2019, Nice, France, Organized under the Auspices of EORTC-IDG and ECMM

Jean-Pierre Gangneux, Olivier Lortholary, Oliver A Cornely, Livio Pagano

► To cite this version:

Jean-Pierre Gangneux, Olivier Lortholary, Oliver A Cornely, Livio Pagano. 9th Trends in Medical Mycology Held on 11-14 October 2019, Nice, France, Organized under the Auspices of EORTC-IDG and ECMM. Journal of Fungi, 2019, 5 (4), pp.E95. 10.3390/jof5040095. hal-02364720

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Conference Report

# 9th Trends in Medical Mycology Held on 11–14 October 2019, Nice, France, Organized under the Auspices of EORTC-IDG and ECMM

Jean-Pierre Gangneux<fnref n="1" />, Olivier Lortholary<fnref n="2" />,<fnref n="3" />, Oliver A. Cornely<fnref n="4" /> and Livio Pagano<fnref n="5" />

Received: 24 September 2019; Accepted: 27 September 2019; Published: 8 October 2019

## Introduction

Dear Friends and Colleagues,

It is a great honor and pleasure for us to invite you cordially to participate in the 9th Congress on Trends in Medical Mycology (TIMM-9), which will be held in 11–14 October 2019 at Nice-Acropolis Convention Center, Nice, France. TIMM-9 is the 9th in the series of TIMM mycological international meetings organized jointly by the European Confederation of Medical Mycology (ECMM) and the Infectious Diseases Group of the European Organisation for Research and Treatment of Cancer (EORTC-IDG).

TIMM has become an important and essential meeting in the field of fungal infections, a forum in which researchers and clinicians from all over the world present the most important advances and research findings in clinical mycology. TIMM-9 will cover all aspects of mycology, with special focus on evidence-based and personalized approach to medical mycology, as well as diagnostic-therapeutic integrative efforts in the quest to improve the present knowledge of epidemiology, diagnosis, clinical course, and pathophysiological mechanisms of fungal diseases. It would be the place to present recent innovations in medical mycology.

The meeting is designed for medical microbiologists, medical mycologists, hematologists, oncologists, transplant physicians, intensivists, immunologists, and all those with interest in medical mycology. We expect TIMM-9 to be at least as successful as previous TIMM Congresses, which brought together around 1000 international delegates from all over the world. Therefore, we would like to invite you to TIMM-9 in Nice to enjoy with us excellent science in a stimulating environment.

We look forward to greeting you in Nice!

Jean-Pierre Gangneux
Olivier Lortholary
Oliver A. Cornely
Livio Pagano

TIMM-9 Executive Committee

<footnote n="1">¹ UMR_S 1085 – Inserm, Institut de Recherche en Santé, Environnement et Travail, CHU de Rennes, Université de Rennes, 35000 Rennes, France; jean-pierre.gangneux@univ-rennes1.fr</footnote>

<footnote n="2">² Necker - Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants malades Hospital, AP-HP, Paris Descartes University, Paris, France</footnote>

<footnote n="3">³ Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses and Antifungals, CNRS UMR 2000, Paris, France; olivier.lortholary@aphp.fr</footnote>

<footnote n="4">⁴ Department I of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; oliver.cornely@uk-koeln.de</footnote>

<footnote n="5">⁵ Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy; livio.pagano@unicatt.it</footnote>
# COMMITTEES

## Executive Committee

- Jean-Pierre Gangneux, ECMM, France

- Olivier Lortholary, EORTC, France

- Livio Pagano, EORTC, Italy

- Oliver A. Cornely, ECMM, Germany

## Local Scientific Committee

- Hamdi Akan, EORTC, Turkey

- Valentina Arsić Arsenijević, ECMM, Serbia

- Sharon Chen, ECMM, Australia

- Raoul Herbrecht, EORTC, France

- Martin Hoenigl, ECMM, Austria

- Nikolai Klimko, ECMM, Rusland

- Katrien Lagrou, ECMM, Belgium

- Johan Maertens, EORTC, Belgium

- Jacques F. Meis, ECMM, the Netherlands

- Tony Pagliuca, EORTC, UK

- Zděnek Racil, EORTC, Czech Republic

- Esther Segal, ECMM, Israel

- Don Sheppard, ECMM, Canada

- Paul Verweij, EORTC, the Netherlands

- Thomas Walsh, ECMM, USA

## International Scientific Committee

- Jean-Pierre Gangneux, Rennes

- Olivier Lortholary, Paris

- Alexandre Alanio, Paris

- Jean-Philippe Bouchara, Angers

- Marie-Elizabeth Bougnoux, Paris

- Stephane Bretagne, Paris

- Christophe D'Enfert, Paris

- Jean-Paul Latgé, Paris

- Laurence Millon, Besançon
## CONTENT

Welcome Address 1

Introduction to the Scientific Programme 5

Scientific Programme 6

Honorary Lectures 16

Plenary Sessions 17

Meet the Expert Sessions 29

Symposia 31

Poster Presentations 97
**Introduction to the Scientific Programme**

**Plenary Sessions:**

No session will be held in parallel to these sessions.

*Plenary sessions are indicated by the prefix: PS*

**Symposia:**

Each day, symposia will convene renowned speakers from several continents, who will cover a wide range of recent developments in their fields.

*Symposia are indicated by the prefix: S*

A part of the symposia includes a selected submitted abstract. These abstracts are marked with an asterisk (*).

**Meet the Expert Sessions:**

The audience will actively participate in these small sessions.

*Meet the expert sessions are indicated by the prefix: M*

**Poster Sessions:**

All poster boards are situated on the exhibition floor of the congress centre. The poster exhibition is open to all participants during the entire congress. The numbers on the poster boards correspond with the abstract numbers in this abstract supplement.

All authors of odd poster numbers must be present at their poster on Saturday 12 October, from 11:30 to 12:30. All authors of even poster numbers must be present at their poster on Sunday 13 October, from 11:30 to 12:30.

*All posters are indicated by the prefix: P*
SCIENTIFIC PROGRAMME

FRIDAY 11 OCTOBER 2019

09:00 ECMM Council Meeting

12:25 Welcome Address

12:45–13:45 Plenary Session 1—Tropical
Chairs: Jean-Pierre Gangneux, FECMM, France & Olivier Lortholary, France

12:45 PS1.1 Histoplasmosis
Matthieu Nacher, France

13:15 PS 1.2 Emergomycosis
Nelesh Govender, FECMM, South Africa

13:45–15:15 Parallel Symposia 1–4

Symposium 1 Water Quality (Mis-)Management—An Opportunity for Fungal Contamination
Chairs: João Brandão, Portugal & Esther Segal, FECMM, Israel

13:45 S01.1 Fungal Contaminants in Drinking Water Regulation? A Tale of Ecology, Exposure, Purification, and Clinical Relevance
Monica Novak Babič, Slovenia

14:05 S01.2 Hospital Environment: Water Supply and Containment of Aerosolised Fungal Particles
How Far Must We Go in Times of Antimicrobial Resistance?
Raquel Sabino, FECMM, Portugal

14:25 S01.3 Potential Transmission Pathways of Clinically Relevant Fungi in Indoor Swimming Pool Facilities
Ciska Schets, the Netherlands

14:45 S01.4* Study of Fungal Environmental Contamination in Nests of the Penguin Enclosure of a Large French Animal Zoo Park
Guillaume Desoubeaux, France

14:55 S01.5* Spectrum of Indoor Fungi Isolated from Indoor Environments in Busia—Kenya
Olga Mashedi, Kenya

Symposium 2 Pneumocystis jirovecii, an Airborne Transmissible and Human-Derived Ascomycete Showing Strong Pulmonary Tropism
Chairs: Philippe Hauser, Switzerland & Gilles Nevez, France

13:45 S02.1 Pneumocystis jirovecii: An Obligate Parasite of Human Lungs with Unique Camouflage and Sex Strategies
Philippe Hauser, Switzerland

14:10 S02.2 High-Throughput Methodologies in Molecular Epidemiology of Pneumocystis Jirovecii Olga Matos, Portugal

14:35 S02.3 Airborne Acquisition and Transmission of Pneumocystis jirovecii: An Update
Gilles Nevez, France

15:00 S02.5* Does Pneumocystis jirovecii Infection Aggravate the Prognosis of Invasive Pulmonary Aspergillosis? Data from the RESSIF Network in France (2012–2016)
Florence Robert-Gangneux, France

Symposium 3 Mucormycosis
Chairs: Fanny Lanternier, FECMM, France & Arunaloke Chakrabarti, FECMM, India

13:45 S03.1 Hospital-Related Mucormycosis
Anna Skiada, Greece
14:00 S03.3 The New Treatment of Mucormycosis
Livio Pagano, FECMM, Italy

14:15 S03.4 Clinical Features Associated to Fungal Species
Dea Garcia Hermoso, France

14:30 S03.5 Molecular diagnosis
Laurence Millon, France

14:45 S03.6 Management of Mucormycosis in Low- and Middle-Income Countries
Arunaloke Chakrabarti, FECMM, India

15:00 Discussion

**Symposium 4**
**MSG Symposium (Trial Design in Clinical Mycology: Innovative Approaches)**

Chairs: Peter Pappas, USA & Sharon Chen, FECMM, Australia

13:45 S04.1 Candidiasis
Bart-Jan Kullberg, The Netherlands

14:05 S04.2 Endemic Mycoses
George Thompson, USA

14:25 S04.3 Cryptococcosis
David Boulware, USA

14:45 S04.4 Aspergillosis and other molds
Tom Patterson, USA

15:05 S04.5* The Lung Transplant Community Is Interested in a Clinical Trial to Determine the Optimal Strategy to Prevent Invasive Mold Disease
Ricardo La Hoz, USA

18:30 EDL **E. Drouhet Lecture (ECMM)**

Chair: Martin Hoenigl, FECMM, Austria

How to Convince European institutions that Medical Mycology is a Major Science

Jean-Paul Latgé, France

## SATURDAY 12 OCTOBER 2019

**08:00–08:45 Meet the Expert Sessions**

08:00 M01 Hematology
Malgorzata Mikulska, FECMM, Italy & Alessandro Busca, Italy

08:00 M02 Peadiatrics
Simone Cesaro, Italy & Adillia Warris, FECMM, UK

08:00 M03 Candida in the ICU
Matteo Bassetti, Italy & Jean-François Timsit, France

08:00 M04 Diagnostics/Laboratory
Alida Talento, Ireland & Michaela Lackner, FECMM, Austria

08:00 M05 Tropical
Arunaloke Chakrabarti, FECMM, India & Rita Oladele, FECMM, Nigeria

**09:00–10:00 Plenary Session 2—Highlights on Fungal Biology**

Chairs: Vishukumar Aimananda, France & Don Sheppard, FECMM, Canada

08:50 PS 2.1 Candida
Christophe D'Enfert, France

09:20 PS 2.2 Aspergillus
Agostinho Carvalho, FECMM, Portugal

09:50 PS 2.3* Lineage-Specific Behavioural Differences in Isolates of Candida auris
Andrew Borman, UK
10:30–11:30 **Plenary Session 3—One World One Guideline ECMM MSG-ERC (EFISG) ISHAM Guidelines Initiative**

Chairs: Martin Hoenigl, FECMM, Austria & John Perfect, USA

10:30 PS3.1 Mucormycosis
Oliver Cornely, FECMM, Germany

10:45 PS3.2 Endemic
George Thompson, USA

11:00 PS3.3 Rare Moulds
Martin Hoenigl, FECMM, Austria

11:15 PS3.4 Rare Yeasts
Sharon Chen, FECMM, Australia

11:30–12:30 **Poster Session**

14:15–15:45 **Parallel Symposia 5–9**

**Symposium 5** **Lung Transplantation**

Chairs: Shahid Husain, FECMM, Canada & Paolo Grossi, Italy

14:15 S05.1 Pretransplant Assessment
Blandine Rammaert, France

14:35 S05.2 Pathophysiology and Epidemiology of Invasive Aspergillosis in Lung Transplant Recipients
Claire Aguilar, France

14:55 S05.3 Current Guidelines
Shahid Husain, FECMM, Canada

15:15 S05.4 Prophylaxis
John Perfect, USA

15:35 S05.5* From the Lung to the Heart: Fatal Dissemination of Azole-Resistant Aspergillus Fumigatus in a Lung Transplant Patient
Rose-Anne Lavergne, France

**Symposium 6** **Prophylaxis during Hematology Malignancies**

Chairs: Livio Pagano, FEMCC, Italy & Oliver Cornely, FECMM, Germany

14:15 S06.1 AML—in the Era of FLT3 Inhibitors
Russel Lewis, Italy

14:35 S06.2 ALL—There Is a Role for Prophylaxis
Daniel Teschner, Germany

14:55 S06.3 Personalized Medicine/Approach by Genetic Risk Factors
Pierre-Yves Bochud, Switzerland

15:15 S06.4 Baseline CT upon Diagnosis of Acute Leukemia
Stefan Schwartz, Germany

15:35 S06.5* Investigating the Impact of Posaconazole Prophylaxis on Systematic Fungal Screening Using Galactomannan Antigen, Aspergillus qPCR and Mucorales qPCR
Anne-Pauline Bellanger, France

**Symposium 7** **Paediatric Mycology (EPMYN)**

Chairs: Emmanuel Roilides, FECMM, Greece & Roger Brüggemann, FECMM, The Netherlands

14:15 S07.1 Fluconazole and Micafungin Dosing in Neonates
Roger Brüggemann, The Netherlands

14:35 S07.2 Antifungal Susceptibility of Pediatric Candidemia
Zoi-Dorothea Pana, Greece

14:55 S07.3 Primary Immunodeficiencies Characterized by Fungal Infections
Fanny Lanternier, FECMM, France

15:25 S07.5* Isavuconazole use in pediatric hematoncologic patients: the Italian
Association of Pediatric Hematology Oncology (AIEOP) experience
Nunzia Decembrino, Italy

**Symposium 8**
**Immunologic Markers for Diagnosis and Treatment Stratification in Invasive Mold Infection**

Chairs: Martin Hoenigl, FECMM, Austria & Agostinho Carvalho, FECMM, Portugal

14:15 S08.1 Antimold Immune Response: the Impact of the Host, the Pathogen, and Translational Implications
Agostinho Carvalho, FECMM, Portugal

14:35 S08.2 Immunologic Markers for Diagnosis of Invasive Aspergillosis and Other Invasive Mold Infections
Carol Garcia-Vidal, Spain

14:55 S08.3 Immunologic Markers For Treatment Stratification in Invasive Mold Infection
Philipp Köhler, FECMM, Germany

15:15 S08.4 Fungal Translocation: From Persistent Inflammation to Non-AIDS Events
Martin Hoenigl, FECMM, Austria

15:35 S08.5* Immunological Characteristics of Broncho Alveolar Lavage in Neutropenic Patients with Invasive Aspergillosis
Claire Aguilar, France

**Symposium 9**
**Chronic Pulmonary Aspergillosis**

Chairs: David Denning, FECMM, United Kingdom & Aleksandra Barac, FECMM, Serbia

14:15 S09.1 Effect of Patient Immunodeficiencies on the Diagnostic Performance of Serological Assays to Detect Aspergillus-Specific Antibodies in Chronic Pulmonary Aspergillosis
Elizabeth Hunter, UK

14:35 S09.2 Diagnosis of CPA. Where Do We Stand?
Aleksandra Barac, FECMM, Serbia

14:55 S09.3 Current Treatment Options for CPA
David Denning, FECMM, UK

15:15 S09.4 Future Directions
David Denning, FECMM, UK

15:25 S09.5* Raised Amphotericin B MIC in Aspergillus fumigatus Isolates from Patients with Chronic Pulmonary Aspergillosis
Fiona Lynch, UK

**16:15–17:45** **Parallel Symposia 10–14**

**Symposium 10**
**Sensing the Host**

Chairs: Muriel Cornet, France & Mihai Mares, FECMM, Romania

16:15 S10.1 S10.1 Cell wall of Aspergillus fumigatus in murine lung tissue
Thierry Fontaine, France

16:45 S10.2 Hybrid Histidine Kinases: Major Sensing Proteins in Pathogenic Fungi
Nicolas Papon, France

17:15 S10.3 Adapting to the Host: How Candida Causes Bloodstream Infection
Oliver Kurzai, Germany

**Symposium 11**
**The Antifungal Pipeline**

Chairs: David Denning, FECMM, United Kingdom & Oliver Cornely, FECMM, Germany

16:15 S11.1 Olorofim—A Novel Mould-Active Antifungal (F2G)
John Rex, FECMM, UK

16:40 S11.2 Fosmanogepix: A Novel, Broad Spectrum Antifungal Therapy in Clinical
Development (Amplyx)

Michael Hodges, USA

17:05 S11.3 Ibrexafungerp (formerly SCY-078) (Scynexis)
David Angulo, USA

**Symposium 12 Environment and Fungal Outbreaks**

Chairs: Jean-Pierre Gangneux, FECMM, France & Tom Chiller, USA

16:15 S12.1 Frogs
Matthew Fisher, UK

16:35 S12.2 Cryptococcus gattii
Ferry Hagen, FECMM, The Netherlands

16:55 S12.3 Natural Disasters
Tom Chiller, US

17:15 S12.4 Genomic Sequencing
Marie Desnos, France

17:35 S12.5* Outbreak of Fluconazole-Resistant Candida Parapsilosis in a Hospital Ward:
Arguments for Clonal Transmission and Environmental Persistence
Arnaud Fekkar, France

**Symposium 13 Fungal Respiratory Infections in Cystic Fibrosis (the ECMM/ISHAM Working Group Fri-CF)**

Chairs: Jean-Philippe Bouchara, France & Petr Hamal, Czech Republic

16:15 S13.1 Rasamsonia Species and Other Emerging Fungi in CF
Solène Le Gal, France

16:35 S13.2 Immunodiagnosis of Scedosporium/Lomentospora Infection—Lessons from Immunoproteomic Studies
Andoni Ramirez-Garcia, Spain

16:55 S13.3 Bacterial/Fungal Interactions in the CF Mucus
Françoise Botterel, France

17:15 S13.4* Morphology, Growth, and Biofilm Formation of the Black Yeast-Like Fungus Exophiala dermatitidis is Influenced by Pseudomonas aeruginosa under in Vitro Cystic Fibrosis Conditions
Lisa Kirchhoff, Germany

17:25 S13.6* Study of Antigenic Markers for Serological Detection of Scedosporium spp. in Cystic Fibrosis Patients
Leire Martin-Souto, Spain

17:35 Discussion

**Symposium 14 Teaching Medical Mycology: What, How, to Whom and When**

Chairs: Patricia Muñoz, Spain & Esther Segal, FECMM, Israel

16:15 S14.1 Mycology Teaching in Medical School—How Much, What to Choose, at What Level
Peter Rath, FECMM, Germany

16:35 S14.2 Mycology Teaching in Medical School—Is Student Demography Important to What Should Be Taught?
Ester Segal, FECMM, Israel

16:55 S14.3 Specific Courses Outside the European Continent—The Indian Example
Ruth Ashbee, United Kingdom

17:15 S14.4 Teaching Clinical Laboratory Mycology—How and Who Is the Audience?
Sevtap Arikan-Akdagli, FECMM, Turkey

17:35 S14.5 The African Example
Aude Sturny, France
SUNDAY 13 OCTOBER 2019

**08:00–08:45 Meet the Expert Sessions 6–10**

08:00 M06 Hematology—hematopoietic stem cell transplantation
Nikolai Klimko, FECMM, Russia & Tony Pagliuca, UK

08:00 M07 Molecular Diagnostics
Maurizio Sanguinetti, Italy & Dieter Buchheidt, FECMM, Germany

08:00 M08 Surgery/Transplantation
Patricia Munoz, Spain & Paolo Grossi, Italy

08:00 M09 Neonates
Thomas Walsh, FECMM, USA & Emmanuel Roilides, FECMM, Greece

08:00 M10 Meet Mr. and Mrs. Fungus
Cornelia Lass-Flörl, FECMM, Austria & Neil Gow, FECMM, UK

**08:50–09:50 Plenary Session 4—Top 10 papers in Mycology**

Chairs: Maiken Arendrup, Denmark & Malcolm Richardson, FECMM, UK

08:50 PS4.1 The Clinical and Translational Perspective
Don Sheppard, FECMM, Canada

09:20 PS4.2 The Microbiology Perspective
Katrien Lagrou, FECMM, Belgium
**ECMM Academy and Excellence Centers: A Story of Success**

Chair: Martin Hoenigl, FECMM, Austria

09:50 ECMM Academy
Katrien Lagrou, FECMM, Belgium

09:55 ECMM Excellence Centers
Cornelia Lass-Flörl, FECMM, Austria

**10:30–11:30 Plenary Session 5—ICU—Candida Infections/Breaking News from Hematology and ICU**

Chairs: Johan Maertens, FECMM, Belgium / Maricela Valerio, Spain

10:30 PS5.1 Abdominal Candidiasis in ICU Patients
Philipp Köhler, FECMM, Germany

10:45 PS5.2 Are the New Management Strategies Useful?
Arnaldo Colombo, FECMM, Brazil

11:00 PS5.3 CNS Infections
Anna Candoni, Italy

11:15 PS5.4 CMV and Aspergillosis in HSCT Patients
Johan Maertens, FECMM, Belgium

**11:30–12:30 Poster Session 2**

**11:30 Video Session**

11:30 V01 Subcutaneous Nodule Caused by Phaeoacremonium fuscum in a Non-Immunocompromised Patient
Sofie Colman, Belgium

11:40 V02 Trichosporon Diagnosis—The Right Path
Thayanidhi Premamalini, India

11:50 V03 Disseminated Rhinosporidiosis with Different Morphological Lesions
Involving Various Anatomical Sites
Jagdish Chander, India

