should be considered in case of treatment failure, and hidden foci such as endocardium, eye and
vertebrae must be investigated because of hematogenous transmission.

P272

Epidemiological trend, spectrum, clinical profile and outcome of fungal keratitis from Delhi, India

M. Capoor¹, S. Kocchar², V. Gupta²

¹Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India,
²Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India

**Objectives:** Fungal aetiology of keratitis ulcer is considered to be one of the leading causes of ocular morbidity, particularly in developing countries including India. More importantly, Fusarium and Aspergillus spp. are reported commonly implicating corneal ulcer and against this background the present work was undertaken so as to understand the current epidemiological trend, clinical profile and outcome of fungal keratitis.

**Methods:** During the study period (2013-2016), the clinical and mycological characteristics of fungal keratitis was investigated. Our aim was to discuss the predisposing factors, clinical manifestations, and epidemiological characteristics of the causative agents and describe the management strategies that have a high probability of successfully treating this disease. The corneal scrapings were processed by direct microscopic methods and standard culture techniques. All the samples were inoculated onto Sabouraud dextrose agar (SDA), potato dextrose agar (PDA), brain-heart infusion based blood agar in the form of a "C" streak. The SDA and PDA plates were incubated at 30°C for 7 days, and the other plates were incubated at 37°C for 7 days.

**Results:** A Total of 143 corneal scrapings from keratitis were processed, 72 (50.3%) revealed growth, of which 60 were culture positive for fungi and 12 were culture positive for bacteria. Direct microscopy revealed hyphae or budding yeasts or fungal elements in 60 cases. Among fungal aetiologies, *Aspergillus spp.* (51.7%) and *Fusarium spp.* (16.7%) were predominantly determined. The spectrum of mycotic keratitis cases was: *Aspergillus flavus* (15), *A.fumigatus* (12), *Fusarium solani* (5), *Fusarium oxysporum* (3), *Curvularia lunata* (3), *C. tropicalis* (3), *C. parapsilosis* (2), *Fusarium dimerum* (2), *Paecilomyces lilanicus* (2), *Alternaria alternata* (2), *A. terreus* (2), *A. tetrazonus* (1), *A.niger* (1), *Bipolaris* (1), *Candida krusei* (1), *Schizophilum commune* (1), *Scedosporium apiospermum* (1), *Chryseosporium keratinophillum* (1), *C. tropicalis* (1) and *Scytalidium dimidiatum* (1). Of the 60 mycotic keratitis male preponderance was seen in 66.66%. Predisposing factors included trauma with vegetative material (98.66%), contact lens use (1.66%), and bird feather hit (1.66%). Pain, redness of eye and dimunition of vision was most common clinical complaints. Steroids and inflammatory drugs were most common pretreatment medication taken. The corneal examination revealed central corneal ulcer with feathery margins, a paracentral superficial ulcer; a central ulcer with an irregular edge, satellite infiltrations, and hypopyon etc. Majority of the patients were given natamycin eye drop alone. Concomitant systemic antifungals and supportive surgical intervention was done in 4 and three cases respectively. Complete loss of vision was seen in one eye was seen in single case.

**Conclusion:** Our study suggests that mycotic keratitis caused by *Aspergillus spp.* especially *A. flavus* may occur more often in a tropical climate, such as in Delhi, India. Aetiological agents other than Aspergillus species and Fusarium species have shown an upward trend. A combination of antifungal therapy and supportive surgical intervention may successfully resolve the mycotic infection. Proper understanding of microbiological and clinical characteristics of keratomycosis will enable ophthalmologist to avoid unnecessary and indiscriminate use of steroids or antimicrobials. Early stage of diagnosis and formulation of an uncompromising management protocol can prevent profound visual morbidity.

P273

Molecular epidemiological investigation of zoonotic outbreaks caused by *Sporothrix* species

J. Carvalho, P. Terra, B. Pinheiro, Z.P.D. Camargo, A.M. Rodrigues

Department Of Microbiology, Immunology And Parasitology, Federal University of São Paulo, São Paulo, Brazil
**Objectives:** Sporotrichosis is a mycosis mostly caused by a group of thermodimorphic fungi embedded in a clinical clade (i.e., *Sporothrix brasiliensis*, *S. schenckii*, *S. globosa*, and *S. luriei*). The infection is caused after a traumatic inoculation of *Sporothrix* propagules into the (sub)cutaneous tissue of mammals. *Sporothrix* species have been reported around the world, mostly in regions with humid (sub)tropical and temperate climates. During the last decades, vast zoonoses have been ongoing in Brazil with Rio de Janeiro as the epicenter of this cat-transmitted epidemic. In this scenario, the development of new molecular markers is mandatory to explore the genetic diversity and track *Sporothrix* expansion during outbreaks. The purpose of this study was to analyze the genetic diversity of *Sporothrix* originating from different geographic regions of Brazil, using AFLP (Amplified fragment length polymorphism) markers.

**Methods:** *Sporothrix* spp. genome sequences were retrieved from Genbank (https://www.ncbi.nlm.nih.gov/genbank/) and were *in silico*-digested with EcoRI and MseI using the software AFLPInSilico. Only fragments of 50-500 bp were considered. A total of 256 combinations of selective pairs of primers (based on 2 selective nucleotides) were employed to generate 2.304 fingerprints profiles with different fragment numbers and sizes (0 to 56 fragments/per combination).

**Results:** *In silico* analysis highlighted 6 combinations to be tested in a subset of 15 medically relevant *Sporothrix* isolates. *In vitro*, AFLP presented strict concordance with *in silico* results considering the number and size of the amplicons resolved during capillary electrophoresis. A total of 58 AFLP markers were unambiguously scored in the electropherograms using the software BioNumerics v.7.6. Dendrograms were constructed (UPGMA, Jaccard Distance) based on a banding match table and isolates were correctly clustered according to the taxon name. Intraspecific variation was observed for all agents, including *S. brasiliensis*, a species previously known to be clonal. Based on the data above we recommend the use of 3 different AFLP combinations to explore genetic diversity and taxonomy in *Sporothrix*.

**Conclusion:** Independent experiments with similar results showed that the AFLP is highly reproducible, making this technique interesting to evaluate the genetic diversity and the spreading of *Sporothrix*. The present content in this study will enable the development of strategies to control the disease and will contribute to further studies about diversity in *Sporothrix*.

P274

Epidemiological and molecular investigation of emerging Histoplasma species in Brazil

A.M. Rodrigues¹, M. Beale², F. Hagen³, M. Fisher⁴, P. Terra¹, G.S. De Hoog⁵, S. Brilhante⁶, R. Cordeiro⁶, D. Castelo-Branco⁶, M. Rocha⁷, J. Sidrim⁷, Z.P.D. Camargo¹

¹Department Of Microbiology, Immunology And Parasitology, Federal University of São Paulo, São Paulo, Brazil, ²Parasites And Microbes Programme, Wellcome Sanger Institute, Cambridge, United Kingdom, ³Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands, ⁴Department Of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom, ⁵Westerdijk Institute, Utrecht, Netherlands, ⁶Postgraduate Program In Medical Microbiology, Federal University of Ceará, Fortaleza, Brazil, ⁷Postgraduate Program In Veterinary Science, Federal University of Ceará, Fortaleza, Brazil

**Objectives:** Histoplasmosis is a serious infectious disease in humans caused by *Histoplasma* spp. (Oxygenales), whose natural reservoirs are thought to be soil enriched with bird and bat guano. The true global burden of histoplasmosis is underestimated and frequently the pulmonary manifestations are misdiagnosed as tuberculosis. Molecular data on the epidemiology of *Histoplasma* are still scarce, even though there is increasing recognition of histoplasmosis in recent years in areas distant from the traditional endemic regions in the Americas.

**Methods:** We used multi-locus sequence data from protein-coding loci (ADP-ribosylation factor, H antigen precursor, and delta-9 fatty acid desaturase), DNA barcoding (ITS1/2+5.8s), AFLP markers and mating type analysis to determine the genetic diversity, population structure and recognize the existence of different phylogenetic species among 436 isolates of *Histoplasma* obtained globally.

**Results:** Our study describes new phylogenetic species and the molecular characteristics of *Histoplasma* lineages causing outbreaks with a high number of severe outcomes in Northeast Brazil
between 2011 and 2015. Genetic diversity levels provide evidence for recombination, common ancestry and clustering of Brazilian isolates at different geographic scales with the emergence of LAm C, a new genotype assigned to a separate population cluster in Northeast Brazil that exhibited low diversity indicative of isolation. The global survey revealed that the high genetic variability among Brazilian isolates along with the presence of divergent cryptic species and/or genotypes may support the hypothesis of Brazil being the center of dispersion of *Histoplasma* in South America, possibly with the contribution of migratory hosts such as birds and bats. Outside Brazil, the predominant species depends on the region. We confirm that histoplasmosis has significantly broadened its area of occurrence, an important feature of emerging pathogens.

**Conclusion:** From a practical point of view, our data point to the emergence of histoplasmosis caused by a plethora of genotypes and will allow the proposal of public policies to contain the spread of histoplasmosis. Furthermore, with the description of such diversity, we open avenues for future comparative genomic studies, which will allow progress toward a consensus taxonomy, improve understanding of the presence of hybrids in natural populations of medically relevant fungi, test reproductive barriers and explore the significance of these variations.

P275

Tuberculosis and Fungal Co-infection of Fungal Infections, University Hospital Center Zagreb, Croatia, During Past Two Years

M. Jandrlić¹, M. Samarzija², V. Rezo Vranješ¹, S. Pleško³, I. Mareković³, A. Jandrlić⁴

¹Department Of Clinical And Molecular Microbiology, University Hospital Centre Zagreb, Zagreb, Croatia, ²Clinic For Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia, ³Department Of Clinical And Molecular Microbiology, University Hopital Centre Zagreb, Zagreb, Croatia, ⁴Laboratory Biomedicine, Faculty of Pharmacy, Ljubljana, Slovenia, Zagreb, Slovenia

**Objectives:** Pulmonary tuberculosis is one of the most important health concerns. Pulmonary fungal infections have clinical and radiological characteristics similar to tuberculosis which may be easily misdiagnosed as tuberculosis. This study aimed to evaluate *Mycobacterium tuberculosis* (MTB) and other non-tuberculous mycobacteria (NTM) with coinfection of fungal infections in patients, during last 2 years.

**Methods:** Microbiological and clinical reports of 149 patients with confirmed mycobacteria have been analyzed. Detection and identification of mycobacteria were performed by the standard culture method using the BACTEC MGIT 960 system (BD) and Lowenstein–Jensen medium. Identification of positive *Mycobacterium tuberculosis* complex (MTBC) was based on positive acid-fast bacilli microscopic smear (Ziehl–Neelsen and fluorochrome), positive niacin accumulation, MALDI-TOF and *Mycobacteria* PCR. TB isolates were also tested for their sensitivity toward first-line anti-MTB drugs.

**Results:** Between April 2017 and April 2019, at 149 patients were detected Mycobacterial infections (MTB 64%, NMT 36%). Mycological tests are not required in 36 24% patients. Mycological tests are required in 113 76% patients. The majority of patients had isolated several types of fungi, 160 episodes. The patients 113 were isolated yeasts, opportunistic and saprophytic molds (54%, 16%, 28%). Frequent Candida were C. albicans, *C. dubliniensis*, *C. parapsilosis* and *C. glabrata* respectively. Frequent *Aspergillus* were *A. niger*, *A. fumigatus* and *A. flavus* respectively. In addition to *Aspergillus*, small number of patient had *Fusarium*, *Rhizopus* and *Pseudallescheria boydii*. Saprophytic molds were confirmed in 28% of patients.

**Conclusion:** Our findings showed the co-infection of fungi agents in patients with tuberculosis that should be considered. Clinical data must be analyzed to be able to distinguish infections, colonization, or part of normal flora.

P276

Prevalence of Aspergillus infection in delay resolution of community-acquired pneumonia in high-risk population in Taiwan
S.F. Huang, F.-D. Wang

Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

**Objectives:** Pulmonary Aspergillosis is a world-widely distributed disease. The prevalence of *Aspergillus* infection in patients with delay resolution community acquired pneumonia (DR-CAP) or lower respiratory tract infection (LRTI) had not been investigated in Taiwan. The aims of the study was prospectively evaluate the prevalence of *Aspergillus* infection by serological testing and microbiological evidence in high risk patients presented with DR-CAP or LRTI.

**Methods:** Patients presented with LRTI or DR-CAP were prospectively enrolled. Patients with underling chronic pulmonary disease (CLD), active tuberculosis (TB), collagen fiber disorders were study groups, and others who were healthy without underling disorders except DR-CAP or LRTI. Delay resolution of community acquired pneumonia (DR-CAP) was defined as clinical diagnosis with community acquired pneumonia not significantly getting resolution after 3-4 weeks of appropriate anti-bacterial antibiotics. Serum gamma-immunoglobulin (IgG) concentration for *Aspergillus niger* (*A. niger*) and *Aspergillus fumigatus* (*A. fumigatus*) were measured by ELISA method. Positive results were recorded by the cut-off-value provided by the company (ImmunoCAP®, ThermoFisher Scientific Inc.). Microbiological evidence for mold infection was record according to the results of fungus culture from sputum, bronchioalveloar lavage fluid (BALF), or nasal/throat swab. Patients were excluded for pulmonary malignancy by diagnostic approach such as bronchoscopic and transthoracic lung biopsy.

**Results:** From 2018 April to 2019 Jan, a total of 99 patients were enrolled. Overall, 38.3%, 25.1%, and 11.1% of patients were with CLD, collagen fiber disorders, and active TB or old TB with complete anti-TB therapy (ATT), respectively. There were 19% of patients were healthy but presented with LRTI not response to anti-bacterial antibiotics. Overall, seroprevalence for *A. niger* and *A. fumigatus* were 32.3% and 22.9%, and the patients with CLD had a highest seroprevalence with 35.4% and 36.6%, respectively. In combination of microbiological and serological results, the prevalence for mold infection was 59%, and CLD remained a highest-risk disorder (48.7%). Overall, concordance between microbiological results for fungus culture and positive serological results for *A. niger* and *A. fumigatus* were 69.6% and 60%, respectively.

**Conclusion:** Both the serological and microbiological evidence for mold or *Aspergillus* infection in high-risk patients with DR-CAP or LRTI were high in Taiwan. We also firstly reporeted the seroprevalence for *Aspergillus spp.* around 10% in patients without underling high-risk disorders, that indicate the populational seroprevalence in north Taiwan.

P280

Co-infection *Candida glabrata* with other *Candida* species in nosocomial candiduria

S.R. Aghili¹, M. Abastabar², A. Soleimani³, A. Akbari Vosta³, S. Azizi⁴, M. Rayatnia⁵, B. Salmanian⁶

¹Invasive Fungi Research Center/department Of Medical Mycology, Mazandaran University of Medical Sciences, Sari, Iran, ²Department Of Medical Mycology, Invasive Fungi Research Center, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran, ³Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran, ⁴Department Of Laboratory Medicine, Faculty Of Allied Medical Sciences, Mazandaran University of medical science, Sari, Iran, ⁵Kidney Center Of Imam Reza Hospital, Mazandaran University of Medical Sciences, Sari, Iran, ⁶Department Of Scienes, Farhangian University, Seddighe tahereh branch, Sari, Iran

**Objectives:** *Candida glabrata* was formerly classified in the *Torulopsis* genera, but it is currently considered to belong to the *Candida* genus. Evidence showed that it is the second causative agent of nosocomial candidiasis, alone or coexisting with other yeasts, particularly other *Candida* species. The reason for this association is often unknown and some have suggested a synergistic pathogenesis. Due to the increasing resistance of *C. glabrata* to many common antifungal drugs, treatment in patients is also accompanied by some problems. Therefore, identification of co-infection in patients and the modification of therapeutic protocols is essential.
**Methods:** This descriptive laboratory-based surveillance study was investigated the incidence of nosocomial candiduria and it determined their etiologic agents in 555 hospitalized patients in two hospitals (253 hemodialysis patients in Hospital hemodialysis center of Amol city and 305 hospitalized patients with heart failure in Heart center of Sari city), Mazandaran province, Iran. The patients' urine samples were cultured in mycological culture media and colony counts >10⁴ CFU/ml were considered significant for candiduria. Species identification was done based on color of colony on CHROMagar Candida and PCR-RFLP method, by ITS region and the MspI restriction enzyme and PCR amplification of *HWP1* gene.

**Results:** We found 40(15.8%) positive candiduria in hemodialysis patients and 58(18.8%) in heart failure patients. C. glabrata(47.1%), C. albicans(17.6%), C. tropicalis(15.7%), C. parapsilosis(15.7%) and C. kefyr(0.4%) were identified as candiduria agents in hemodialysis patients and C. glabrata(40.3%), C. albicans(40.3%), C. tropicalis(7.5%), C. parapsilosis(7.5%) and C. krusei(4.4%) were candiduria agents in heart failure patients. C. glabrata, alone as a single-species candiduria agent was detected in many patients. However, in these two patient groups, it has associated with other Candida species as mix-infection. Nine hemodialysis patients had mix-infection by C. glabrata associated with other Candida species (7 cases C. glabrata + C. albicans, 2 cases C. glabrata + C. albicans + C. kefyr) and 9 heart failure patients had mix-infection by C. glabrata associated with one other species too (4 cases C. glabrata + C. albicans, 2 cases C. glabrata + C. tropicalis, 2 cases C. glabrata + C. parapsilosis and 1 case C. glabrata + C. krusei).

**Conclusion:** Studies indicate increasing azole antifungal prophylaxis treatment and invasive application lead to an increase in low susceptibility to azoles non albicans species, and C. glabrata became second causative nosocomial infection agent now. The data suggest that the growth of other Candida species was stimulated by the presence of C. glabrata and this species in the biofilms more active than other species that produce biofilms with more biomass. Although, C. glabrata is generally considered a species of low virulence, mortality rate of patients with candidiasis caused by this species is higher than C. albicans because of complicates the treatment. Given the prevalence of C. glabrata and other candida species co-infection, it is necessary to understand the mechanisms used by C. glabrata in collaboration with them and the use of rapid identification methods for candidiasis agents can be a great help to treat these patients, more effectively.

P281

## An Open-Label Multicenter Observational Study Of Anidulafungin For The Treatment Of Invasive Candidiasis In Russia

O. Kozlova¹, V. Rubinchik², M. Sobol³, V. Larionova⁴, V. Tyrenko⁵, S. Zhuravel⁶, E. Petrova⁷, T. Truhina⁸, N. Klimko¹

¹Department Of Clinical Mycology, Allergology And Immunology, North-Western State Medical University n.a. I.I. Mechnikov, Saint-Petersburg, Russian Federation, ²V.A. Almazova NMI, St. Petersburg, Saint-Petersburg, Russian Federation, ³Irkutsk Regional Cancer Center, Irkutsk, Irkutsk, Russian Federation, ⁴n «N.N. Blokhin National Medical Research Center of Oncology» of the Ministry of Health of the Russian Federation, MoscowFederal State Budgetary Institutio, Moscow, Russian Federation, ⁵S.M. Kirov Military Medical Academy, St. Petersburg, Saint-Petersburg, Russian Federation, ⁶N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, Moscow, Russian Federation, ⁷State Budgetary Healthcare Institution Infectious Diseases Hospital № 2 Moscow Health Department, Moscow, Moscow, Russian Federation, ⁸Tula Regional Oncology Center, Tula, Tula, Russian Federation

**Objectives:** Publications about "real life" using of anidulafungin are limited. Study of anidulafungin for the treatment of invasive candidiasis (IC) in actual clinical practice in Russia.

**Methods:** The primary endpoints were global response (clinical + microbiological response) at end of treatment (EOT), and the 30 days overall survival rate. For diagnosis of invasive candidiasis (IC) we used criteria EORTS/MSG, 2008.

**Results:** In 2015-2017 yy. in a prospective multicenter (n = 23) study included 300 adult patients who were treated with anidulafungin. Men were 57%, median age – 49 y (from 18 to 98). All examined
patients had risk factors for IC. In 85% patients, a fever resistant to the use of broad-spectrum antibacterial drugs for ≥ 4 days was noted. Median APACHE II at the start of anidulafungin therapy was 18.8. Anidulafungin was used for the empirical therapy of IC in 82% patients. Global response at EOT was 79%, the 30 days overall survival rate was 78%. Anidulafungin was generally well tolerated with few treatment-related adverse events (hypokalemia – 1%, angioedema – 0.5%), which were not the cause of drug withdrawal. IC was laboratory confirmed in 25% patients. *Candida non-albicans* (57%) prevailed among IC pathogens. In patients with proven IC the 30 days overall survival rate was 66%, which is significantly higher than in the earlier multicenter study in Russia (43%).