**14:15–15:45 Parallel Symposia 15–19**

**Symposium 15 Aspergillus in the ICU**

Chairs: Katrien Lagrou, FECMM, Belgium & Alessandro Pasqualotto, FECMM, Brazil

14:15 S15.1 Influenza
<table>
  <tbody>
    <tr>
      <td>14:35</td>
      <td>S15.2</td>
      <td>Invasive Aspergillosis in Patients with Underlying Liver Cirrhosis<br/>Juergen Prattes, Austria</td>
    </tr>
    <tr>
      <td>14:55</td>
      <td>S15.3</td>
      <td>Renal Failure<br/>Riina Richardson Rautema, FECMM, UK</td>
    </tr>
    <tr>
      <td>15:15</td>
      <td>S15.4*</td>
      <td>Fungal Pneumonia in Critically Ill Cirrhotics: Spectrum, Outcomes, Comparison of Diagnostic Methods and Biomarkers<br/>Pratibha Kale, India</td>
    </tr>
    <tr>
      <td>15:25</td>
      <td>S15.5*</td>
      <td>IPAFLU Survey: Invasive Aspergillosis among Patients with Severe Influenza in Intensive Care Units<br/>Joost Wauters, Belgium</td>
    </tr>
    <tr>
      <td>15:35<br/>from</td>
      <td>S15.6*</td>
      <td>Trend of Candidemia with Bloodstream Infection in Intensive Care Units<br/>2006 to 2017: Results from the Korean National Healthcare-Associated Infections Surveillance System<br/>Young Hwa Choi, Korea</td>
    </tr>
    <tr>
      <td colspan="3"><strong>Symposium 16 Dermatology</strong></td>
    </tr>
    <tr>
      <td>14:15</td>
      <td>S16.1</td>
      <td>Cutaneous Aspergillosis, Is It So Rare?<br/>Sevtap Arıkan Akdagli, FECMM, Turkey</td>
    </tr>
    <tr>
      <td>14:35</td>
      <td>S16.2</td>
      <td>Is Resistance a Problem for Dermatophytosis?<br/>Pietro Nenoff, Germany</td>
    </tr>
    <tr>
      <td>14:55</td>
      <td>S16.3</td>
      <td>Phaeohyphomycosis<br/>Teresa Martin, Spain</td>
    </tr>
    <tr>
      <td>15:15</td>
      <td>S16.4</td>
      <td>Blastomycosis<br/>Ilan Schwarz, Canada</td>
    </tr>
    <tr>
      <td>15:35</td>
      <td>S16.5*</td>
      <td>Galleria mellonella as a Novelty Model to Study Host—Pathogen Interaction in Malassezia furfur CBS 1878<br/>Adriana Marcela Celis Ramirez, Colombia</td>
    </tr>
    <tr>
      <td colspan="3"><strong>Symposium 17 HIV-Associated Cryptococcal Meningitis</strong></td>
    </tr>
    <tr>
      <td>14:15</td>
      <td>S17.1</td>
      <td>Screening in Low-Resource Areas<br/>Elvis Temfack, Cameroon</td>
    </tr>
    <tr>
      <td>14:35</td>
      <td>S17.2</td>
      <td>Current Therapeutic Strategies<br/>Olivier Lortholary, France</td>
    </tr>
    <tr>
      <td>14:55</td>
      <td>S17.3</td>
      <td>Towards Having Antifungal Drugs in Low-Resource Areas<br/>Ida Kolte, UK</td>
    </tr>
    <tr>
      <td>15:15</td>
      <td>S17.4</td>
      <td>Early versus Delayed Antiretroviral Treatment in HIV-Positive People with Cryptococcal Meningitis<br/>Tihana Bicanic, FECMM, UK</td>
    </tr>
    <tr>
      <td>15:35</td>
      <td>S17.5</td>
      <td>Current and Future Clinical Trials on HIV-Associated Cryptococcal Meningitis<br/>Tom Harrison, UK</td>
    </tr>
    <tr>
      <td colspan="3"><strong>Symposium 18 Antifungal Stewardship in the Era of Resistance</strong></td>
    </tr>
    <tr>
      <td>14:15</td>
      <td>S18.1</td>
      <td>Antifungal Stewardship: A Practical Experience in a Tertiary Care Institution<br/>Maricela Valerio, Spain</td>
    </tr>
    <tr>
      <td>14:35</td>
      <td>S18.2</td>
      <td>Stewardship and Azole-Resistant Aspergillosis: A Challenge for Farmer or Physician?<br/>Paul Verweij, FECMM, The Netherlands</td>
    </tr>
    <tr>
      <td>14:55</td>
      <td>S18.3</td>
      <td>Rapid Diagnosis of Fungal Infections: Impact on Stewardship</td>
    </tr>
  </tbody>
</table>
Souha Kanj, FECMM, Lebanon

15:15 S18.4 Mycology Laboratory Diagnostic Capabilities in Different Areas of the World
Alessandro Pasqualotto, FECMM, Brazil

15:35 S18.5* Optimising Antifungal Stewardship: An Evaluation of Candidaemia Guideline Compliance and Clinical Outcome
Laura Cottom, UK

**Symposium 19** **Pneumocystis**

Chairs: Enrique Calderon, Spain & Stephane Bretagne, FECMM, France

14:15 S19.1 Diagnosis
Alexandre Alanio, FECMM, France

14:40 S19.2 Pneumocystosis in HIV and Non-HIV Patients
Joseph Kovacs, USA

15:05 S19.4 Pneumocystosis in Neonates
Enrique Calderon, Spain

15:30 S19.5* Evaluation of a Novel Commercial Loop-Mediated Isothermal Amplification (LAMP) Assay for Rapid Detection of Pneumocystis jirovecii
Dirk Schmidt, Germany

**16:15–17:45 Parallel Symposia 20–24**

**Symposium 20 Candida auris**

Chairs: Nelesh Govender, FECMM, South Africa & Anuradha Chowdhary, FECMM, India

16:15 S20.1 Schizophrenic Gram-Negative Yeast Conquering the World
Jacques Meis, FECMM, The Netherlands

16:35 S20.2 In the US
Tom Chiller, USA

16:55 S20.3 Outbreak Control
Alba Ruiz, Spain

17:15 S20.4 In Resource-Limited Countries
Anuradha Chowdhary, FECMM, India

17:35 S20.5* Understanding Echinocandin Activity towards Candida auris
Milena Kordalewska, USA

**Symposium 21 Immunotherapy for Opportunistic Fungal Infections**

Chairs: Carol Garcia-Vidal, Spain & Dimitrios Kontoyiannis, FECMM, USA

16:15 S21.1 CAR-T Cells, NK Cells
Dimitrios Kontoyiannis, FECMM, USA

16:35 S21.2 WBC Transfusions
Livio Pagano, FECMM, Italy

16:55 S21.3 Cytokines
George Chamilos, Greece

17:15 S21.4* Novel Chimeric Antigen Receptor T Cells for Invasive Aspergillosis Immunotherapy
Michelle Seif, Germany

17:25 S21.5* Comparison Of Circulating Lymphocyte Populations CD4+ and CD8+ T Cells, B and NK lymphocytes According to the Favorable or Worsening Evolution of Patients with Pneumocystosis
Eléna Charpentier, France

17:35 S21.6* Glucosylceramides from Lomentospora prolificans Induce Cytokines Production and Increase the Microbicidal Activity of Macrophages
Mariana Ingrid Dutra Silva Xisto, Brazil

**Symposium 22 NGS and Mycobiota**
<table><tbody><tr><td></td><td></td><td>Chairs: Laurence Delhaes, France & Jean-Pierre Gangneux, FECMM, France</td></tr><tr><td>16:15</td><td>S22.1</td><td>Bacterial-Fungal Interactions at the Airway Mucosa and Implications for Chronic Rhinosinusitis<br>Emily Cope, USA</td></tr><tr><td>16:35</td><td>S22.2</td><td>Respiratory Mycobiome-A Clinical Perspective<br>Robert Krause, FECMM, Austria</td></tr><tr><td>16:55</td><td>S22.3</td><td>Characterization of Indoor Dust Microbiota in Homes of Asthma and Non-Asthma Patients<br>Jean-Pierre Gangneux, FECMM, France</td></tr><tr><td>17:15</td><td>S22.4</td><td>Understanding the Role of the Gut Mycobiome in Health and Disease<br>Maria Vehreschild, FECMM, Germany</td></tr><tr><td>17:35</td><td>S22.5*</td><td>An ECMM-ESCMID Survey on Goals and Practices for Mycobiota<br>Characterization Using Next-Generation Sequencing in European Laboratories<br>Jean-Pierre Gangneux, FECMM, France</td></tr></tbody></table>

<table><tbody><tr><td></td><td></td><td><strong>Symposium 23</strong><br><strong>The Funny Life of C. albicans in the Oral Tract</strong><br>Chairs: Marie-Elisabeth Bougnoux, France & Anna Maria Tortorano, Italy</td></tr><tr><td>16:15</td><td>S23.1</td><td>Within-Host Genomic Diversity of Candida albicans in Healthy Carriers<br>Marie-Elisabeth Bougnoux, France</td></tr><tr><td>16:35</td><td>S23.2</td><td>Activation of Oral Immune Responses by C. albicans<br>Julian Naglik, UK</td></tr><tr><td>16:55</td><td>S23.3</td><td>Modulation of the Fungal-Host Interaction by the Intraspecies Diversity of C. albicans<br>Dominique Sanglard, Switzerland</td></tr><tr><td>17:15</td><td>S23.4</td><td>Intestinal Th17 Drives Airway Inflammation in ABPA<br>Petra Bacher, Germany</td></tr><tr><td>17:35</td><td>S23.5*</td><td>Persistence of Clonal Azole-Resistant Isolates of Candida albicans from a Patient<br>with Chronic Mucocutaneous Candidiasis in Colombia<br>Andres Ceballos-Garzon, Colombia</td></tr></tbody></table>

<table><tbody><tr><td></td><td></td><td><strong>Symposium 24</strong><br><strong>Fungal Neglected Tropical Diseases</strong><br>Chairs: Flavio Queiroz-Telles, Brazil & Leila Lopes Bezerra, Brazil</td></tr><tr><td>16:15</td><td>S24.1</td><td>Mycetoma<br>Wendy van de Sande, FECMM, The Netherlands</td></tr><tr><td>16:35</td><td>S24.2</td><td>Chromoblastomycosis<br>Flavio de Queiroz-Telles, FECMM, Brazil</td></tr><tr><td>16:55</td><td>S24.3</td><td>Sporotrichosis<br>Leila Lopes Bezerra, Brazil</td></tr><tr><td>17:15</td><td>S24.4</td><td>Novel Diagnostic and Treatment Strategies for the Southeast Asian Fungus<br>Talaromyces marneffei<br>Thuy Le, USA</td></tr><tr><td>17:25</td><td></td><td>Discussion</td></tr></tbody></table>

## MONDAY 14 OCTOBER 2019

### 08:00–8:45 Meet the Expert Sessions 11–15

<table><tbody><tr><td>08:00</td><td>M11</td><td>HIV<br>Blandine Denis, France & Nelesh Govender (FECMM), South Africa</td></tr><tr><td>08:00</td><td>M12</td><td>Environment<br>Ester Segal, FECMM, Israel & Raquel Sabino, FECMM, Portugal</td></tr><tr><td>08:00</td><td>M13</td><td>Diagnostics/Imaging<br>Frédéric Lamoth, FECMM, France & Christopher Thornton, UK</td></tr></tbody></table>
08:00 M14 Resistance
Maiken Arendrup, Denmark & Lewis White, FECMM, UK

08:00 M15 Registries
Danila Seidel, Germany & Oscar Marchetti, Switzerland

08:50–10:00 **Plenary Session 6—Management of IFD in Pediatrics (EPMYN)**
Chairs: Adilia Warris, FECMM, United Kingdom & Andreas Groll, FECMM, Germany

08:50 PS6.1 Biomarker-Based Diagnostic Work-Up of IFD in Immunocompromised Pediatric Patients
Thomas Lehrnbecher, Germany

09:20 PS6.2 Pre-Emptive Versus Empiric Antifungal Therapy in Children with Cancer
Maria Elena Santolaya, Chile

09:50 PS6.3* Invasive Mucormycosis in Children with Hematological Malignancies and Solid Tumors: Report from the Infection Working Group of the Hellenic Society of Pediatric Hematology Oncology (2008–2017).
Emmanuel Roilides, Greece

10:30–11:15 **Plenary Session 7—Superficial and Dermatology**
Chairs: Arnaldo Colombo, FECMM, Brazil & Yee-Chun Chen, Taiwan, Province of China

10:30 PS7.1 When the Skin Is the Portal of Invasive Infections
Yee-Chun Chen, Taiwan, Province of China

11:00 PS7.2 When the Skin Talks for Systemic Infections
Fanny Lanternier, FECMM, France

11:15–12:30 **Plenary Session 8—New (Antineoplastic) Drugs, New Risks**
Chairs: Livio Pagano, FECMM, Italy & Johan Maertens, FECMM Belgium

11:30 PS8.1 In Hematology
Alessandro Busca, Italy

12:00 PS8.2 In Oncology
Lubos Drgona, FECMM, Slovakia

12:30 **Closing TIMM-9**
# Honorary Lectures

## E. Drouhet lecture

### EDL

### How to convince European institutions that Medical Mycology is a major science

J.-P. Latgé

*University of Crete, Heraklion, Greece*

How to convince Europe that Medical Mycology is a major science

Biochemistry; Molecular biology; Immunology

There are many reasons for flying the flag of Medical Mycology in medicine but also in science in Europe. First, morbidity and mortality due to fungi is much higher than the one due to tuberculosis and malaria in Europe. Second, essential advances in immunology such as TLR or C-type lectins, had their root in the analysis of the host response against fungal infections. Fungi continue to be models of choice for deciphering new immunological pathways. Cell wall which is a unique feature of these eukaryotic microorganisms, has been instrumental on this medical theme but also on the finding of new essential enzymes in glycobiology. Third, Mycobiota is a majority underrecognized and understudied component of the microbiota which is more and more recognized as an important constituent of human health. Fourth, analysis of fungal biochemical and molecular pathways can help understanding human diseases or metabolic dysregulations or stem cell dormancy. Finally, more than other microbes, fungi have to be loved for their natural beauty. All these cases will be illustrated with examples taken from the study of Aspergillus fumigatus which has been my "baby" for the last 30 years.

Ranking of importance: Medicine, Lobbying or Science? The three for sure.

## Plenary session 1—Tropical

### PS1.2

### Emergomycosis

N. Govender

National Institute for Communicable Diseases, Johannesburg, South Africa

Five species of thermally-dimorphic fungi within a new genus *Emergomyces* cause a disseminated mycosis among immunocompromised persons. Distinct from the closely-related *Emmonsia* and *Blastomyces* genera, *Emergomyces* strains have only been isolated from human infections and all species produce yeast cells (usually <5 µm diameter and with narrow-based budding) in the thermotolerant phase. The type species, *Emergomyces pasteurianus* was first described from a case in 1992 and has an apparently cosmopolitan distribution with cases diagnosed in Europe, Africa and Asia. The other four species were described to have emerged over the last decade, coinciding with increasing use of molecular diagnostic techniques in clinical and research laboratories, and may be geographically restricted. Overall, *Emergomyces africanus* has been implicated in the largest number of reported cases of emergomycosis. Restricted to southern Africa and first described by Kenyon et al in 2013, *E. africanus* causes a multi-system disease among persons living with advanced HIV disease. Systemic infection is presumed to occur following inhalation of air-borne conidia from a soil reservoir, with a subsequent temperature-mediated phase transition to a yeast form and dissemination through the reticuloendothelial system among immunocompromised individuals.

Most cases are diagnosed by conventional culture of blood, tissues and fluids and/or histopathological tissue examination, both of which require technical expertise. Limited pulmonary disease is probably under-diagnosed in resource-limited settings; this has only been described to occur in the single case of *Emergomyces europaeus* infection. The full spectrum of clinical infection and prevalence in different populations could potentially be determined by better use of non-culture-based methods, including antigen and PCR assays, in clinical settings and for epidemiological surveillance. For instance, *E. africanus* is known to cross-react with a commercially-available *Histoplasma* galactomannan antigen assay and *Emergomyces canadensis* with a commercial DNA probe for *Blastomyces dermatitidis*. Although the attributable mortality has not been defined, the crude mortality in a South African case series was approximately 50%. Screening for emergomycosis among high-risk patients in endemic areas could detect active disease earlier and thus reduce mortality
associated with late presentation. Treatment recommendations for emergomycosis are the same as for patients with disseminated histoplasmosis and are based only on observational data.

# Plenary session 2—Highlights on fungal biology

## PS2.1

### Candida albicans genome diversity: mechanisms and consequences

C. D'Enfert

Fungal Biology and Pathogenicity, Institut Pasteur, INRA, Paris, France

The fungal pathogen *Candida albicans* shows significant diversity at the genetic and phenotypic levels. Here, I will review our current knowledge of the *C. albicans* diploid genome and its variability, the genetic structure of the *C. albicans* population and the mechanisms that are involved in *C. albicans* genome dynamics, with a focus on the parasexual cycle and loss-of-heterozygosity events. I will further explore the impact of genetic diversity and genome dynamics on *C. albicans* phenotypic diversity. Finally, I will discuss how our current knowledge of *C. albicans* genetic diversity could be leveraged in the future in order to get insights in the mechanisms underlying important biological attributes that are subject to variations across *C. albicans* isolates.

## PS2.2

### Metabolic regulation of innate immunity to Aspergillus fumigatus

S. Gonçalves, C. Cunha, A. Carvalho

Life and Health Sciences Research Institute (icvs), University of Minho, Braga, Portugal

The reprogramming of cellular metabolism was recently recognized as a fundamental mechanism through which innate immune cells meet the energetic and anabolic needs during host defense against invading pathogens. Sensing of microbial ligands by macrophages drives the upregulation of glycolysis, which delivers a rapid source of energy to support antimicrobial functions and the production of cytokines and other inflammatory mediators. The stimulation of immune cells with structural components of the fungal cell wall, such as β-1,3-glucan, has been demonstrated to promote the metabolic and functional reprogramming of immune cells during infection with the yeast *Candida albicans*. However, how the immune response to other fungi, such as *Aspergillus fumigatus*, is also regulated at the metabolic level and whether other cell wall constituents also participate in these signaling events remains unknown. Fungal melanin is a major virulence factor, endowing *A. fumigatus* with the ability to survive killing by phagocytes. By resorting to in vitro and in vivo models of infection and patients suffering from invasive pulmonary aspergillosis (IPA), and using different pharmacological and genetic tools to manipulate both the host and the pathogen, we reveal a novel mechanism whereby fungal melanin is perceived by the host to regulate adequate immunometabolic responses and susceptibility to infection. Specifically, we demonstrate that the host counters the immune inhibitory mechanisms deployed by fungal melanin, by "sensing" its removal during intracellular swelling inside the phagosome, and using these signals to rewire cellular metabolism towards enhanced glycolysis and promote antifungal immune responses. The contribution of glucose homeostasis to human antifungal immunity is further supported by genetic variation in glycolytic regulators that act as cytokine quantitative trait loci and predispose patients at-risk to IPA. Given the current limitations in diagnosis and therapy of fungal diseases as well as concerns over the emergence of antifungal resistance, these results may contribute towards the design of innovative therapeutic approaches or metabolic adjuncts to reorient host cells towards immune protection against IPA.

## PS2.3

### Lineage-specific behavioural differences in isolates of Candida auris

A. Borman<fnref n="1" />, A. Szekely<fnref n="1" />, L. Majoros<fnref n="2" />, S. Lockhart³, G.S. De Hoog⁴, R. Ben-Ami⁵, E. Johnson<fnref n="1" />

<footnote n="1">¹Public Health England UK National Mycology Reference Laboratory, Bristol, United Kingdom,</footnote>

<footnote n="2">²Department Of Medical Microbiology, University of Debrecen, Debrecen, Hungary, ³Centres For</footnote>
Disease Control and Prevention, Atlanta, United States of America, ⁴Westerdijk Institute, Utrecht, Netherlands, ⁵Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel

**Objectives:** *Candida auris* is a serious nosocomial health risk, with widespread outbreaks in hospitals worldwide. Sequence analyses of outbreak isolates revealed that *C. auris* has simultaneously emerged as multiple distinct, geographically restricted clonal lineages. We previously reported multiple independent introductions of *C. auris* isolates from at least three of these lineages (S. Asia, S. Africa and Japan/Korea) into hospitals across the UK, and that isolates circulating in the UK displayed two different cell phenotypes which correlated with differences in virulence in *Galleria mellonella*. The present study aimed to more fully characterise clade-specific differences in the behaviour of *Candida auris* isolates. **Methods:** Multiple independent *Candida auris* isolates corresponding to 4 of the known geographically-restricted clonal lineages (S. Asia, S. Africa, S. America/Israeli and Japanese/Korean) were subjected to extensive phenotypic characterisation (cellular morphology, actidione tolerance, virulence in insect [*Galleria mellonella*] and mammalian [mouse] infection models, antifungal susceptibility profiles, antifungal drug-mediated morphological changes) using well-established methodologies. **Results:** Significant clade-dependent differences in *C. auris* isolate behaviour were noted with respect to all of the biological features examined, including cellular morphology, resistance to actidione, virulence, antifungal susceptibility and morphological responses to antifungal drug exposure. Several of these differences may be correlated with previously described differences in cellular aggregation capacity, ERG11 resistance mutations and gene copy numbers, biofilm formation and efflux pump activity. **Conclusion:** The present data demonstrate that "one size does not fit all for *Candida auris*" and that the behaviour of individual isolates is at least in part dependent on the clonal lineages from which they originate. Further studies will aim to elucidate whether such differences have clinical significance, and to attempt to establish why isolates of three of the principal clonal lineages (S. Asian, S. African, S. American/Israeli) have been reported from large scale nosocomial outbreaks but none to date have been attributed to isolates from the Japanese/Korean clade.

# Plenary session 3—One World One Guideline ECMM MSG-ERC (EFISG) ISHAM Guidelines initiative

## PS3.1

**Global guideline for the diagnosis and management of mucormycosis: An initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium**

O.A. Cornely¹,²,³,⁴, A. Alastruey-Izquierdo⁵, D. Arenz¹,³, S.C.-A. Chen⁶, E. Dannaoui⁷, B. Hochhegger⁸,⁹, M. Hoenigl¹⁰,¹¹, H.E. Jensen¹², K. Lagrou¹³, R. Lewis¹⁴, S. Mellinghoff¹³, M. Mer¹⁵, Z. Pana¹⁶, D. Seidel¹,³, D.C. Sheppard¹⁷, R. Whaba¹⁸, A. Chakrabarti¹⁹, M. Akova²⁰, A. Alanio²¹, A. Al-Hatmi²², S. Arikan-Akdagli²³, H. Badali²⁴, R. Ben-Ami²⁵, A. Bonifaz²⁶, S. Bretagne²¹, E. Castagnola²⁷, M. Chayakulkeeree²⁸, A. Colombo²⁹, D.E. Corzo-León³⁰, L. Drgona³¹, A.H. Groll³², J. Guinea³³, C.-P. Heussel³⁴, A.S. Ibrahim³⁵, S. Kanj³⁶, N. Klimko³⁷, M. Lackner³⁸, F. Lamothe³⁹, F. Lanternier⁴⁰, C. Lass-Flörl³⁸, D.-G. Lee⁴¹, T. Lehrnbecher⁴², B.E. Lmimouni⁴³, M. Mares⁴⁴, G. Maschmeyer⁴⁵, J. Meis⁴⁶, J. Meletiadis⁴⁷, O. Morrissey⁴⁸, M. Nucci⁴⁹, R. Oladele⁵⁰, L. Pagano⁵¹, A. Pasqualotto⁵², A. Patel⁵³, Z. Racil⁵⁴, M.D. Richardson⁵⁵, E. Roilides⁶, M. Ruhnke⁵⁶, S. Seyedmousavi²⁴,⁵⁷,⁵⁸, N. Sidharthan⁵⁹, N. Singh⁶⁰, J. Sinko⁶¹, A. Skiada⁶², M. Slavin⁶³,⁶⁴, R. Soman⁶⁵, B. Spellberg⁶⁶, W. Steinbach⁶⁷, B.H. Tan⁶⁸, A.J. Ullmann⁶⁹, J.-J. Vehreschild¹,², M.J.G.T. Vehreschild¹,²,⁷⁰, T. Walsh⁷¹, P.L. White⁷², N. Wiederhold⁷³, T. Zaoutis⁷⁴

¹Department I Of Internal Medicine, University Hospital of Cologne, Cologne, Germany, ²German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany, ³Cecad Cluster Of Excellence, University of Cologne, Cologne, Germany, ⁴Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany, ⁵Mycology Reference Laboratory, National Centre For Microbiology, Instituto de Salud Carlos III, Madrid, Spain, ⁶Centre For Infectious Diseases And Microbiology Laboratory Services, New South Wales Health Pathology, And The Department Of Infectious Diseases, Westmead Hospital, School of Medicine, University of Sydney, Sydney,
Australia, ⁷Unité De Parasitologie-mycologie, Service De Microbiologie, Université Paris-Descartes, Faculté de Médecine, APHP, Hôpital Européen Georges Pompidou, Paris, France, ⁸Radiology, Hospital São Lucas da Pontifícia Universidade Catolica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil, ⁹Radiology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil, ¹⁰Section Of Infectious Diseases And Tropical Medicine And Division Of Pulmonology, Medical University of Graz, Graz, Austria, ¹¹Division Of Infectious Diseases, Department Of Medicine, University of California San Diego, San Diego, United States of America, ¹²Faculty Of Health And Medical Sciences, University of Copenhagen, Copenhagen, Denmark, ¹³Department Of Microbiology, Immunology And Transplantation, Clinical Department Of Laboratory Medicine And National Reference Center For Mycosis, KU Leuven, University Hospitals Leuven, Leuven, Belgium, ¹⁴Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy, ¹⁵Divisions Of Critical Care And Pulmonology, Department Of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, ¹⁶Infectious Diseases Unit, 3rd Department Of Paediatrics, Faculty Of Medicine, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece, ¹⁷Division Of Infectious Diseases, Department Of Medicine, Microbiology And Immunology, McGill University, Montreal, Canada, ¹⁸Department Of General, Visceral And Cancer Surgery, University Hospital of Cologne, Cologne, Germany, ¹⁹Department Of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India, ²⁰Department Of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey, ²¹Institut Pasteur, National Reference Center For Invasive Mycoses And Antifungals, Department Of Mycology, Cnrs Umr2000, Parasitology-mycology Laboratory, Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France, ²²Directorate General Of Health Services, Ministry of Health, Icri, Oman, ²³Department Of Medical Microbiology, Hacettepe University School of Medicine, Ankara, Turkey, ²⁴Department Of Medical Mycology/invasive Fungi Research Center (ifrc), School Of Medicine, Mazandaran University of Medical Sciences, Sari, Iran, ²⁵Infectious Diseases Unit, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, ²⁶Dermatology Service & Mycology Department, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico, ²⁷Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genova, Italy, ²⁸Department Of Medicine, Faculty Of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, ²⁹Special Mycology Laboratory, Division Of Infectious Diseases, Department Of Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil, ³⁰Department Of Epidemiology And Infectious Diseases, Hospital General Dr. Manuel Gea González, Mexico City, Mexico, ³¹Oncohematology Clinic, Faculty Of Medicine, Comenius University and National Cancer Institute, Bratislava, Slovak Republic, ³²Infectious Disease Research Program, Department Of Paediatric Hematology/oncology And Center For Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany, ³³Clinical Microbiology And Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain, ³⁴Diagnostic And Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany, ³⁵Division Of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-University of California, Torrance, United States of America, ³⁶Department Of Internal Medicine, Division Of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon, ³⁷Department Of Clinical Mycology, Allergology And Immunology, North Western State Medical University, St. Petersburg, Russian Federation, ³⁸Division Of Hygiene And Medical Microbiology, Department Of Hygiene, Microbiology And Public Health, Medical University Innsbruck, Innsbruck, Austria, ³⁹Infectious Diseases Service, Department Of Medicine And Institute Of Microbiology, Lausanne University Hospital, Lausanne, Switzerland, ⁴⁰Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Department of Mycology, CNRS UMR2000, Paris Descartes University, Necker-Enfants Malades University Hospital, Department of Infectious Diseases and Tropical Medicine, Centre, Paris, France, ⁴¹Division Of Infectious Diseases, Department Of Internal Medicine, Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea, Democratic People's Republic of, ⁴²Division Of Paediatric Haematology And Oncology,
Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany, ⁴³School Of Medicine And Pharmacy, University Mohammed the fifth, Rabat, Morocco, ⁴⁴Laboratory Of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, Iasi, Romania, ⁴⁵Department Of Hematology, Oncology And Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany, ⁴⁶Department Of Medical Microbiology And Infectious Diseases, Centre Of Expertise In Mycology, Radboudumc/Canisius Wilhelmina Hospital, Nijmegen, Netherlands, ⁴⁷Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Athens, Greece, ⁴⁸Department Of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia, ⁴⁹Department Of Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, ⁵⁰Department of Medical Microbiology & Parasitology, College of Medicine, University of Lagos, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom, ⁵¹Department Of Hematology, Fondazione Policlinico Universitario A. Gemelli -irccs-, Universita Cattolica del Sacro Cuore, Rome, Italy, ⁵²Federal University of Health Sciences of Porto Alegre, Hospital Dom Vicente Scherer, Porto Alegre, Brazil, ⁵³Infectious Diseases Clinic, Vedanta Institute of Medical Sciences, Ahmeddabad, India, ⁵⁴Department Of Internal Medicine, Hematology And Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic, ⁵⁵UK NHS Mycology Reference Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom, ⁵⁶Department Haematology / Oncology, Paracelsus Klinik, Osnabrück, Germany, ⁵⁷Center of Expertise in Microbiology, Infection Biology and Antimicrobial Pharmacology, Tehran, Iran, ⁵⁸Molecular Microbiology Section, Laboratory Of Clinical Immunology And Microbiology, National Institute Of Allergy And Infectious Diseases, National Institutes of Health, Bethesda, United States of America, ⁵⁹Department Of Hemato Oncology, Amrita Institute Of Medical Sciences, Amrita Viswa Vidyapeetham University, Kochi, India, ⁶⁰Division of Infecatious Diseases, University of Pittsburgh Medical Center and VA Pittsburgh Helthcare System, Infectious Diseases Section, University of Pittsburgh, Pittsburgh, United States of America, ⁶¹Infectious Diseases Unit, Szent Istvan and Szent Laszlo Hospital, Budapest, Hungary, ⁶²Department Of Infectious Diseases, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece, ⁶³University of Melbourne, Melbourne, Australia, ⁶⁴The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia, ⁶⁵Dept. Of Medicine, P. D. Hinduja Hospital & Medical Research Centre, Mumbai, India, ⁶⁶Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, United States of America, ⁶⁷Division Of Pediatric Infectious Diseases, Department Of Pediatrics, Duke University Medical Center, Durham, United States of America, ⁶⁸Department Of Infectious Diseases, Singapore General Hospital, Singapore, Singapore, ⁶⁹Department For Internal Medicine Ii, University Hospital Würzburg, Würzburg, Germany, ⁷⁰Department Of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt, Germany, ⁷¹Departments Of Medicine, Pediatrics, Microbiology & Immunology, Weill Cornell Medicine, and New York Presbyterian Hospital, New York, United States of America, ⁷²Public Health Wales Microbiology Cardiff, UHW, Cardiff, United Kingdom, ⁷³Fungus Testing Laboratory, The University of Texas Health Science Center at San Antonio, San Antonio, United States of America, ⁷⁴Division Of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, United States of America

**Abstract:** Background Mucormycosis is a difficult to diagnose rare disease with high morbidity and mortality. Diagnosis is often delayed, and disease tends to progress rapidly. Urgent surgical and medical intervention is lifesaving. Guidance on the complex multidisciplinary management has potential to improve prognosis, but approaches differ between health care settings. Methods from January 2018, authors from 33 countries in all United Nations regions analysed the published evidence on mucormycosis management and provided consensus recommendations addressing differences between the regions of the world as part of the "One World One Guideline" initiative of the European Confederation of Medical Mycology (ECMM). The author group based in 17 time zones, relied on electronic media including video tutorial on methodology, and central document repository with several daily updates. Results Signs and symptoms of mucormycosis depend on
organ patterns and underlying conditions. Diagnostic management does not differ greatly between world regions. Upon suspicion of mucormycosis appropriate imaging is strongly recommended to document extent of disease and is followed by strongly recommended surgical intervention. First-line treatment with high-dose liposomal amphotericin B is strongly recommended, while intravenous isavuconazole and intravenous or delayed release tablet posaconazole are recommended with moderate strength. Both triazoles are strongly recommended salvage treatments. Amphotericin B deoxycholate is recommended against, because of substantial toxicity, but may be the only option in resource limited settings. Conclusion Management of mucormycosis depends on recognising disease patterns and on early diagnosis. Limited availability of contemporary treatments burdens patients in low and middle income settings. Areas of uncertainty were identified and future research directions specified.

## PS3.3

### Rare moulds: Clinical Practice Guideline of the ECMM and the MSG-ERC

M. Hoenig¹,²

¹Division of Infectious Diseases, University of California, San Diego, United States of America,
²Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria

**Abstract:** In the context of a growing population of immunocompromised patients at risk for opportunistic infections, prevalence of invasive mould infections, including moulds other than *Aspergillus* and Mucorales, are on the rise. While new diagnostic and therapeutic options are now available to tackle rare invasive mould infections, up to date guidance for the correct utilization in the clinical setting is urgently needed. On that background, ECMM together with MSG-ERC set out an unprecedented orphan diseases guidance initiative involving all disciplines involved in diagnosis and treatment of rare mould infections. Utilizing the global network of the ECMM Academy and the ECMM Excellence Centers, clinicians, microbiologists and other medical professionals from around the world will be invited by ECMM to contribute their expertise to the project "One World-One Guideline". The rare mould guideline covers diagnosis and treatment of infections caused by Fusarium, Lomentospora, Phaeohyphomycetes/dematiaceous fungi/black fungi, Rasamsonia, Scedosporium, Schizophyllum and other basidiomycetes, Scopulariopsis, Penicillium, and Talaromyces other than marneffei. The guideline will include taxonomy and epidemiology and give detailed recommendations regarding diagnosis and clinical management of these rare mould infections for adults and the pediatric population. The guideline follows the structure and definitions of the ESCMID/ECMM guidelines on invasive fungal infection, and the ECMM MSG-ERC guideline on mucormycosis, which are in accord with the GRADE and AGREE systems.

## Plenary session 5—ICU—candida infections/Breaking news from Hematology and ICU

### PS5.1

#### Abdominal Candidiasis in ICU patients

P. Köhler

Department I for Internal Medicine, European Excellence Center for Medical Mycology (ecmm), Germany and Cecad Cluster of Excellence, University of Cologne, Cologne, Germany

**Abstract:** With increased admission rates to intensive care unit and high morbidity and mortality in the presence of severe sepsis or septic shock abdominal candidiasis is a frequent complication in surgical patients. In the majority of cases *Candida* species are part of polymicrobial infections after upper gastrointestinal tract perforation, anastomotic leaks after bowel surgery, acute necrotizing pancreatitis or peritoneal dialysis. Further risk factors comprise premorbid conditions, total parenteral nutrition, and previous antibiotic therapy among others. Blood cultures are often negative and the serum beta-D-glucan assay can support diagnosis in patients with suspected intraabdominal candidiasis. The diagnosis is achieved by aspiration of fluid under ultrasound or CT guidance or at
the time of surgery. Current treatment strategies comprise both surgical intervention and antifungal therapy, preferably with an echinocandin. Therapy should continue for at least two weeks and often longer, until the abscess and all signs and symptoms of peritonitis are resolved.

## PS5.2

### Are the new management strategies useful?

A. Colombo

Medicine, Federal University of São Paulo, São Paulo, Brazil

**Abstract:** Along the last decades, we faced a substantial progress in the clinical validation of new diagnostic and therapeutic tools for treating patients with invasive Candidiasis (IC). However, we still have several gaps in knowledge that may mitigate our results in the clinical management of complex patients with invasive candidiasis. We selected 3 main topics to be addressed along this presentation: (1) How Candida Biomarkers might be utilized in the clinics, (2) Should we continuous to order universal screening of eye infection and endocarditis for candidemic patients? (3) Concerns in the clinical management of neutropenic patients with candidemia.

## PS5.3

### Breaking news from Hematology and ICU: CNS infections.

A. Candoni

University Hospital, Asuiud, Division of Hematology and Stem Cells Transplantation, Udine, Italy

**Abstract:** Fungal Infections of the Central Nervous System (IFI-CNS) are rare life-threatening infections in hematologic patients and their management remains a challenge despite availability of new diagnostic techniques and novel antifungal agents (1–4). In addition, analyses of large cohort of patients focusing on these rare IFIs, are still lacking. The most important causative agent remains *Aspergillus* species and a concomitant extra-CNS involvement (mainly lung) is common. Recent reports highlight that the fungal biomarkers in CSF could be highly informative reinforcing that diagnostic lumbar puncture should be performed when IFI-CNS is suspected, enabling diagnosis confirmation and prompt initiation of targeted therapy (2). Surgical approach of this complications is feasible only in a minority of cases (those with focal, cortical-subcortical lesions and no severe thrombocytopenia), and, even with a broad spectrum of antifungal drugs, overall response rate remains poor (less than 40%) with a 12-months survival probability less than 30% (1–4). Availability of new drugs, with better CNS permeability and less interaction with immunosuppressive agents and chemotherapy (such as Isavuconazole), and prompt diagnostic work-up (high diagnostic value of CSF biomarkers) can guide a rapid, specific and aggressive therapy (including combination antifungal therapy ± surgery) to further improve outcomes of IFI-CNS in hematologic patients (1–4).

(1) Pagano L, Caira M, Falcucci P, Fianchi L. Fungal CNS infections in patients with hematologic malignancy. *Expert Rev Anti Infect Ther.* 2005;3:775–85.

(2) Candoni A, Klimko N, Busca A, et al Fungal infections of the central nervous system and paranasal sinuses in onco-haematologic patients. Epidemiological study reporting the diagnostic-therapeutic approach and outcome in 89 cases. *Mycoses*. 2019;62(3):252–260.

(3) Schwartz S, Kontoyiannis DP, Harrison T, Runke M. Advances in the diagnosis and treatment of fungal infections of the CNS. *Lancet Neurology*. 2018;17:362–372.

(4) McCarthy M, Rosengart A, Schuetz AN, et al. Mold Infections of the Central Nervous System. *N Engl J Med*. 2014; 10(371-2): 150–160.

## Plenary session 6—Management of IFD in paediatrics (EPMYN)

### PS6.1

#### Biomarker based diagnostic work-up of IFD in immunocompromised paediatric patients

T. Lehrnbecher

Pediatric Hematology and Oncology, University of Frankfurt, Frankfurt, Germany

**Abstract:** Immunocompromised pediatric patients such as children undergoing therapy for hematological malignancies or receiving allogeneic hematopoietic stem cell transplantation are at
high risk for invasive fungal diseases, which are a major cause of morbidity and mortality in these patient populations. Unfortunately, clinical signs and symptoms of invasive fungal disease are mostly unspecific, which makes early diagnosis difficult. However, early diagnosis and prompt treatment of invasive fungal disease is associated with better outcome. Non-invasive antigen-based assays such as galactomannan (GM) or β-D-glucan and molecular biomarkers in peripheral blood have the potential to indicate invasive fungal disease prior to the development of clinical symptoms, and may therefore be helpful in the decision to institute and choose antifungal compounds and also to guide duration of therapy. When GM in blood is used as a diagnostic test in neutropenic children with prolonged febrile neutropenia unresponsive to broad-spectrum antibiotics or in children with a pulmonary infiltrate in the CT scan, sensitivity and specificity of the assay do not significantly differ between children and adults. However, the utility of the assay is clearly limited by the poor positive predictive value and the fact that despite the high negative predictive value of the test, a negative GM assay does not rule out non-Aspergillus molds. Data on β-D-glucan in immunocompromised children are too limited to give a final recommendation on its use, and similarly, the results of PCR testing in blood are variable and do not allow a firm conclusion on its utility. However, despite these limitations, biomarkers in blood may help to plan invasive diagnostic procedures such as bronchoalveolar lavage (BAL) or bioptic procedures. As compared to blood, both galactomannan and PCR testing in BAL lavage seem to be superior, but again, further studies in the pediatric population are warranted. Regarding the value of biomarker in CNS samples such as cerebrospinal fluid, little is known in both pediatric and adult patients. Further pediatric studies are warranted to evaluate whether the combination of diagnostic methods can improve sensitivity and specificity, but in addition, new diagnostic tools are needed that will improve the early and reliable diagnosis of invasive fungal disease in children.

PS6.2

Pre-emptive versus empiric antifungal therapy in children with cancer

M.E. Santolaya

Hospital de niños Dr. Luis Calvo Mackenna, Santiago, Chile

**Abstract:** Invasive fungal disease (IFD) causes significant morbidity and mortality in paediatric cancer patients with high-risk febrile neutropenia (HRFN), along with high utilization of resources for prevention, diagnosis and treatment. Early diagnosis of IFD and prompt implementation of aggressive antifungal treatment have proven to be critical for patient survival. Nevertheless, early identification of the causal pathogen of an IFD continues to be difficult. The classic approach is currently based on clinical, imaging, microbiological (cultures from sterile sites) and histological studies. Major advances for early diagnosis of IFD have been made by the development of non-culture assays such as detection of galactomannan (GM) antigen, (1-3)-b-D-glucan antigen detection and nucleic acid detection, by PCR techniques. Despite these advances, IFD diagnosis continues to be a challenge and current recommendations propose to initiate empirical antifungal therapy in IFD high-risk paediatric patients with persistent (96 h) fever and neutropenia that are unresponsive to broad-spectrum antibacterial agents. The downside of this approach is the overtreatment of patients meeting the above criteria but who do not have an IFD, leading to an increase in adverse events, prolonged hospitalizations and elevated costs associated with the use of antifungal drugs. A more reasonable approach in cancer subjects would be to consider early identification of patients at high risk of IFD, application of a complete screening diagnosis strategy followed by a rational approach to antifungal therapy based on results of this early and extensive diagnostic workup, adopting a more selective preemptive treatment strategy in patients with persistent fever and neutropenia. We performed a prospective, multicenter study in children with cancer and persistent HRFN, aimed to determine the efficacy of pre-emptive treatment compared with current standard empirical antifungal treatment. In our study, pre-emptive antifungal therapy was as effective as empirical antifungal therapy, with a significant reduction in antifungal use. A reduction of antifungal use, based on stringent diagnostic criteria, could favor the adoption of evidence-based management strategies in this population. This approach requires optimal laboratory support with rapid
turnaround response. Introduction of non-culture-based diagnostic techniques into clinical practice could contribute to better management of these patients, favoring the possibility of patient-based individualized therapy. Active monitoring and early diagnostic workup is a necessary step prior to proposing an evidence-based management strategy. In our experience, 58% of patients of the pre-emptive group did not receive antifungal therapy, with similar clinical outcome to the empirical group, with the aim of reserving antifungal therapy for the subset of patients who have early evidence of IFD by careful clinical, laboratory, imaging and microbiological assessment. The main findings of our study lead us to propose a step forward in the rational approach to treating children with cancer focusing on one yet-unresolved issue in the management of the patients: adoption of a more selective pre-emptive antifungal treatment strategy in children with prolonged fever and neutropenia.

PS6.3

Invasive mucormycosis in children with hematological malignancies and solid tumors: Report from the Infection Working Group of the Hellenic Society of Pediatric Hematology Oncology (2008-2017).

C. Antoniadi¹, I. Lialias², H. Tsipou³, N. Kazakou⁴, E. Iosifidis², E. Papakonstantinou⁵, S. Polychronopoulou¹, A. Kattamis³, E. Roilides², A. Tragiannidis⁴

¹Department of Pediatric Hematology-oncology, "Agia Sofia" Children's Hospital, Athens, ATHENS, Greece, ²³rd Pediatric Department, Aristotle University of Thessaloniki, Hippokration Hospital, THESSALONIKI, Greece, ³Pediatric Hematology-oncology Unit, 1st Pediatric Department, National and Kapodistrian University of Athens, "Agia Sofia" Children's Hospital, ATHENS, Greece, ⁴Haematology-oncology Unit, 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece, ⁵Department Of Pediatric Hematology-oncology, Hippokration Hospital, THESSALONIKI, Greece

**Objectives:** Mucormycosis is an invasive, life-threatening fungal infection that mainly affects immunocompromised hosts. Zygomycetes can invade virtually any tissue or organ, resulting in a variety of clinical presentations. The Infection Working Group (IWG) of the Hellenic Society of Pediatric Hematology-Oncology (HELSPHO) collected and analyzed data of pediatric mucormycosis cases from 7 Hematology-Oncology Departments within 2008–2017.

**Methods:** Six cases of proven invasive mucormycosis were reported retrospectively (female/male: 2/4, median age: 9.6 years, range: 2–15 years) during chemotherapy for hematologic malignancies and solid tumors within 2008–2017.