**Conclusion:** The overall efficacy of anidulafungin was high (79%), the 30 days overall survival rate was 78%. Adverse events occurred in 1,5% cases and were not the cause of drug withdrawal. In 82% patients anidulafungin was used for empiric therapy. In patients with proven invasive candidiasis the 30 days overall survival rate was 66%.

P282

**Two cases of Pseudomembranous Tracheobronchitis due to Amphotericin B-resistant *Aspergillus flavus***

D. Hare¹, A. Griffin¹, N. Akasheh², C.L. Bacon³, I. Martin-Loeches⁴, T. R Rogers¹,⁵, B. O' Connell¹

¹Department Of Clinical Microbiology, St James's Hospital, Dublin, Ireland, ²Department Of Medicine, St. James's Hospital, Dublin, Ireland, ³Department Of Haematology, St. James's Hospital, Dublin, Ireland, ⁴Department Of Intensive Care Medicine, St. James's Hospital, Dublin, Ireland, ⁵Trinity College Dublin, Dublin, Ireland

**Case Report:** Introduction: Pseudomembranous Aspergillus Tracheobronchitis (PMAT) is an uncommon manifestation of invasive pulmonary aspergillosis (IPA). Patients are typically immunocompromised although sporadic cases have been reported in previously immunocompetent individuals.¹*Aspergillus flavus* is the second most frequent *Aspergillus* species causing bronchopulmonary disease and isolates typically display MICs to amphotericin B (amB) which are two-fold dilution steps higher than *A. fumigatus*.² Although the clinical significance of *in vitro* antifungal susceptibility is debated, there is evidence to suggest that *A. flavus* isolates demonstrating resistance to amB are associated with increased mortality.³ We present two cases of *A. flavus* PMAT with raised MICs to amB and contrasting host risk-factors. Methods: Susceptibility testing was performed using E-test on RPMI agar and confirmed at a reference laboratory using broth-microdilution in accordance with CLSI methodology. As no species-specific breakpoints have been established for *A. flavus*, resistance was defined as ≥2mg/L based on expected MIC ranges.³ Results: Patient 1: A 39-year-old male was admitted for an Allogeneic Haematopoetic Stem Cell Transplant for Acute Lymphoblastic Leukaemia. Post-transplant, his medications included prophylactic liposomal amB. On day 4, he became febrile with an undetectable neutrophil count. Therapeutic doses of liposomal amB were subsequently added due to persistent fevers. Chest CT showed bronchial narrowing suggestive of mucous plugging and bronchoscopy revealed pseudomembranous tracheobronchitis. Bronchoalveolar-lavage (BAL) cultured *A. flavus* with an MIC to amB of 4.0mg/L. His antifungal regimen was changed to IV voriconazole and caspofungin. He required admission to ICU due to respiratory failure but died at 31 days post-transplant. Patient 2: A 51-year-old previously immunocompetent male presented to hospital with fevers and progressive shortness of breath. Chest X-ray showed patchy infiltrates and he was commenced IV co-amoxiclav, clarithromycin and oseltamivir. By day 2, he required admission to ICU due to respiratory failure. A nasopharyngeal aspirate PCR returned positive for Influenza A RNA and IV hydrocortisone was added as an adjunct to his antiviral therapy. Bronchoscopy showed a pseudomembranous tracheobronchitis and brushings cultured *A. flavus* with an MIC of 2.0mg/L to amB. He received dual antifungal therapy with IV voriconazole and amphotericin B but died at 31 days post admission. **Conclusion:** These cases contrast a neutropenic patient with classical risk-factors for IPA with a patient who was not immunocompromised but was diagnosed with PMAT following Influenza infection. Diagnosis may be delayed by the absence of clearly distinguishable symptoms, laboratory parameters or imaging findings, and cases may be refractory to antifungal therapy. Our experience
is consistent with evidence demonstrating poor outcomes in patients with *A. flavus* infections with *in-vitro* resistance to amB, and underline the importance of performing susceptibility testing to guide antifungal therapy. References: 1. Khalid S *et al*. Pseudomembranous aspergillar tracheobronchitis in a non-neutropenic critically ill patient in the intensive care unit. J Community Hosp Intern Med Perspect. March 2017 p.43-45 2. Van Der Linden, J. W.M *et al*. Aspergillus species intrinsically resistant to antifungal agents. Medical Mycology, Vol.49, Issue Supplement_1, April 2011, p.S82-S89 3. Inès Hadrich *et al*. Amphotericin B in vitro resistance is associated with fatal Aspergillus flavus infection, Medical Mycology, Vol.50, Issue 8, November 2012, p829-834

P283

**Influenza-associated invasive pulmonary aspergillosis in a 25-bed Greek ICU during 2018-2019 influenza season.**

E. Douka¹, F. Perlikos¹, S. Malachias¹, E. Gavrielatou¹, K. Sarri¹, M. Kougias¹, G. Adamos¹, S. Kostourou², S. Zakinthinos¹

¹Icu, Evangelismos General Hospital, Athens, Greece, ²Infection Control, Evangelismos General Hospital, Athens, Greece

**Objectives:** Invasive pulmonary aspergillosis (IPA) is an opportunistic fungal infection that often affects severely immunocompromised hosts. It has been recently documented as a co-infection in critically ill patients with severe viral influenza infection, although the exact risk rate is less well determined. To study the prevalence of IPA in critically ill patients with severe influenza in Evangelismos General Hospital, Greece.

**Methods:** We retrospectively reviewed all the ICU records for the 2018-2019 influenza season. Influenza was diagnosed using the polymerase chain reaction. Co-infection had to be confirmed using standard bacteriological tests. 28-day ICU and hospital mortality was calculated.

**Results:** Of the 69 patients diagnosed with influenza (34 H1NH, 31 Influenza A, 1 H1N2, 1 H1N3, 1 H1N4) in our 1000-bed tertiary hospital, 9 patients where admitted to the ICU (5 H1N1, 1 Influenza A, 1 H1N3, 1H1N4). Two patients had a co-infection (2,9% of the hospitalized patients with influenza and 22% of influenza patients admitted to the ICU). 3 ICU patients suffering influenza were severely immunocompromised but none of them developed IPA. Underlying medical conditions included hematology malignancy (3), diabetes mellitus (2), chronic renal failure (2). IPA was confirmed by histopathological findings in one patient and in combination of clinical, microbiological and radiological criteria in both. The galactomannan test in BAL was positive only in the patient with endobronchial bulky disease. Microbiology BAL cultures were *Aspergillus spp* positive both (*A. Fumigatus* and *A. Niger* respectively). Both patients were treated with isavuconazole (6 and 12 weeks respectively) and were completely cured. The 28-days ICU mortality was 22,2% in influenza ICU patients group. 90-day hospital mortality was 44,4%. None of the 2 patients with IPA co-infection has died.

**Conclusion:** IPA co-infection in critically ill patients with severe influenza has been increasingly reported worldwide in recent years. Infection with influenza may increase the risk of invasive aspergillosis by breaking down the bronchial mucosa facilitating Aspergillus invasion, inducing immunomodulatory effects. Aspergillus infection should be considered as a possible cause of persistent or progressing respiratory failure in immunocompetent critically ill patients suffering from influenza. The diagnosis of IPA requires awareness in order to conduct timely and appropriate testing. Microbiology laboratories also need to be aware of the suspicion of IPA. IPA is a rapidly progressive disease with high mortality rates up to 90%. Mortality can be reduced with prompt initiation of effective antifungal therapy. Isavuconazole has shown promising results in our clinical setting, for the primary treatment of IPA, especially in patients with endobronchial bulky disease and chronic renal failure.

P284

*Candida auris* bloodstream infection in Egypt
M. El-Kholy¹, S. Shawky², A. Fayed³, J. Meis⁴

¹Department Of Microbiology And Biotechnology, College of Pharmacy, Arab Academy for Science, Technology and Maritime Transport (AASTMT), Alexandria, Egypt, ²Department Of Microbiology, Medical Research Institute, University of Alexandria (MRI), Alexandria, Egypt, ³Department Of Critical Care Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt, ⁴Department Of Medical Microbiology And Infectious Diseases, Excellence Center For Medical Mycology (ecmm), Canisius Wilhelmina Hospital, Nijmegen, Netherlands

**Case Report:**

**Objectives:** *Candida auris* was first identified and described in 2009 in Japan. Genomic analysis has shown that *C. auris* emerged in at least 3 different continents, including the Middle-East, almost simultaneously. Here we report the first case of *C. auris* infection in Egypt.

**Methods:** We present the first case of *C. auris* fungemia from a patient in Egypt.

**Results:** A 53-year-old male was admitted in December 2017 to a hospital in Cairo just after returning travelling from Saudi Arabia. He suffered from vomiting, abdominal pain, bone aches and muscle weakness. Further investigations showed a positive C-ANCA and in a renal biopsy, small vessel vasculitis consistent with Wegeners granulomatosis. He received steroids and endoxane after which he improved temporarily. However, he became more ill and was transferred to ICU where he was intubated and received plasmapheresis. Due to kidney failure he required hemodialysis during his ICU admission. On day 40 of hospitalization he was transferred to a tertiary care facility in Alexandria with cardiovascular, respiratory and renal failure. He appeared septic with leukocytosis and elevated C-reactive protein of 223. Peripheral blood cultures were obtained and broad-spectrum empirical therapy with iv meropenem, colistin and caspofungin was started. Bronchoalveolar cultures showed growth of multidrug resistant *Pseudomonas aeruginosa* (only colistin and amikacin susceptible) and blood cultures showed the growth of yeasts which were identified as *C. auris* with the VITEK2 with updated database (version 8.01) and confirmed with MALDITOF. Despite the early proper empiric treatment with caspofungin the patient passed away on day 4 after admission. Urine cultures were negative for yeasts. After diagnosis, strict contact precautions were installed and no further *C. auris* cultures were identified in our healthcare facility in the past year. CLSI antifungal susceptibility testing showed resistance to fluconazole (64 mg/L), a higher MIC of amphotericin B (1 mg/L) and low MICs of echinocandins (0.063 mg/L). AFLP and MLVA genotyping showed that the isolate clustered with the south-Asian *C. auris* Clade.

**Conclusion:** We report the first case of *C. auris* (south-Asian clade) bloodstream infection in Egypt. Since the patient resided shortly before in Saudi Arabia it is highly likely that he was colonized while staying abroad and that his fast progressing illness predisposed for this fatal outcome of *C. auris* fungemia. In the year after discovery no secondary cases were detected in our healthcare facility.

P285

**Invasive pulmonary aspergillosis in patients admitted to the intensive care unit with severe
influenza pneumonia: An observational study from a developing country**

M. Irfan¹, M. Hussain¹, K. Jabeen², S. Awan³, J. Farooqi², N. Nasir⁴, Z. Hasan⁵

¹Medicine, Aga Khan University, Karachi, Karachi, Pakistan, ²Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, ³Medicine, Aga Khan University, Karachi, Karachi, Pakistan, Pakistan, ⁴Adult Infectious Diseases, Aga Khan University, Karachi-KHI, Pakistan, ⁵Department Of Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan

**Objectives:** Invasive pulmonary aspergillosis (IPA) in patients with influenza is increasingly being identified in recent years. Cases of influenza-associated IPA with high mortality have been reported from several developed countries with a reported incidence between 19-28 % (1, 2). So far no significant data is available from developing countries. The aim was to determine the incidence and outcome of IPA in patients with severe influenza pneumonia admitted in an intensive care unit (ICU) of a developing country.

**Methods:** This was an observational study on confirmed influenza patients with respiratory failure admitted to the Aga Khan University hospital (AKUH) ICU from November 2018- March 2019.
Patients older than 18 years, acute respiratory failure, pulmonary infiltrates on imaging, and a confirmed influenza infection based on a positive influenza PCR were included. The diagnostic criteria used for IPA was based on suggestive clinical signs and symptoms, radiological findings and mycological data (2). Like other studies, we have also not included the host factors as this criterion was largely created for immunosuppressed hosts, and influenza-related aspergillosis may occur in previously normal hosts (2). The clinical characteristics, radiology, laboratory data and outcome were recorded on a predesigned performa.

**Results:** A total of 92 patients with confirmed influenza were admitted at AKUH during study period. Of these 16/92 (17.02%) were admitted in ICU due to respiratory failure. Among these 16 patients, IPA was diagnosed in 5 patients, giving an incidence of 31.25%. The mean age of IPA patients was 61.2 (±5.02) years (Range 53-65 years) and 60% were female. Three (60%) patients had non H1N1 Influenza A and 2 (40%) had H1N1 Influenza A infection. Three (60%) patients had underlying diseases (diabetes, hypertension and ischemic heart disease) and one patient was immunosuppressed. Systemic steroids were used after ICU admission in all patients. On admission 3 (60%) patients had acute kidney injury and 2 (40%) had deranged liver enzymes. Invasive positive pressure ventilation (IPPV) was required in 04 (80%) patients and one patient was managed on noninvasive ventilation (NIV). The average duration of IPPV use was 10.8 (range: 5-24) days. All 5 patients had received voriconazole after diagnosis of IPA. The overall mortality rate of influenza patients admitted in ICU was 50% and in patients with IPA was 60%. The causes of death were ARDS and multisystem organ failure.

**Conclusion:** High incidence (31.25%) of IPA was found in influenza patients requiring ICU admission and was associated with high (60%) mortality. High index of suspicion, early diagnosis and appropriate treatment can improve outcome in these patient. Future large multicenter studies are required to assess the risk factors and role of antifungal prophylaxis to improve the outcome of influenza-associated aspergillosis. **References:** Schauwvlieghe A, Rijnders BJA, Philips N, Dutch-Belgian Mycosis study group et al. Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study. *Lancet Respir Med* 2018. Huang L, Zhang N, Huang X, et al. Invasive pulmonary aspergillosis in patients with influenza infection: A retrospective study and review of the literature. *Clin Respir J*. 2019 Apr;13(4):202-211.

P286

**Hellenic Invasive Candidiasis Study (HELICAS): Identification and Antifungal Susceptibility of Candida species in Greek ICUs.**

G. Vrioni<fnref n="1" />, D. Tsilakis², V. Grammelis², G. Cheliotis³, V. Baka⁴, M. Christofidou⁵, S. Karahalios⁶, P. Kazila⁷, V. Mamali⁸, S. Maraki⁹, G. Maropoulos¹⁰, M. Panopoulou¹¹, E. Perivolioti¹², E. Petinaki¹³, E. Platsouka¹⁴, K. Themeli-Digalaki⁸, S. Tsiplakou¹⁵, E. Tsorlini¹⁶, E. Vagdatli¹⁷, E. Vogiatzakis¹⁸, S. Vourli¹⁹, L. Zerva¹⁹, E. Karahaliou<fnref n="1" />, K. Theodoridou<fnref n="1" />, C. Tsianos<fnref n="1" />, I. Skiadas², A. Armaganidis²⁰, A. Tsakris<fnref n="1" />

<footnote n="1">¹Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece,
²Medical Affairs, Pfizer Hellas, Athens, Greece,
³Biometrics Program Manager, Health Data
Specialists, Athens, Greece,
⁴Microbiology, Red Cross General Hospital, Athens, Greece,
⁵Microbiology, Rio University Hospital, Patras, Greece,
⁶Microbiology, Agioi Anargyroi Oncology
Hospital, Athens, Greece,
⁷Microbiology, Theageneio Oncology Hospital, Thessaloniki, Greece,
⁸Microbiology, Tzaneio General Hospital, Athens, Greece,
⁹Microbiology, University Hospital Crete,
Herakleio, Greece,
¹⁰Microbiology, Laiko General Hospital, Athens, Greece,
¹¹Microbiology, University Hospital of Alexandroupolis, Alexandroupolis, Greece,
¹²Microbiology, Evangelismos
General Hospital, Athens, Greece,
¹³Microbiology, Larissa University Hospital, Larissa, Greece,
¹⁴Microbiology, "Konstantopouleio-Patission" General Hospital of Neas Ionias, Athens, Greece,
¹⁵Microbiology, KAT General Hospital, Athens, Greece,
¹⁶Microbiology, "G. Papanikolaou" General
Hospital, Thessaloniki, Greece,
¹⁷Microbiology, "Ippokrateio" General Hospital, Thessaloniki, Greece,
¹⁸Microbiology, Sotiria General Hospital, Athens, Greece,
¹⁹Microbiology, Attiko University Hospital,
Athens, Greece,
²⁰Intensive Care Unit, Attiko University Hospital, Athens, Greece</footnote>
**Objectives:** HELICAS (HELlenic Invasive CAndidiasis Study) was a prospective non-interventional study aiming to compare the cost of treatment of documented invasive candidiasis (IC) by *C. albicans* and *C. non-albicans* species, in 18 Greek intensive care units (ICUs). As part of this study, isolated *Candida* species were collected and analyzed. Additionally, the epidemiology of IC by *C. albicans* and *C. non-albicans*, was evaluated by collecting retrospective data from participating ICUs for at least 3-month period.

**Methods:** A total of 100 adult subjects (49% *C. albicans*, 51% *C. non-albicans*) were enrolled according to a pre-specified sample size, for both *C. albicans* and *C. non-albicans* cases. Demographics, days of ICU stay, antifungal and concomitant medications, hospital supplies, laboratory investigations and treatment patterns, as well as patient outcomes and survival were documented. Eighty-two of the collected *Candida* isolates (39 *C. albicans*, 43 *C. non-albicans*) were sent to the Department of Microbiology, Athens Medical School, for further investigation. *Candida* isolates were identified by conventional, biochemical tests (CHROMagar*Candida* Medium, Becton Dickinson; API 32C, BioMérieux), supplemented with mass spectrometry (Vitek MS, BioMérieux), if the identification score was < 95%. Antifungal susceptibility testing for amphotericin B, 5-flucytocine, itraconazole, fluconazole, voriconazole, posaconazole, micafungin, caspofungin, and anidulafungin was performed with the broth microdilution method (MICRONAUT-AM MHK 2, MERLIN Diagnostika GmbH), according to CLSI 2012 M27-A3 document. Revised CLSI M27-S4 species-specific clinical breakpoints were applied.

**Results:** Eighty-two strains were studied, the majority isolated from candidemia cases; 39 (47.6%) *C. albicans*, 26 (31.7%) *C. parapsilosis*, 9 (11.0%) *C. tropicalis*, 6 (7.3%) *C. glabrata*, 1 (1.2%) *C. kefyr*, and 1 (1.2%) *C. lusitaniae*. All strains showed low MICs to amphotericin B, with MIC values ranging from 0.0625 to 1 µg/ml. Sixteen isolates were resistant to fluconazole: 15 *C. parapsilosis* (MIC range 8-32 µg/ml) and 1 *C. albicans* (MIC ≥ 128 µg/ml), while 13 isolates exhibited dose-dependent susceptibility: 6 *C. glabrata*, 4 *C. parapsilosis*, 2 *C. tropicalis* and 1 *C. albicans*. Only 2 isolates, i.e.1 *C. albicans* (MIC ≥ 128 µg/ml) and 1 *C. parapsilosis*, were resistant to voriconazole, while 3 *C. parapsilosis* and 1 *C. tropicalis* exhibited dose-dependent susceptibility. Resistance to echinocandins was not detected in any strain. Intermediate susceptibility was demonstrated in 2 *C. tropicalis* to caspofungin and anidulafungin, and in 2 *C. glabrata* to caspofungin. Based on the epidemiology data, extrapolated to one year, the majority (64.3%) of IC cases in the participating ICUs were caused by *C. non-albicans* spp. (*C. parapsilosis*: 45.7%), with the remaining 35.7% being due to *C. albicans*.

**Conclusion:** Epidemiological patterns of IC reveal a predominance of *C. non-albicans* spp. in Greek ICUs, especially *C. parapsilosis*. Since 15/26 (57.7 %) of *C. parapsilosis* isolates were resistant to fluconazole, this observation raises concerns, as fluconazole has traditionally been considered the first-line choice for *C. parapsilosis*. In vitro antifungal susceptibility testing should be performed to assist in the selection of the most appropriate antifungal therapy, and in monitoring the development of resistance.

P287

**Species distribution and antifungal susceptibility patterns of *Candida* isolated from a Tunisian burn intensive care unit**

S. Cheikhrouhou<sup>1,2</sup>, D. Aloui<sup>1,2</sup>, M. Bouchekoua<sup>1,2</sup>, A. Messadi<sup>2,3</sup>, L. Thabet<sup>2,3</sup>, S. Trabelsi<sup>1,2</sup>, S. Khaled<sup>1,2</sup>
<sup>1</sup>Laboratory Of Parasitology And Mycology, Charles Nicolle Teaching Hospital, Tunis, Tunisia,
<sup>2</sup>Faculty of Medicine of Tunis-Tunis El Manar University, Tunis, Tunisia, <sup>3</sup>Ben Arous Trauma and burn center, Tunis, Tunisia, Ben Arous, Tunisia

**Objectives:** The objective of this study was to analyze the species distribution of *Candida* isolates from a Tunisian burn intensive care unit and their antifungal susceptibility patterns.

**Methods:** We performed a retrospective review of 35 severely burned patients admitted to the burn intensive care unit of Ben Arous Trauma and Burn Center with one or more positive culture sites for *Candida*, during the 28-month period from January 2017 to April 2019. The susceptibility for 6 antifungal drugs (5-fluorocytosine, fluconazole, ketoconazole, micronazole, itraconazole, amphotericin B) was determined using the Fungitest® broth dilution method for patients with
infected normally sterile body sites or a *Candida* colonization index superior or equal to 0.4. Voriconazole and caspofungine were tested when needed.

**Results:** A total of 74 *Candida* isolates were obtained. Positive urine cultures yielded 30% of *Candida* isolates. The rectal site represented 15% of colonized body sites, followed by nasal and oral sites (13,5% each), axillary (9,4%), ocular (8%) and cutaneous and auricular sites (5,4% each). *Candida albicans* was the predominant species (43.2%), followed by *C. glabrata* (31%), *C. tropicalis* (17,5%), *C. parapsilosis* (3%), *C. colliculosa* (3%) and *C. sake* (1%). Among the strains whose antifungal susceptibility were determined, the majority of *Candida* isolates were susceptible to fluconazole (64%), 20,5% of the isolates were intermediate and 15,4% were resistant to this antifungal drug, mainly *C. tropicalis* and *C. glabrata*. There was a high rate of strains with intermediate susceptibility to itraconazole (46%), miconazole (50%) and ketoconazole (23%). Only one strain was resistant to amphotericin B which was *C. tropicalis*.

**Conclusion:** Although the prevalence of non-*albicans* species has increased over recent years, *C. albicans* remains the most frequent species in burn unit-acquired candidiasis. Our antifungal susceptibility test results did not exhibit significant levels of resistance, but non-*albicans* species must be taken into consideration when choosing antifungal agents for calculated therapy.

P288

**Performance of the (1,3)-β-DG-glucan assay for detection of candidemia in adult ICU patients: a preliminary evaluation**

G.M.B. Del Negro¹, G. Naves², V.L. Freitas³, M. Magri⁴, J. De Almeida Junior⁵, E. Abdala⁶, O.N. Sejas⁶

¹Laboratório De Investigação Médica Lim53, Insituto de Medicina Tropical, São Paulo, Brazil,
²Laboratório De Investigações Médicas 53, Insituto de Medicina Tropical, São Paulo, Brazil,
³Laboratório De Investigação Médica Em Imunologia Lim48, Insituto de Medicina Tropical, São Paulo, Brazil,
⁴Clinica De Molestias Infecciosas, Hospital das Clinicas da FMUSP, São Paulo, Brazil,
⁵Divisão De Laboratorio Central, Hospital das Clinicas da FMUSP, São Paulo, Brazil,
⁶Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil

**Objectives:** Invasive candidiasis (IC), including candidemia episodes, is a considerable cause of morbidity and mortality in immunocompromised critically ill patients. Studies have been reported that early diagnosis of IC is crucial for an appropriate treatment and successful outcome of patients. Analyses using serum levels of the β-D-glucan (BDG) biomarker have shown promising results for the early diagnosis of IC/candidemia. This study aimed to evaluate the performance of the BDG assay as a diagnostic tool for candidemia detection in ICU adult patients with risk factors for IC.

**Methods:** Thirty-nine patients admitted to five ICU from two tertiary hospitals were enrolled, being 11 with proven candidemia (at least one blood culture positive for *Candida*) and 28 patients with negative bloodstream cultures but clinical findings consistent with candidemia (probable candidemia). Blood samples for cultures and BDG testing were collected before administration of antifungal therapy. *Candida* spp. were isolated from blood by using the Bactec™ system and identified by VITEK® MS which uses MALDI-TOF technology. BDG serum concentrations were measured using the Fungitell® assay following the standard operating procedures. All samples were tested in duplicate. The analyses were performed using SPSS Statistics version 24.0.

**Results:** All patients with proven candidemia presented positive results with significantly higher BDG values than those with probable candidemia (median 437.7 vs. 70.6 pg/ml, p <0.001). Among the probable candidemia patients, four (14.3%) showed positive BDG results (ranging from 85 to 276.5 pg/ml), two of them had proven bacteremia, and three patients (10.7%) presented indeterminate values (≥ 60 and ≤ 80 pg/ml). Seven patients of the probable candidemia group (negative bloodstream cultures) presented positive cultures for *Candida* spp. in blood samples harvested from central venous catheter. These seven patients showed significantly higher BDG values when compared to patients with no positive cultures at all (median 151.4 vs. 51.7 pg/ml, p< 0.007).

**Conclusion:** We presented preliminary results from a prospective study for early laboratory diagnosis of candidemia in ICU adult patients at high risk of this systemic infection. Patients with proven candidemia had significantly higher BDG levels than those patients in whom the bloodstream
*Candida* infection could not be demonstrated. The BDG positive values observed in patients with positive blood catheter cultures signal that these patients might have true candidemia in spite of negativity of blood cultures. By the other hand, the possibility of false-positive results in this group should be considered and in this scenario another non-culture based methodology, such as real time PCR technique would be required to firmly establish the diagnosis of candidemia.

P289

Influenza associated invasive pulmonary aspergillosis in Indian intensive care units

S. M Rudramurthy¹, A. Chakrabarti², P. Shastri³, A. Patel⁴, J. Savio⁵, R. Karthik⁶, H. Kaur²

¹Medical Microbiolgoy, Postgraduate Institute of Medical Education and Research, Chandigarh, India, ²Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, ³Critical Care, Sri Gangaram Hospital, Delhi, India, ⁴Infectious Disease, Sterling Hospitals, Ahmedabad, India, ⁵Microbiology, St. John's Medical College, Bangalore, India, ⁶Infectious Disease, Christian Medical College, Vellore, India

**Objectives:** Beyond the classical neutropenic hosts, invasive pulmonary aspergillosis (IPA) is increasingly reported in non-neutropenic critically ill patients. Influenza A H1N1 infection is one among those emerging non-classical risk factors. In a multicentre prospective observational study on invasive mould infections (IMIs)in Indian ICUs, we identified 12 cases of IPA associated with influenza H1N1 [1]. Here, we analysed those influenza associated aspergillosis (IAA) cases to evaluate its epidemiology in Indian ICUs.

**Methods:** The study captured all cases of IMIs at 11 ICUs across India during April 2016 through September 2017. IMI was diagnosed as proven, probable and possible based on the EORTC-MSG criteria in the classical immunosuppressed subjects (2), the criteria proposed by Bulpa et al. in subjects with COPD (3), and Vandewoude et al. in non-COPD subjects admitted to the ICU (4). Demographic, clinical presentation, laboratory investigations, treatment and management of proven and probable IMIs were collected using predesigned proforma (1). The present study is the subgroup analysis of clinical and laboratory variables and management of 12 patients diagnosed as IAA.

**Results:** During the study period 135 IPA cases (proven and probable) were reported, 37 (27.5%) had classical risk factor and 98 (72.5%) non-classical risk factors. Among non-classical risk factors 12 patients had IAA; one patient was proven and 11 cases were probable IPA. Those patients were from four centres of India (north-1, south -2, and west-1) and majority (58.3%) cases from a single centre at Delhi. 10/12 cases occurred in summer. The mean age of those patients was 56.8 ± 12.34 years with equal distribution of sex. The mean APACHE score was 18.41 ± 4.56. The diagnosis of IPA was made at a mean of 3.83 ± 2.94 days after ICU admissions. The solid organ malignancies were co-morbidities in two patients, eight patients were on ventilator. *Aspergillus* species was isolated from ten cases (*Aspergillus flavus*-5, *A. fumigatus* -2, *Aspergillus* spp. – 2 and *A. flavus*+*A. fumigatus* -1). Serum and/or BAL galactomannan was positive in eleven patients. Radiological evidence in the form of opacity (10 cases), cavity (1 case), nodules (5 cases), infiltrates (2 cases), consolidation (7 cases) or pleural effusion (3 cases) was noted in those patients. None of them had classical air crescent or halo sign. The patients were treated with voriconazole (8 cases) or voriconazole + amphotericin B deoxycholate (1 case), voriconazole + caspofungin (1 case) and liposomal amphotericin B (1 case). But, the 42-day or 84-day mortality remained at 58.3% despite targeted antifungal therapy.

**Conclusion:** The study emphasizes that influenza H1N1 is an emerging risk factor for IPA in Indian ICUs. Unlike other reports of *A. fumigatus*, *A. flavus* is the predominant causative agent in Indian scenario. During influenza season, critically ill patients should be thoroughly investigated for IPA. Early diagnosis and prompt therapy may reduce high mortality rate of IAA cases. **References** Chakrabarti et al. (2019). J Crit Care 51, 64–70. De Pauw B et al (2008). Clin Infect Dis 46:1813–21. Bulpa P(2007) Eur. Respir. J. 30:782–800. Blot SI et al (2012) Am J Respir Crit Care Med: 186:56–64

P290

Early detection of circulating candida antigen and antibodies in ICU patients with candidemia
S. Anitha¹, A. Yamini¹, A.J. Kindo²

¹Microbiology, Sri Ramachandra Institute of Higher Education and Research Institute, Chennai, India, ²Microbiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India

**Objectives:** Early detection of candida in blood using lateral flow assays and candida mannan assay in ICU patients at risk of invasive candidiasis selected by candida scoring and to compare the results with the Gold standard blood culture method.

**Methods:** Patients having an ICU stay of > 7 days were taken up. Candida scoring was done and 33 patients who had scored ≥3 were considered for the study. Patients Age, gender, clinical presentations at admission, severity scores including Acute Physiological and Chronic Health Evaluation II ( APACHE II), co-morbid medical conditions, surgical and invasive procedures, exposure to antibiotics, corticosteroids, antifungals, secondary bacterial infections, antifungal treatment instituted in the ICU and final outcome were recorded. Patients were divided into 2 groups based on the presence or absence of candida. The blood samples were collected at the onset of sepsis and assays were performed. The samples were tested for the presence of IgM and IgG antibodies specific for candida using lateral flow assay kits and mannan antigen using candida mannan assay kit (Dynamiker Biotechnology (Tianjin) Co., Ltd) which would provide early detection of candida in blood and thus facilitating in early start of suitable antifungal therapy and a favorable outcome.

**Results:** A total of 33 patients admitted to the ICU from Jan 2019-April 2019 based on candida scoring were considered for the study. Of the 33 patients, six were proven cases of candidemia and the remaining 27 were did not grow candida in blood culture. The mean age of the patients who had candidemia ranged from 45-82yrs. Among the candidemia patients the male:female ratio was equally distributed. The duration of stay in ICU was more for candidemia patients (median days 15). The APACHEII scoring was high among candidemia patient (median 54.5) compared to non candidemia patients (median 36.5). Also the candida scoring among candidemia patients was found to be high (median 4.5). The analysis of the results for the presence of IgG, IgM antibodies specific for candida and mannan antigen will be done and compared with gold standard blood culture method.

## Demographic characteristics of studied groups

<table><thead><tr><th rowspan="2">Characteristics</th><th>Candidemia</th><th>No candidemia</th></tr><tr><th>n=6</th><th>N=27</th></tr></thead><tbody><tr><td>Age (Range)</td><td>45-82yrs</td><td>24-86yrs</td></tr><tr><td>Male</td><td>3</td><td>17</td></tr><tr><td>Female</td><td>3</td><td>10</td></tr><tr><td>ICU stay (median days)</td><td>15</td><td>14.5</td></tr><tr><td>APACHE II scoring (median)</td><td>54.5</td><td>36.5</td></tr><tr><td>Candida scoring (median)</td><td>4.5</td><td>3</td></tr></tbody></table>

**Conclusion:** The three methods will be compared so that we don't have to rely always on culture to start the treatment. Development of diagnostic and predictive tests will probably lead to increased use of preemptive therapy. The presence of biomarkers is an indicator to assist in decision to start or stop antifungal treatment. In case of positivity of fungal biomarker, it recommends to initiate preemptive therapy. In case of negativity of fungal biomarker, it suggests to stop empiric therapy.
J. Helweg-Larsen¹, M. Steensen², F. Møller Pedersen³, P. Bredahl Jensen³, J. Bonde², M. Perch⁴, K. Møller⁵, B. Riis Olesen⁶, M.C. Arendrup⁷

¹Department Of Infectious Medicine, Rigshospitalet, Copenhagen, Denmark, ²Department Of Intensive Care Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, ³Department Of Thoracic Anaesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, ⁴Department Of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, ⁵Department Of Neuroanaesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, ⁶Department Of Economy, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, ⁷Rigshospitalet, Dept. of Clinical microbiology, Copenhagen, Denmark

**Objectives:** Management of invasive candidiasis (IC) in ICU patients is challenging since traditional diagnostic methods and prediction scores have limited sensitivity and specificity. Non-culture-based biomarkers could potentially improve diagnosis and antifungal treatment (AFT), enabling safer discontinuation of unneeded therapy. We evaluated a new antifungal stewardship programme (AFSP) including T2Candida and *Candida* mannan antigen (MAg) screening of high-risk ICU patients.

**Methods:**
<figure><img src="image_74.png" /></figure>

# ICU – Invasive Candidiasis Guideline

## For patients without significant neutropenia/severe immunosuppression

<footnote>** Colonisation: Urine and TS colonisation higher importance than GI colonisation. Colonisation should not be treated. Oral, vaginal Candida: local treatment. † Suspicion of IC: No other verified explanation.</footnote>
<table><thead><tr><th colspan="2">Invasive Candidiasis Classification</th></tr></thead><tbody><tr><td>Proven</td><td>1) Growth of Candida in a BC, or<br>2) Fulfilling <u>all of:</u><br>i) Growth of Candida in a tissue biopsy or sample from a drain at placed within 24 hours.<br>ii) Sampling from a normally sterile site using sterile procedures<br>iii) Clinical or radiological signs of infection at that site.</td></tr><tr><td>Likely</td><td>No alternative microbiological diagnosis (+/- 3 days) and severe sepsis despite 3 days of broad-spectrum antibacterial treatment with<br>1) Candida isolated from at least two nonsterile sites (+/-3 days) and<br>2) Candida MAg >250 mg/L or T2Candida positive.</td></tr><tr><td>Possible</td><td>Sepsis and clinical illness compatible with IC despite 3 days of broad-spectrum antibacterial treatment and either<br>1) Candida MAg >125 mg/L or T2Candida positive and Candida isolated from at least 2 non-sterile sites (+/- 3 days)<br>2) Colonised with the same Candida species from at least 2 non-sterile sites (+/- 3 days)</td></tr><tr><td>Unlikely</td><td>All remaining cases</td></tr></tbody></table>

Patients in two ICU's (abdominal/general and thoracic, respectively) at a tertiary university hospital were eligible. The Figure and Table summarise inclusion criteria, AFSP algorithm and IC classification criteria. The diagnostic value of T2Candida and MAg in relation to traditional methods were evaluated. Consumption of antifungals during the AFSP and the preceding 2 years was compared.

**Results:** 219 patients with 504 T2Candida/MAg samples were included. Median age was 63 years, median ICU stay was 19 days, 45% were receiving renal-replacement-therapy; 29% TPN, 22% underwent acute surgery and the overall in-hospital mortality was 42%. At inclusion, 32% of patients had received AFT for >3 days. 30 patients had positive T2Candida; 24 positive MAg and 18 had positive blood cultures (BC). IC was classified as proven in 29, likely in seven and possible in 10 patients. Defining IC as proven/likely versus unlikely, sensitivity/specificity/NPV values were 47%/100%/91% for BC; 56%/97%/90% for T2Candida; and 39%/96%/88% for MAg. MAg identified five patients with IC, in whom T2Candida or BC were negative. Of these, one had proven *C. lusitaniae* IC and four had possible IC (colonizing isolates without species-identification). The best diagnostic performance was the combination of T2Candida&MAg taken ≤3 days after AFT: sensitivity/specificity/PPV/NPV of 70%/90%/ 63%/93%, versus 61%/93%/63%/ 92% for all patients, respectively. Overall, similar performance was observed if IC was defined as proven/likely/possible. The use of T2Candida/MAg contributed to 15% of patients receiving early (<3 days) AFT after a positive test, 25% of patients having early AFT discontinuation and 24% of patients being managed without AFT. No reduction or overall change in use of echinocandin or azole treatment was observed at the two ICU's in the study period compared to the two previous years.

**Conclusion:** Introduction of an AFSP based on T2Candida and MAg screening of high-risk patients contributed to reducing unnecessary treatment but not overall AFT use. The diagnostic performance of T2Candida for IC was higher than for BC and MAg, but lower than initially reported. T2Candida detects cell-associated Candida DNA and thus depend on circulating Candida cells. A significant proportion of our patients were already on antifungal therapy at the time of sampling or suffered from BC-negative IC thus likely representing patients with a low number of circulating Candida cells. Moreover, a significant proportion of patients were only tested once or twice. Taken together, our
study suggests that the combination of T2Candida and MAg improved diagnostic performance compared to T2Candida alone with a sensitivity of 70% and NPV of 93% in patients with ≤3 days AFT. This combination may contribute to improved management of IC in the setting of an AFSP particularly if initiated before AF prescription and with strict adherence to the AFSP.

P292

Incidence, treatment and outcome of ICU-acquired Candidemia in 5 ICU from Cluj-Napoca, Romania during a 6 years period

M. Lupse¹, M.A. Rus¹, L. Herbel², M. Flonta³

¹Infectious Diseases, University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania,
²Icu, University Hospital of Infectious Diseases, Cluj-Napoca, Romania, ³Microbiology, University Hospital of Infectious Diseases, Cluj-Napoca, Romania

**Objectives:** To evaluate the incidence, etiology and outcome of candidemia in ICU from our city

**Methods:** We retrospectively analyzed all cases of candidemia diagnosed based on patients files, considering only the first episode/patient. We included non-neutropenic patients from 5 ICU from our city (1pediatric ICU, 1 medical ICU and 3 surgical ICU) during 6 years (Jan 2007- Dec 2012). We evaluated: demographic data, etiology, antifungal treatment and outcome.

**Results:** There were 107 patients, average age 44.5 (median age 55, min 1 day, max 85 years, median age for PICU patients was 1.4 months), 50 female (46.73%). The incidence was 25.8/1000 admission in PICU and 2.8/1000 admission in SICU. The etiology was represented by *Candida albicans* in 53 (48%) patients, *Candida parapsilosis* in 31 (29%), *Candida glabrata* in 7 (6%) and other species in 15 patients. *Candida parapsilosis* was the most frequent etiology of candidemia for children (45%). Crude mortality rate was 59.8%, higher in adults and in patients infected with *Candida glabrata* (5/6) and *Candida tropicalis* (5/5). 55 patients were treated with fluconazole, 14 with caspofungin, 3 with voriconazole, 10 with ketoconazole and 25 patients did not receive any antifungals. Resistance to fluconazole was 23.36% (24.48% for *Candida albicans*).

**Conclusion:** Candidemia was a frequent situation in ICU non-neutropenic patients. The involvement of *Candida albicans* and *Candida non-albicans* was almost equal but significantly different in adults and children. Fluconazole was the most used antifungals but the resistance to Fluconazole was high. The mortality rate was very high, significantly higher in adults than in children and in *Candida* sp. other than *Candida parapsilosis*.

P293

A Native Human Burn Infection Model of Candidiasis

F. Bulman¹,², D. Rosenberger²,³, C. Von Mueller²,³, S. Vylkova²,³

¹Jena University Hospital, Jena, Germany, ²Septomics Research Center, Friedrich Schiller University, Jena, Germany, ³Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, Jena, Germany

**Objectives:** A tenfold rise in fungal burn wound infections (BWI) has been observed globally since the 1960s due to the introduction of broad spectrum antimicrobial agents (Sarabahi et al, 2012). The fungal opportunistic pathogen *Candida albicans* is a common isolate from BWI (Branski, Al-Mousawi et al. 2009). Systemic candidiasis originating from burn wounds can result in up to 70% mortality rates, yet nothing is known about the biology of infection. The objective of this study was to develop a reliable model of infection. Current animal models such as murine, rat and porcine have major differences in skin biology and inflammatory responses compared to human and are ethically questionable. Therefore, we have developed a novel *ex vivo* human skin model of burn wound *C. albicans* infection and examined the role of key fungal virulence determinants and host responses throughout the progression of infection.