**Results:** Among the 6 children with invasive mucormycosis, three presented with acute lymphoblastic leukaemia (ALL), one with acute myeloid leukemia (AML), one with neuroblastoma and one child with brain tumor, as the primary underlying malignancy. In 4/6 children (66%), mucormycosis occurred within the first 20 days from the diagnosis of the underlying disease. One child with ALL developed mucormycosis 4 months since the initial diagnosis, with prior invasive aspergillosis two months earlier treated with voriconazole. Four out of 6 patients had received prolonged corticosteroid treatment and 3/6 had severe neutropenia with a neutrophil count <500 µL at the time of diagnosis. Four out of 6 patients (66%) had received intensive chemotherapy within the last 4 weeks and all patients had been hospitalized for at least 20 days. All patients presented with fever (100%), 4/6 with pain (66%), 3/6 with palpable mass (50%) (one at the left forearm and two at the orbit) and 3 patients presented with central nervous system symptoms (seizures, headache, and blur of vision) (50%). Primary infection sites were combined paranasal sinus with orbital involvement (2), central nervous system (1), occipital area (1), orbital involvement (1) and forearm (1). The diagnosis of mucormycosis was documented by histology and mycology (PCR or culture) in all patients (2 *Rhizopus arrhizus*,1 *Mucor* spp., 1 *Absidia* spp., 2 unidentified Mucorales). Dissemination was defined by clinical signs, imaging studies and histology in 4/6 (66%) patients. Four (4) out of 6 patients had received prophylactic treatment with antifungal agents (2/4 patients received micafungin and 2/4 L-Amphotericin B). Therapeutically, all patients received L-Amphotericin B (L-AmB) (median dose: 7.5mg/kg, range: 3-10 mg/kg). Two (2) patients received combined antifungal treatment with L-AmB and caspofungin, one (1) L-AmB and voriconazole, one (1) L-AmB and
posaconazole and one (1) L-AmB, voriconazole and caspofungin. Three (3) patients received maintenance treatment with posaconazole. Surgical excision was performed in 4/6 cases (66%). Two out of 6 patients (33%) died, after 6 and 12 months, respectively.

**Conclusion:** Pediatric invasive mucormycosis mainly presents as paranasal sinus and orbital disease and is still related to high mortality rates. Our data demonstrated that the disease occurs early after initiation of intensive chemotherapy and febrile neutropenia and prolonged corticosteroids are the main predisposing factors. Early recognition and prompt intervention with combined prolonged antifungal and surgical treatment may rescue the patients and improve overall survival.

# Plenary session 8—New (antineoplastic) drugs, new risks

## PS8.1

### New antineoplastic drugs, new risks in hematology

#### A. Busca

Division of Hematology, AOU Citta della Salute e della Scienza, Torino, Turin, Italy

**Abstract:** Over the last 10 to 15 years, therapeutic options for patients with hematologic malignancies have largely increased with the growth of new immunotherapeutic agents. At least two issues regarding invasive fungal infections (IFI) and the new immunotherapeutic agents should be addressed. First, there are relevant pharmacokinetic interactions of the new targeted therapies with coadministered mold active azoles, namely posaconazole and voriconazole that are strong inhibitors of CYP3A4. Awareness of these interactions is of paramount importance for optimization of the treatment of patients, since we are asked to monitor for potential toxicity, or to modulate the dose of the drugs or rather to avoid the combination and consider alternative therapy. Second, is the risk of IFI increased with the use of the new agents? For many of these, for instance monoclonal antibodies (MoAb), bcl-2 inhibitors (i.e. venetoclax) and tyrosine kinase inhibitors (TKI) (i.e. sorafenib and midostaurin) when used for the treatment of patients with acute leukemia, it is hard to realize whether they have an additive risk to the underlying disease: indeed, there are very few information respect the incidence of IFI based on the clinical trials published so far. By contrast, several studies raised concern that the Bruton's tyrosine kinase inhibitor Ibrutinib may increase the risk for IFI in patients with lymphomas. In this respect, different mechanisms by which Ibrunitib may favor the occurrence of IFI have been described, including alveolar macrophage, neutrophil, T-cell, and platelet function as well as alterations of cytokine environment. A recent study of Ibrutinib treatment for primary CNS lymphoma reported a 39% rate of invasive aspergillosis in patients concurrently receiving steroids even in absence of neutropenia, while in other reports the incidence appears to be much lower in the 3-4% range. Conversely, the risk of IFI with the use of Idelalisib, another B-cell receptor inhibitor, seems to be restricted to *Pneumocystis jirovecii* pneumonia only. Until more detailed epidemiological data will be available, anti-mold prophylaxis is not recommended for patients receiving Ibrutinib or Idelalisib. Chimeric antigen receptor (CAR) T cell therapy is an innovative strategy to harness the immune system to treat patients with diffuse large B cell lymphoma (DLBCL). CAR-T cells are T lymphocytes genetically engineered to express a tumor-targeting receptor, directing T cells to bind to a tumor-associated antigen, namely the CD19 in the case of DLBCL. A recent study evaluated infectious complications in 133 patients with ALL and lymphomas treated with CD19 CAR-T cells: IFI occurred in 5% of the patients during the first 28 days after CAR-T cell infusion, all of whom had severe cytokine release syndrome (CRS) or neurotoxicity requiring tocilizumab and/or corticosteroids. CRS severity was the only factor after CAR-T cell infusion associated with infection in a multivariable analysis. In summary, the risk of IFI in patients receiving targeted therapies needs to be defined by further experience in clinical practice and ongoing research trials. Preventive strategies of IFI in patients managed long term with immunotherapy remain at the present a challenge.

## PS8.2

### In oncology
**L. Drgona**

Department of Oncohematology, Comenius University and National Cancer Institute, Bratislava,
Slovak Republic

**Abstract:** The field of new antineoplastic therapeutical agents is increasing rapidly over the last decade. New drugs in oncology are basically considered as targeted ones due to their mechanism of action. These drugs directly target the cells or pathways involved in pathophysiology of neoplastic disease. Cell surface receptors, cytokines, immunoglobulines, intracellular enzymes are the most common targets involved in the therapy. Other drugs are focusing on the patient's own immune system with the aim to boost the responsible cells to fight against the disease. The new drugs have different mechanisms of action resulted in less "classical" toxicity known from chemotherapy agents. The adverse events after the targeted therapy are mainly caused by interaction with the immune system—targeted sites are often key elements of physiological processes like cell cycle control. This may have an influence on responses to acute infection or on control of latent/chronic infection. Theoretically, the potential of the new drugs to predispose to infection depends on their site of action. But this is simplification of the whole problem, because cancer patients are treated for months or years before the installation of the innovative therapy. Thus, an old, traditional risk factors for infectious complications should be added to the overall risk for the given patient. Invasive fungal diseases (IFDs) are associated with the treatment of cancer, patients with solid tumors have lower risk than majority of patients with hematological malignancies. The obvious risk factors for IFDs in patients with solid tumors are neutropenia, steroids, central venous catheter, progressive or refractory malignancy, gastrointestinal surgery with leak of anastomosis among others. Invasive candidiasis followed by invasive aspergillosis are the most common IFDs in this setting, other pathogens are less involved. With the advent of the new therapeutic approaches in oncology patients and physicians are challenged with the new spectrum of adverse events including infections. Generally, monoclonal antibodies, tyrosine kinase inhibitors, check point inhibitors and other targeted and biological agents are not associated with the increasing risk of IFDs in solid tumor patients. In special circumstancies patient undergoing such antineoplastic therapy may have an additional risk for IFDs. An example are the patients with melanoma or lung cancer treated with check point inhibitor developing an immune related adverse event. High dose steroids with or without anti-TNF blocker are recommended in the management of the serious toxicity; these patients are potentially at risk for IFD development due the supportive treatment of AE. Risk of IFD will be discussed in the patients with solid tumors reflecting the advances of antineoplastic treatment. Despite the relatively low risk for the development of IFDs and slowly growing experience some recommendations could be made. Anticipation, prediction and alertness are the pillars of action in this setting of cancer patients.

**Meet the expert sessions**

M04

**Novelties in the molecular diagnostics of fungal infections**

**M. Lackner**

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

The aim of this meet the expert session is to provide an overview on the most recent developed diagnostic kits in the field of medical mycology. We aim to present and compare novel diagnostic tools with established assay based on our personal experience and available literature. The presentation will be based on a literature review of the past 18 months and a web search for commercially available products. A mix of currently developed assays of research groups will be presented, as well as CE-IVD labelled commercial tests. The most promising innovative diagnostic assays will be presented and discussed. The audience is invited to share their experience with novel assays to enable a lively discussion and exchange of opinions.
## M12

### Environment

R. Sabino¹, E. Segal²

¹Reference Unit for Parasitic and Fungal Infections, Infectious Diseases, National Health Institute Dr. Ricardo Jorge, Lisbon, Portugal, ²Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel

**Abstract:** Exposure to environmental fungi, whether this occurs indoors or outdoors, in leisure activities, in the workplace or in the home, is an everyday occurrence. Different types of environment may contain variable levels of fungal particles and include viable and non-viable yeasts, conidia, hyphal fragments, as well as fragments derived from the fungal cell wall. Mycotoxins and other volatile organic compounds should also be considered as environmental potential hazards. Recognition of the importance of the environment as a source of human infection has come about, at least in part, as result of the emergence of an unprecedented number of ubiquitous environmental fungi as major causes of disease. Exposure to environmental fungi is associated with high number of hospital admissions, and asthma related ailments. Allergic bronchopulmonary mycosis, rhinosinositis, asthma with fungal sensitization and hypersensitivity pneumonitis are among the diseases more frequently associated with fungal exposure. In addition, immunocompromised patients are at higher risk for the development of invasive infections. Changes in environmental factors, including changing land-use patterns, use of antifungals in agriculture, and climate changes have led to epidemiological shifts. Therefore, special attention should be paid in regard to the isolated fungal species. Environmental fungal species such as *Aspergillus* spp., *Mucorales*, *Candida* spp., dermatophytes and dimorphic fungi will be discussed during this session; emphasizing their importance as etiological agents of fungal infections.

## M13

### Diagnostics/Imaging

C. Thornton

Biosciences, University of Exeter and ISCA Diagnostics Ltd., Exeter, United Kingdom

**Abstract:** Bench-to-Bedside Diagnosis of Invasive Pulmonary Aspergillosis. Invasive pulmonary aspergillosis (IPA) is a life-threatening lung disease of haematological malignancy and bone marrow transplant patients caused by the air-borne mould *Aspergillus*. Current diagnostic tests for the disease lack sensitivity or specificity, and culture of the fungus from invasive lung biopsy, considered the gold standard for IPA detection, is slow and often not possible in critically ill patients. While Computed Tomography (CT) is a non-invasive diagnostic procedure, it has limited clinical utility for IPA diagnosis, but is nevertheless used as a trigger for commencing antifungal treatment in a number of centres. Innovative approaches to the diagnosis of IPA are needed to enable diagnostic-driven treatment with mould active drugs. In this talk, I will discuss the development of diagnostic technologies for IPA detection based on the *Aspergillus*-specific mouse monoclonal antibody JF5, including the CE-marked *Aspergillus* lateral-flow device (OLM Diagnostics), and CE-marked *Aspergillus*-ELISA (Euroimmun AG). In addition, I will describe the humanisation of mAb JF5 for PET/MR imaging of *Aspergillus* lung infections *in vivo*, and translation of the imaging technology to the clinical setting. I will finish by describing the recent development of a mAb, PD7, specific to A. fumigatus, and its use to detect a novel protein biomarker of IPA in urine.

## M14

### Resistance—Utilizing molecular methods

P. White

Microbiology, Public Health Wales Microbiology, Cardiff, United Kingdom

**Abstract:** Until recently the identification of antifungal resistance has been based on the availability of a cultured organism to perform susceptibility testing to determine a MIC against a particular antifungal agent. The development of molecular techniques has provided an alternative option, by identifying genetic markers potentially associated with resistance or identifying species that may be inherently resistant, or have an increased likelihood of resistance to particular drugs. Indeed,
molecular assays offer the only alternative to culture dependent procedures, that themselves can
suffer from limited sensitivity and delayed time to result. However, molecular approaches are not
without limitations. PCR based methods targeting specific mutations (for example: single nucleotide
polymorphisms and/or tandem repeats), by design have a limited detection range, missing existing,
likely less prevalent mutations, but also the presentation of novel genetic mechanisms. PCR methods
that identify species that are usually resistant to certain antifungal drugs will be reliant on the
knowledge of local epidemiology and the subsequent susceptibility testing of relevant cultures to
guide antifungal prescribing. The use of PCR-sequencing, but more so next generation sequencing,
will help identify a wider range of polymorphisms in genes encoding the proteins targeted by
antifungal therapy and also in promoter regions that may enhance up-regulation, but the detection
of novel mutations may lack the necessary phenotypic evidence confirming associated resistance. In
addition, PCR-sequencing is associated with a significant processing time and has only had limited
evaluation of direct specimen testing, where sensitivity may be lacking when targeting single copy
genes. As of yet none of these methods can be confidently associated with a specific MIC range, and
the presence of well defined polymorphisms have been associated with typically susceptible MIC
values. This presentation will describe the benefits and limitations of using molecular methods for
determining antifungal resistance, while providing data on the clinical performance of assays,
including those that are commercially manufactured.

Symposium 1 Water quality (mis-)management—an opportunity for fungal contamination

S01.1

Fungal Contaminants in Drinking Water Regulation? A Tale of Ecology, Exposure, Purification and Clinical Relevance

M. Novak Babič<fnref n="1" />, N. Gunde-Cimerman<fnref n="1" />, J. Brandão<fnref n="2" />

Safe drinking water is one of the fundamental human rights according to the Resolution 64/292 issued by the United Nations Human Rights Council [1]. Although the parameters for safe drinking water depend on the living conditions and vary between continents and countries, they strive for a common goal: drinking water is suitable for users when it does not contain dangerous chemical substances and microorganisms [2]. To achieve this, raw water from an underground or surface source is subject to various purification techniques before entering the distribution system. The processes usually include aeration, coagulation, flocculation, sedimentation, and ultrafiltration, depending on the location and quality of raw water [3]. Finally, water quality in Europe is controlled based on the parameters listed in Drinking Water Directive (98/83/CE). Water not reaching the required microbiological minimum is additionally subject to chemical treatment, mostly chlorination. Fungi are not listed in the current directive and are therefore not specifically monitored. Yet, their presence in fresh water is well documented and has been studied in at least 19 countries of Europe over the past 30 years [3]. More than 400 different species of fungi have been reported from water sources intended for human consumption, with prevailing presence of ascomycetous fungi of the genera Alternaria, Acremonium, Aspergillus, Aureobasidium, Candida, Cladosporium, Exophiala, Fusarium, Penicillium, Phoma, Sarocladium, Scopulariopsis, Sporothrix, Stachybotrys and Trichoderma, followed by Absidia, Mortierella, Mucor and Rhizopus from subphylum Mucoromycotina. Most commonly encountered yeasts were basidiomycetous genera Cystobasidium, Naganishia (formerly Cryptococcus) and Rhodotorula [3]. While water purification procedures remove 8–90% of fungal propagules, the remaining will ultimately form mixed biofilms inside the tap water distribution systems, later affecting the taste and odour of drinking water. Also, several water-related fungal species were recognised as opportunistic or emerging pathogens, although their transmission and effect on the health of drinking water consumers remains poorly investigated.

<footnote n="1">¹Department Of Biology, University of Ljubljana, Biotechnical Faculty, Ljubljana, Slovenia,</footnote>

<footnote n="2">²Department Of Environmental Health, National Institute of Health Doutor Ricardo Jorge, Lisbon, Portugal</footnote>
Besides drinking, consumers use potable water also for daily activities such as cooking, washing and personal hygiene. During these activities they are in constant contact with fungi and their metabolites directly with the skin while washing, the digestive system while drinking, and through the respiratory system by inhaling aqueous aerosols [3,4]. With increasing transitory and serious immune alterations among patients as well as an increase of azole-resistant fungal strains in recent years also a need for monitoring of fungi increased, not only in drinking water but also in relation to materials in contact with drinking water. References: [1] UN. Resolution adopted by the General Assembly on 28 July 2010 64/292. The human right to water and sanitation. United Nations: New York, USA, 2010; p. 3. [2] WHO. Guidelines for Drinking Water Quality, 4th ed.; World Health Organization: Geneva, Switzerland, 2011; p. 564. [3] Novak Babič, M., et al. Fungal Contaminants in Drinking Water Regulation? A Tale of Ecology, Exposure, Purification and Clinical Relevance. Int. J. Environ. Res. Public Health 2017, 14, 636. [5] DEFRA. A Review of Fungi in Drinking Water and the Implications for Human Health, 1st ed.; BIO Intelligence Service: Paris, France, 2011; p. 107.

## S01.2

**Hospital environment: water supply and containment of aerosolised fungal particles. How far must we go in times of antimicrobial resistance?**

R. Sabino

Reference Unit for Parasitic and Fungal Infections, Infectious Diseases, National Health Institute Dr. Ricardo Jorge, Lisbon, Portugal

Invasive fungal infections depend on the interplay between host susceptibility and environmental exposure. Therefore, hospital environment is one of the major concerns in the management of nosocomial fungal infections, especially in wards bearing immunocompromised patients. Particular attention should be paid to the environmental risks associated with water since fungi can be aerosolized at water taps and showers. This may lead to fungal exposure by inhaled and ingested droplets, or even by direct contact with mucosae. Studies report that filamentous fungi and yeasts are commonly found on water-pipe inner surfaces, even in the presence of free chlorine. Air levels of *Fusarium* and *Aspergillus* conidia were found to increase in hospital environments after running showers multiple times. Species of these two genera are described as the most frequently found in this setting due to their conidial dispersion mode, as well as their ability to form biofilms. Despite the intrinsic resistance found in some species of these two genera, fungal exposure to antifungal agents via medical or agricultural use of these compounds, appears to have a major impact on acquisition of resistance to azoles; namely in *Aspergillus fumigatus*. The isolation of this species in hospital water and water reservoirs is therefore an even bigger matter of concern. More recently, several reports on nosocomial outbreaks caused by *Candida auris* have been described. This species is resistant to several classes of antifungals and is associated with high mortality. Contamination of hospital environment or transient colonization of medical devices and equipment may display an important role in the transmission of this species. *C. auris* was already found in water samples and therefore this reservoir should not be excluded as possible source of infection. In conclusion, fungal counts and detection of potential pathogenic species in water were, until a few years ago, the major concern of clinical and scientific community towards the reduction of nosocomial fungal infections originating in water devices. The emergence of infections caused by fungal isolates with intrinsic or acquired antifungal resistance triggered new levels of alert in this field.

## S01.5

**Spectrum of indoor fungi isolated from indoor environments in Busia-Kenya**

O. Mashedi<fnref n="1" />, E. Amukoye², C. Bii³, B. Kimani³, A. Chepchirchir⁴, S. Okoth⁵

<footnote n="1">¹Centre For Respiratory Disease Research, Kenya Medical Research Institute, Nairobi, Kenya,
²Centre For Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya,
³Centre For Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya,
⁴School Of Health Sciences, University of Nairobi, Nairobi, Kenya,
⁵School Of Biological Sciences, University of Nairobi, Nairobi, Kenya</footnote>
**Objectives:** The unplanned growth, rapid evolution of industrialization has deteriorated the ambient air quality. Anthropogenic indoor air pollution continues to be seen as an environmental and public health problem. Its seriousness lies in exposure to fungi that can trigger allergic reactions, hypersensitivity pneumonitis, allergic rhinitis, and some types of asthma. Very few studies in Kenya have been conducted to determine the possible types of indoor fungi allergens in indoor environment and to evaluate the relationship between allergen exposure in residential environments and respiratory morbidity. The aim of this study is to determine the prevalence of fungal indoor pollution in residential environments and to establish allergens which are associated with fungal pathogens.

**Methods:** This was a cross-sectional study carried out in 60 households in Busia County. Sedimentary and Volumetric sample collection method was used on water, air, swabs of dust and surfaces from homes. Mycological procedures in identification and analysis were used in fungal characterization. Comprehensive questionnaires were administered to determine the risk factors associated with indoor fungi infestation.

**Results:** 60 study participants were interviewed from Busia urban setting with mean age of 35.2 ± 7.7 (SD) years where most 60.3% of them were aged between 40–49 years; while 19.0% were aged 20–29 years. 68.4% of the respondents were females. As regard to education background, 61.4% of the respondents had primary education as the highest education level whereas 3.5% had tertiary level. 43.1% of the households were occupied by more than 5 people. Filamentous and yeast fungi were both isolated. *Candida albicans* and *Rhodotorula* accounted for the 39% of the isolated yeast species. Among the filamentous fungi *Fusarium* had the highest prevalence of 79.7%, followed by *Cladosporium* spp, *Alternaria* spp, *Acremonium Apergillus* and *Penicillium* respectively. There was a significant association between *Fusarium* and *Acremonium* moulds and respiratory conditions. *Acremonium* species was significantly associated with itchy eyes allergies, *p* = 0.023.

**Conclusion:** There is a need for the identification and monitoring of fungi in our home environment. Residential environment could potentially be considered an effective target for interventions aimed at reducing inciting fungi exposures to prevent upper respiratory allergies and infection in urban populations.

# Symposium 2 Pneumocystis jirovecii, an airborne transmissible and human derived ascomycete showing strong pulmonary tropism

## S02.1

*Pneumocystis jirovecii:* an obligate parasite of human lungs with unique camouflage and sex strategies

P. Hauser

Institute of Microbiology, CHUV Hospital, Lausanne, Switzerland

**Abstract:** *Pneumocystis jirovecii* is a fungus colonizing the human lungs. Should the immune system weaken, it can turn into an opportunistic pathogen causing severe pneumonia that can be fatal if not treated. A method of in vitro long-term culture for this pathogen is not available yet. Nevertheless, the advent of the high throughput DNA sequencing methods allowed sequencing the *P. jirovecii* genome out of the lung microbiome. The analysis of this genome revealed the loss of several synthesis pathways, demonstrating that this fungus is an obligate parasite. The presence of a fusion of the minus and plus mating-type loci suggested that its mode of sexual reproduction is primary homothallism (self-fertility). The sexuality of *P. jirovecii* proved to be obligatory with human lungs, which is compatible with asci and/or ascospores being the particles responsible for the transmission between humans by the air route. Long reads sequencing permitted characterizing six hypervariable gene families encoding surface antigens within the subtelomeres of all chromosomes. These gene families are responsible for surface antigenic variation allowing presumably escape from the human immune system, as well as for adhesion to host cells. The most abundant family is subject to mutually exclusive expression of a single gene, whereas each gene of the other families possesses its own promoter, suggesting independent expression. Recombinations between members of each family is thought to generate gene mosaicism that contribute to antigenic variation. The mechanisms involved
in *P. jirovecii* antigenic variation suggest that the infecting populations are antigenically heterogeneous, i.e., made of subpopulations displaying each a unique antigen of the most abundant family, as well as a minority of antigens of the other families.