**Methods:** NativeSkin® human tissue (Genoskin, France) was burned with a 350°C soldering iron for 15 sec, debrided and infection was initiated with 1x10⁵ cells of *C. albicans* wild-type SC5314 strain expressing luciferase. The progress of infection was measured by bioluminescence at 1 and 6 days after burn induction, followed by sample fixation for further histological analysis and
immunofluorescence staining. Immune cell populations were analysed by flow cytometry and media was measured for the presence of proinflammatory cytokines and lactate dehydrogenase (LDH), a cytotoxicity marker. In some experiments, we supplemented the media with 2x10⁶ polymorphonuclear neutrophils (PMNs) to observe tissue infiltration and effects on healing of the burn.

**Results:** The protocol proved to reliably cause third degree burn wounds in an operator independent manner. Staining for high mobility group box 1 protein (HMGB1) showed that while the unburned skin retained viability after 6 days, the burned skin samples had marked necrosis. Histological analysis showed reduced depth of burn and area of burn injury at day 6 compared to day 1, indicative of tissue regeneration. Flow cytometry analysis of immune cell populations present in control (unburned) skin detected CD1a+ and CD207+ cells, indicating populations of viable langerhans and dendritic cells. Further, staining for neutrophil elastase (NE) showed the presence of PMNs at the edge of the burn. Levels of cytokines IL-1β, IL-6 and Il-8 were variable between skin donors and experimental conditions, with the highest concentration found in burned and infected samples. BWI with *C. albicans* resulted in prominent tissue penetration, especially following debridement of the burn.

**Conclusion:** A reliable and ethical human skin *ex vivo* model for fungal BWI has been established and various analyses methods were tested. Genoskin NativeSkin® samples exhibit good healing potential, have viable immune cell populations and allow supplementation with PMNs and other cells/factors, thus representing an excellent model for BWI candidiasis. The outlook includes testing key virulence determinants for candidiasis, including dual transcriptional profiling; mixed bacterial and fungal infections, and alterations of approved treatment regimes. Such a model may shed light on early signs and symptoms of candidiasis in the burn population, which could help to develop guidelines in patient care.

P295

**Laboratory tools applied in the diagnosis of invasive fungal infections at laboratory of medical parasitology and mycology of the CHU of Annaba. Algeria.**

R. Mansouri1, S. Touta1, A. Fetni1, F. Saadni1, S. Akil2, F. Grifi2, A. Atik2

1Pharmacy, faculté de medecine, annaba, Algeria, 2Medecine, faculté de medecine, annaba, Algeria
**Objectives:** Invasive fungal infections play an important role as severe infection, constantly rising in the services in charge of patients at risk. Diagnosis and treatment are difficult because of the absence of pathognomonic signs and symptoms. The delay in diagnosis leads to delayed treatment and thus worsened prognosis The objective of this study is to identify the place of laboratory tools applied in the diagnosis of deep candidiasis, Cryptococcosis, Pneumocystosis and invasive aspergillosis.

**Methods:** This is a descriptive prospective study spanning 07 years (2010-2016) and having respective 998 samples from patients from several medical services: intensive care, Internal Medicine, major burned, Onco-Hematology, infectious diseases, Cardiology, Gastroenterology, Nephrology and Pediatrics. The search of the mannan antigen for the diagnosis of invasive candidiasis and galactomannan antigen for the diagnosis of invasive aspergillosis occurs by Enzyme Linked ImmunoSorbent Assay . The search for the capsular antigen of Cryptococcus held by slide agglutination and Pneumocystis spp. by DFA. The search for antibody anti-Candida and anti-Aspergillus occurs by Enzyme Linked ImmunoSorbent Assay. Blood cultures and device samples are also studied for these patients.

**Results:** Among the 371 sera studied for suspected invasive candidiasis, 53 were positive (14.28%) and among 286 sera investigated for suspected invasive aspergillosis, 22 were positive (7.69%). Four cases of Cryptococcosis were confirmed and three cases of Pneumocystosis. Specie isolated from Blood cultures, device and peripheral samples were 93 % C. albicans , 1,5 % were other species : C. parapsilosis, C.zeylanoides, C. glabrata, C.krusei.
**Conclusion:** Invasive fungal infections remain under-diagnosed clinically and therefore mycologically. The mycological diagnosis associated with sero-immunological diagnosis is a decisive contribution in these conditions. A delay in diagnosis worsens the prognosis of these violations where the interests of a multidisciplinary proper care.

P296

Non-HIV female cryptococcal meningitis with and without autoimmune diseases

J. Liu, J. Ying, P. Fu Hua

the Third Affiliated Hospital of Sun Yat-Sen University, guangzhou, China

Objectives: Cryptococcal meningitis (CM) is a rare infection in autoimmune diseases (AIDs) patients. CM complicated with AIDs is more common in women. The aims of this study were to describe the differences of female CM patients with and without AIDs.

Methods: We retrospectively compared the differences between 21 non-HIV female CM with AIDs and 23 non-HIV female CM without AIDs from 2011 to 2018. Their demographic data, clinical manifestations, cerebrospinal fluid (CSF) and MR features were analysed.

Results: We found that female CM with AIDs had lower CSF pressure, higher CPR and ESR than female CM without AIDs when admitted to the hospital. There was no statistical difference in clinical and MRI features between two groups. After antifungal therapy, headache, fever, mRs scores and some CSF index were significantly improved in both groups. In female CM with AIDs, mRs was positively correlated with India ink Cryptococcus count and had no correlation with CSF pressure. But in female CM without AIDs, we found that mRs was positively correlated with CSF pressure and had no correlation with India ink Cryptococcus count.

**Conclusion:** Our data suggested that SLE was the most common in female CM with AIDs, and revealed for the first time a difference between female CM with and without AIDs. Although presenting symptoms of female CM patients with AIDs are usually unspecific. But it is curable if timely make the diagnosis and treatment.

P297

Invasive aspergillosis in HIV-positive patients

O. Shadrivova¹, O. Leonova², D. Bubnova³, A. Volkova⁴, M. Popova⁴, T. Bogomolova⁵, S. Ignatyeva⁵, L. Zubarovskaya⁴, B. Afanasyev⁴, N. Vasilyeva⁵, N. Klimko¹

¹Department Of Clinical Mycology, Allergy And Immunology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ²St. Petersburg Center for the Prevention and Control of AIDS and Infectious Diseases, St. petersburg, Russian Federation, ³North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ⁴I.Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russian Federation, ⁵Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation

**Objectives:** Analysis of underlying diseases, risk factors, etiology, clinical features, treatment and survival rates in HIV-positive patients with IA.

**Methods:** Retrospective analysis of the register of patients with IA in 1998-2018. For diagnosis IA we used criteria EORTS/MSG, 2008.

**Results:** In group I we included 12 HIV-positive adult patients with IA from 25 to 52 years old, median – 34, males – 58%. The control group consisted of 545 adult patients with hematological malignancies, from 18 to 78 years old, median – 47, males – 58%. The study of risk factors showed significant differences between these groups. Lymphocytopenia was detected predominantly in HIV-positive patients 75% vs 56%, duration 35 vs 14,5 days, (p = 0.006), while agranulocytosis in this group
was observed less frequently – 58% vs 81%, p = 0.008, duration 8 vs 13 days (p = 0.01). Among the HIV+ patients there were no recipients of allogeneic stem cell transplants (0% vs 19%, p = 0.001) and patients receiving immunosuppressive therapy (0% vs 29%, p = 0.02). The main sites of infection were lungs - 100% vs 98%, however hemoptysis and dissemination of infection more often registered in HIV+ patients – 17% vs 6% (p = 0.03) and 17% vs 8% (p = 0.04), respectively. Galactomannan test in BAL was positive in 42% vs 75% cases. *Aspergillus spp.* were isolated in 42% vs 44%, in all HIV+ patients the main etiological agent of IA was *A. fumigatus* - 100% vs 45% (p = 0.001). Mixed fungal infection was detected in 33% vs 11% (p = 0.001). «Proven» IA was diagnosed in 17% vs 7% (p = 0.02). Antifungal therapy was used in 100% vs 99% of patients; the most commonly used drug was voriconazole (58% vs 77%). Twelve weeks overall survival rate was 80% vs 81%.

**Conclusion:** The features of invasive aspergillosis in HIV-positive patients were: prolonged lymphocytopenia (75%), agranulocytosis was a rare risk factor (58%), more frequent mixed infection - 33%, and high frequency of dissemination of aspergillosis – 17%. The overall 12-week survival did not differ in the studied groups (82% vs 79%).

P298

**Invasive aspergillosis in patients with multiple myeloma.**

O. Shadrivova¹, V. Pivovarova¹, Y. Chudinovskikh², T. Shneyder³, O. Uspenskaya³, M. Popova⁴, A. Volkova⁴, E. Desyatik⁵, Y. Borzova⁵, S. Ignatyeva⁵, T. Bogomolova⁵, L. Zubarovskaya⁴, B. Afanasyev⁴, N. Vasilyeva⁵, N. Klimko¹

¹Department Of Clinical Mycology, Allergy And Immunology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ²N.N. Petrov National Medical Research Centre of Oncology, Ministry of Health of Russian Federation, St. Petersburg, Russian Federation, ³Leningrad Regional Clinical Hospital, St. Petersburg, Russian Federation, ⁴I.Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russian Federation, ⁵Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation

**Objectives:** Identification of features of invasive aspergillosis (IA) in patients with multiple myeloma(MM).

**Methods:** Retrospective analysis of 337 adult hematological patients with IA. In the main group were included 39 patients with MM, median age – 56 years (41 - 79), females - 59%. The control group included 298 hematological patients (acute leukemia – 45%, lymphoma – 36%; chronic leukemia – 13%, myelodysplastic syndrome – 5%; other – 1%), median age – 53 years (40 - 78), females – 56%. The EORTS/MSG 2008 criteria were used for IA diagnosis and assessment of response of therapy.

**Results:** The main risk factors for IA were steroid use (87.5% vs 59.5%, p = 0.03), severe neutropenia (51% vs 76%, p = 0.03; median 14 vs 18 days), lymphocytopenia (33% vs 53%, median 10 vs 12.5 days), auto-HSCT (28% vs 4%, p = 0.01), and allo-HSCT (8% vs 13%). The main sites of infection were lungs (97,4% vs 97,3%), usually bilateral (69% vs 77%). The main clinical symptoms were fever (80% vs 78%), cough (69% vs 61%), chest pain (16% vs 5%, p = 0.03), and hemoptysis (0% vs 6.4%, p = 0.001). *Aspergillus* spp. positive culture was received in 69% vs 46% patients. The etiology of IA in patients with MM: *A. niger* – 45%, *A. fumigatus* – 35%, *A. flavus* – 10%, *A. candidus* – 5%, *A. ochraceus* – 5%. Antifungal therapy (voriconazole – 68,2% vs 64%) was used in 100% MM and 98% control group patients. The overall 12-weeks survival rate was 96% vs 80%, p = 0.01.

**Conclusion:** The typical risk factors for invasive aspergillosis in multiple myeloma patients were steroids use (87,5%), and auto-HSCT (28%). The main sites of infection were lungs (97,4%). The main etiological agents were *A. niger* (45%) and *A. fumigatus* (35%). In multiple myeloma patients the overall 12-weeks survival rate was significantly higher compared to the control group (96% vs 80%, p = 0.01).

P299

**Analysis of invasive mycoses in hiv-infected patients by autopsy results in Saint Petersburg, Russia**
O. Shadrivova¹, D. Bubnova², M. Pogromskai³, N. Klimko¹

¹Department Of Clinical Mycology, Allergy And Immunology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ²North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ³Department Of Infectious Diseases, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation

**Objectives:** Retrospective analysis of the autopsy data of HIV-infected patients with invasive mycoses (IM).

**Methods:** In retrospective analysis were included 18 HIV-infected patients at the AIDS stage, who were hospitalized in 2018 in the Saint-Petersburg Botkin's hospital. The median age of patients was 38 years (28 - 67), men – 83%.

**Results:** The duration of HIV infection before the IM development was > 10 years in 44% patients, 5-10 years - 17%, < 5 years – 11%. IM developed before the antiretroviral therapy in 28% patients. Viral hepatitis was concomitant infection in 56% patients, other viral infections (cytomegalovirus, Epstein-Barr and herpes zoster) – 61%, bacterial diseases – 44% (pneumonia – 39%, sepsis – 5%), pulmonary tuberculosis – 11%, toxoplasmosis – 11%. Chronic renal failure was comorbid pathology in 33% patients. The main risk factors of the IM development were CD3+CD4+ <200 cells/mcl – 100%, intensive care unit stay – 67%, and glucocorticosteroid therapy > 21 days (median - 29 days) – 17%. *Pneumocystis jiroveci* pneumonia (PjP) was diagnosed in 67% patients, cryptococcal meningitis – 28%, combination of PjP and cryptococcosis – 5%. PjP was diagnosed ante mortem in 77% patients. Therapeutic doses of co-trimoxazole were used in 60% PjP patients, low doses – 40%. Cryptococcosis was diagnosed ante mortem in 83% patients. Amphotericin B 50 mg/d was used in 67% of these patients(the median duration – 3,5 days (1 - 9), fluconazole 600–800 mg/d – 23%. The overall 14 days survival rate of patients with IM was 39%, 30 days – 28%, 12 weeks – 5,5%.

**Conclusion:** The main risk factor of invasive mycoses (*P. jirovecii* pneumonia – 67%, cryptococcosis – 28%, combination – 5%) in HIV-infected patients was a decrease of CD3 + CD4 + < 200 cells/mcl (100%). The overall 12-weeks survival rate on patients with invasive mycoses was 5,5%.

P300

Fatal case of *Cryptococcus albidus* fungaemia in an elderly immunocompromised woman presented with pleural effusion

G. Rodríguez-Leguizamón¹, E. Coque-Burgos², O. Espitia-Castro¹, C. Firacative³

¹Hospital Universitario Mayor - Méderi, Bogota, Colombia, ²Compensar, Bogota, Colombia, ³School Of Medicine And Health Sciences, Universidad del Rosario, Bogota, Colombia

**Case Report:** Cryptococcosis is an important opportunistic fungal infection that occurs globally and in the vast majority of cases is caused by *Cryptococcus neoformans*, a basidiomycetous encapsulated yeast. Although this mycosis presents most frequently as meningitis or meningoencephalitis, pulmonary disease is an underdiagnosed clinical presentation, mainly due to nonspecific symptoms and broadly categorized findings. Similarly to *C. neoformans*, *Cryptococcus albidus* is a free-living, encapsulated yeast that resides in the environment, but that has been rarely recognized as a human pathogen, as is the case for other non-*neoformans* cryptococci, and whose clinical relevance remains unknown. Here we describe a fatal case of *C. albidus* fungaemia in an 85-year old woman from Colombia, who presented with pleural effusion. The patient had an underlying condition of type 2 diabetes mellitus (T2DM) and arterial hypertension and was admitted to the hospital for hyperglycemia, presenting fatigue, polyuria, polydipsia, and nocturia. On day 4 after admission, she had an episode of atrial fibrillation. A computed tomography (CT) scan of the head showed an old lacunar infarction on the left superior cerebellar artery and chronic ischemic microangiopathy. On day 7, hypoxia (85%) and another episode of atrial fibrillation occurred. Chest radiography showed opacification of the left hemithorax, cardiac silhouette was not visible, and prominent pulmonary hilar vessels with atelectasis on the apical right lobe were observed. A chest and an abdominal CT scans confirmed left-sided pleural effusion and showed an abdominal mass, which suggested a metastatic pleural neoplasm. The condition of the patient deteriorated and she died after 21 days of
admission. *C. albidus* was recovered from blood culture *post-mortem* and identified with VITEK®2 YST ID card and confirmed by MALDI-TOF MS. This is the first report to describe a fatal case of cryptococemia caused by a non-*neoformans* species, *C. albidus*, in a non-HIV, yet immunocompromised female patient, who presented with pleural effusion. Not only are cryptococcal infections of the pleura unusual amongst the pulmonary manifestations but, interestingly, such infections caused by a non-*neoformans* species are even rarer. With an incremental rise in the number of at-risk patients having predisposing factors such as T2DM, the incidence of cryptococcal infection due to non-*neoformans* species has also increased, with *C. albidus* and *C. laurentii* accounting for 80% of reported cases. Although bloodstream and central nervous system are the most common sites of infection of these infrequent pathogens, cases of pulmonary infection are also present and are mostly manifested as chronic, indolent illnesses and pulmonary involvement that includes pneumonia, lung abscess and empyema, which may appear as pulmonary nodules, masses or infiltrates, mediastinal lymphadenopathy or, less frequently, pleural effusions. Among the few cases of cryptococcal pleural effusion that have been reported, only one was caused by a non-*neoformans* species, specifically *C. laurentii*. This case of lethal fungaemia in an elderly woman highlights the importance of considering not only the advanced age and the underlying diseases of the patient, but also the emergence of new pathogens, including fungal species, in order to give an appropriate and prompt diagnostic.

P301

Isavuconazole (ISAV) as Primary Anti-Fungal Prophylaxis (PAP) in Patients (pts) with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndrome (MDS): An Open-Label, Prospective Study

P. Bose¹, D. Mccue¹, S. Wurster¹, N. Wiederhold², T. Kadia¹, G. Borthakur¹, F. Ravandi-Kashani¹, L. Masarova¹, M. Konopleva¹, Z. Estrov¹, K. Takahashi¹, M. Yilmaz¹, C. Rausch¹, K. Marx¹, W. Qiao¹, X. Huang¹, C. Bivins¹, S. Pierce¹, H. Kantarjian¹, D. Kontoyiannis¹

¹Ut Md Anderson Cancer Center, 1515 Holcombe, Houston, United States of America, ²Pharmacy, The University of Texas Health Science Center at San Antonio, San Antonio, United States of America

**Objectives:** Mold-active antifungal prophylaxis (ppx) is recommended in neutropenic pts with newly diagnosed AML or MDS. ISAV is an extended spectrum triazole with superior tolerability, reliability of absorption, fewer drug-drug interactions, lack of QTc prolongation or need for therapeutic drug monitoring, approved for the treatment of invasive aspergillosis (IA) and mucormycosis. NCT03019939 is an investigator-initiated, phase 2 trial of PAP with ISAV in pts with AML/MDS.

**Methods:** Treatment-naïve adult pts with AML or MDS initiating remission-induction chemotherapy (RIC) received ISAV per the dosing recommendations in the US label until recovery from neutropenia (neutrophils (ANC) ≥ 0. 5 x 10⁹/L) and attainment of complete remission (CR), occurrence of proven or probable invasive fungal infection (IFI, EORTC/MSG criteria), or for a maximum of 12 weeks. The primary endpoint was incidence of proven/probable IFI during the study period (up to 30 days from the last dose of ISAV).

**Results:** 67 pts were enrolled (April 28, 2017 to February 14, 2019) and 60 pts were eligible for assessment (median age 67 years, 57 pts with AML, median ANC on enrollment was 660). Reasons for study completion were achievement of CR with ANC recovery (n = 35), completion of 12 weeks of PAP (n = 9), possible IFI (n = 7), investigator decision (n = 3), death (n = 2, 1 disease progression, 1 cardiac arrest), proven/probable IFI (n = 3), and mild transaminitis, possibly ISAV-related (n = 2). The median durations of neutropenia and ISAV ppx were 33 (7-86) and 31 (7-86) days, respectively. One microbiologically-proven (gluteal abscess due to *Candida glabrata*) and 2 cases of probable breakthrough IFIs (probable IA with positive galactomannan) occurred (IFI incidence 5%). ISAV trough serum concentrations were available in 31 pts on both day 8 (median 3. 74 µg/mL, 2. 03-7. 65) and day 15 (median 4. 10 µg/mL, 2. 17-9. 25), and were not significantly different.

**Conclusion:** ISAV is a safe and effective alternative for PAP in pts with newly diagnosed AML/MDS undergoing RIC, with a breakthrough (proven/probable) IFI rate of 5%. ISAV serum levels were
adequate in pts with AML/MDS undergoing RIC. Pharmacological features make ISAV attractive for PAP in the era of recently approved or emerging small-molecule AML therapies.

P302

Retrospective analysis of invasive aspergillosis in pediatric patients with acute myeloid leukemia

Y. Dinikina¹, O. Shadrivova², M. Belogurova¹, S. Ignatyeva², T. Bogomolova², S. Khostelidi², E. Boichenko³,⁴, N. Klimko²

¹Department Of Chemotherapy And Bone Marrow Transplantation For Children, Almazov National Research Centre, Saint-Petersburg, Russian Federation, ²Department Of Clinical Mycology, Allergy And Immunology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ³Pediatric Hematology, City Clinical Hospital №1, Saint-Petersburg, Russian Federation, ⁴Department Of Pediatric Oncohematology, City Clinical hospital №1, Saint-Petersburg, Russian Federation

**Objectives:** To examine the epidemiological, clinical, and therapeutic features of invasive aspergillosis cases in children with acute myeloid leukemia. To underline the necessity of early recognition and initiation of antifungal treatment for the infection control and possibility to continue anticancer treatment.

**Methods:** Retrospective analysis of IA cases in pediatric patients with AML without stem cell transplantation (SCT) registered from 1997 to January 2019. For the probable and proven IA diagnosis EORTC / MSG, 2008 criteria were used.

**Results:** 46 pediatric patients with malignancies were included, median age - 8 years (1-18), males – 69,5%. Hematological malignancies were underlying diseases in 39 patients (84,7%), solid tumors – 7 (15,2%). Most frequent hematological diagnoses were myeloid leukemia - 16 (34,7%) and acute lymphoblastic leukemia (34,7%). Median age of pts with AML – 11 years, males – 62,5%. IA was diagnosed after cytostatic chemotherapy in 13 patients (81,3%), prior to chemotherapy in 3 (18,7%) pts. Median number of chemotherapy courses before IA manifestation was 3. Two pts were without neutropenia at AML and IA presentation. Risk factors were: prolonged neutropenia – 81,3%, median - 43,9 days, and lymphocytopenia – 81,3%, median – 27,4 days. Severe bacterial infections were diagnosed in 37,5% and cytomegalovirus infection in 18,7%. Main signs of IA were fever (93,7%), cough (75%), respiratory failure (33,4%). Main site of IA were lungs (93,7%). Disseminated IA was diagnosed in 2 pts (12,5%), endophthalmitis - 1 case (6,25%). Typical findings on chest CT scan included the halo sign – 37,5%. Bronchoscopy with bronchoalveolar lavage was performed in 7 (37,5%) pts. *Aspergillus* spp. were isolated in culture in 12,5%: *Aspergillus fumigatus* – 6,25%, *A.niger* – 6,25%. Galactomannan test was positive in 92,8%. According received results "probable IA" was diagnosed in 87,5% of pts and "proven" in 12,5%. Antifungal treatment received 100% of patients, with voriconazole only – 50%. Surgical treatment (splenectomy) was performed in 1 patient with disseminated IA. Combined antifungal therapy received 33,3% of pts. Overall 12-week survival was 87,5%. In all cases of IA before chemotherapy after infection control anticancer therapy was continued.

**Conclusion:** Among children with IA and malignancies, the AML patients without SCT account for 34%. The main risk factors of IA were prolonged neutropenia (81,25%) and lymphocytopenia (81,25%). The main sites of IA were lungs. 12-weeks overall survival was 87,5%. There were no contraindications for anticancer therapy resumption after infection control.

P303

Species distribution and antifungal susceptibility profile of *Candida* spp. recovered from liver transplant patients with oral candidiasis

C. Sabadin¹, S. Lopes¹, O. Gompertz¹, L. Rigo², A. Melo¹, D. Barbosa¹

¹Federal University of São Paulo, São Paulo, Brazil, ²Meridional Faculty – IMED, Passo Fundo, Brazil
**Objectives:** To identify by molecular method *Candida* isolates recovered from liver transplant patients with oral candidiasis and to determine the antifungal susceptibility profile.
**Methods:** In a prospective cohort study, 97 liver transplant patients from a hospital in southern Brazil were followed up from June 2016 to September 2018. On clinical examination of oral cavity 15 of them presented oral candidiasis and were included in this study. Two oral swabs were collected from these 15 patients with interval of 6 months apart (collections 1 and 2) to detect the presence of infection/colonization by *Candidaspp.* Patients who had candidiasis were treated with topical nystatin for 30 days. The swabs were cultured on CHROMagar® Candida and the yeast colonies were genotypically identified by sequencing the intergenic transcribed sequence (ITS region) of ribosomal DNA. The susceptibility test was performed with the following antifungal agents: Fluconazole, Amphotericin B and Micafungin using broth microdilution method for yeasts recommended by Clinical and Laboratory Standards Institute (CLSI), document M27-A3.

**Results:** Among fifteen patients included in this study, eight(53.4%) presented oral candidiasis episodes in Collection 1 and seven (46.7%) in Collection 2. In fact, all these patients had isolates recovered in both collections, isolates from patients without clinical manifestation were classified as colonization. Of those, eight patients who presented oral candidiasis in the Collection 1, five were atrophic candidiasis (AC) caused by *Candida glabrata*(*n* = 3), *C. albicans*(*n* = 1) and *C. tropicalis*(*n* = 1), and threepseudomembranous candidiasis (PC) caused by *C. albicans*(*n* = 2) and *C. tropicalis*(*n* = 1). In the Collection 2, seven patients presented oral candidiasis, five were AC, caused by *C. albicans*(*n* = 4) and *C. dubliniensis*(*n* = 1); two patients had PC caused by *C. albicans*. The yeasts classified as colonizers were *C. albicans*(*n* = 9), *C. glabrata*(*n* = 3), *C. dubliniensis*(*n* = 2) and *C. tropicalis*(*n* = 1). None of the patient had infection or colonization by more than one *Candidaspecies*. Regarding fluconazole susceptibility, 10 of 15 *Candidaisolates* recovered from patients with infection were susceptible (S), 4 isolates were susceptible-dose dependent (SDD) and 1 resistant (R). Of those recovered from colonized patients 12 were S, 2 were SDD and 1 was R (table 1). All isolates studied were susceptible to amphotericin B and micafungin.

<table><caption>**Table 1.** Species identification and susceptibility to fluconazole of 15 liver transplanted patients with oral candidiasis.</caption><thead><tr><th colspan="4">Collection -1</th><th colspan="3">Collection - 2</th></tr><tr><th>Patients</th><th>Oral Condition</th><th>Species</th><th>FLC MIC</th><th>Oral Condition</th><th>Species</th><th>FLC MIC</th></tr></thead><tbody><tr><td>C18</td><td>Inf</td><td>C. glabrata</td><td>S</td><td>Col</td><td>C. glabrata</td><td>S</td></tr><tr><td>C26</td><td>Inf</td><td>C. albicans</td><td>S</td><td>Col</td><td>C. albicans</td><td>S</td></tr><tr><td>C38</td><td>Inf</td><td>C. tropicalis</td><td>R</td><td>Col</td><td>C. glabrata</td><td>S</td></tr><tr><td>C47</td><td>Inf</td><td>C. glabrata</td><td>SDD</td><td>Col</td><td>C. glabrata</td><td>S</td></tr><tr><td>C87</td><td>Inf</td><td>C. glabrata</td><td>S</td><td>Col</td><td>C. albicans</td><td>R</td></tr><tr><td>C33</td><td>Inf</td><td>C. albicans</td><td>S</td><td>Col</td><td>C. albicans</td><td>S</td></tr><tr><td>C79</td><td>Inf</td><td>C. albicans</td><td>S</td><td>Col</td><td>C. dubliniensis</td><td>S</td></tr><tr><td>C61</td><td>Inf</td><td>C. tropicalis</td><td>SDD</td><td>Col</td><td>C. tropicalis</td><td>SDD</td></tr><tr><td>C72</td><td>Col</td><td>C. albicans</td><td>S</td><td>Inf</td><td>C. albicans</td><td>SDD</td></tr><tr><td>C07</td><td>Col</td><td>C. albicans</td><td>SSD</td><td>Inf</td><td>C. albicans</td><td>SDD</td></tr><tr><td>C20</td><td>Col</td><td>C. dubliniensis</td><td>S</td><td>Inf</td><td>C. dubliniensis</td><td>S</td></tr><tr><td>C57</td><td>Col</td><td>C. albicans</td><td>S</td><td>Inf</td><td>C. albicans</td><td>S</td></tr><tr><td>C85</td><td>Col</td><td>C. albicans</td><td>S</td><td>Inf</td><td>C. albicans</td><td>S</td></tr><tr><td>C28</td><td>Col</td><td>C. albicans</td><td>S</td><td>Inf</td><td>C. albicans</td><td>S</td></tr><tr><td>C43</td><td>Col</td><td>C. albicans</td><td>S</td><td>Inf</td><td>C. albicans</td><td>S</td></tr></tbody></table>

Legend: Inf: Oral infection; Col: oral colonization; S: susceptible; SDD: dose-dependent susceptibility; R: resistant; FLC: fluconazole; MIC: minimal inhibitory concentration.

**Conclusion:** The main type of oral candidiasis identified in hepatic transplant patients was AC. *Candida albicans* was the most prevalent species identified in this study. The presence of *Candidaspp.* was constant in the oral cavity regardless clinical manifestation. Most isolates were susceptible to antifungal agents, however, one *C. tropicalisisolate* and one *C. albicans* were resistant to fluconazole.

P304

Cerebral Aspergillosis Lesion Study (CEREALS) : a multicenter retrospective French study

A. Serris<fnref n="1" />, F. Danion<fnref n="1" />, J. Benzakoun², R. Sonneville³, M. Wolff³, S. Bretagne⁴, T. Sharshar², G. Jouvion⁵, R. Herbrecht⁶, O. Naggara², O. Lortholary<fnref n="1" />, F. Lanternier<fnref n="1" />

<footnote n="1">¹Infectious Diseases, Necker hospital, Paris, France, ²Neuroradiologie, Sainte Anne Hospital, Paris, France, ³Icu, Bichat hospital, Paris, France, ⁴Mycology, Saint Louis hospital, Paris, France, ⁵Pasteur Institute, Paris, France, ⁶Hematology, CHU de Strasbourg, Strasbourg, France</footnote>
**Objectives:** Central nervous system (CNS) aspergillosis is a rare form of invasive aspergillosis. The objective of this study is to describe the clinical, mycological, radiological features and outcomes of the patients with CNS aspergillosis.

**Methods:** A multicenter, retrospective study was performed involving adults and children with a diagnosis of proven or probable cerebral aspergillosis according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) definitions of invasive fungal infections (IFI) published in 2008, modified by adding diabetes to the host criteria, between January 2006 and September 2018.

**Results:** 119 patients with CNS aspergillosis (54 proven, 65 probable) were included in 20 French hospitals. Sixty-six percent were men and the median age was 58 years [48-66]. Hematologic malignancies (39.5% of the patients), solid organ transplantation (28.6%), diabetes (8.4%), autoimmune diseases requiring steroid or immunosuppressive treatment (7.6%), cirrhosis (2.5%) and a history of neuro or sinus surgery (2.5%) were the predominant comorbid conditions. Eleven patients (9.2%) had no identified risk factors of IFI. Fever was present in 40.3% of the patients and 88% of them had an abnormal neurological examination. Only 23.5% of the patients had a history of neutropenia in the month preceding the diagnostic. Infection of the CNS occurred by hematogenous dissemination from an extracerebral site in 77 patients (64.7%) and direct extension from the paranasal sinuses in 27 patients (22.7%). Fifteen patients had no obvious primary organ involvement. Hematogenous dissemination was more frequent in patients with hematologic malignancies (68% of the patients) and solid organ transplantation (79%) whereas contiguous extension was more common in patients with diabetes (60%, p = 0.01). Sensitivity of β-D-glucan, galactomannan and aspergillus PCR in sera were 83.3%, 63.5% and 55.1% respectively. Galactomannan was positive in 68.9% of the cerebrospinal fluids tested. A fungal co-infection was diagnosed in 10.9% of the patients. Seventy-two percent of the patients were treated with voriconazole alone or in dual therapy as a first line treatment. Twenty-one patients underwent neurosurgical procedures, including abscess resection or drainage of abscesses and ventricular shunt. Forty-three percent of the patients presented a complication of the surgery such as edema, bleeding or nosocomial infection. Overall survival was 48.3% at 3 months and 37.7% at 12 months. Contiguous infection of the CNS was associated with a lower sensitivity of galactomannan antigen, a higher frequency of vascular complication and a better outcome. Patients with hematologic malignancy had a poorer survival (p = 0.04). Although a selection bias should be considered, the sub-group of patients who had had neurosurgery had a better survival (p = 0.003).

**Conclusion:** CNS aspergillosis should be considered in patients with hematologic malignancies and solid organ transplantation with or without neutropenia but also in patients with less (such as diabetes or cirrhosis) or no known immunosuppression. Mortality among CNS aspergillosis patients remains high. When feasible, neurosurgical procedures may improve prognosis although with significant morbidity.

P305

**Impact of Invasive Aspergillosis occurring during remission-induction therapy on outcome of Acute Myeloid Leukemia (SEIFEM 2012B Study).**

A. Candoni<fnref n="1" />, F. Farina², K. Perruccio³, R. Di Blasi⁴, M. Criscuolo⁴, C. Cattaneo⁵, M. Delia⁶, D. Lazzarotto<fnref n="1" />, M.V. Dubbini<fnref n="1" />, G. Dragonetti⁴, R. Fanci⁷, B. Martino⁸, M.I. Del Principe⁹, L. Potenza¹⁰, N. Vianelli¹¹, A. Chierichini¹², M. Garzia¹³, G. Nadali¹⁴, L. Verga¹⁵, A. Busca¹⁶, L. Pagano⁴

<footnote n="1">¹University Hospital, Asuiud, Division of Hematology and Stem Cells Transplantation, Udine, Italy,
²IRCCS San Raffaele, Milan, Italy, ³Division of Pediatric Hematology, University Hospital of Perugia,
Perugia, Italy, ⁴Division of Hematology, IRCCS A Gemelli-University CSR, Rome, Italy, ⁵Division of
Hematology, Spedali Civili, Brescia, Brescia, Italy, ⁶Division of Hematology, University of Bari, Bari,
Italy, ⁷Division of Hematology, University of Firenze, Firenze, Italy, ⁸Division of Hematology,
Hospital B. Melacrino Morelli, Reggio Calabria, Reggio Calabria, Italy, ⁹Division of Hematology,
University "Tor Vergata", Rome, Rome, Italy, ¹⁰Division of Hematology, University of Modena and
Reggio Emilia, Modena, Italy, ¹¹Division of Hematology, University of Bologna, Bologna, Italy,</footnote>
¹²Division of Hematology, San Giovanni Addolorata Hospital, Rome, Rome, Italy, ¹³Division of Hematology, San Camillo Hospital, Rome, Rome, Italy, ¹⁴Division of Hematology, University of Verona, Verona, Italy, ¹⁵Division of Hematology, San Gerardo Hospital, Monza, Monza, Italy, ¹⁶Division of Hematology, AOU Citta della Salute e della Scienza, Torino, Turin, Italy

**Objectives:** Acute myeloid leukemia (AML) patients are at high risk of invasive aspergillosis (IA) and required a mould active antifungal prophylaxis during induction chemotherapy (CHT). Although IA risk factors have been identified, few data are available on impact of IA, occurring during first remission induction phase, on overall AML outcome.

**Methods:** The primary endpoint of this prospective, multicentric, case-control study, was to evaluate if IA, occurring during first remission-induction CHT, can affect treatment schedule and, consequently, patient overall survival (OS). We identified 40 AML patients (cases) who developed IA during induction phase, 31 probable (67%) and 9 proven (33%) IA. These cases were matched with a control group (80 AML) without IA, balanced according to age, type of induction CHT, AML characteristics and cytogenetic-molecular risk factors. The overall response rate to induction CHT was the same in the 2 groups.

**Results:** In the 40 cases with IA, the overall response rate (ORR) to antifungal treatment was favorable (ORR 80%) but it was significantly affected by the achievement of leukemia complete remission (CR) with induction CHT. In fact, in cases with AML responsive to induction CHT, complete responses of IA to antifungal therapy were 96% compared to 21% in cases of AML not responsive to induction CHT (p < 0.0001). The adherence to schedule and full doses of CHT was reported in 35% of cases (14/40) and in 76% of controls (61/80) (p = 0.0001). After induction CHT a significant higher number of cases (15/40; 37.5%) compared to controls (21/80; 26%) could not receive additional cycles of CHT (p = 0.01). The IFI related mortality was 22.5%. Comparing OS of 40 cases with the OS of the 80 controls, the median OS of cases was significantly worse with a difference of 12.3 months (12.1 vs 24.4 months, p = 0.04-**Figure 1A**). However, the occurrence of IA during induction phase did not have a significant impact on the OS of cases who achieved a CR with induction CHT which are able to proceed, despite the IA, with their intensive therapeutic program, achieving the same OS as the control group with an AML in CR (p = ns-**Figure 1B**).

<figure><img src="image_75.png" /><figcaption>**FIGURE 1 A.** OS of 40 CASES compared to 80 CONTROLS</figcaption></figure>

Number at risk
Group: 1-Black-Cases

40

20

12

2

0

Group: 2-Red-Controls

80

55

34

12

0

<figure><img src="image_76.png" /><figcaption>**FIGURE 1 B.**</figcaption></figure>

<figure><img src="image_77.png" /><figcaption>**FIGURE 1 C.**</figcaption></figure>
**Conclusion:** These data showed that IAs during induction CHT can delay the subsequent therapeutic program and has a significant impact on OS of AML, specifically in those patients with IA occurring during induction phase who did not achieved a CR of AML with the first course of CHT (Figure 1C).

P306

**Invasive pulmonary infection by Syncephalastrum: two case reports**

M. Irshad¹, N. Nasir¹, U. Haider Hashmi², J. Farooqi³, S.F. Mahmood¹

¹Adult Infectious Diseases, Aga Khan University, Karachi-KHI, Pakistan, ²Haemonc, Aga Khan University, Karachi-KHI, Pakistan, ³Microbiology, Aga Khan University, Karachi-KHI, Pakistan

**Case Report:** Invasive pulmonary infection by Syncephalastrum: two case reports Memoona Irshad; Nosheen Nasir; Urooj Haider Hashmi; Joveria Farooqi; Syed Faisal Mahmood **ABSTRACT** *Mucormycosis* also known as *Zygomycosis* is a class of fungi including three orders. The largest order is Mucorlaes. Most common species of this order are *Rhizopus* and *Mucor* but there are certain rare species such as Syncephalastrum spp. These are often responsible for opportunistic fungal infections in immunocompromised patients. *Syncephalastrum racemosum* is the species of the genus *Syncephalastrum* and is potentially fatal to human beings. Although usually results in cutaneous infections and onychomycosis, there have been few cases reports of respiratory and CNS infections in immunocompromised hosts. Since this is a rare entity, so hardly any data is available on treatment response to different antifungal agents. However recent improvements in diagnostic strategies result in early identification and treatment. Amphotericin B is the drug of choice due to its low MIC.

**Objective:** To describe the clinical manifestations of the rare fungal species Syncephalastrum
**Methods:** Two cases of this rare fungus presented with respiratory complaints during 2019 **Case
presentation 1:** A 55 years old gentleman recently diagnosed with Acute Myeloid Leukemia and not
on treatment, presented with severe shortness of breath in emergency. Patient was provisionally
diagnosed with hospital acquired pneumonia in view of recent hospitalization and was started on
empirical treatment with intravenous piperacillin tazobactam and vancomycin. However his
symptoms progressively worsened. Sputum cultures of this patient showed Methicillin resistant
*Staphylococcus aureus* and Syncephalastrum spp in a good quality specimen. Patient was continued
on intravenous vancomycin and started on intravenous conventional amphotericin B. **Case
presentation 2:** 73 years old gentleman with known comorbid of chronic obstructive pulmonary
disease for which he was on long term systemic and inhaled steroids, presented with shortness of
breath in emergency room. Chest radiograph showed bilateral infiltrates with left sided cavity
formation. Patient was started on empirical treatment for hospital acquired pneumonia in view of his
recent hospitalization. Sputum cultures of this patient showed methicillin resistant *Staphylococcus
aureus*, *Aspergillus flavus* and *Syncephalastrum* spp in a good quality specimen. Patient was started on
intravenous conventional amphotericin B along with vancomycin and voriconazole. However he
developed amphotericin induced nephrotoxicity and doses were renally adjusted **Result:** Both cases
were started on amphotericin B, case 1 continued to deteriorate rapidly and expired after 12 days of
therapy. However case 2 is under treatment, patient developed amphotericin induced nephrotoxicity
so he is currently on renal adjusted dose of amphotericin B and is currently doing well so we had
different outcomes in two different patients on same treatment. **Conclusion:** Invasive pulmonary
infection by *Syncephalastrum* species is a rare entity. It is usually identified and reported as an
environmental contaminant but when identified as a pathogen it can have fatal outcome in
immunocompromised patients. Due to rarity of this infection its course and treatment response are
not completely understood.