## S02.2

### High-throughput methodologies in molecular epidemiology of *Pneumocystis jirovecii*

O. Matos

Medical Parasitology Unit, Group of Opportunistic Protozoa/hiv and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal

**Abstract:** The microscopic fungus *Pneumocystis jirovecii* is a pathogen that can cause fatal pneumonia (PcP) in immunocompromised patients (AIDS, transplant recipients, patients with haematologic and solid malignancies, patients with rheumatoid conditions and connective tissue disorders, patients receiving immuno-modulatory therapies or with pre-existing chronic lung conditions) worldwide. In the absence of an in vitro culture system to isolate and maintain live organisms, previous efforts to understand transmission patterns to develop methods of intervention and management for PcP relied on PCR-based approaches. Several genotyping methods have been used so far to address the genetic heterogeneity of *P. jirovecii*, PCR of multiple *loci* followed by direct DNA sequencing (Sanger), restriction fragment length polymorphism (RFLP), single-strand conformation polymorphism (SSCP), short tandem repeat (STR) or single-base extension (SBE). These methodologies were followed by the introduction of next generation sequencing (NGS), which is considered a revolution in the field of DNA analysis. NGS has been applied in the assembly of *P. jirovecii* whole genome and in amplicon analysis, especially for outbreaks investigation. Here we will explore the advantages and disadvantages of these approaches applied in the expansion of knowledge of the epidemiology of *P. jirovecii*.

## S02.3

### Airborne acquisition and transmission of *Pneumocystis jirovecii*: an update

G. Nevez<fnref n="1" />,², P. Laurence<fnref n="1" />,², S. Le Gal<fnref n="1" />,²

¹University of Brest, Brest, France, ²Host-Pathogen Interaction Study Group, SFR ICAT 4208, Univ Angers, Univ Brest, Institute of Biology in Health, IRIS, University Hospital Center, Angers, France, Angers Cedex, France

**Abstract:** Airborne transmission of Pneumocystis sp. from host to host has been demonstrated in rodent models and several observations suggest that interindividual transmission occurs in humans. Moreover, it is accepted that the Pneumocystis organisms infecting each mammalian species are host specific. Thus, the hypothesis of an animal reservoir for *Pneumocystis jirovecii* (*P. jirovecii*), the human-specific Pneumocystis species, can be excluded. An exosaprophytic form of the fungus cannot be strictly ruled out. Nonetheless, these data point out that: (i) the specific host may serve as its own reservoir (ii) Pneumocystis infection in humans is an anthroponosis with humans as a reservoir for *P. jirovecii*. This review highlights the main data on host-to-host transmission of Pneumocystis sp. in rodent models and in humans by the airborne route. Specifically, recent data on *P. jirovecii* exhalation by patients developing PCP or with pulmonary colonization in their surrounding environment are described. Taken together, these recent findings render it possible to provide a rationale for prevention of *P. jirovecii* acquisition and transmission within the hospitals.

## S02.5

### Does *Pneumocystis jiroveci* infection aggravate the prognosis of invasive pulmonary aspergillosis? Data from the RESSIF network in France (2012–2016)

F. Robert-Gangneux<fnref n="1" />, G. Bouzille², F. Dromer³, J.P. Gangneux⁴, T.H.E. French Mycoses Study Group⁵

<footnote n="1">¹Univ Rennes, CHU Rennes, Inserm, EHESP, IRSET UMR S_U1085, RENNES, France, ²Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, RENNES, France, ³National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, Paris, France,</footnote>
⁴Laboratoire De Parasitologie-mycologie, CHU de Rennes, Rennes, France, ⁵National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, RENNES, France

**Objectives:** *Pneumocystis jiroveci* pneumonia (PjP) is a frequent opportunistic infection in immunocompromised patients with various immune deficiency backgrounds, whereas invasive aspergillosis (IA) mostly occurs in patients with neutropenia or neutrophil impairment. Occasionally both fungi can be detected simultaneously. In that instance, Pj detection is sometimes considered as simple colonization, particularly when microscopic examination is negative and PCR is positive. In this study, we addressed the question of the presence of Pj as an aggravating factor during IA.

**Methods:** We took advantage of the surveillance of invasive fungal infections (IFIs) implemented by the National Reference Center for Invasive Mycoses and Antifungals through the RESSIF network. All cases of IA and PjP recorded during a 5-year period (2012–2016) were analyzed. Multivariate analysis compared cases of IA and cases of IA+PjP co-infection, using Cox regression after multiple imputation of missing data. All cases with a follow-up of 90 days were taken into account, extra-pulmonary aspergillosis was excluded. The following variable were included for analysis: age, sex, clinical background (hematological malignancy, allogeneic stem cell transplantation (allo-HSCT), auto-HSCT, graft versus host (GVH) disease, solid organ transplantation (SOT), cancer), corticotherapy or biotherapy, delay of AI onset, AI classification (proven, probable), and *Aspergillus* species.

**Results:** 730 patients were included, of whom 701 had IA and 29 had IA+PjP. The mean age of patients with IA and IA+PjP was 58.5 and 61.3, respectively (p = 0.08). There were no statistical differences in the sex ratio, clinical background, type of SOT, corticotherapy or biotherapy exposure, time from transplantation to diagnosis, time from hospitalization to IA diagnosis, time to death, nor classification of IA, between the two groups. The mortality rate was higher in the group IA+PjP than in IA alone (65% versus 39%, respectively, p = 0.009). Species from the Fumigati section accounted for 58.6% and 43.1% of cases in IA+PjP and IA, respectively (ns). In the multivariate analysis, the factors independently associated with death at 3 months were: age > 60 years (HR = 1.74 ; CI95% [1.4–2.2]), solid cancer (HR = 2.2 ; CI95% [1.1–4.6]), co-infection AI+PjP (HR = 1.9 ; CI95% [1.2–3.1]) and section Fumigati IA (HR = 1.65 ; CI95% [1.3–2.1]).

**Conclusion:** Pj infection is an aggravating factor of IA, particularly in patients with solid cancer. No other associated risk factor was uncovered probably due to the limited number of co-infections recorded. We plan to extend the study period to increase the statistical power of the analysis.

# Symposium 3 Mucormycosis

## S03.1

### Hospital related mucormycosis

#### A. Skiada

1st Dpt. of Medicine, Laiko Hospital, Athens University, Athens, Greece

**Abstract:** Mucormycosis is a rare invasive fungal infection due to fungi of the order Mucorales. The usual underlying diseases are hematological malignancies and diabetes mellitus, but a significant proportion of patients are immunocompetent. The main clinical presentations are rhinocerebral, pulmonary, cutaneous and disseminated. The agents of mucormycosis are ubiquitous in nature, and they are transmitted by inhalation, direct inoculation or ingestion. There have been multiple reports of healthcare associated mucormycosis, either as isolated cases or as outbreaks. In a publication from India, during an eighteen month period, 75 cases of mucormycosis were reported, of which 9% were nosocomial. Healthcare associated mucormycosis has been attributed to various exposures in the hospital environment, including: (a) Use of non-sterile products. This is the most commonly suspected cause of infection. Bandages, adhesives, nitroglycerin patches, contaminated linen, wooden tongue depressors, ostomy bags, probiotics, have all been implicated. There has even been a report of an outbreak due to allopurinol tablets and pre-packaged food. (b) Various procedures and medical devices, such as catheters, insulin pumps and finger sticks, as well as insertion of tubes, tooth
extractions and surgery. (c) Environmental factors may also be a source of infection. Molds may be found in the air, dust, water or any surfaces in the hospital. Construction works increase the risk of invasive fungal infections. Outbreaks have been linked to defective ventilation systems and water leakage. The clinical presentation varies, depending on the source of infection. Infections due to bandages, adhesives or contaminated wound dressings are mostly cutaneous. Percutaneous exposure in immunocompromised patients has led to disseminated disease. Inhalation leads to pulmonary and rhino-cerebral infection, while ingestion of tablets or food, as well as the use of tongue depressors, are responsible for gastrointestinal mucormycosis. Dialysis catheters have been linked to peritonitis. It is not easy to investigate a possible mucormycosis outbreak. The Centers of Disease Control of USA have recently published a guide to investigating suspected outbreaks due to mucormycosis. Due to the rarity of the disease, investigation is warranted even when it is unclear if there is a true outbreak. The first step is to verify the diagnosis and define a case. Histopathology and culture are the mainstay of diagnosis. In recent years, newer tools have been added to our diagnostic armamentarium. These include PCR, whole-genome sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The next step in the investigation of an outbreak is to describe the epidemiologic features of the cases, scrutinize patient care activities and determine environmental involvement. The management of outbreaks is multi-disciplinary and should include treating physicians, hospital administration, workers in the microbiology laboratory and health departments. Rapid identification of cases and initiation of treatment is important, in order to decrease mortality of existing cases and prevent the emergence of new ones.

S03.3

The new treatment of mucormycosis

L. Pagano

Fondazione Policlinico Universitario A. Gemelli-IRCCS-Universita Cattolica del Sacro Cuore,
Rome, Italy

The antifungal drug that showed the best in vivo activity in the past has been deoxycolate
Amphotericin B (d-AmB). Although this molecule, although extremely effective, has been
characterized by an important series of side effects (i.e. renal insufficiency, hypokalemia) which have
made its use disadvantageous. In more recent years, the introduction of new formulations of AmB in
lipid formulations (L-AmB, ABCD, ABLC) have mitigated the unpleasant side effects without
eliminating them completely but have made their use more manageable. Nowadays lipid
formulations, and especially L-AmB, are considered by all the international guidelines as the first-
choice drugs for the treatment of mucormycosis. In recent years new azole formulations, first and
second-generation azoles (i.e. posaconazole, isavuconazole) have shown considerable efficacy in the
treatment of these molds even in highly immunocompromised patients such as those suffering from
acute leukemia or undergoing bone marrow transplantation, whereas voriconazole and itraconazole
show no effect on mucorales. Posaconazole was registered as a drug to be used as an alternative to
liposomal amphotericin and often the availability of the oral solution alone has considerably limited
its use. The oral-only route of posaconazole is anyway a great limitation, especially in hematologic
patients, often unable to take drug per os or undergoing chemotherapy with subsequent high
incidence of vomiting. However the availability of posaconazole in intravenous formulation and in
coated tablets has favored a greater absorbability and, consequently, greater efficacy. Isavuconazole
in registrative trial has shown a good efficacy in the treatment of this fungal complication and is now
recognized as an excellent alternative. We must also take into account the possibility, supported in
recent years by multiple studies in real life, to approach the most aggressive and disseminated forms
of mucormycosis with the combination of multiple drugs. L-Amb combined with caspofungin would
appear to be preferable due to the lack of negative interactions between the drugs used, however
there are multiple reports showing that L-Amb plus posaconazole may have a positive role.

S03.4
## Clinical features associated to fungal species

D. Garcia-Hermoso¹, K. Sitbon¹, C. Gautier¹, F. Dromer², T.H.E. French Mycoses Study Group²

¹National Reference Center for Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, PARIS, France, ²National Reference Center for Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, Paris, France

**Background** Fungi of the order of *Mucorales* are ubiquitous saprobes that can be responsible for life-threatening infections especially in immunocompromised patients but also in immunocompetent individuals. An increased incidence of mucormycosis has been reported mostly due to the rise of populations at risk and the use of better diagnostic tools. There are more than 20 pathogenic species involved in this type of infections, with some of them associated with specific body sites. The main localizations of mucormycosis are rhino-orbito-cerebral and pulmonary infections, depending on the underlying conditions of the patient. We present here a preliminary analysis aiming to dissect the association between clinical manifestations and *Mucorales* species using the active surveillance system (RESSIF) implemented in France at the NRCMA since 2012.

**Methods** Three-hundred cases of probable and proven mucormycosis were so far collected through RESSIF. The isolates were characterized using phenotypic analysis by morphological methods, and antifungal susceptibility testing of 8 antifungal drugs done using EUCAST microdilution method. In addition, a multi-locus sequencing based on LSU, ITS, TEF-1 was performed.

**Results** Among those 300 cases of invasive mucormycosis, lung involvement was the main presentation (52%) followed by rhinocerebral (18%) and cutaneous (15%) involvement. Deep infections occurred most often in patients with hematological malignancies. Six major species of *Mucorales* were identified with *Rhizopus arrhizus* being the most frequent fungus. Our current data expand previous findings showing that distribution of these 6 major species depended on the body site localizations and underlying condition of the patient.

S03.5

## Molecular diagnosis of mucormycosis

L. Millon

Parasitology—Mycology—Umr6249 Cnrs Chrono-environnement, University Hospital Besançon, Besançon, France

Molecular techniques have provided a new understanding of the epidemiology of mucormycosis. Several factors may explain the growing incidence of mucormycosis, especially the increase in the number of susceptible people and the change in antifungal practices (which may have altered the relative frequency of mucormycosis and aspergillosis among patients at risk for both infection). In addition, the routine use of molecular techniques has helped to accurately identify Mucorales fungi in tissue samples when cultures are negative. As a result, the number of mucormycosis cases diagnosed in the last 10 years has increased. The use of molecular techniques has also improved the therapeutic management of mucormycosis. Indeed, mucormycosis and aspergillosis have similar underlying conditions, and similar radiological and clinical signs, but their antifungal treatments are different. For each of these infections, early diagnosis and early initiation of directed treatment are essential to improving patient outcome Molecular techniques may help to provide fast, effective treatment by accurately identifying the causative fungi. PCR amplification and sequencing were first applied to better identify isolates grown from cultures of biopsies or bronchalveolar lavage samples collected in patients with Mucorales infection. Molecular techniques have also been used to identify the fungus directly from the tissue samples when cultures were negative. The first technical approach for detection fungi in tissue samples consists of using panfungal primers, targeting ITS regions, followed by sequencing. The second possible approach consists of using Mucorales-specific primers. Diverse PCR techniques were tested and were successful, and several studies confirmed that PCR results were better in fresh/ frozen samples than in formalin-fixed paraffin-embedded samples. Molecular detection of fungi on hyphal positive biopsy samples is now strongly recommended (AII) by the European ESMID and ECMM joint clinical guidelines. Recent studies confirmed that Mucorales quantitative PCR (qPCR) applied on bronchoalveolar lavage fluid could provide
additional arguments favoring earlier initiation of specific antifungal therapy, thus improving the outcome of pulmonary mucormycosis patients. However, these tools require invasive sampling (biopsy, bronchoalveolar lavage), which is not feasible in patients in poor condition in Hematology or Intensive Care units. QPCR-based procedures to detect Mucorales DNA in non-invasive samples such as plasma or serum have proved successful in diagnosing mucormycosis early (as early as 8 days before mycological diagnosis and 3 days before imaging in patients with hematological malignancies). The test can be performed in all patients, even those who cannot endure a biopsy or bronchoalveolar lavage. The Mucorales qPCR performed on serum or plasma is becoming essential to improve the management of at-risk patients. The main problem at the moment is a lack of standardization, because of the use of multiple in-house assays. Efforts from the Fungal PCR Initiative (FPCRI)/Mucorales Lab working group of the International Society for Human and animal Mycology (ISHAM) are currently ongoing to improve standardization and provide recommendations, as was previously done for *Aspergillus* PCR assays by the European *Aspergillus* PCR Initiative (EAPCRI) working group.

## S03.6

### Management of mucormycosis in low and middle income countries

#### A. Chakrabarti

Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

The epidemiology of mucormycosis is different in low and middle income countries (LMIC) from developed nations. In LMIC the number of mucormycosis cases is alarmingly high in diabetic patients, the spectrum of causative agents is wide with lack of knowledge on antifungal susceptibility of the new agents. Occasional unusual clinical presentation baffles the clinicians about diagnosis, and delay in seeking healthcare by patients leads to poor outcome of the disease. Additionally, the lack of awareness of the disease among clinicians, the lack of availability of appropriate diagnostic facilities, poor availability and affordability of antifungal agents pose serious challenge in the management of the disease. In a recent descriptive study covering 465 mucormycosis cases from 13 centres in India, it was noted that 24% patients could not complete or start antifungal therapy due to affordability issue and nearly 20% patients were treated with amphotericin B deoxycholate. In 4.2% patients the therapy was shifted from liposomal to deoxycholate preparation of amphotericin B after certain period due to financial constraints, and improper antifungal therapy was prescribed in 7% patients. Due to those challenges, 90-day mortality was 52.0%, though majority (78.2%) of the patients had rhino-cerebral or cutaneous mucormycosis, which were not difficult for early diagnosis. Deferasirox of label use was also noted in certain number of patients.

## Symposium 4 MSG symposium (Trial Design in Clinical Mycology: Innovative Approaches)

## S04.5

### The Lung Transplant Community is Interested in a Clinical Trial to Determine the Optimal Strategy to Prevent Invasive Mold Disease

R. La Hoz¹, C. Jones², G. Mcgwin³, T. Patterson⁴, P. Pappas³, J. Baddley³, O. Morrissey⁵

¹Internal Medicine, UT Southwestern Medical Center, Dallas, United States of America, ²The Ohio State University, Columbus, United States of America, ³University of Alabama at Birmingham, Birmingham, United States of America, ⁴University of Texas Health Science Center at San Antonio, San Antonio, United States of America, ⁵Monash University, Melbourne, Australia

**Objectives:** The objectives of this survey were to: (1) describe the strategies used to prevent invasive mold disease in lung transplant recipients, (2) quantify the interest in participating in a clinical trial
to determine the optimal prophylactic strategy for invasive mold disease in lung transplant recipients
and (3) to describe the design types and factors that influence willingness to participate in the clinical
trial.

**Methods:** We invited transplant providers to participate in an anonymous cross-sectional web-based survey via email between December 2018 and February 2019. The 139-item survey was hosted on the University of Alabama at Birmingham Research Electronic Data Capture (REDCap) server. The contact list was generated from a variety of sources. The study was approved the University of Alabama at Birmingham Institutional Review Board.

**Results:** Of the 238 practitioners contacted, 50 (21.0%) responded to the survey. Responses were mainly from the United States 85.7% (36/42) and were transplant infectious diseases physicians 65.2% (30/43). The number of transplants performed at the responder's centers during 2016 was less than 20 in 44.4% (16/36), 21 to 50 in 19.4% (7/36) and more than 50 in 36.1% (13/16). Most responders, 81.0% (30/37), had a mold prevention protocol at their program. Universal prophylaxis was the most common prevention strategy 75.7% (28/37), followed by pre-emptive prophylaxis 10.8% (4/37), and targeted prophylaxis 5.4% (2/37). A quarter of the responders (7/34) used prophylaxis for <3 months, 58.8% (20/34) for 3 to 6 months, 11.8% (4/34) for 6 to 12 months and 8.8% (3/27) for more than 12 months. The majority of the responders, 84.6% (22/26) were interested in participating in a clinical trial to assess the optimal prophylactic strategy for mold infections in lung transplant recipients. Almost a quarter of the participants were willing to participate of the clinical trial with a universal prophylaxis study design of new azole formulation to mold active azole (Figure 1). The study design arms and the anti-fungals selected for the study arms were the factors that had the most influence in study participation (Figure 2).
## Percentage of Responders Willing to Participate in a Clinical Trial by Universal Study Design

<figure><img src="image_3.png" /></figure>

## Percentage of Responders Willing to Participate in a Clinical Trial by Universal vs. Pre-emptive Study Design

<figure><img src="image_4.png" /></figure>

## Percentage of Responders Willing to Participate in a Clinical Trial by Pre-emptive Study Design

<figure><img src="image_5.png" /></figure>

## Factors Influencing the Participation of Responders in a Clinical Trial

<figure><img src="image_6.png" /></figure>
**Conclusion:** Universal prophylaxis was the most common strategy to prevent invasive mold disease in lung transplant recipients. The majority of the responders were interested in a clinical trial to determine the optimal strategy to prevent mold disease in lung transplant recipients. The study design arms and the anti-fungals selected for the study arms were the factors that had the most influence in study participation.

# Symposium 5 Lung transplantation

## S05.1
Pre-transplant assessment

B. Rammaert¹,²,³

¹Infectious Diseases, CHU Poitiers, Poitiers, France, ²U1070, INSERM, Poitiers, France, ³Faculté De Médecine Et Pharmacie, Université de Poitiers, Poitiers, France

All the three main chronic pulmonary diseases leading to lung transplantation are at risk for fungal respiratory tract colonization: cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), and interstitial lung diseases (ILD). *Aspergillus* and *Scedosporium* species are the two main molds found in the lower respiratory tract of lung transplant candidates. Colonization in CF patients could be explained by impairment of muco-ciliary clearance, and in COPD and ILD patients by use of inhaled or systemic corticosteroids that alter pulmonary immunity. Mortality due to invasive fungal diseases in post-transplantation can reach 60% depending on the causal species. Therefore, fungal colonization of the lower respiratory tract is on the list of relative contraindications for lung transplantation. Although passage from colonization to infection is not well understood, fungal spores could remain quiescent in the lungs, and secondarily reactivate once patients have received immunosuppressive drugs. Donor-derived fungal infection is one of the best examples of this reactivation. Pre-transplant colonization is not considered predictive for fungal invasive disease in post-transplantation. However, the timing and bronchoalveolar lavage protocols for fungal screening in respiratory tract before lung transplantation are heterogeneous between centers. In addition, culture of lower respiratory tract specimens has to be done on specific media such as Sabouraud glucose agar or yeast extract-peptone-dextrose-agar (YPDA), which could miss out on some fungi. Utilization of culture media supplemented with antibiotics has increased the number of CF patients culture-positive for fungi in their respiratory specimens from 18% to 78%. *Scedosporium* specific media such as Scesel+ increase the detection of *Scedosporium* spp. compared to Sabouraud glucose agar. Active screening for fungal colonization during the pre-transplant period is consequentley crucial not only in patients on a waiting list, but also in donors. There is an urgent need for bronchoalveolar lavage and fungal culture standardization in the different mycological laboratories dealing with lower respiratory tract specimens before focusing on pre-transplant fungal colonization.