P307

**A case report of *Talaromyces marneffei* pharyngo-laryngitis: A rare manifestation of talaromycosis**

A. Jitmuang¹, T. Wongkamhla¹, P. Chongtrakool²

¹Medicine, Siriraj Hospital Faculty of Medicine, Mahidol University, Bangkok, Thailand,

²Microbiology, Mahidol University, Bangkok, Thailand
**Case Report:** *Talaromyces marneffei* is a dimorphic fungus predominantly endemic in Southeast Asia. After effective antiretroviral treatment, the incidence of *T. marneffei* infection in HIV-infected individuals has been decreasing. However, the rate of *T. marneffei* infection is rising among non-HIV immunodeficient persons, particulary patients with anti-interferon-gamma autoantibodies. Of these, *T. marneffei* usually causes invasive and disseminated infection including fungemia. *T. marneffei* pharyngo-laryngitis is a very rare manifestation of talaromycosis. Herein, we demonstrate a case of *T. marneffei* pharyngo-laryngitis in a patient who had underlying anti-interferon-gamma autoantibodies. **Case report** A 52-year-old Thai woman has been diagnosed anti-interferon-gamma (IFN-γ) autoantibodies for 4 years. Last 4 years, she presented with prolonged fever, weight loss 10 kilograms, and multiple cervical lymphadenopathies. Tissue biopsy from left cervical lymph node grew *Mycobacterium abscessus*. Accordingly, disseminated *M. abscessus* infection was diagnosed. She denied using illicit drugs, herbal medicines, or corticosteroids. Immunological studies including anti-HIV testing were all negative, but anti-IFN-γ autoantibodies was highly positive. She received intravenous imipenem 2 g/day and amikacin 750 mg/day for a primary anti-mycobacterial therapy, later they were switched to oral clarithromycin 1,000 mg/day and linezolid 600 mg/day for a maintenance therapy. Following the treatment, she was in remission, and still has been receiving the oral maintenance therapy. Before this admission, she had sore throat, particularly more painful at right side of pharynx, and hoarseness for 3 weeks. She also had febrile and lost her weight 5 kilograms. She received oral amoxicillin 1.5 g/day from a primary physician, but her symptoms did not resolve. She denied foreign body sensation, and had no dysphagia, stridor, or difficult breathing. Physical examination revealed marked swelling and hyperemia of both sides of tonsils including uvula and palatal arches, and a single left submandibular lymph node, sized 1 cm. was identified. Indirect laryngoscopy demonstrated moderate swelling of epiglottis, arytenoid, and vocal cord with normal airway opening. There were no skin nodules or hepatosplenomegaly found. Blood chemistries including plain chest radiography were unremarkable. The patient was performed right tonsillar biopsy at 1 day following the admission. The tissue biopsy Gram's stain including the pathological sections exhibited few oval and elongated yeast-like organisms with some central transverse septum seen, and it subsequently grew few mold colonies with diffusible red-colored pigment on fungal cultures suggestive of *T. marneffei*. An amphotericin B deoxycholate 45 mg/day was commenced as a primary therapy for 1 weeks, followed by an oral itraconazole 400 mg/day. Four weeks after the treatment, the swelling of pharynx and larynx were markedly reduced. She had continued itraconazole for 4 months, later the dose of 200 mg/day has been using for secondary prophylaxis. Her symptoms completely resolved without complication. **Conclusion** In patients with anti-IFN-γ autoantibodies, *T. marneffei* can rarely cause a local infection involving pharynx and larynx. Fungal culture and pathological examination are warranted for diagnosis *T. marneffei* pharyngo-laryngitis. This condition requires a long term antifungal therapy.

P308

Retrospective analysis of single nucleotide polymorphisms (SNPs) on TLR-4, PTX-3, Dectin-1 genes and the association with the development of invasive fungal infections among hematopoietic stem cell transplant recipients with oncohematological conditions

A. Kalkanci¹, E. Tug², I. Fidan¹, O. Guzel Tunccan³, Z.N. Ozkurt⁴, Z.A. Yegin⁴, E.A. Sahin¹, Z. Kuralay¹

¹Department Of Medical Microbiology, Gazi University School of Medicine, Ankara, Turkey,
²Department Of Medical Genetics, Gazi University School of Medicine, Ankara, Turkey,
³Department Of Infectious Disease And Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey,
⁴Department Of Internal Medicine, Division Of Hematology, Gazi University School of Medicine, Ankara, Turkey

**Objectives:** *Candida* and *Aspergillus* are the two most common causes of invasive fungal infections after stem cell transplantation. The development of fungal infections can be associated with several risk factors however, it is still difficult to predict why certain individuals develop severe infections, while others, under similar conditions, do not. Genetic polymorphisms are recognized as potential factors that could affect in the progress of the infectious disease. Pattern recognition receptors (PRR)
are germline encoded receptors that recognise a variety of pathogen associated molecular patterns (PAMPs) expressed by an invading microorganism. Single nucleotide polymorphisms (SNPs) on coding genes of PRRs; Toll like receptor-4 (TLR-4), dendritic cell-associated C-type lectin-1 (Dectin-1) as a C-type lectin receptor (CLR) and among signaling molecules; Pentraxin-3 (PTX-3) in the complement activation cascade were analysed in order to show associations with the development of invasive fungal infections (IFIs) among hematopoietic stem cell transplant recipients with hematological conditions.

**Methods:** In this case control study, a cohort of 62 patients with hematological malignancies were assigned by the EORTC-MSG criteria. There were 9 proven, 7 probable,13 possible, total 29 IFI patients and 33 patients with no evidence of fungal disease included in this study from 2008 to 2018 in Hospital of Gazi University. DNA and RNA were isolated from deposited bone marrow samples of the patients, using DNA and RNA Isolation kit (SNP Biotechnology, Turkey), respectively. Expression levels of *TLR4*, *Dectin-1* and *PTX-3* genes were determined by normalized to the *Actin* gene using the One-run RT-PCR kit (SNP Biotechnology, Turkey). The polymorphisms of *TLR4* (rs4986790, rs4986791), *Dectin-1* (rs16910526, rs7309123) and *PTX-3* (rs2305619, rs3816527) were determined by RT-PCR. Continuous variables are reported as means ± standard error mean (SEM), while categorical variables are reported as frequencies and percentages (%). The odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated by unconditional logistic regression analysis. The homozygote for the most frequent allele was regarded as the reference group. SPSS statistical package, version 11.0 (SPSS Inc., Chicago, IL, USA) for Windows was used for statistical analyses. All *p* values was considered to be statistically significant when *p*< 0.05.

**Results:** *TLR-4*, *PTX-3*, *Dectin-1* genes were down-regulated in IFIs group when compared to patients with no evidence of fungal disease in the group of hematological conditions. A higher expression of *TLR-4* was revealed in controls (0.0626±0.032) compared to IFI patients (0.0077±0.014), significantly different (*p* = 0.026), as well as *PTX-3* in controls (0.5265±0.0043) compared to patients (0.0043±0.004), (*p* = 0.035). *Dectin-1* expression was down-regulated in IFI group (0.1887±0.072 & 0.0655±0.010), however, not statistically significant (*p*>0.05). Conditional logistic regression analyses indicated that the GT genotype of rs16910526 polymorphism in *Dectin-1* gene was associated with lower risk of IFIs. (Odds ratio = 3.635, 95% confidence interval = 0.690-3.138, *p* = 0.04

**Conclusion:** Our study continues to highlight the important role of the host's underlying genetic profile in determining susceptibility to IFIs. Selective genetic immunodeficiencies stratify "at-risk" patients to specific pathogens. Dissecting the contribution that host genetic variation has on the susceptibility to fungal infection will be principal for personalizing medicine in infectious diseases.
**Methods:** Two strains of *L. corymbifera* were used, one reference strain - IHEM 21658 - and one strain isolated from skin lesions in burn patient. Spores and germ tubes were obtained from cultures on SDA-amikacin and liquid medium with yeast extracts, mannitol and glucose, respectively. Monosaccharides composition (MC) analysis of the cell wall was conducted on spores and germ tubes, on alkali-insoluble and alkali-soluble fractions through gas-chromatography using flame-ionisation detector. The same analysis was also performed on secreted extracellular polysaccharides obtained after an 8-day culture in YNB with glucose. Determination of the glycosidic linkages was performed on soluble oligosaccharides isolated sequentially after zymolyase and chitinase digestion. Confocal microscopy after immunofluorescence staining with two lectins (Con-A and WGA, binding mannose and N-acetyl-glucosamine -GlcNAc-, respectively), and one anti-β-1,3-glucan monoclonal antibody (1A5), was performed to determine the parietal remodeling during germination. THP-1-derived macrophages stimulated by various fungal fractions were used to assess fungi-host interaction in terms of Toll-like receptor and cytokine expression.

**Results:** MC of both strains showed a large amount of glucose (69.9%) with smaller amounts of mannose (16.5%) and GlcNAc (12.8%) and traces of glucuronic acid (0.9%) in spores. Enrichment using alkalino-treatment showed the presence of glucuronic acid and galactose in the alkali-soluble fraction. Fucose appeared in germ tubes. Analysis of extracellular polysaccharides showed the presence of fucose, glucose, mannose, galactose and GlcNAc. Tagging the spores with Con-A and WGA revealed the presence of mannose around spores, whereas mannose was spread more evenly in germ tubes. Chitin emerged along the germ tube and β-1,3-glucan was present in swollen conidia.

**Conclusion:** During the first hours of *L. corymbifera* germination, fungal cells synthetize polysaccharides composed chiefly by glucose, GlcNAc and mannose, and to a lesser extent by galactose, glucuronic acid and fucose. The role of these latter carbohydrates remains uncertain (Bartnicki-Garcia 1968). Confocal microscopy suggests that the emergence of these carbohydrates leads to a parietal reorganization of the cell wall. In the near future, data from the *in-vitro* model could help us to understand the impact of these changes on the primary immune response.

P310

Saprochaete clavata outbreak in a Hematology Unit in Marseille, France

E. Menu¹, A. Criscuolo², M. Desnos-Ollivier³, C. Cassagne⁴,⁵, S. Ranque⁴,⁶, P. Berger⁷, F. Dromer³

¹AP-HM La Timone - IHU Méditerranée Infection, Marseille, France, ²Hub De Bioinformatique Et Biostatistique – Département Biologie Computationnelle, Usr 3756 Cnrs, Institut Pasteur, Paris, France, ³National Reference Center For Invasive Mycoses & Antifungals, Molecular Mycology Unit, Cnrs Umr2000, Institut Pasteur, Paris, France, ⁴IHU-Méditerranée Infection, Marseille, France, ⁵Vitrome, Aix Marseille UnivIRD, AP-HM, SSA, Marseille, France, ⁶Vitrome, Aix Marseille Univ, IRD, AP-HM, SSA, Marseille, France, ⁷Institut Paoli-Calmettes, Marseille, France

**Objectives:** **Objectives:** *Saprochaete clavata* is a rare pathogenic yeast that has been involved in invasive fungal infection outbreaks in immunocompromised patients especially in patient with haematological malignancies. From January 2016 to January 2018, infections due to *S. clavata* were diagnosed in nine patients at a cancer center in Marseille, France raising the question of a common source and of the mode of transmission.

**Methods:** **Methods:** We retrospectively reviewed patients' files to assess risk factors, hospitalization units and treatments, and carried out an environmental survey (59 samples collected). Whole genome sequencing (WGS) was performed for 17 clinical isolates collected during (n = 15) or before (n = 2) the outbreak and 10 environmental isolates. The type strain (CBS425.71) and representative clinical isolates related (clade A) or unrelated (clade B) to the French national outbreak in 2012 (Vaux et al., 2014) were used as reference.

**Results:** **Results:** All nine patients were hospitalized at the stem-cell transplant or hematological intensive care units. The median age was 58 years (range: 38 to 68) and six (67%) were male. The most common underlying disease was acute myeloid leukemia (56%) and 67% of patients were treated with cytarabine. A total of 40 samples were found positive for *S. clavata*: blood (n = 35, 1 to 9 /8 patients), bronchoalveolar fluid or tracheal aspirates (n = 5), and fecal swab (n = 1). The case fatality
rate at day 60 was 44%; death occurred at a median of 9.5 days after diagnosis. *Saprochaete clavata* was also cultured from 10 environmental samples including one from a surface in a patient's room, 5 from the dishwasher (water outlet, inside and door seal) made available to patients and families, and 4 others from pitchers (lids and inside of 2 milk and coffee thermos). In order to control the outbreak, all the contaminated materials were replaced and the dishwasher was discarded. No new case was reported after the implementation of corrective actions. Phylogenetic analysis based on WGS data showed that all clinical and environmental isolates from Marseille belong to the same clade which was unrelated to clades A and B previously identified in France. Of note, attempt to grow *S. clavata* failed at temperatures above 48°C.

**Conclusion:** Our results place the dishwasher as the source of the transmission of *S. clavata* and suggest that its heating system may have been deficient. Whether the source of *S. clavata* was a diary product as in previously reported outbreaks remains unclear. Vaux, S., Criscuolo, A., Desnos-Ollivier, M., et al. (2014). Multicenter outbreak of infections by Saprochaete clavata, an unrecognized opportunistic fungal pathogen. *MBio*, *5*(6), e02309-14.

P311

**18F-FDG PET-computed tomography to assess chronic disseminated candidiasis: results of a French pilot prospective multicentric study (CANHPARI)**

B. Rammaert¹,², C. Maunoury³, T. Rabeony⁴, C. Elie⁴, P. Bakouboula⁴, S. Alfandari⁵, P. Berger⁶, M.-T. Rubio⁷, T. Braun⁸, J.-M. Correas⁹, F. Montravers¹⁰, O. Lortholary²

¹Current Address: Infectious Diseases, CHU Poitiers, Poitiers, France, ²Infectious Diseases, APHP, Hopital Necker-Enfants malades, Paris, France, ³Nuclear Medicine, Hopital europeen Georges Pompidou, Paris, France, ⁴Urc Necker-cochin, APHP, Paris, France, ⁵Infectious Diseases, Centre hospitalier Tourcoing, Tourcoing, France, ⁶Institut Paoli-Calmettes, Marseille, France, ⁷Hematology, CHU Nancy, Nancy, France, ⁸Hematology, APHP, hopital Avicenne, Bobigny, France, ⁹Adult Radiology, APHP, hopital necker-enfants malades, Paris, France, ¹⁰Nuclear Medicine, APHP, hopital tenon, Paris, France

**Objectives:** Chronic disseminated candidiasis (CDC) occurs after profound and prolonged neutropenia, and consists in persistent fever and multiple abscesses in liver and/or spleen. International guidelines recommend protracted course of antifungal therapy, although there is some evidence that CDC belongs to spectrum of immune reconstitution inflammatory syndromes. The aim of this study was to assess 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the diagnosis and follow-up of CDC.

**Methods:** A pilot prospective study was conducted in 38 French centers from November 2013 to March 2017 (NCT01916057). Hematological adult patients having experienced febrile profound (neutrophils <100/mm3) and prolonged (≥10 days) neutropenia, and suspect for CDC on imaging (<10 mm multiple nodules on liver and/or spleen) were included. PET/CT and abdominal conventional imaging (CT or MRI) were performed initially and at 3 months (M3). MSG/EORTC criteria were adapted to assess response to treatment. At M3, clinical success was defined by resolution of fever attributable to CDC, complete biological response was defined by normal liver enzymes and CRP ≤20 mg/L, and complete radiological response by disappearance of lesions compared to initial imaging. The primary endpoint was the global response to antifungal treatment at M3 defined by clinical success and extinction of hepatosplenic metabolic uptake on PET/CT.

**Results:** A total of 52 cases were included; 6 were secondarily excluded for alternative diagnosis and 2 for absence of PET/CT at diagnosis. Among the 44 remaining cases, CDC was proven in 7 (6 candidemia, 1 positive culture of liver biopsy), probable in 13, possible in 24. Patients were mostly male (55%), with a median age of 46 y.o. (IQR 32-62). Among 43 underlying hematological disease, there were 46% acute myeloid leukemia, 30% acute lymphoid leukemia, 17% allogenic and 2% autologous stem cell transplantation, and 5% lymphoma. One patient had a solid cancer. Corticosteroids were prescribed in 47% of patients ≤ 1 month before CDC diagnosis, growth factors in 68%, antifungal prophylaxis in 64%. Patients were colonized with ≥1 *Candida* species in 75% of cases before CDC diagnosis, mainly *C. albicans*. At diagnosis, fever and liver enzyme abnormalities
were present in 81% and 82% of cases, respectively. C-reactive protein was elevated in 85%. All patients were treated with antifungal drugs, combined with corticosteroids in 41%. At M3, 25% (8/32) of evaluable patients met the primary endpoint criteria. However, among 35 patients who had clinical success, 77% (27/35) had complete biological response, but 83% (29/35) failed to respond on conventional imaging. Among these patients, extinction of hepatosplenic metabolic uptake on PET/CT was observed in 17% (5/29).

**Conclusion:** Clinical improvement of CDC occurs before radiological normalization. In patients with clinical success at M3, PET/CT could be more helpful than conventional imaging to guide antifungal duration.

P312

**Invasive fungal disease with isavuconazole treatment failure diagnosed using a combination of fungal biomarkers.**

A.-P. Bellanger¹, A. Berceanu², E. Scherer³, Y. Desbrosses², E. Daguindeau², S. Rocchi¹, L. Millon¹

¹Mycology, University Hospital Jean Minjoz, Besançon, France, ²Hematology, University Hospital Jean Minjoz, BESANCON, France, ³Mycology - Umr6249 Cnrs Chrono-environnement, University Hospital Besançon, Besançon, France

**Case Report:** Isavuconazole is the most recent antifungal azole available to treat invasive fungal disease (IFD) and has been approved as first line treatment for invasive aspergillosis (IA) and as alternative treatment for mucormycosis. We present two cases of IFD with isavuconazole treatment failure in acute myeloid leukemia (AML) patients with prolonged neutropenia 100 days after hematopoietic stem cell transplantation (SCT) and severe digestive graft-versus-host disease (GVHD). The first patient was diagnosed with a probable invasive aspergillosis and a TR34/L98H azole resistant *Aspergillus fumigatus* and the second patient was diagnosed with a mixed *Aspergillus fumigatus-Rhizomucor* sp co-infection. The IFD were diagnosed using a combination of fungal biomarkers, applied systematically and including the galactomannan antigen (GM) detection and fungal qPCRs, targeting both *A. fumigatus* and Mucorales; this strategy proved to be optimal. These cases highlight the interest of applying a close surveillance using fungal biomarkers in very immunocompromised patients under antifungal treatment. Interestingly, the fungal biomarkers were alternatively positive. Moreover, these cases also raise several questions such as for example the influence of severe digestive GVHD on isavuconazole levels.

P313

**Six consecutive patients surviving invasive Mucormycosis: a result of improved interdisciplinary management?**

R. Datcu¹, M. Risum¹, J. Helweg-Larsen², P. Kampmann³, U.M. Overgaard³, O.J. Nielsen³, L. Munksgaard⁴, N. Rubek⁵, L.V. Hansen⁶, R. Hare¹, M.C. Arendrup¹,⁷,⁸

¹Mycology Unit, Statens Serum Institute, Copenhagen, Denmark, ²Department Of Infectious Medicine, Rigshospitalet, Copenhagen, Denmark, ³Department Of Hematology, Rigshospitalet, Copenhagen, Denmark, ⁴Department Of Hematology, Roskilde Sygehus, Roskilde, Denmark, ⁵Department Of Otorhinolaryngology, Rigshospitalet, Copenhagen, Denmark, ⁶Department Of Orthopaedic Surgery, Rigshospitalet, Copenhagen, Denmark, ⁷Rigshospitalet, Dept. of Clinical microbiology, Copenhagen, Denmark, ⁸University Of Copenhagen, Dept. of Clinical Medicine, Copenhagen, Denmark

**Objectives:** *Mucorales* infections are life-threatening, with mortality rates approaching 100% in disseminated cases. ESCMID/ECMM guidelines strongly recommend surgical debridement, liposomal amphotericin B, L-AmB (≥5 mg/kg/day), and reversal of predisposing conditions. We introduced a multidisciplinary and aggressive management approach for invasive mucormycosis. Here we present data on six patients managed by this approach, whom all had a successful outcome.

**Methods:** Management principle: repeated surgical debridement until biopsies taken from the resection margins were clean, defined by negative Blankophor microscopy, *Mucorales* specific PCR (both reported within 24h) and cultures. Cultured isolates underwent ITS sequencing for species
identification and EUCAST E.Def 9.3.1 susceptibility testing. Targeted antifungal therapy (mono/combination) combined with topical therapy (when possible) was given according to the MIC (mg/L) and severity of infection. High trough azole levels above MIC were ensured by therapeutic drug monitoring (TDM) (mg/L). Fungal free survival was evaluated by case record review.

Results:

<table><caption>Table. Patient characteristics.</caption><thead><tr><th>Patient no.</th><th>Patient #1</th><th>Patient #2</th><th>Patient #3</th><th>Patient #4</th><th>Patient #5</th><th>Patient #6</th></tr></thead><tbody><tr><td>Age</td><td>26 year</td><td>48 year</td><td>19 year</td><td>60 year</td><td>21 year</td><td>3 year</td></tr><tr><td>Sex</td><td>Female</td><td>Male</td><td>Male</td><td>Female</td><td>Male</td><td>Female</td></tr><tr><td>Underlying disease</td><td>Burkitt-lymphoma</td><td>Aplastic anaemia</td><td>Lymphoblast T-cell lymphoma</td><td>Relapse -acute myeloid leukaemia</td><td>Diffuse large B-cell lymphoma</td><td>Pre-B Acute lymphoblastic leukaemia</td></tr><tr><td>Site of mucormycosis</td><td>Liver</td><td>Right sinus maxillary and orbital</td><td>Hard palate, facial muscles, right maxilla and maxillary sinus</td><td>Right side sinusitis</td><td>Lung, liver, vertebrae.</td><td>Rhino-orbital-cerebral</td></tr><tr><td>Pathogen</td><td>Lichtheimia ramosa/ corymbifera</td><td>Rhizopus microsporus</td><td>Rhizopus arrhizus</td><td>Rhizopus arrhizus</td><td>Rhizomucor pusillus</td><td>Lichtheimia corymbifera</td></tr><tr><td>Number of surgical revisions</td><td>1 liver drainage 1 resection of the liver, but without hyphae (one year after diagnose)</td><td>Aboul 7 (positive for Rhizopus microsporus) and afterwards 11 (when topical treatment continued to be given)</td><td>27 (positive for Rhizopus arrhizus) and afterwards 12 (Mucorales free)</td><td>3 (the third without sign of Mucorales infection macroscopically)</td><td>1 (back) +1 (lung resection, six months after diagnose), both R. pusillus PCR positive</td><td>14</td></tr><tr><td>Systemic antifungal treatment</td><td>Isavuconazole</td><td>L-AmB (2-5 mg/kg) plus isavuconazole</td><td>L-AmB (5-8 mg/kg) plus isavuconazole</td><td>L-AmB (5 mg/kg) plus isavuconazole</td><td>L-AmB (7-10 mg/kg, then 3mg/kg) + isavuconazole + high dose terbinafine</td><td>L-AmB plus posaconazole (OS) plus terbinafine</td></tr><tr><td>Topical antifungal treatment/HBO/ Granulocyte Transfusion (GT)</td><td>Not given</td><td>L-AmB topically (intraorbital and in sinus) + about 12 HBO + GT</td><td>AmB i sinuses + 30 HBO</td><td>AmB topically</td><td>14 AmB intrathecally + Local AmB in cage via catheter installed under operation</td><td>AmBd in the sinuses and intrathecally (114 doses) + 33 HBO</td></tr><tr><td>Azole trough level range</td><td>Median 4.7 Range 0.2-8.4</td><td>Median 3.8 Range 1.4-5.7</td><td>Median 6.2 Range 1.2-15.4</td><td>Not taken</td><td>Median 3.4 Range 1.5-7.3</td><td>Median 1.55 Range 0.42-4.73</td></tr><tr><td>Outcome</td><td>Healthy (follow-up 30 months)</td><td>Alive and cured for fungal infection (follow-up 19 months)</td><td>Total remission of infection but death from progressive leukaemia, 10 months after diagnosis of mucormycosis.</td><td>Not known (travelled abroad permanently)</td><td>Alive (follow-up 7 months)</td><td>Healthy (follow-up 70 months)</td></tr></tbody></table>

Demographic, microbiological, management and outcome data for the six patients are summarised in the Table. All were neutropenic after chemotherapy except patient #5 at time of diagnosis. Patient #1 developed *Lichtheimia ramosa/corymbifera* infection in the liver (PCR). Management included isavuconazole and surgery. Patient #2 developed sino-orbital *Rhizopus microsporus* infection. The patient had smoked cannabis. Therapy included surgery, L-AmB and isavuconazole. Isavuconazole MIC: 1 mg/L. Patient #3 developed *Rhizopus arrhizus* infection extending extensively from the hard palate (picture). The patient had smoked marihuana. Treatment consisted of unilateral hemimaxillectomy followed by frequent supplementary debridements guided by PCR of resection margins. The exposed bone was covered during palatal reconstruction with a free flap after several mycosis negative debridements. Antifungal therapy included L-AmB and isavuconazole (target TDM initially: >2 mg/L, then >6-8 mg/L until negative diagnostics followed by maintenance >2 mg/L (isavuconazole MIC: 1 mg/L). Patient #4 developed *Rhizopus arrhizus* sinuses infection during posaconazole prophylaxis. Management included L-AmB and surgery, followed by isavuconazole (isavuconazole MIC: 2 mg/L). Patient #5 developed disseminated *Rhizomucor pusillus* (lumbar spondylitis, a subdiaphragmatic and a lung abscess). Surgical debridement including removal of vertebrae L4 in toto and surrounding muscle and soft tissue. The spine was then stabilized with cage and pedicle screws. PET-CT afterwards showed regression of the spondylitis. Target TDM for isavuconazole >2 mg/L. Patient #6 developed *Lichtheimia corymbifera* sinus infection. Despite targeted posaconazole oral solution aiming a target for TDM >2 mg/L (MIC: 0.25 mg/L), the infection progressed to nasopharynx, orbit and brain. The patient recovered after surgical and triple-compound systemic and amphotericin B intrathecal antifungal therapy¹. Outcome: At follow-up 6-70 months after diagnosis, patient #1-4 and #6 were cured of infection, and patient #5 has had no sign of relapse (7 months follow-up).
<figure><img src="image_78.png" /></figure>

**Conclusion:** Our data suggest improved outcome of *Mucorales* infections by a multidisciplinary approach including: 1) Repeated (except patient #5) biopsy-controlled surgery until resection boarders are negative, 2) Systemic and in most cases combination, TDM-adjusted high dose systemic antifungal therapy, and 3) Topical therapy when possible to improve antifungal exposure in tissue not sufficiently perfused due to the angioinvasive pathology of the infection. ¹Jensen, TSR et al. *J Pediatr Hematol Oncol.* 2017;39(4):211-215.

P314

**Majocchi's Granuloma by Trichophytum rubrum in a kidney transplant patient - A Case Report**

S. Matos Cruz¹, L. Silva², G. Catorze², R. Sabino³, C. Verissimo³, C. Toscano¹

¹Microbiology Laboratory, Hospital Egas Moniz - CHLO, Lisbon, Portugal, ²Dermatology Department, Hospital Egas Moniz - CHLO, Lisbon, Portugal, ³Reference Unit For Parasitic And Fungal Infections, Infectious Diseases, National Health Institute Dr. Ricardo Jorge, Lisbon, Portugal

**Case Report:**

**Introduction:** *Trichophytum rubrum* is a filamentous fungus, with worldwide distribution, that usually causes superficial infections of skin and nails, namely *tinea pedis*, *tinea corporis*, *tinea cruris* and onychomycosis. Rarely, severe dermatophytosis can occur, presenting as deep dermatophytosis, Majocchi's Granuloma or extensive dermatophytosis.

**Objectives and Methods:** Case report of Majocchi's Granuloma in a kidney transplant patient.

**Results:** A case of a 55-year-old woman who underwent a kidney transplant 7 months before, under immunosuppressive therapy with tacrolimus and mycophenolate mofetil. She attended a Dermatology consultation to clarify skin lesions that appeared 6 months earlier. The skin exam revealed hard and painful plaque lesions on both legs, with an ulcer on the left leg lesion, violaceous papular lesions on the dorsum of the left foot and toes and a hard consistency nodule on the left leg. Some of the toe nails presented dystrophy or onycholysis. The patient denied any previous trauma or contact with plants or soil. Biopsies of lesions of the left leg and foot dorsum where sent for
histology and mycological culture and toe nails for mycological culture. The histological
examinations showed, in the reticular dermis and reaching the hypodermis, suppurative granulomas
with multinucleated giant cells and areas of necrosis. PAS (Periodic Acid-Schiff) and GMS (Grocott's
Methenamine Silver) staining revealed multiple spores and septate hypha within the granulomas but
not in the *stratum corneum*. No remnants of hair follicles where found. Culture of skin biopsies were
positive for *Tricophytum rubrum* but nails' culture was negative. Identification was further confirmed
by sequencing of ITS region of ribosomal DNA (GenBank accession number MK967277). Oral
Itraconazole 100mg bid and topic Sertoconazole where initiated. The patient was observed one month
after and reported general malaise, tiredness, exertional dyspnea, whitish stools and increased
abdominal volume. The physician chose to discontinue itraconazole and initiate oral terbinafine
250mg id. After two months on oral terbinafine, there was regression of the legs' and left foot lesions
with ulcer healing and disappearance of the left leg nodule. **Conclusion:** Diagnosis of deeper
dermatophytosis is difficult, in part because there is no specific clinical presentation and, in many
cases, it is even polymorphic. However, especially in patients with immunodeficiency, this
hypothesis should be weighed. Confirmation is achieved by finding hyphae compatible with
dermatophytes in the dermis and a positive culture for a dermatophyte. Treatment should include
systemic antifungal agents, to which topical medication may be associated. Multiple therapeutic
regimens have been proposed, but randomized trials or large case series are lacking. Antifungal
therapy should be continued until the lesions are completely resolved. Surgical treatment has been
reported as an option for highly localized lesions.

P315

Clinical Characteristics and Outcomes of *Lomentospora prolificans* Infections in Fungiscope™ Registry

J. Jenks¹, D. Seidel², O.A. Cornely³, C. Kauffman⁴, M. Miceli⁵, M. Slavin⁶, S. Chen⁷, S. Mehta¹, S. Reed¹, M. Hoenigl¹

¹Medicine, University of California San Diego, San Diego, United States of America, ²Department I Of Internal Medicine, Ecmm Excellence Centre Of Medical Mycology, Cologne Excellence Cluster On Cellular Stress Responses In Aging-associated Diseases (cecad), University Hospital Cologne, Cologne, Germany, ³Department I Of Internal Medicine, Ecmm Excellence Centre Of Medical Mycology, Cologne Excellence Cluster On Cellular Stress Responses In Aging-associated Diseases (cecad), German Centre For Infection Research, Partner Site Bonn-cologne, Clinical Trials C, University Hospital Cologne, Cologne, Germany, ⁴University of Michigan, Ann Arbor, United States of America, ⁵Medicine, University of Michigan, Ann Arbor, United States of America, ⁶Medicine, University of Melbourne, Parkville, Victoria, Australia, ⁷Medicine, The University of Sydney, Camperdown, New South Wales, Australia

**Objectives:** *Lomentospora prolificans* are filamentous fungi commonly found in soil and polluted waters and are emerging opportunistic pathogens in immunocompromised individuals, accounting for 2.4% and 11.1% of non-*Aspergillus* invasive fungal infections (IFIs) in haematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) infections, respectively. The objective of this study was to describe clinical manifestations, treatment and outcomes of patients with *L. prolificans* infections causing IFI in cases documented in Fungiscope™ - A Global Emerging Fungal Infection Registry, created in 2003.

**Methods:** We performed a retrospective review of medical records of all patients with IFIs caused by *L. prolificans* in Fungiscope™ between 01/01/2008 - 12/31/2017 (10 year period). Infections were determined to be disseminated if *L. prolificans* was isolated from the blood or two non-contiguous anatomic sites. The study was approved by the UCSD Human Research Protection Program (IRB #181119).

**Results:** A total of 37 cases with IFIs caused by *L. prolificans*, including 7 cases from the University of California San Diego, were identified (Table 1). In all but one case (36/37, 97.3%), a risk factor for IFI was found, including hematologic malignancy (20/37, 54.1%), solid organ transplant (SOT) (3/37, 8.1%), ICU stay or trauma (6/37, 16.2%). The majority of infections were diagnosed based on positive
culture (35/37, 94.6%) or histopathologic findings plus culture (5/37, 13.5%) and most patients had signs of IFI on CT scan (15/20, 75%), MRI (1/2, 50%), or CXR (1/2, 50%). At final assessment, 19/37 (51.3%) were deceased, 8/37 (21.3%) had complete cure, and 8/37 (21.6%) and partial resolution or stable disease. Of those who received antifungal therapy following diagnosis and had an evaluable outcome (31/37, 84%), the majority were treated with combination antifungal therapy (24/31, 77%; 54% survived). Most antifungal regimens included voriconazole (VRC; 28/31, 90%; 54% survived) and/or terbinafine (TRB; 19/31, 61%; 63% survived). Among those receiving a combination of both VRC and TRB (+/- other antifungal agents) 11/17 (65%) survived, while 5/14 (36%) survived among those receiving other treatments (p = 0.11). Overall, 7/37 patients (18.9%) received surgery, including 5/7 enucleation or vitrectomy and two extensive debridement (1 died, 5 survived, 1 with unknown outcome). Table 1.
<table><caption>**Table 1.** Demographic, clinical characteristics and outcomes of invasive *L. prolificans* infection</caption><thead><tr><th>Characteristic</th><th>L. prolificans (n = 37)<br>N (%)</th></tr></thead><tbody><tr><td>Female sex</td><td>16 (43)</td></tr><tr><td>Age at diagnosis (years) [median (range)]</td><td>60 (9-80)</td></tr><tr><td>Underlying disease/risk factors (n)</td><td></td></tr><tr><td>Hematologic malignancy</td><td>20 (54.1)</td></tr><tr><td>Allo HSCT</td><td>5 (13.5)</td></tr><tr><td>Auto HSCT</td><td>2 (5.4)</td></tr><tr><td>Other</td><td>10 (27.0)</td></tr><tr><td>Trauma/major surgery</td><td>6 (16.2)</td></tr><tr><td>Chronic pulmonary disease</td><td>4 (10.8)</td></tr><tr><td>Co-infection with other IFIs</td><td>3 (8.1)</td></tr><tr><td>SOT</td><td>3 (8.1)</td></tr><tr><td>Cardiovascular disease</td><td>2 (5.4)</td></tr><tr><td>DM mellitus</td><td>2 (5.4)</td></tr><tr><td>Obesity</td><td>2 (5.4)</td></tr><tr><td>Non-hematologic cancer</td><td>1 (2.7)</td></tr><tr><td>ICU</td><td>1 (2.7)</td></tr><tr><td>Source of isolate (n)</td><td></td></tr><tr><td>Disseminated</td><td>22 (59.5)</td></tr><tr><td>Blood culture*</td><td>18 (48.6)</td></tr><tr><td>Lung</td><td>15 (40.5)</td></tr><tr><td>Eye</td><td>8 (21.6)</td></tr><tr><td>CNS</td><td>4 (10.8)</td></tr><tr><td>Skin</td><td>4 (10.8)</td></tr><tr><td>Bone</td><td>3 (8.1)</td></tr><tr><td>Heart</td><td>2 (5.4)</td></tr><tr><td>Joint</td><td>2 (5.4)</td></tr><tr><td>Kidneys</td><td>2 (5.4)</td></tr><tr><td>Liver</td><td>2 (5.4)</td></tr><tr><td>Sinus</td><td>2 (5.4)</td></tr><tr><td>Spleen</td><td>2 (5.4)</td></tr><tr><td>Peritoneum</td><td>1 (2.7)</td></tr><tr><td>Foreign body/catheter</td><td>1 (2.7)</td></tr><tr><td>Deep soft tissue</td><td>1 (2.7)</td></tr><tr><td>Bowel</td><td>1 (2.7)</td></tr><tr><td>Imaging and IFI signs (n)</td><td></td></tr><tr><td>CT scan</td><td>20 (54.1)</td></tr><tr><td>Yes</td><td>15 (40.5)</td></tr><tr><td>No</td><td>5 (13.5)</td></tr><tr><td>MRI</td><td>2 (5.4)</td></tr><tr><td>Yes</td><td>1 (2.7)</td></tr><tr><td>No</td><td>1 (2.7)</td></tr><tr><td>Chest x-ray</td><td>2 (5.4)</td></tr><tr><td>Yes</td><td>1 (2.7)</td></tr><tr><td>No</td><td>1 (2.7)</td></tr></tbody></table>
<table><tr><td>None</td><td>13 (35.1)</td></tr><tr><td>Microbiologic diagnosis (n)</td><td></td></tr><tr><td>Culture</td><td>35 (94.6)</td></tr><tr><td>Histopathology + Culture</td><td>5 (13.5)</td></tr><tr><td>PCR</td><td>1 (2.7)</td></tr><tr><td>MALDI</td><td>1 (2.7)</td></tr><tr><td>Response at Day 28 (n)</td><td></td></tr><tr><td>Death</td><td>17 (45.9)</td></tr><tr><td>Partial</td><td>6 (16.2)</td></tr><tr><td>Progression</td><td>4 (10.8)</td></tr><tr><td>Stable</td><td>4 (10.8)</td></tr><tr><td>Complete</td><td>3 (8.1)</td></tr><tr><td>Unknown</td><td>3 (8.1)</td></tr><tr><td>Response at Final Assessment (n)</td><td></td></tr><tr><td>Death</td><td>19 (51.3)</td></tr><tr><td>Complete</td><td>8 (21.3)</td></tr><tr><td>Partial</td><td>4 (10.8)</td></tr><tr><td>Stable</td><td>4 (10.8)</td></tr><tr><td>Progression</td><td>0</td></tr><tr><td>Unknown</td><td>2 (5.4)</td></tr></table>

Allo: allogeneic; Auto: autologous; HSC: hematopoietic stem cell transplant; ICU: intensive care

unit; IF: invasive fungal infection; SOT: solid organ transplant; DM: diabetes mellitus; CT:

computed tomography; MRI: magnetic resonance imaging; PCR: polymerase chain reaction;

MALDI: matrix assisted laser desorption/ionization

*Cases with a positive blood culture are considered to have disseminated infection as well

**Conclusion:** In this study, the majority of patients had a significant underlying risk factor for infection including hematologic malignancy, SOT, ICU admission, or preceding trauma. Despite the use of combination antifungal therapy, the overall mortality rate from invasive *L. prolificans* infection was 51%, with a trend towards lower infection-related mortality (35%) in those receiving a combination treatment including both VRC and TRB.

P316

Making continuous prospective surveillance of invasive mold diseases real-time in hospitals using artificial intelligence

M. Ananda-Rajah<sup>1,2</sup>, J. Seah<sup>2</sup>, M. Liu<sup>3</sup>, G. Haffari<sup>3</sup>, C. Bergemeir<sup>3</sup>, T. Peel<sup>1</sup>

¹Infectious Diseases, Alfred Health, Melbourne, Australia, ²Alfred Health, Melbourne, Australia, ³It, Monash University, Clayton, Australia

**Objectives:** Surveillance, audit and feedback of invasive mold diseases (IMD) is fundamental to antifungal stewardship (AFS) but current methods are inefficient and restrictive. Continuous prospective surveillance of IMD in all haematology patients has not been possible because the majority of these infections present as a culture negative pneumonia. Artificial intelligence (AI) targeting medical imaging provides an opportunity to identify fungal pneumonia in real-time in order to present actionable data at the point of care. Here we report preliminary results of real-world prospective validation of deep learning based natural language processing (NLP) of chest imaging reports for real-time detection of IMD in haematology patients that is part of a multicentre clinical trial (Clin Trials.gov NCT03793231). **Objective:**To validate NLP of chest computed tomography reports for prospective surveillance of IMD in all hospitalised haematology patients. As a validation study, NLP alerts are not being fed back to clinicians but rather the machine is being validated against human surveillance. Presented here are preliminary results from one activated site, Alfred Health, a major quaternary Australian transplant centre.