## S05.5
From the lung to the heart: fatal dissemination of azole-resistant *Aspergillus fumigatus* in a lung transplant patient

R.-A. Lavergne¹,², T. Lepoivre³, T. De Groot⁴, F. Jeddi², D. Boutoille⁵, I. Danner-Boucher⁶, F. Morio¹,², J. Meis⁷, P. Le Pape¹,²

¹Ea1155 Parasitology And Mycology Department, Nantes University, Nantes, France, ²Parasitology And Mycology Laboratory, Nantes University Hospital, Nantes, France, ³Thoracic Transplantation Intensive Care Unit, Nantes University Hospital, Nantes, France, ⁴Medical Microbiology And Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands, ⁵Tropical Infectious Diseases, University Hospital of Nantes, Nantes, France, ⁶Pneumology Unit, Nantes University Hospital, Nantes, France, ⁷Department Of Medical Microbiology And Infectious Diseases, Excellence Center For Medical Mycology (ECMM), Canisius Wilhelmina Hospital, Nijmegen, Netherlands
Azole resistance in *Aspergillus fumigatus* has emerged as a worrisome problem since the last ten years.
Patients suffering from cystic fibrosis (CF) are at risk of being colonized with azole-resistant isolates.
At our CF reference center hospital, prevalence of azole resistance in *A. fumigatus* reached 6.8% in
2015. Though resistance is increasingly described, its impact in CF patients is yet poorly known. Here, we describe the case of a CF patient having long-term colonization of the respiratory tract with a non-*cyp51A* mediated azole-resistant *Aspergillus fumigatus* isolate, prior to lung transplantation. Then, proven azole-resistant invasive aspergillosis and mucormycosis were diagnosed in the first days after transplantation and treated with liposomal amphotericin B. Two years later, azole-resistant *Aspergillus fumigatus* mitral-aortic endocarditis was diagnosed. Despite surgery and multiple antifungal regimens, the patient died with intracerebral hematoma. **Objectives:** The aim of the study was to investigate the genetic relationship between isolates collected at the time of transplantation and those from the native valve. **Methods:** Five isolates were retrospectively investigated for azole susceptibility to itraconazole (ITR), voriconazole (VOR), posaconazole (POS) and isavuconazole (ISA) (EUCAST method). Identification of *A. fumigatus sensu stricto* was confirmed using partial beta-tubulin sequencing. Molecular mechanisms leading to resistance (nucleotide sequencing of *cyp51A* gene and its promotor) and *STRAf* genotypes were determined. **Results:** Two isolates were collected at time of transplantation (bronchial secretion (*n* = 1) and postoperative wound (*n* = 1)) and three isolates were collected during endocarditis episode (respiratory tract (*n* = 2) and mitral valve (*n* = 1)). All isolates were identified as *Aspergillus fumigatus* and were pan-azole resistant (MIC ITR: > 8 mg/L, VOR: 4 to 16 mg/L, POS: 0.5 to 1 mg/L, ISA: 8 to >16 mg/L). Sequencing of the *cyp51A* gene and its promotor (4 isolates) showed wildtype *cyp51A* and promotor. All isolates shared the same *STRAf* genotype (M2: 26-20-8 M3: 35-9-7 M4: 9-10-20) confirming dissemination of this isolate from the lung tissue to the heart. **Conclusion:** This case report highlights the need for regular screening for azole resistance in CF patients especially for those awaiting lung transplantation. Physicians should keep in mind that azole-resistant colonizing isolates could be a possible source of life threatening invasive infection after lung transplantation. Yet, antifungal treatment of *Aspergillus* endocarditis is based on voriconazole or lipid formulation of amphotericin B but no data are available in case of azole-resistant isolate.

# Symposium 6 Prophylaxis during hematology malignancies

## S06.1

### AML—in the era of FLT3 inhibitors

R. Lewis¹,²

¹Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy, ²Department Of Medical And Surgical Sciences, University of Bologna, Bologna, Italy

FLT3 mutations are among the most common genetic mutations in acute myeloid leukemia (AML) associated with increased risk of disease relapse and poorer survival. A number of small molecule tyrosine kinase inhibitors (TKI) of FLT3 signalling have shown promise for reducing relapse of FLT3+ AML. One TKI, midostaurin, received fast-track approval in 2017 for the treatment of FLT3 positive AML on the basis of data demonstrating, for the first time in over 45 years, improved survival compared to standard induction 7+3 (cytarabine/anthracycline) chemotherapy. The use of FLT3 inhibitors, however, is problematic in patients who require antifungal prophylaxis or treatment with triazole antifungals. In general FLT3 inhibitors are extensively metabolized by CYP3A4 to active metabolites with high potency and potential off-target effects. When coadministered with triazoles, FLT3 exposures may increase between 1.3 to 10 fold and alter production of active metabolites essential for FLT3 inhibition or increase off-target effects. Indeed, higher rates of pulmonary toxicity including fatal events, were observed among patients receiving midostarin with azole antifungals. Currently, the midostaurin SmPC does not recommend the co-administration of strong CYP3A4 inhibitors such as voriconazole or posaconazole; although this recommendation is not practical for many patients especially with active fungal disease. Unfortunately, second-generation FLT3 inhibitors currently in clinical studies (e.g., quizartinib) also appear to have similar risks as midostaurin as well as greater risk for dose-limiting myelotoxicity and QTC prolongation. It is clear that striking the balance between optimal antifungal prophylaxis vs. optimal FLT3 inhibition will
become a major challenge in the management of AML in the coming decade. This presentation will discuss the pros and cons of possible strategies for managing drug-drug interactions with FLT3 inhibitors and antifungals in the absence of clearly-defined guidance.

## S06.4

### Baseline CT upon diagnosis of acute leukemia

S. Schwartz

Charité Berlin, Berlin, Germany

Computed tomography (CT) is a routine diagnostic procedure in immunocompromised patients (i.e. patients with long-lasting neutropenia) with suspected fungal pneumonia. Particular radiological appearances of lung infiltrates (e.g. halo-sign) have been associated with lung infections caused by molds and findings have been incorporated into the well acknowledged definitions of invasive fungal infections developed by the EORTC/MSG (1). A conventional chest X-ray is usually performed in immunocompromised patients with fever, but the value of a conventional chest X-ray has been questioned due to its poor diagnostic yield and most recommendations advocate CT (2). A baseline chest CT in asymptomatic patients scheduled for therapies resulting in a profound immunosuppression (e.g. induction chemotherapy for acute leukemia) appears meaningful, but published data about this are limited. In a prospective study, 198 adult patients scheduled for hematopoietic stem cell transplantation or intensive chemotherapy were evaluated with a baseline CT (3). Overall, 72 (36%) patients showed lung abnormalities. Of these, 19 exhibited disease-defining lesions according to the EORTC/MSG definitions (nodules, halo sign, cavitation) and 53 patients showed other abnormalities (most frequently consolidations or ground-glass opacifications). Nine patients in each group were subsequently categorized as having proven or probable invasive mold infections. The risk of developing an invasive pulmonary mold infection was significantly higher among patients with disease-defining lesions according to the EORTC/MSG definitions or, less pronounced, with other abnormalities compared to patients with a normal baseline CT. In another study, 145 baseline CT scans from patients with acute leukemia scheduled for their first induction therapy were assessed retrospectively (4). Remarkably, the majority of baseline CT scans disclosed abnormalities (127; 88%) with nodules in 71 (49%) patients. Cavitations or lesions with a halo- or an air-crescent-sign were not present in this patient series. However, an independent radiological review and results from a comprehensive diagnostic evaluation were not available from this study. The high frequency of lung lesions at baseline, including disease-defining lesions associated with invasive mold infections, in patients scheduled for intensive chemotherapy or hematopoietic stem cell transplantation is striking. A baseline CT scan in these patients appears reasonable, but the overall benefit of this diagnostic approach in asymptomatic patients should be explored further in future studies. It would be desirable to evaluate in more detail other underlying, infectious/non-fungal and non-infectious, conditions (e.g. opacities associated with hyperleukocytosis) associated with lung lesions (5). **Literature 1.** de Pauw B, et al. Clin Infect Dis 2008;46(12): 1813–21. 2. Maschmeyer G. Curr Opin Oncol 2001;13: 229-35. 3. Ceesay MM, et al. Br J Haematol 2018;182: 723–27. 4. Vallipuram J, et al. Leuk Lymphoma 2017;58: 834–41. 5. Stefanski M, et al. Medicine 2016;95: e5285.

## S06.5

### Investigating the impact of posaconazole prophylaxis on systematic fungal screening using galactomannan antigen, Aspergillus qPCR and Mucorales qPCR.

A.-P. Bellanger¹, N. Tatoyan¹, A. Berceanu², H. Gbaguidi-Haore³, T. Monnot⁴, D. Bichard⁴, L. Millon¹

¹Mycology, University Hospital Jean Minjoz, Besancon, France, ²Hematology, University Hospital Jean Minjoz, BESANCON, France, ³Infectious Risk Control, University Hospital Jean Minjoz, BESANCON, France, ⁴Pharmacy, University Hospital Jean Minjoz, BESANCON, France

**Objectives:** At the University Hospital of Besancon, a systematic panel of fungal biomarkers is applied systematically to screen for invasive fungal infection (IFI) highly immunocompromised patients of the Hematology Department. This panel of biomarkers does include the galactomannan antigen (GM), Aspergillus qPCR and Mucorales qPCR. Most of the stem cell transplant (SCT)
recipients receive now posaconazole prophylaxis. The pertinence of systematic fungal screening has been discussed in the literature for patients under active antifungal prophylaxis, especially the realization of the GM. In this context, our main objective was to investigate retrospectively if the posaconazole prophylaxis influenced the numeric value of the GM. Our secondary aims were to assess the contribution of Aspergillus qPCR and Mucorales qPCR as well as the prevalence of IFI under active antifungal prophylaxis.

**Methods:** The results of systematic fungal screening (GM, Aspergillus and Mucorales qPCR) were collected for all the SCT recipients, treated with posaconazole as prophylaxis treatment for more than 8 days, from January 2015 to December 2016. Similarly, results of systematic fungal screening were collected for patients without posaconazole as prophylaxis treatment (induction chemotherapy- January 2010 to December 2015). The statistical analysis of data was performed using the Stata 2 software.

**Results:** For the group of patients receiving posaconazole prophylaxis: 60 patients were included, with a mean period of prophylaxis of 107 days and a total 916 fungal screenings. The mean value of the GM was 0.17 (±0.32), the frequency of positive GM was 4.37%, the frequency of positive Aspergillus qPCR was 0.68% and the frequency of positive Mucorales qPCR was 3.66%. The frequency of IFI in this group was estimated at 5%. For the control group: 38 patients were included with a total of 392 fungal screenings. The mean value of the GM was 0.22 (±0.64), the frequency of positive GM was 5.61%, the frequency of positive Aspergillus qPCR was 12.35% and the frequency of positive Mucorales qPCR was 5.33%. The frequency of IFI in this group was estimated at 13%. The statistical analysis showed that posaconazole prophylaxis did not affect significantly neither the numeric value nor the frequency of positivity of the GM. A significant decrease of the frequency of positive Aspergillus qPCR was observed (0.68 *vs* 12.35, *p* = 0.015). A tendency of decreased frequency of IFI was also observed (5% *vs* 13%, *p* = 0.076).

**Conclusion:** Our study did not demonstrate any negative effect of the posaconazole prophylaxis on the GM. This study highlights the high efficacy of the posaconazole prophylaxis, especially when using the tablet form, which was supported by a significant decreased frequency of positive Aspergillus qPCR and relatively lower frequency of IFI. The current screening strategy combining GM and fungal qPCRs is of high interest, even if the posaconazole prophylaxis is efficient, in a context of emerging infection with azole resistant strains of *Aspergillus fumigatus* and risk of *A. fumigatus* - Mucorales mixed infections.

Symposium 7 Paediatric Mycology (EPMYN)

S07.5

**Isavuconazole use in pediatric hematoncologic patients: the Italian Association of Pediatric Hematology Oncology (AIEOP) experience**

N. Decembrino¹, K. Perruccio², A. Colombini³, E. Calore⁴, P. Muggeo⁵, E. Soncini⁶, A. Comelli⁷, M. Molinaro⁸, B.M. Goffredo⁹, S. De Gregori⁸, I. Giardini⁸, S. Cairoli⁹, L. Scudeller¹⁰, M. Zecca¹, S. Cesaro¹¹

¹Pediatric Hematology/oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Pavia, Italy,
²Division of Pediatric Hematology, University Hospital of Perugia, Perugia, Italy,
³Pediatric Hematology/oncology, Fondazione Monza e Brianza per il Bambino e la Mamma, Monza, Monza, Italy,
⁴Clinic Of Pediatric Hemato- Oncology, Department Of Women's And Children's Health, University Hospital of Padova, Padova, Italy, Padova, Japan,
⁵Department Of Pediatric Oncology And Hematology, University Hospital of Policlinico, Bari, Italy, Bari, Italy,
⁶Pediatric Hematology/oncology, Spedali Civili, Brescia, Italy, Brescia, Italy,
⁷Department Of Infectious And Tropical Diseases, Spedali Civili, Brescia, Italy, Brescia, Italy,
⁸Clinical And Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Pavia, Italy,
⁹Metabolic Pathology Lab, Ospedale Pediatrico Bambino Gesù, Roma, Roma, Italy,
¹⁰Clinical Epidemiology And Biometric Unit, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Pavia, Italy,
¹¹Pediatric Hematology/oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy,
Verona, Italy
**Objectives:** Isavuconazole (ISA) is a new triazole approved for invasive aspergillosis and mucormycoses treatment in adults only. Advantages are activity against both moulds and yeasts spp, excellent bioavailability after oral administration without relevant food or gastric pH effect, a water-soluble prodrug without nephrotoxic excipients, poor drug-drug interactions. We analyzed ISA use, safety and efficacy in immunocompromised children.

**Methods:** Italian Association Paediatric Hematology Oncology (AIEOP) multicentric retrospective analysis of pediatric hematoncologic patients who received ISA asinvasive fungal disease (IFD) treatment or prophylaxis. Due to the lack of recommended dosing in children and of PK/PD target value, therapeutic monitoring (TDM) was applied by a validated liquid chromatography-tandem mass spectrometry (HLPC-MS/MS) assay technique. ISA trough plasma concentrations (C0) and 3 hours after drug intake (C3h) were measured.

**Results:** Twenty-nine patients were included, (M/F 20/9); median age: 14.5 years (range 3–18), median bodyweight 47 kg (range 15–80). Ten patients only received chemotherapy, 19 patients received allogeneic hematopoietic stem cell transplantation (HSCT). Donors were haploidentical in 9 patients, matched-sibling in 4, allogenic-unrelated in 4 cases. ISA was used as prophylaxis in 5 patients, as IFD treatment in 24 cases: 20 for previous therapeutic failure (7 L-AMB, 4 Voriconazole, 5 combination therapy, 1 Posaconazole, 3 Caspofungin), 4 as first line therapy. According to EORTC criteria, IFD was proven in 5 patients (1 *Aspergillus* spp, 1 *Aspergillus flavus*, 1 *Aspergillus fumigatus*, 1 *Penicillium* spp. and 1 *Mucor* spp), probable in 9 and possible in 10 patients. Lungs were the main localization (18 cases), liver was involved in 2 cases, 3 patients had sinus involvement (2 with central nervous system localizations), 1 had a disseminated infection. Patients under 30 kg bodyweight received half ISA dose, the others received adult schedule (200 mg TID loading dose on days 1 and 2, 200 mg/die maintenance); only 13 patients received loading dose. Ten patients only received oral therapy, in the others IV route was switched to oral during treatment. ISA was administered for a median of 75.5 days (range 6–523 day), in combination with other antifungals in 7 patients (Caspofungin in 3 cases, L-AMB in 4). Overall response rate was 70.8%. IFD complete remission was achieved in 12 cases, partial remission in 5. Treatment failure was experienced by 5 patients, in 3 cases fungal lesions remained stable. No breakthrough infections were registered in prophylaxis group. TDM was applied to 17 patients including 1 with severe veno-occlusive disease and 1 with renal failure secondary to thrombotic-microngiopathy. Overall median ISA Cthroughss concentration observed was 4.91 mg/L (2.15–8.54); Conc/Dose (kg) ratio was 1.13 (0.47–3.42). In 6 cases a 12h-PK profile was carried out and median AUC0–12h of 153,16 mgxh/L (range 86.31–169.45) was obtained. CTAE grade II-III toxicity was observed in 6 patients, with increased transaminase and/or creatinine levels which resolved after temporary ISA withdrawal. We did not observe drug-drug interactions in the patients receiving immunosuppressant as graft versus host disease prophylaxis (5 cyclosporine, 2 sirolimus, 1 tacrolimus).

**Conclusion:** Isavuconazole may be useful and safe in the pediatric population with hematoncologic diseases, even in the HSCT setting. Prospective studies are warranted.

# Symposium 8 Immunologic markers for diagnosis and treatment stratification in invasive mold infection

S08.3

## Immunologic Markers for Treatment Stratification in Invasive Mold Infection

P. Köhler

Department I Of Internal Medicine, University Hospital of Cologne, Cologne, Germany
The two major entities, invasive aspergillosis and mucormycosis account for the majority of fungal mould infections in haematology and oncology. With increased hospital admission rates and admission to intensive care unit and high morbidity and mortality the need for prompt identification and outcome prediction is needed. Current in vitro diagnostic approaches comprise direct observation of fungi in biopsy or bronchoalveolar lavage samples, blood cultures and detection of diagnostic antigens such as galactomannan. New immunologic markers for diagnosis and treatment
stratification have been recently published. Fungus-reactive CD4 T cells, interleukin profiling and inflammation parameters will be discussed with regard to treatment stratification depending of response of invasive mould infections. Possible developments could lead to algorithms incorporating measurement of these biomarkers at admission and throughout initial treatment for the purpose of identifying patients who warrant more aggressive treatment.

## S08.4

### Fungal Translocation: from persistent inflammation to non-AIDS events

M. Hoenig¹,²

¹Division Of Infectious Diseases, Department of Medicine, UCSD, San Diego, United States of America, ²Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria

**Abstract:** 1,3-β-D-glucan is a fungal cell wall polysaccharide produced by ascomycete fungi including Candida albicans and other yeast that colonize the GI tract. Recently we and others have shown that in the absence of an invasive fungal infection blood 1,3-β-D-glucan levels may serve as a marker of microbial translocation in patient populations with hypoperfusion of the gut and those with persistent inflammation, including patients with advanced liver cirrhosis, sepsis or HIV infection, where blood 1,3 β-D-glucan have been shown to be elevated compared to HIV negative controls and to correlate with other biomarkers of microbial translocation, with markers of immune activation and with lower Lactobacillales proportion (i.e. less protective) in the gut microbiome. In animal models 1,3-β-D-glucan has been shown to decrease Dectin-1 (innate pattern recognition receptor essential for the control of fungal infections), and also NKp30 (NK receptor mediates direct fungal recognition and killing) on monocytes and NK cells respectively, and induced pro-inflammatory cytokines secretion, indicating a potential role in pathogenesis of clinical events. Going one step further, studies have shown clear correlations between blood 1,3-β-D-glucan levels and non-AIDS events, including cardiopulmonary morbidity, and neurocognitive impairment. Only few studies to date have evaluated a potential benefit of antifungal treatment for tackling fungal translocation and reducing blood 1,3-β-D-glucan levels. In vitro model of mixed rat neuronal cultures that screened more than 2000 compounds, half of which were US Food and Drug Administration approved drugs for putative neuroprotective effects against oxidative stress-mediated neuronal injury not only paroxetine, a selective serotonin reuptake inhibitor, but also fluconazole, protected hippocampal neurons. In another study, the combination of paroxetine and fluconazole protected macaques from simian immunodeficiency virus-associated neurodegeneration. However, a phase 1/2, randomized, double-blind, placebo-controlled study for the treatment of HIV-associated neurocognitive impairment did not show an improvement of neurocognitive outcomes among the 9 participants randomized to fluconazole treatment alone, indicating that more research and larger studies are needed on how to prevent/treat fungal translocation.

## S08.5

### Immunological characteristics of Broncho alveolar lavage in neutropenic patients with invasive aspergillosis

C. Aguilar¹, S. Moshkelgosha², W. Gohir¹, K. Yee³, A. Schimmer³, M. Minden³, A. Schuh³, C. Ryan⁴, S. Juvet², S. Husain¹

¹Transplant Infectious Diseases, University Health Network, Toronto, Canada, ²Lung Transplant Program, University Health Network, Toronto, Canada, ³Hematology Department, University Health Network, Toronto, Canada, ⁴Respirology, University Health Network, Toronto, Canada

**Objectives:** Invasive aspergillosis (IA) is a major complication in patients with acute leukemia receiving high dose chemotherapy. Diagnosis of IA classically relies on radiological criteria associated with direct and/or indirect microbiological tests, which have some limitations. some limitations. Antifungal immunity involves phagocytic cells including neutrophils and macrophages, as well a dendritic cells presenting antigen to T-CD4+ T cells. Antigen presentation leads to differentiation of CD4+ T cells into Th1 and Th17 cells, under the influence of cytokinic environment.
Those cells secrete cytokines and amplify effector functions of phagocytic cells in order to kill the fungus. The triggering of those mechanisms relies on the recognition of fungal patterns by receptors of innate immunity, both soluble (such as PTX-3) and membrane bound (such as Dectin-1 and Dectin-2). In this study we aimed to assess the immunological parameters of broncho alveolar lavage (BAL) fluid of neutropenic patients with or without IA.

**Methods:** We included acute myeloid leukemia patients who were neutropenic after receiving high dose chemotherapy and who underwent a bronchoscopy for diagnosis of pneumonia. Ten milliliters of BAL fluid were collected for the research study. Supernatant and cell pellet were separated and frozen until use. The level of 35 cytokines (EGF, Eotaxin, FGF basic, G-CSF, GM-CSF, HGF, IFN-α, IFN-γ, IL1-ra, IL-1α, IL1-β, IL-2, IL-2r, IL-3, IL-4, IL-5, IL-6, IL-7, IL-7, IL-8, IL-9, IL-10, IL-12 (p40/p70), IL-13, IL-15, IL-17A, IL-17F, IL-22, IP-10, MCP-1/CCL2- MIG, MIP-α, RANTES, TNF-α, and VEGF) was measured in BAL supernatant using Luminex technology. PTX-3 level in BAL supernatant was measured by Enzyme-linked immunosorbent assay. The cell pellet was analyzed by flow cytometry for expression of CD45, CD206, CD163, Dectin-1 and Dectin-2.

**Results:** Forty three patients were included in the study. Seven patients were diagnosed with probable IA and 20 with possible IA. One patient had mucormycosis diagnosed on lung biopsy and 1 patient had fusariosis. While PTX-3 level was not significantly different in patients with probable IA compared to patients without IA, IL-6, IL-8 and GM-CSF levels were higher in patients with probable IA compared to patients without invasive fungal infection. Flow cytometry could be performed on 31 BAL cell pellets. The proportion of alveolar macrophages (CD163⁺ CD206⁺) among CD45 positive cells was similar in all groups. Dectin-1 and Dectin-2 expression on alveolar macrophages (CD163⁺ CD206⁺ cells) was similar in patients with and without invasive fungal infection.

**Conclusion:** Neutropenic patients with probable IA exhibit higher IL-8, IL-6 and GM-CSF levels in BAL supernatant compared to neutropenic patients without any fungal infection. The cellular expression of membranar receptors Dectin-1 and Dectin-2, as well as the level of soluble PTX-3 were not significantly modified in patients with IA. Further studies are needed to assess the role of immunological parameters, especially cytokines profile, in the panel of tests used for the diagnosis of IA in immunocompromised patients.

# Symposium 9 Chronic Pulmonary Aspergillosis

## S09.2

### Diagnosis of CPA. Where do we stand?

#### A. Barac

Clinic for Infectious and Tropical Diseases, Clinical Center of Serbia, Belgrade, Serbia

**Abstract:** Chronic pulmonary aspergillosis (CPA) is an uncommon, slowly destructive pulmonary disease characterized by progressive cavitation, fibrosis, and pleural thickening. CPA is usually seen in immunocompetent individuals with underlying respiratory disorders. Estimates suggest that up to 3 million people are affected worldwide causing high rates of morbidity and mortality. Diagnosis of CPA is often challenging and delayed and should be based upon a combination of characteristics. Patients are present with indolent, non-specific symptoms such as fatigue, weight loss, sweats, cough, dyspnea, or hemoptysis. The disease often remains undiagnosed for years, resulting in progression. A high index of suspicion is required in patients with predisposing factors such as previous tuberculosis (TB) with residual cavities, severe chronic obstructive pulmonary disease, previous treatment for lung cancer, or nontuberculous mycobacteria. The most important diagnostic finding is changes on chest imaging, usually CT scan. The most common presentation is one or more cavities, characteristically with an irregular or thick wall, but occasionally thin-walled, with or without intracavitary material or well-formed aspergilloma. Cavities tend to affect the upper lobes and often cause para-cavitary or adjacent pleural fibrosis. In early stages, nodules may be present, which may develop into cavitary disease over time. Differential diagnosis includes mycobacterial infection, bacterial abscess, cancer, or vasculitis. Expertise of the reporting radiologist is essential in
highlighting the possibility of CPA. In addition to compatible radiological findings, microbiological and/or serological evidence of Aspergillus infection is required, in addition to ruling out alternative diagnoses. Direct microscopy for hyphae, fungal culture of respiratory secretions and histology are all recommended for diagnosis of CPA. Sensitivity of sputum or bronchoalveolar lavage (BAL) culture remains moderate at best, even when specific fungal media are used. Culturing a higher volume of sputum may lead to increased sensitivity. Sensitivity is significantly higher with the high-volume culture, which in addition detected azole-resistant isolates that could be missed with conventional culture. When microscopy and cultures are negative, molecular markers like Aspergillus polymerase chain reaction (PCR), as well as beta D-glucan, galactomannan (GM) testing in BAL samples can be used to increase sensitivity. In addition, using these tests in combination may result in better PPV. The usefulness of testing GM in sputum is not clear in a cohort of patients with CPA and ABPA. Therefore, sputum GM cannot be recommended for the diagnosis of CPA at present. Serological methods can contribute to the diagnosis of CPA. Aspergillus precipitins were used previously but have been supplanted by more sensitive serologic assays. Several assays detecting Aspergillus-specific immunoglobulin G (IgG) are commercially available. In summary, clinical and radiological findings, along with microbiological and serological tests are used in combination to diagnose CPA. There is no individual reference-standard test as all tests are characterized by suboptimal sensitivity and specificity. A high index of suspicion is needed, along with the need to rule out alternative diagnoses like TB or lung cancer.

S09.5

## Raised amphotericin B MIC in *Aspergillus fumigatus* isolates from patients with Chronic Pulmonary Aspergillosis

F. Lynch<sup>1,2</sup>, C. Moore<sup>2,3</sup>, R. Rautemaa-Richardson<sup>1,2,4</sup>

<sup>1</sup>Infectious Diseases, Manchester University NHS Foundation Trust, Manchester, United Kingdom,
<sup>2</sup>National Aspergillosis Centre, Manchester, United Kingdom, 
<sup>3</sup>Mycology Reference Centre, Manchester, Manchester University NHS Foundation Trust, Manchester, United Kingdom, 
<sup>4</sup>Division Of Infection, Immunity And Respiratory Medicine, University of Manchester, Manchester, United Kingdom

**Objectives:** Chronic pulmonary aspergillosis (CPA) is a fungal infection of the lung caused by *Aspergillus* species, which usually affects patients with an underlying respiratory condition. The mainstay of treatment is prolonged antifungal therapy to improve symptoms and prevent disease progression. *Aspergillus fumigatus* with elevated minimum inhibitory concentrations (MIC) for amphotericin B (AMB) have been isolated. The aim of this study is to investigate the emergence and clinical relevance of elevated AMB MICs in *A. fumigatus*.

**Methods:** Patients with CPA reported with AMB resistant (MIC > 4 mg/L) *A. fumigatus* were identified from the Mycology Reference Centre Manchester databases. All *A. fumigatus* isolates reported from these patients were included in the analyses. The date of sampling and resistance patterns of the isolates were analysed against the antifungal history of each patient. EUCAST antifungal breakpoints were used to determine sensitivity. Clinic letters and dispensing records were used to determine medical history, antifungal therapy and clinical outcomes.

**Results:** Nine patients reported with one or more AMB resistant *A. fumigatus* isolates and a total of 148 isolates from these patients were identified. Of the isolates, 34 (22%) were resistant to AMB; 13 (38%) had an MIC of 4 mg/L, five (15%) had an MIC of 8 mg/L and 16 (47%) had an MIC of >8 mg/L. In addition, 18 (12%) isolates were reported as intermediate to AMB (MIC = 2 mg/L). Five of the nine patients had prior exposure to AMB (IV AmBisome). Patients received 3-5 mg/kg once daily and different treatment regimens were used; one patient had one 3-week course, two patients had two 3-week courses and two patients received long term therapy three times weekly (for up to 3 years). Four patients had no exposure to AMB. Of the 5 patients exposed to AMB, 4 developed resistance during therapy, and 1 patient first showed resistance 5 years after their 3-week course. All patients had prior azole exposure, and the duration of azole exposure prior to AMB resistance was from 8 months to 5 years. All AMB resistant isolates showed some level of azole resistance and 27 (82%)
were pan-azole resistant. Example patient timeline

## Patient 3

<figure><img src="image_7.png" /></figure>

**Conclusion:** All patients reported with *A. fumigatus* with elevated MIC for AMB had previously been treated with azole antifungals and developed resistance against one or more azoles. Many AMB resistant isolates were pan-azole resistant suggesting a link between AMB and azole resistance. Antifungal drug resistance can have significant implications on patient care due to limited treatment options. A better understanding of the development, genetic mechanism, and clinical relevance of AMB resistance is needed. Therefore, all isolates identified in this study will next be sequenced and typed.

# Symposium 10 Symposium 10 Sensing the host

## S10.2

### Hybrid histidine kinases: major sensing proteins in pathogenic fungi

N. Papon¹, S. Kabbara¹, A. Hérivaux¹, B. Bidon¹, J. Kilani¹, Y. Le Govic¹, A. Gastebois¹, T. Dugé De Bernonville², M. Clastre², V. Courdavault², S. Le Gal¹, G. Nevez¹, J.-P. Bouchara¹

¹Host-Pathogen Interaction Study Group, SFR ICAT 4208, Univ Angers, Univ Brest, University Hospital Center, Angers, France, ²Ea2106 "biomolécules Et Biotechnologies Végétales", Université de Tours, Tours, France

Protein phosphorylation is one of the most extensively used modifications in signal transduction pathways in both prokaryotic and eukaryotic cells. Prominent families of enzymes that perform these protein phosphorylations encompass serine/threonine kinases, tyrosine kinases, and histidine kinases (HKs). While HKs dominate prokaryotic signaling pathways, they are less prevalent in eukaryotes, and most importantly, absent in animals. Historically, a small number of eukaryotic HKs have been studied in plants, yeasts, filamentous fungi, and slime molds. Recent studies have expanded characterization of HKs in other eukaryotic lineages and archaea, allowing a broader assessment of the types of signaling systems mediated by HKs, their phylogenetic distribution and evolution. HKs are central to regulatory systems that impact agriculture, the environment, and both beneficial and pathogenic interactions of microbes with humans and other animals. Their great diversity, versatility, and broad distribution make them attractive targets for therapeutics, biotechnological interventions, and also as building blocks for engineered biosensor systems. From a structural perspective, fungal HKs are commonly composed of three main regions. The first region referred to as the "sensing domain" corresponds to a highly variable N-terminal sequence that determines the stimulus perceived. The central "transmitter region" is made of two conserved domains: a dimerization histidine phosphotransfer (DHp) domain and a catalytic ATP-binding (CA) domain. The DHp domain includes an H-box, usually containing the phosphorylatable histidine residue, and an X-box. The CA subdomain includes four distinct sequence motifs: the N-, G1-, F-, and G2-boxes. In contrast to prokaryotic HKs, most eukaryotic HKs harbor an additional C-terminal receiver domain (REC) that includes a phosphorylatable aspartate residue. Thus, eukaryotic HKs are
generally called "hybrid HKs" (HHKs). From a mechanistic point of view, HHKs constitute in fungal cells the initial sensing proteins of a four-step phosphorelay signaling pathway involving phosphorylation events of two downstream effectors, *i.e.* histidine phosphotransfer shuttle proteins (Hpts) and response regulators (RRs) (Figure 1). The perception of a stimulus induces the trans-autophosphorylation of a conserved His residue in the DHp domain by the CA catalytic part of the HHK. The phosphate of this histidine is then transferred to the conserved Asp residue in the REC domain prior to transfer to the Hpt domain, and finally to the conserved aspartate residue of the protein belonging to the RR family. The phosphorylation state of this RR orchestrates subsequent molecular events underlying the response to the input signal.

<figure><img src="image_8.png" /><figcaption>**Figure 1.** Multi-step phosphorelay involving HHKs in fungi. The perception of a stimulus induces the autophosphorylation of a conserved His residue in the DHp domain by the CA catalytic part of the HHK. The phosphate is then transferred to a conserved Asp residue in the REC domain prior to transfer to the Hpt, and finally to the conserved aspartate residue of the protein belonging to the RR family. The phosphorylation state of this RR orchestrates subsequent molecular events that constitute the response to the input signal.</figcaption></figure>

Here, we review the distinct genetic approaches carried out over the last fifteen years and that allowed the elucidation of the function of several HKs in prominent fungal pathogens. However, because their roles in regulating fundamental cellular processes are still largely obscure in fungi, we will discuss the major challenges that remain to improve our knowledge about the function of HKs in fungi and to design specific inhibitors for future therapeutic development.

S10.5

The analysis on the genes related to the biofilm formation of *Candida glabrata*

X. Chen¹, T.W. Widiyanto¹, H. Chibana2, S. Kajiwara1

1School Of Life Science And Technology, Tokyo Institute of Technology, Yokohama, Japan, 2Medical
Mycology Research Center, Chiba University, Chiba, Japan

Objectives: Candida glabrata is capable of developing biofilm on the surface of host cells and medical materials. The biofilm formation is considered as one of pathogenic factors on infection to the host, which shows increase in the resistance to antifungals and host immune defense compared to the planktonic cells. Until now, the mechanism of biofilm formation of C. glabrata has not been studied well compared with C. albicans. Therefore, the aim of our study was to isolate and characterize some genes related with the biofilm formation of C. glabrata. Methods: The in vitro model of biofilm formation was constructed by using multi-well plates and the metabolic activity were detected by XTT assay. The susceptibility of biofilm formation was also detected towards different antifungals. Gene expression was analyzed by qPCR. Vacuolar morphology was observed by staining with FM4-64 fluorescent dye. The growth fitness was detected in buffered media with different pH and intracellular pH was measured with flow cytometry. Results: Upon the result of a genetic comprehensive screening by using C. glabrata mutant library, two gene mutants decreased metabolic activity of biofilms drastically and the transcriptional expressions of these two genes in biofilm formation showed more than two times higher than those of planktonic cell growth. One gene showed high homology with Saccharomyces cerevisiae SYN8 gene, then was named as CgSYN8. S. cerevisiae Syn8p was identified as a SNARE protein, acting in membrane fusion of vesicles. C. glabrata syn8Δ mutant was defective in both the metabolic activity and the biomass of the biofilm. Deletion of SYN8 also led to decrease in the adhesion ability during the biofilm formation, which may link to the repression of two adhesin genes, EPA10 and EPA22. Additionally, C. glabrata syn8Δ mutant revealed the abnormal vacuolar morphology. Therefore, it was suggested Syn8p is not only required for the normal vacuolar function but also influence the biofilm formation of C. glabrata. Another gene related to the biofilm formation of C. glabrata was named as CgQDR2. QDR (quinidine
drug resistance) family genes in S. cerevisiae belong to MFS (Major Facilitator Superfamily) transporters, which mediate the ability of membrane transport to actively efflux the drug out of the cell. C. glabrata qdr2Δ mutant exhibited significant reduction in the biofilm formation and fluconazole drug susceptibility during biofilm formation. In addition, our results suggested QDR2 deletion caused an impaired ability of C. glabrata to maintain pH homeostasis, then might lead to the reduction of cell growth at neutral-basic pH conditions. These results may explain how the QDR2 gene affect the biofilm susceptibility and drug efflux towards antifungal drugs in C. glabrata. Conclusion: CgSYN8 and CgQDR2 were suggested to be involved in biofilm formation of C. glabrata. These findings provide more understanding on the biofilm formation of this fungus and more information for the development of clinical treatment in future.

# Symposium 12 Environment & fungal outbreaks

## S12.1

**'Once is a misfortune, twice is carelessness...': Lessons to be learnt from pandemic fungal infections of amphibians**

M. Fisher

Department Of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom

**Abstract:** Discovering that chytrid fungi cause the disease chytridiomycosis in amphibians represented a paradigm shift in our understanding of how emerging infectious diseases contribute to global patterns of biodiversity loss. In this lecture I describe how the use of multidisciplinary biological approaches has been essential to pinpoint the origins of pathogenic chytrids, to time their emergence and pathways of spread and to identify the core mechanisms that underpin their pathogenicity. I will discuss the potential for using bioinformatics toolkits and experimental methods to allow a fuller understanding of these chytrids biology in order to leverage emerging technologies aimed at their control. The impacts of infectious diseases in wild populations are not restricted to wild animals and plants; they also threaten public health through the attrition of ecosystem services as well acting as reservoirs and amplifiers of disease inocula. I will argue that the lessons learnt from tracking amphibian chytrid fungi are also of relevance to understanding and tackling emerging patterns of fungal disease in humans. Paraphrasing Oscar Wilde, 'to allow one fungal pandemic is misfortune, to allow two is carelessness, to allow three...'.

## S12.2

**_The Cryptococcus gattii_ species complex**

F. Hagen¹,²,³

¹Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands, ²Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands, ³Department Of Dermatology, Jining No. 1 People's Hospital, Jining, China

**Abstract:** The *Cryptococcus gattii* species complex placed itself in the spotlights of the medical mycology community with the unprecedented and ongoing outbreak that emerged in the temperate climate of Vancouver Island (British Columbia, Canada) during the late 1990s. A few years thereafter the outbreak was found to have spread to the Canadian mainland and the Pacific Northwest of the U.S.A. This pathogenic yeast, at that time named *Cryptococcus neoformans* variety *gattii*, was mostly known as being a tropical or subtropical pathogen that caused disease among apparently immunocompetent subjects. It was observed that the outbreak in Canada and the U.S.A. was due to an until then rare genotype named AFLP6/VGII, mostly known from Australia and the South American continents. Subsequent molecular typing showed that the outbreak was caused by a major (AFLP6A/VGIIa) and a minor (AFLP6B/VGIIb) genotype that had different virulence properties. In 2002 C. neoformans variety *gattii* was raised to species level as *Cryptococcus gattii*. Using several molecular techniques five lineages were recognized, nowadays known as molecular types (genotypes) VGI (AFLP4), VGII (AFLP6), VGIII (AFLP5) and VGIV (AFLP7), the fifth lineage is
extremely rare and known as genotype AFLP10/VGIIIc. Although *C. gattii* was just proposed as being a separate species, the debate was already ongoing whether or not to further differentiate it into more species related to the molecular defined lineages. A further refinement for a taxonomic revision was supported by the availability of more molecular, phenotypic, antifungal sensitivity, geographic distribution and predilection for certain hosts. In 2015 a proposal was made to raise the five lineages to species level: *C. gattii sensu stricto* (AFLP4/VGI), *C. bacillisporus* (AFLP5/VGIII), *C. deuterogattii* (AFLP6/VGII), *C. tetragattii* (AFLP7/VGIV) and *C. decagattii* (AFLP10/VGIIIc). Due to the outbreak with *C. deuterogattii* in North America most of the focus was on this species, but what do we know about the other members of the *C. gattii* species complex in terms of environmental distribution and clinical relevance?

S12.4

**Whole genome sequencing: a valuable tool to study outbreaks due to uncommon yeast species**

M. Desnos-Ollivier

National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, CNRS UMR2000, Institut Pasteur, Paris, France

**Abstract:** Rapid genotyping tools such as Multi Locus Sequence Typing (MLST) and Variable Number Tandem Repeat (VNTR) are frequently used for common yeast species involved in invasive human infection (Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, Pichia kudriavzevii, Cryptococcus neoformans/gattii complex). These methods are very useful to determine potential link between clinical and/or environmental isolates but implementation/validation requires a large number of unrelated isolates. Grouped-cases of infection or colonization due to uncommon or emerging pathogenic yeast species are usually considered to be due to a single strain. Since there is no genotyping method for these uncommon species and considering that origin of the infection can be endogenous and/or exogenous, this hypothesis should be verified. Whole genome sequencing (WGS) has become relatively simple, fast and inexpensive but analysis remains time-consuming and requires bioinformatic expertise. Since 2012 and the first French outbreak due to Saprochaete clavata, we started using WGS to study relationship between isolates involved in grouped cases and belonging to uncommon yeast species. Different approaches involving different parts of the genome can be considered. For S. clavata, alignment of whole genome allowed to identify different clades, one of which was responsible for the national epidemic with specific Single Nucleotide Polymorphism positions (SNP). Then, some SNPs were selected to design a real time PCR with allele-specific oligonucleotide (ASO) which allowed us to rapidly detect isolate belonging to the epidemic clade. Another approach was the use of WGS data of Yarrowia lipoytica to identify intergenic regions highly polymorphic and usable as molecular tool. Finally, the alignment of SNPs positions localized all over the genome was used to study genomic diversity of Trichosporon asahii and Magnusiomyces capitatus population. Although the presence of a rare species in several patients in the same hospital over a short period of time suggest a common source of infection, this is not always the case especially for species that are supposed to be part of the normal biota of skin and/or gastrointestinal tract. Our data confirm the importance of data and isolate centralization in a Reference Laboratory for molecular epidemiology. The routine WGS as a typing method for uncommon yeasts requires prior validation with varied sampling together with bioinformatics experts and mycologists to avoid misinterpretation.

S12.5

**Outbreak of fluconazole-resistant *Candida parapsilosis* in a hospital ward: arguments for clonal transmission and environmental persistence**

A. Fekkar<fnref n="1" />,², A. Bougle³, A.C. Normand<fnref n="1" />, M. Palous<fnref n="1" />, R. Piarroux<fnref n="1" />, S. Imbert<fnref n="1" />

<footnote n="1">¹Laboratoire De Parasitologie-mycologie, APHP La Pitié Salpétrière, PARIS, France, ²Sorbonne Université, Inserm, CNRS, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, F-75013, PARIS, France, ³Réanimation Chirurgie Cardiaque, La Pitie Salpetriere Hospital, Paris, France</footnote>
**Objectives:** The emergence of multidrug-resistant fungal agent is a threat for human health. In recent years, breakthroughs of infections due to fluconazole-resistant *Candida parapsilosis* isolates have been increasingly reported in different countries. We have recently faced with invasive infections due to resistant isolates and have decided to further investigate this phenomenon.

**Methods:** We conducted a monocentric study at La Pitié-Salpêtrière Hospital, a tertiary care center in Paris, France. All *Candida parapsilosis* isolates collected between January 2012 and April 2019 for which sensitivity to antifungal agents had been determined were analyzed. Antifungal susceptibility testing was performed using Etest (Biomerieux) method and confirmed according the EUCAST broth microdilution reference method. Minimal Inhibitory Concentrations were determined for azoles drugs (i.e. fluconazole, itraconazole, voriconazole, posaconazole and isavuconazole). For fluconazole resistant isolates and a random selection of susceptible isolates, the *erg11* gene was sequenced and isolates were genotyped by a microsatellite method based on 6 markers.

**Results:** 193 isolates (193 patients) sampled between 2012 and 2019 were analyzed. We observed an increase of fluconazole resistance rate among *Candida parapsilosis* isolates (MIC > = 8 µg/mL) between the periods 2012-2016 (3/97, 3.1%) and January 2017-April 2019 (10/96, 10.4%) (p<0.05 by Fisher's Exact test) : three fluconazole-resistant isolates were detected in 2012-2013, none in 2014-2016 and 10 between January 2017 and April 2019. All the resistant isolates presented the previously described A395T mutation in the *erg11* gene that confers the amino acid change Y132F. This mutation was absent in azole-sensitive isolates. Genotyping showed 4 different microsatellite profiles for resistant isolates (R1, R2, R3 and R4) while susceptible isolates were not related each other's and showed a greater diversity (Figure 1).

<figure><img src="image_9.png" /></figure>

Two resistant clusters (R1 and R3) were related to grouped cases in a single intensive care unit (ICU). Isolates belonging to the R3 profile (n = 7) were detected since November 2017, were responsible of 7 deep infections and presented the highest MICs to fluconazole (> 64 mg/L) and a cross resistance with voriconazole (MIC > 0.5 mg/L). Epidemiological and chronological analyses furnish clues for a patient-to-patient transmission but also suggest an ability of resistant isolates to persist in the ward environment. Indeed, two isolates of the same genotype R1 were detected 4 years apart in the same ICU.

**Conclusion:** Our work shows an increase of the incidence of fluconazole-resistant *Candida parapsilosis* isolates in intensive care units in relation to the clonal spread of few strains. Our results provide evidence of i. patient-to-patient transmission and ii. persistence of resistant clone over time in the
same unit. Our study urges for a better investigation of fungal resistance and improved eradication measures to limit the spread of this resistant emerging pathogen.

# Symposium 13 Fungal respiratory infections in cystic fibrosis (the ECMM/ISHAM working Group Fri-CF)

## S13.1

### Rasamsonia species and other emerging fungi in CF

S. Le Gal¹,², G. Nevez¹,², L. Favennec³,⁴, J.-P. Bouchara⁵,⁶

¹Laboratory of Parasitology-Mycology, University Hospital Center, Brest, France, Brest, France, ²Host-pathogen Interaction Study Group Ea3142, University of Brest - University of Angers, BREST, France, ³Laboratoire De Parasitologie-mycologie, CHU de Rouen, Rouen, France, ⁴Protozooses Transmises Par L'alimentation, University of Rouen - University of Reims, Rouen, France, ⁵Host-Pathogen Interaction Study Group, SFR ICAT 4208, Univ Angers, Univ Brest, Institute of Biology in Health, IRIS, University Hospital Center, Angers, France, Angers Cedex, France, ⁶Laboratory of Parasitology-Mycology, University Hospital Center, Angers, France, Angers, France

**Abstract:** Cystic fibrosis (CF) is the most common genetic inherited disease in the European Caucasian population. The disease is caused by mutations in the gene CFTR (Cystic Fibrosis Transmembrane conductance Regulator) which encodes a membrane transporter involved in electrolytic exchanges across the apical membrane of epithelial cells. Several organs are therefore affected by these mutations, but the clinical picture is dominated by respiratory infections. Indeed, because of the resulting thickening of the bronchial mucus, the respiratory tract is often colonized by microorganisms, leading to respiratory infections which are the major cause of morbidity and mortality in patients with CF. Bacteria, mainly Staphylococcus aureus and Pseudomonas aeruginosa, are the major cause of these infections. However, several yeasts and filamentous fungi may also colonize the airways of patients with CF, sometimes leading to pulmonary infections and to severe disseminated infections after lung transplantation. Moreover, even in the absence of clinical signs, this fungal colonization could contribute to the inflammatory reaction and thus to the progressive deterioration of the lung function. If the epidemiology and pathophysiology of fungal infections still remain largely unknown, the frequency of these infections increases together with life expectancy of CF patients. Aspergillus fumigatus ranks first among the filamentous fungi colonizing the airways of patients with CF, followed by Scedosporium species, Exophiala dermatitidis, Lomentospora prolificans (formerly Scedosporium prolificans), and Aspergillus terreus. The prevalence of these fungi varies from one study to another because of: i) differences in patient recruitment (age, CFTR genotype); ii) lack of standardization of the procedures used for mycological examination of respiratory secretions; iii) geographical and climatic variations. In addition, other fungal species have been increasingly reported during the past decade, such as the yeasts Candida blankii, Trichomonas ciferrii and Blastobotrys adeninivorans / Blastobotrys raffinosifermentans. These yeasts share the capability to use diamines, such as putrescine, which may explain that they multiply in the bronchial mucus during pulmonary exacerbations since the concentration of putrescine increases in this context. Likewise, some filamentous fungi including Arthrographis kalrae and species of the Rasamsonia argillacea complex (formerly Geosmithia argillacea, but first reported in CF as Penicillium emersonii) seem to be emerging in CF. Although it is usually well tolerated, the chronic colonization of the airways by these fungi should not be disregarded since it constitutes a risk factor for disseminated infections in the case of lung transplantation. The emergence of these fungi could be explained at least in part by improvements in diagnostic methods, or by selection pressure caused by repeated antifungal cures. Our knowledge of the ecology of these filamentous fungi still remains in infancy; nevertheless, regarding species of the Rasamsonia argillacea complex, some observations suggest that they could be xylophagous fungi that have spread in Europe since the end of the last century as a consequence of global warming and of the many storms that have crossed Europe since the end of the nineties.
S13.2

Immunodiagnosis of Scedosporium/Lomentospora infection - lessons from immunoproteomic studies

A. Ramirez-Garcia¹, L. Martin-Souto¹, L. Aparicio-Fernandez¹, I. Buldain¹, A. Antoran¹, J.-P. Bouchara², M.T. Martin-Gomez³, A. Rementeria¹, F.L. Hernando¹

¹Immunology, Microbiology And Parasitology, University of the Basque Country (UPV/EHU), Leioa, Spain, ²Laboratory of Parasitology-Mycology, University Hospital Center, Angers, France, Angers, France, ³Microbiology, Vall d'Hebron University Hospital, Barcelona, Spain

**Abstract:** The detection and diagnosis of *Scedosporium/Lomentospora* still relays on traditional methods and, in spite of being the second most common etiological agent among filamentous fungal infections, very few advances have been achieved in this field during the last decades. This fact is especially worrying in Cystic Fibrosis (CF) patients, whose characteristics favor the microbial presence. In these patients, the fungal detection does not mean that an infection is occurring, but it may increase the risk of suffering from it or other health problems. Therefore, it would be interesting to dispose an easy, rapid and non-invasive detection method for monitoring these patients and study the evolution of the fungus. With this purpose, some groups are focusing their efforts on finding new approaches to design a serologic system. In fact, techniques such as counterimmunoelectrophoresis or ELISA using recombinant proteins of some well-described virulence factors are being used by some laboratories, which design their own assays. Our research group addressed this problem using different immunoproteomics-based approaches. First, four different *Scedosporium boydii* protein extracts were studied by ELISA to select the most useful one for IgG detection in CF patients. The extracts used were a whole-cell extract, fungal cell-surface extract, conidia cell surface extract and secreted extract, all of them being able to discriminate acceptably the *Scedosporium/Lomentospora*-infected patients from *Aspergillus*-infected and non-infected patients. However, the best results were obtained with the whole-cell extract, which showed specificity, sensitivity, predicted positive and negative values comparable with commercial kits for other fungal diagnosis purposes. In spite of the excellent results obtained, to increase the specificity and avoid the problems derived from the use of a complex extract, the immunoreactivity of a collection of sera from CF patients infected with *Scedosporium/Lomentopora* against *S. boydii* was also studied in comparing with sera from CF patients infected with *Aspergillus* or without fungus. The analysis, made by 2-DE and WB, allowed the identification of antigens specifically detected by CF patients with *Scedosporium/Lomentopora*, two of them being identified because of their promising results. In addition, to shed light on the problematic of whether the fungal presence in CF patients is a colonization or an infection, we used sera from mice infected intravenously with different species of *Scedosporium/Lomentospora* to detect infection- related antigens of *S. boydii*. Interestingly, all the sera showed a very similar immunorecognition patterns, but different from the recognized by sera from *Aspergillus*-infected mice. Therefore, we purified six antigens and tested their interest for diagnosis analyzing their immunoreactivity by WB against sera from CF patients, two of them showing interesting results. Altogether, these results obtained by immunoproteomics-based techniques open up door in the looking for a serologic test for the detection of *Scedosporium/Lomentospora* in CF patients, as well as the monitoring of the fungal presence. Specifically, although the results have to be further studied and standardized, the ELISA test using whole-cell extract appears to be a very useful, and the antigens identified seems to be interesting candidates to be include in the diagnostic procedure.

S13.4

Morphology, growth and biofilm formation of the black yeast-like fungus *Exophiala dermatitidis* is influenced by *Pseudomonas aeruginosa* under *in vitro* cystic fibrosis conditions.

L. Kirchhoff¹, P.-M. Rath¹, J. Steinmann¹,²

¹Institute Of Medical Microbiology, University Hospital Essen, Essen, Germany, ²Institute Of Clinical Hygiene, Medical Microbiology And Clinical Infectiology, Klinikum Nuernberg, Nuremberg, Germany
**Objectives:** *Exophiala dermatitidis*, belonging to the melanized fungi, is frequently colonizing the respiratory tract of cystic fibrosis (CF) patients in rates up to 19 %. It was recently reported that *E. dermatitidis* is capable to form biofilms in a strain-dependent manner. However, little is known about *E. dermatitidis* behavior in co-culture with other CF-relevant pathogens, e.g. one of the most prevalent bacterial species, *Pseudomonas aeruginosa*. Growth, biofilm formation capabilities and morphology of *E. dermatitidis* in an artificial sputum medium (ASM), mimicking the CF sputum conditions, were assessed in mono- and in co-culture with *P. aeruginosa*.

**Methods:** *P. aeruginosa* (PA07 & PA14, including PA14 ΔlasR and ΔrhlR) and *E. dermatitidis* (clinical isolate) were analyzed in growth experiments over a period of 48 hours at 36°. Growth was determined by colony forming unit (CFU) counts. Biofilm, formed on polystyrene surfaces under standard protocols, was determined after 24 and 48 hours of incubation at 36°C without agitation by stain with crystal violet, by CFU counts after biofilm detachment using 0.1% dithiothreitol, for species-specific cell counts and by confocal laser scan microscopy determining the thickness of extracellular matrix (ECM). Morphology of the dimorphic *E. dermatitidis* was monitored in light microscopy. Lengths of fungal hyphae were estimated and compared.

**Results:** *P. aeruginosa* showed growth inhibiting effects on *E. dermatitidis*. Cell count of the fungus was decreasing in co-culture with *P. aeruginosa*. In contrast, *E. dermatitidis* biofilm formation was induced after 24 h and reduced after 48 h in co-culture with *P. aeruginosa*. A lack of *P. aeruginosa* quorum sensing (QS) systems lasR and rhlR resulted in induced fungal biofilm formation. At the same time, presence of lasR and rhlR lacking mutants caused an increased amount of *E. dermatitidis* hyphal structures whereas co-cultivation with the *P. aeruginosa* wildtype resulted in decreased hyphae amounts, compared to mono-culture.

**Conclusion:** Interactions between *P. aeruginosa* and *E. dermatitidis* result in altered growth, biofilm formation capabilities and morphology of the fungus in an *in vitro* CF model. A role of *P. aeruginosa* QS systems in these interactions is suggested.

S13.6

Study of antigenic markers for serological detection of *Scedosporium* spp. in Cystic Fibrosis patients

L. Martin-Souto¹, M. Areitio¹, L. Aparicio-Fernandez¹, I. Buldain¹, A. Antoran¹, J.-P. Bouchara², M.T. Martin-Gomez³, A. Rementeria⁴, F.L. Hernando⁴, A. Ramirez-Garcia⁴

¹Immunology, Microbiology And Parasitology, University of the Basque Country (UPV/EHU), Leioa, Spain, ²CHU d'Angers, Angers, France, ³Microbiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain, ⁴Immunology, Microbiology And Parasitology, University of the Basque Country (UPV/EHU), Leioa, Spain

**Objectives:** Cystic fibrosis (CF) is the major genetic disorder among the Caucasian population. CF patients produce a thick and sticky bronchial mucus in their respiratory tract, which facilitates the growth of airborne pathogens. In addition to bacteria, several fungi colonize the respiratory tracts of these patients. Species of *Scedosporium* and *Lomentospora* genera are emergent fungal pathogens ranking the second, only behind *Aspergillus* spp., among filamentous fungi causing a chronic colonization of the airways of CF patients. This may lead to chronic inflammation or even to life-threatening invasive disease in cases of severe immunosuppression. Detection of *Scedosporium/Lomentospora* relies upon low sensitivity and specificity non-standardized procedures. To contribute to the finding of new diagnostic methods, this work aims to characterize some molecular targets and to study their usefulness for serological detection of infections caused by *Scedosporium* spp. in CF patients.

**Methods:** A total of 191 CF patients' sera were used in this study. First, we classified these sera into 3 groups: patients with positive sputum cultures for *Scedosporium* (S+), for *Aspergillus* (A+), and patients with negative fungal cultures (Ctrl). A serological study of the sera was carried out to detect specific IgG response against *Scedosporium boydii* total protein extract by ELISA. In the search of diagnostic markers that allow the discrimination between colonization and infection, we performed an *in vivo* infection in a murine model to obtain sera that allow the detection of antigens associated
with a disseminated infection by two dimensional western blot. These antigens were electroeluted from protein gels and blotted individually against CF patients' sera to observe the immunological response.

**Results:** The ELISA assay provided good specificity, and positive and negative predictive values to discriminate among S+, A+ and Ctrl patients. However, the sensitivity was influenced by differences in the humoral response of the S+ group. This suggests different levels of fungal presence, from colonization to infection, among S+ patients. To solve this problem, we looked for *S. boydii* antigens associated with a disseminated infection in a murine model selecting the six proteins with the highest immunoreactivity. Two of them were specifically recognized by most of S+ sera, especially by those that were more reactive in the ELISA assay.

**Conclusion:** Two proteins of *S. boydii* resulted to be potential diagnostic markers for the detection of the infection caused by *Scedosporium* spp. in CF patients. The use of them in combination with an ELISA using *S. boydii* total protein extract might help in the detection of *Scedosporium* spp. in CF patients and the monitoring of the fungal presence.

## Symposium 14 Teaching Medical Mycology: what, how, to whom and when

### S14.2

#### Mycology teaching in Medical School - Is student demography important to what should be taught

*E. Segal*

Sackler School Of Medicine, Clinical Microbiology And Immunology, Tel Aviv University, Tel Aviv, Israel

**Abstract:** Mycology which is the discipline devoted to the study of fungi, is one of the four parts comprising Microbiology, the basis for understanding infectious diseases. Medical Mycology is the part of Mycology which focuses on those fungi known to cause or potentially can cause infections in human hosts. As such, study of Medical Mycology is an integral part of the education of physicians and is included in the curriculum of Medical Schools. One of the questions associated with the teaching of Medical Mycology is at which level should Medical Mycology be taught: at the basic sciences level, with other parts of Microbiology, or at a later stage in the frame of Infectious Diseases, as part of Internal Medicine. The answer to this dilemma may vary among different Medical Schools. Another question associated with teaching Medical Mycology in Medical Schools is as to the content of the subject: should it reflect the specific geographic-climatic conditions of the given Medical School or should a more general, broader approach be used. An additional dilemma regarding teaching of Medical Mycology in Medical Schools is whether the specific student demography should affect what is taught and to what extent. The latter is the subject of the following presentation. In the presentation different teaching possibilities will be demonstrated and discussed, as to pro- or contra- of the impact of student demography on what is taught. Examples of different approaches to the dilemma will be shown and discussed. Participation of the audience in the discussion will be encouraged.

### S14.3

#### Specific courses outside European Continent – The Indian Example

*R. Ashbee*

University of Leeds, Leeds, United Kingdom

*HR Ashbee, RD Sahni & JS Michael* Teaching medical mycology in the Indian setting presents some unique challenges and opportunities. The diversity of mycoses seen is extensive and presentations can be unusual with disease sometimes occurring in patients not traditionally 'at risk'. Whilst dermatophytosis and superficial candidosis is often neither diagnosed nor treated, fungal keratitis and sinusitis, subcutaneous and systemic mycoses represent a significant burden on the healthcare system. In combination with this, diagnostic facilities vary from virtually nil to fully equipped laboratories with well-trained staff. The Christian Medical College Hospital in Tamil Nadu, south India has had a mycology laboratory since the 1950's, has highly skilled staff and a massive number of clinical samples – hence it is ideally suited to deliver comprehensive mycology training. The first
course in 2007 was aimed at technical staff working in laboratories and junior faculty, primarily
focusing on basic medical mycology and identification of fungal pathogens. The course was attended
by 30 participants from all over India, some traveling for 30 hours by train to take part in the course.
The need for training was apparent and further courses were planned The current course has been
re-designed and is run in two parts. The first 3-day part is aimed at registrars/residents in
microbiology and provides an integrated approach to teaching with clinicians presenting cases and
the laboratory aspects taught in practical, hands-on sessions after the cases. The full range of diseases
are covered, including the superficial mycoses, subcutaneous mycoses, candidosis, cryptococcosis,
mucormycosis, aspergillosis and endemic mycoses. Hands-on practical sessions also cover setting up
of antifungal susceptibility tests and their interpretation. The second part of the course held over 2 ½
days is for consultant microbiologists and this includes a full day of practical molecular mycology,
including DNA extraction, setting up PCR and trouble-shooting molecular assays, use of
commercially available assays, as well as molecular detection of antifungal resistance. Antifungal
susceptibility testing is taught in another full day practical session with participants taken through
the whole CLSI method, from making up the medium, preparing antifungal dilutions, making up
plates and preparing the inoculum, to reading and interpreting results. Other methods such as E-test
and disc diffusion are also taught. The practicals take place in small groups so every participant can
get hands-on experience of each technique. Discussion sessions make up the remainder of the time
with ample opportunity for participants to ask questions and clarify any problems. Participants are
also encouraged to maintain contact after the workshop and help is provided with testing or fungal
identification by CMC staff if required. The courses represent a significant investment of time and
resources by the staff of CMC and overseas faculty but feedback has been extremely good and
demonstrates that provision of high quality, comprehensive mycology training is both very much
needed but also very well received.

S14.4

Teaching Clinical Laboratory Mycology : How and who is the audience?

S. Arikan-Akdagli

Medical Microbiology, Mycology Laboratory, Hacettepe University Medical School, ANKARA,
Turkey

Expertise in Clinical Laboratory Mycology requires hands-on experience and in-depth basic
knowledge. Challenges regarding teaching Clinical Laboratory Mycology are numerous. First, the
number of invasive fungal infections is increasing with more infections due to rare and less-
recognized species and the education for management of this growing problem is yet inadequate.
Second, Mycology education was rather less emphasized until recent years. Teaching for Clinical
Laboratory Mycology practices is usually limited during training of a Clinical Microbiologist and the
numbers of well-equipped Clinical Mycology Laboratories and experts are also relatively limited
worldwide. Third, the characteristics of Y (and Z) generation(s) are unique. The members of
generation Y are primarily among the current audience and they are largely influenced by
technology. Therefore, broader training and diverse teaching methods are required to meet all these
challenges. Clinicial Laboratory Mycology training is a part of speciality/subspeciality, PhD or Master
of Science training programs in Medical Microbiology/Mycology. Also, Infectious Diseases/Infectious
Diseases and Clinical Microbiology Joint Training, and Pathology Training Programs include training
in Mycology at required levels. For Medical Faculty students, on the other hand, basic Clinical
Laboratory Mycology teaching is incorporated in the program at some institutions in order to
integrate the previously taught theoretical knowledge with that on mycological diagnosis in the last
year(s) of education. Laboratory technicians are also among the audience for teaching Clinical
Laboratory Mycology at required and specifically technical level. Combining conventional teaching
methods with digital technologies is needed for contemporary high quality Clinical Laboratory
Mycology education. The common approach for teaching requires expert(s), a well-equipped
Mycology Laboratory, and reliable basic information sources, including physical books or e-books.
In lack of these facilities or for advancement for higher levels, in-person courses and workshops are
very beneficial. However, they are costly and require qualified instructors and resources. E-learning courses, webinars, and educational websites are also very helpful in expanding the trained audience. Teaching Clinical Laboratory Mycology is a difficult task and requires dedicated Mycologists.

## S14.5

### Capacity building for invasive fungal infections in Africa: concrete examples through mycology courses and the DREAMM implementation project

A. Sturny Leclère¹, D. Garcia-Hermoso², T. Boyer-Chammard¹, I. Kolte³, F. Dromer⁴, A. Alanio⁵, O. Lortholary⁶, A. Loyse³

¹Molecular Mycology, IP Paris, Paris, France, ²National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, PARIS, France, ³Institute Of Infection And Immunity, St. George's University of London, London, United Kingdom, ⁴National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, Paris, France, ⁵Paris-diderot, Sorbonne Paris Cité University, Institut Pasteur, Molecular Mycology Unit, Cnrs Cmr2000, Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France, ⁶Infectious Diseases, APHP, Hopital Necker-Enfants malades, Paris, France

Across the world, fungal pathogens are omnipresent in the environment, affect over a billion and kill more than 1,5 million people. Despite these figures, invasive fungal infections (IFIs) do not gather as much press coverage as tuberculosis or malaria. AIDS represents one of the major risk factors for IFIs together with other acquired immunodeficiencies. Invasive fungal infections should be a concern everywhere by their incidence, severity and high burden. Worldwide IFIs are not recognized due to lack of surveillance systems together with a lack of mandatory reporting, limited teaching in medical schools and therefore limited awareness and expertise of clinicians and biologists, lack of reliable diagnostic procedures for many IFIs, and limited number of commercialized antifungal drugs. In resource limited countries, the lack of basic laboratory equipment and poor access to essential medicines are additional major barriers. Outcomes of cryptococcal meningitis, a leading cause of HIV-related death, are still poor despite updated WHO guidelines. The DREAMM project aims to reduce the mortality of cryptococcal meningitis in resource limited settings by providing rapid diagnostic tests, essential medicines and reinforcing basic and mycology trainings for all staff members involved (technicians, nurses, physicians, biologists). Through this program, a better awareness of all IFIs is expected and results are already visible.

## Symposium 15 Aspergillus in the ICU

### S15.1

#### Influenza-associated aspergillosis in ICU: when the flu get mouldy

J. Wauters

Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium

Worldwide, 3-5 million people develop severe influenza every year, leading to 50.000-100.000 deaths annually in the European Union and the USA. Of the patients hospitalized, 5-10% needs ICU admission due to severe illness. Patients with severe illness initially present with typical influenza symptoms, but are rapidly evolving into respiratory deterioration due to bacterial superinfection but also influenza in itself can cause severe acute respiratory distress syndrome (ARDS), the latter being associated with a mortality of 14% to 41%. Although bacterial co-infection is already known for decades, influenza-associated aspergillosis (IAA) was recently found to be a frequent and severe complication of influenza pneumonia in critically ill patients. Classically, invasive pulmonary aspergillosis (IPA) typically occurs in a severely immunocompromised host. Influenza-associated aspergillosis (IAA) was occasionally described decades ago and several small case series were reported recently. 65% of the reported cases did not have classic host factors for IPA as defined by the EORTC/MSG. Recently, we published a large multicentre case-control study within the Dutch-Belgian Mycosis Study Group (7 Belgian and Dutch ICUs, 2009-2016) including 432 severe influenza