**Methods:** Prospective active manual and electronic surveillance of invasive fungal diseases (IFD) among hospitalised patients under the haematology service commenced on 1 December 2018. Hospitalised patients with IFD were identified by research coordinators through active case finding every week. All suspected IFD cases were reviewed again at 30 days and data collected to determine if they met internationally accepted criteria for IFD diagnosis (EORTC/MSG 2008 definitions). Chest CT reports were prospectively processed by NLP hosted on the hospital server and predictions were compared to IFD cases detected by active surveillance.

**Results:** From 1 December 2018 to 31 April 2018, there were 8 patients with suspected IFD identified. Of these, one case was excluded because it did not meet internationally accepted criteria for IFD,
resulting in 7 patients with confirmed IFD associated with the following characteristics: all had IMD; all had pulmonary site of infection; 2 cases were probable/proven; 2 possible cases had a positive Aspergillus PCR on bronchoalveolar lavage. There were 6 cases of breakthrough IMD on antifungal prophylaxis involving posaconazole in 4, liposomal amphotericin in 1 and fluconazole in 1 case. Of 90 chest CT reports screened by fungal Ai-NLP over the study period, 6 of the 7 IFD patients were correctly flagged. The case missed by NLP was an intubated patient with probable pulmonary invasive Aspergillosis associated with isolation of *A. terreus*. The NLP output in this case had probabilities of 37.8% and 41.0% on serial reports which was below the 50% threshold for triggering a positive alert. The radiologist's conclusion was not definitive in either report. There were 10 (11%) false positive reports. NLP is tuned for fungal pneumonia so may miss extra-pulmonary sites. False positives could be minimised with multimodal analysis combining other sources of data.

**Conclusion:** Real-time, embedded, NLP of chest imaging reports facilitates surveillance of diagnostically challenging IMD for an entire haematology population. NLP utilises diagnostic imaging readily available in hospitals rather than the electronic medical record. Generalisability of NLP will be enhanced by our multicentre clinical trial.

P317

**The case of successful treatment of disseminated cryptococcosis in a patient with Non-Hodgkin's lymphoma**

J. Melekhina¹, Y. Borzova², S. Ignatyeva², E. Desyatik³, T. Bogomolova⁴, I. Ziuzgin⁵, N. Vasilyeva², N. Klimko¹

¹Department Of Clinical Mycology, Allergology And Immunology, North-Western State Medical University named after I.I. Mechnikov, Saint-Petersburg, Russian Federation, ²Kaschkin Research Institute Of Medical Mycology. Department Of Medical Microbiology, North-Western State Medical University named after I.I. Mechnikov, Saint-Petersburg, Russian Federation, ³Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ⁴North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russian Federation, ⁵FSBI «Petrov Research Institute of Oncology» of the Ministry of Healthcare of the Russian Federation, Saint-Petersburg, Russian Federation

**Case Report: Objectives.** Clinical case of successful treatment of disseminated cryptococcosis in patient with Non-Hodgkin's lymphoma. **Methods.** The EORTC/MSG 2008 diagnostic criteria were used. **Results.** Patient B., 32-year-old, was hospitalized in a city hospital in June 2016. Non-Hodgkin's lymphoma was diagnosed. He received 8 cycles of R-CHOP therapy, two cycles of R- DHAP with peripheral blood stem cell transplantation, one cycle of GDP protocol and after achieving partial remission, the patient was consolidated with peripheral blood stem cell transplantation using the BEAM conditioning regime. In September 2017, hematological remission was achieved. In October 2018 an infiltrate 17x12 mm in the right lung S4 was revealed on computed tomography (CT) scan. Surgical removal the lung lesion was performed. Histological examination revealed granulomatous inflammation, and culture was positive with *Cryptococcus neoformans*. Positive “Crypto +” test in blood serum and cerebrospinal fluid was detected and diagnosis disseminated cryptococcosis was established. The patient was treated with amphotericin B 50 mg/day for 14 days, followed by fluconazole 800 mg/day with positive effect. In February 2019 the decrease of infiltration and the reduction of the cavity were detected on chest CT scan. Cryptococcal antigen test was negative in the blood serum and in the cerebrospinal fluid. The total duration of antimycotic therapy was six months.

**Conclusion.** Disseminated cryptococcosis is possible in patients with Non-Hodgkin's lymphoma.

P318

**Comparison of fluconazole and posaconazole based antifungal prophylaxis in patients with newly diagnosed acute myeloid leukemia**

O. Kandemir¹, A. Tombak², M. Bakır Koyuncu³, S. Şahinoğlu³, A. Türker³, E. Sahin Horasan⁴

¹Infection Diseases, Mersin University, mersin, Turkey, ²Hematology, mersin university, MERSIN, Turkey, ³Mersin University, MERSIN, Turkey, ⁴Infection Diseases, mersin university, mersin, Turkey
**Objectives:** Antifungal prophylaxis with posaconazole during remission induction chemotherapy of patients with newly diagnosed acute myeloid leukemia has been shown to decrease invasive fungal infections (IFI) and increase overall survival. However, real-life studies about this issue is not much.

**Methods:** This was a retrospective cohort study including a total of 58 patients with acute myeloid leukemia who were received intensive remission induction therapy. 27 patients received fluconazole prophylaxis between January 2013 and January 2015, 31 patients received posaconazole prophylaxis between February 2015 and February 2017.

**Results:**

<table><caption>Table-1. Patient and disease characteristics</caption><thead><tr><th></th><th>Fluconazole (n=27)</th><th>Posaconazole (n=31)</th><th>P value</th></tr></thead><tbody><tr><td>Age (median)</td><td>54</td><td>49</td><td>0,11</td></tr><tr><td>Total days of neutropenia (mean days)</td><td>26.0</td><td>20.0</td><td>0,006</td></tr><tr><td>Neutropenic fever</td><td>5</td><td>1</td><td>&lt;0,001</td></tr><tr><td>Bacteremia</td><td>1</td><td>0</td><td>0,305</td></tr></tbody></table>

<table><caption>Table 2: incidence of breakthrough invasive fungal infections, breakthrough invasive fungal infections and outcome</caption><thead><tr><th></th><th>Fluconazole</th><th>Posaconazole</th><th>P value</th></tr></thead><tbody><tr><td>Possible IFIs</td><td>74.1</td><td>45.2</td><td>0,026</td></tr><tr><td>Breakthrough IFIs</td><td>29.6</td><td>31.3</td><td>0,829</td></tr><tr><td>100-day overall mortality</td><td>25.9</td><td>32.3</td><td>0,597</td></tr><tr><td>Death during active treatment</td><td>32.3</td><td>44.4</td><td>0,340</td></tr></tbody></table>

Demographic characteristics of the patients were similar in both groups (Table-1). At day 100, patients receiving posaconazole had a significantly lower incidence of possible IFIs (45.2% vs 74.1%, p = 0,026). There was no significant difference in 100-day overall mortality (32.3% in the posaconazole group vs. 25.9% in the fluconazole group, p = 0,597), breakthrough IFIs (31.3% in the posaconazole group vs. 29.6% in the fluconazole group, p = 0,829) and death during active treatment (44.4% in the posaconazole group vs. 32.3% in the fluconazole group, p = 0,340) (Table-2).

**Conclusion:** Posaconazole prophylaxis decreased the incidence of IFIs but did not improve short-term overall survival.

P319

B-1 cell deficiency decreases the population and function of dendritic cells in murine encephalitozoonosis

A. Pereira¹, D. Langanke Dos Santos², A. Alvares-Saraiva², E. Hurtado², J. Alvarez², M. Lallo²

¹Biomedicina, Centro Universitário São Camilo, São Paulo, Brazil, ²Post-graduation Program In Environmental And Experimental Pathology, Paulista University, São Paulo, Brazil

**Objectives:** Microsporidia are obligate intracellular pathogens belonging to the *kingdom Fungi*, relatively common enteric microorganisms that usually result in self-limited or asymptomatic infections in humans. Although protection against microsporidia is predominantly dependent on the onset of a strong T cell response, dendritic cells (DCs) play a critical role in stimulating T cell response through pattern recognition receptors. Previous studies have suggested that DCs can regulate B cell activity and *Encephalitozoon intestinalis* infection blocks the differentiation of DCs, thus compromising the immune response against the pathogen, characterizing an evasion mechanism. The present study aimed to evaluate the relation between B-1 cells and DCs of *Peyer's* patches (PPs) in mice infected with *Encephalitozoon cuniculi*, a species of microsporidia.

**Methods:** BALB/c mice, BALB/c Xid mice (deficient in B-1 cells) and Xid+B-1 (B-1 cells adoptive transfer to mice) were infected or not with *E. cuniculi* orally and the same immunosuppressed with cyclophosphamide (Cy) because it is an opportunistic pathogen. After 21 days of the infection, the DCs of PPs were quantified by flow cytometry.
**Results:** Infected mice had a lower population of DCs on PPs than uninfected animals (fig. 1). This result suggests the ability to block DC differentiation for the pathogen *E. cuniculi*. The BALB/c mice, with higher resistance to *E. cuniculi* infection, had the highest DCs populations when compared to the other groups (Fig.1). Xid animals showed the smallest populations of DCs, with the exception of the Xid animals that received B-1 cell transfer. MHC II expression decreased in Xid animals. Cy induced an increase in the DCs population in PPs from uninfected BALB/c mice in relation to the other uninfected groups, indicating an immunomodulatory effect of the drug.

<figure><img src="image_79.png" /><figcaption>**Figure 1.** Evaluation of dendritic cells present in the Peyer's Patches from BALB/c, BALB/c XID and XID+B-1 mice inoculated (+) or not (-) with *E. cuniculi*. A) Percentage of CD11c⁺ dendritic cells in non-treated mice. B) Geometric mean of the fluorescence intensity of the MHC II molecule in dendritic cells CD11c⁺. C) Percentage of CD11c⁺ dendritic cells. Two-way ANOVA analysis with Tukey post-test revealed # statistically significant differences and p <0.05*, versus BALB XID and versus XID+B-1, respectively (A). Data were transformed for statistical analysis, analysis of two-way ANOVA with Tukey test post revealed p <0.05* versus BALB c.</figcaption></figure>

**Conclusion:** These data suggest that B-1 cell deficiency compromises the population and the DCs response of PPs in *E. cuniculi* infection.

P320

**Evaluation of the Wako™ β-D-Glucan assay in Patient Serum for the Diagnosis of Invasive Aspergillosis.**

F. Hegarty

Microbiology, Mater Misericordiae University Hopsital, Dublin, Ireland

**Objectives:** Invasive Aspergillosis is a fungal disease that can carry a high morbidity and mortality, especially in those patients who are immunosuppressed. Early diagnosis of Invasive Aspergillosis (IA) is key to implementing early treatment and improve patient prognosis. Currently in MMUH, serum β-D-Glucan (BDG) is available as an external referral test only (average TAT 109.5 days). Expanding our current repertoire of tests to include BDG, would greatly aid in the early diagnosis of IA. Delay or misdiagnosis of IA can result in drug toxicity due to inappropriate treatment, high
medical expenses and mortality. Given the complexity of invasive fungal diseases a number of tests are required for correct diagnosis. Therefore implementation of another test that can quickly and accurately aid in the diagnosis of IA would have great benefits for overall patient care, whilst limiting unnecessary use of antifungal therapy within the hospital. **Aim:** To evaluate the Wako™ β-D-Glucan assay in the laboratory and its' implications for clinical practice. To assess the contribution this test can make to patient care

**Methods:** Fifty-one random patient samples (serum) were used to complete this pilot study. Samples included ICU, lung transplant and haematology patients. Positive and negative controls were included weekly. The Wako™ β-D-Glucan was evaluated as per the manufacturer's guidelines

**Results:** The results obtained from the BDG were compared to external referral results. They were also analysed in conjunction with previous microbiological cultures, galactomannan, OLM™ lateral flow device calcofluor/KOH results, histological specimens, radiological imaging and clinical details where applicable. EORTC criteria were used to categorise patients into proven, probable or possible IA. BDG results demonstrated 83% sensitivity and 100% specificity as well as a positive predictive value of 100% and a negative predictive value of 88%.

**Conclusion:** Based on results of this study, Wako™ β-D-Glucan will be introduced in MMUH, for patients with suspected IA, or those severely immune-suppressed.

P320

Evaluation of the Wako™ β-D-Glucan assay in Patient Serum for the Diagnosis of Invasive Aspergillosis.

F. Hegarty

Microbiology, Mater Misericordiae University Hospital, Dublin, Ireland

**Objectives:** Invasive Aspergillosis is a fungal disease that can carry a high morbidity and mortality, especially in those patients who are immunosuppressed. Early diagnosis of Invasive Aspergillosis (IA) is key to implementing early treatment and improve patient prognosis. Currently in MMUH, serum β-D-Glucan (BDG) is available as an external referral test only (average TAT 109.5 days). Expanding our current repertoire of tests to include BDG, would greatly aid in the early diagnosis of IA. Delay or misdiagnosis of IA can result in drug toxicity due to inappropriate treatment, high medical expenses and mortality. Given the complexity of invasive fungal diseases a number of tests are required for correct diagnosis. Therefore implementation of another test that can quickly and accurately aid in the diagnosis of IA would have great benefits for overall patient care, whilst limiting unnecessary use of antifungal therapy within the hospital. **Aim:** To evaluate the Wako™ β-D-Glucan assay in the laboratory and its' implications for clinical practice. To assess the contribution this test can make to patient care

**Methods:** Fifty-one random patient samples (serum) were used to complete this pilot study. Samples included ICU, lung transplant and haematology patients. Positive and negative controls were included weekly. The Wako™ β-D-Glucan was evaluated as per the manufacturer's guidelines

**Results:** The results obtained from the BDG were compared to external referral results. They were also analysed in conjunction with previous microbiological cultures, galactomannan, OLM™ lateral flow device calcofluor/KOH results, histological specimens, radiological imaging and clinical details where applicable. EORTC criteria were used to categorise patients into proven, probable or possible IA. BDG results demonstrated 83% sensitivity and 100% specificity as well as a positive predictive value of 100% and a negative predictive value of 88%.

**Conclusion:** Based on results of this study, Wako™ β-D-Glucan will be introduced in MMUH, for patients with suspected IA, or those severely immune-suppressed.

P321

Evaluation of OLM™ Lateral Flow Device (LFD) in Bronchoalveolar Lavage for the Diagnosis of Invasive Aspergillosis
F. Hegarty

Microbiology, Mater Misericordiae University Hopsital, Dublin, Ireland

**Objectives:** Invasive Aspergillosis is a fungal disease that can carry a high morbidity and mortality, especially in those patients who are immunosuppressed. Early diagnosis of Invasive Aspergillosis (IA) is key to implementing early treatment and improve patient prognosis. While respiratory samples may culture *Aspergillus*, it is essential to differentiate between active infection verses colonisation of the lung. This differentiation can often be difficult as well as time consuming. This potential for delay in treatment commencement could contribute to a poor outcome, or if treated incorrectly may expose the patient to unnecessary antifungal therapy. Therefore utilisation of a test that can reliably differentiate between colonisation and active infection would have benefits for patient care.
**Aim:** To evaluate the OLM™ LFD in the laboratory and implications for clinical practice.
To assess the contribution this test can make to patient care

**Methods:** Twenty random patient samples (bronchoalveolar lavage) were used to complete this pilot study. Nine samples were *Aspergillus* culture positive, fifteen samples were *Aspergillus* culture negative and two samples NEQAS controls; *Aspergillus* sp. and *Trichophyton* sp. culture positive. The OLM™ LFD was evaluated as per the manufacturer's guidelines, which included the pre-treatment steps as required

**Results:** The results obtained from the LFD analysed in conjunction with previous microbiological cultures, calcofluor/KOH results, histological specimens, radiological imaging and clinical details where applicable. LFD results demonstrated 100% sensitivity and 85% specificity as well as a positive predictive value of 71% and a negative predictive value of 100%. The LFD detected the presence of *Aspergillus* in three samples which was missed in the previously carried out culture and calcofluor/KOH. In this instance, *Aspergillus* infection was suspected from patient scans, which nicely correlated with the LFD result.

**Conclusion:** Based on results of this study, OLM™ LFD will be introduced in MMUH, for patients with suspected IA, or those severely immune-suppressed.

P322

The first case of invasive candidiasis caused by two pathogens (Candida albicans and Candida glabrata) in a patient with Hodgkin's lymphoma

E. Shagdileeva¹, O. Shadrivova¹, J. Chudinovsky², M. Motalkina², I. Zyuzgin², T. Bogomolova³, I. Vybornova³, I. Ryabinin³, A. Hohlova², A. Artemeva², N. Klimko¹

¹North-West State Medical University named after I.I. Mechnikov, Saint-Petersburg, Russian Federation, ²N.N. Petrov National Medical Research Centre of Oncology, Saint Petersburg, Russian Federation, ³Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation

**Case Report:** Woman with HL, 32 years old, in severe condition was admitted to the Petrov Oncology National Medical Research Centre for cytotoxic chemotherapy on 23.01.2019. Risk factors for IC were central venous catheter (CVC), broad-spectrum antibacterial drugs therapy, prolonged neutropenia, and glucocorticosteroids treatment. The patient didn't receive antifungal prophylaxis. Clinical manifestation of IC was body temperature > 38°C, refractory to antibiotic use. Diagnosis of invasive candidiasis was confirmed with blood culture – *C.albicans* with susceptibility to fluconazole and voriconazole *in vitro*. Pathogen identification was determined by MALDI-TOF mass spectrometry. In the first 24 hours after diagnosis antifungal therapy (caspofungin) was used, and CVC was removed. Anaphylactic reaction with angioedema developed after caspofungin administration, and liposomal amphotericin B (7 days), then fluconazole (7 days) and amphotericin B deoxyholate (6 days) were used. Death was caused by septic shock after 20 days of antifungal therapy. On the autopsy IC with lungs, liver, spleen, and skin involvement was found. Culture from the autopsy materials was identified as *C.glabrata* with dose-dependent susceptibility to fluconazole *in vitro*. **Conclusion.** In the treatment of invasive candidiasis in immunocompromised patients, the possibility of several pathogens should be considered.
**Pulmonary aspergillosis in patient with autoimmune hepatitis: the report of unusual case**

A. Antonets¹, O. Kit², O. Kutsevalova³, N. Panova³, D. Miroshnichenko⁴, E. Popovyan⁵, O. Homenko⁶
¹Laboratory Of Molecular Oncology, Rostov Research Institute of Oncology, Rostov-on-Don, Russian Federation, ²Rostov Research Institute of Oncology, Rostov-on-Don, Russian Federation, ³Laboratory Of Clinical Microbiology, Rostov Research Institute of Oncology, Rostov-on-Don, Russian Federation, ⁴Clinical Pharmacology Department, Rostov Rostov Regional Clinical Hospital №2, Rostov-on-Don, Russian Federation, ⁵Pulmonology Department, Rostov Rostov Regional Clinical Hospital №2, Rostov-on-Don, Russian Federation, ⁶Hepathology Department, Central City Hospital №1 named N.A. Semashko, Rostov-on-Don, Russian Federation

**Case Report: Objectives:** To present the case of immunocompromised patient who was diagnosed with pulmonary aspergillosis in a short period of time after established diagnosis of autoimmune hepatitis. **Methods:** We examined 69-year-old man who had spitting blood, cough, signs of abscess pneumonia in x-ray examination after 5 weeks of immunosuppressive therapy with decreasing dose of glucocorticoids that was prescribed after the second episode of bilirubinemia when diagnosis of autoimmune hepatitis was established after scrutinizing diagnostic search. Sputum was analyzed with standard and fluorescent microscopy with white calcofluor and cultural method. Standard methods were applied to exclude tuberculosis and aspergillosis. Galactomannan (GM) detection was performed with immunoenzymatic assays XEMA GaIMAg EIA kit (Russia). Positive level of GM accounted for ≥0.59 OD (optical density). **Results:** Cultural methods revealed the presence in sputum *E.coli* (10⁷) and *A.flavus* (10⁵) (pic.1).

<figure><img src="image_80.png" /></figure>

GM level initially was positive in blood (0.73 OD). Antifungal voriconazol therapy was started immediately. One week after starting treatment the second cultural testing of nose crust showed *A.flavus* (10⁴) (pic.2);

<figure><img src="image_81.png" /></figure>

GM was negative in blood and urine (0.41 OD and 0.14 OD respectively), and positive in bronchoalveolar lavage fluid (BALF) accounting for 2.34 OD. Further cultural testing did not detect *A.flavus*. GM level was positive only in BALF. Spiral computed tomography revealed several aspergillomas, the size of the largest one was 70x50 mm. The patient did not have leukopenia at any
time from the first episode of hepatitis, however slight lymphopenia was observed. One month after diagnosis of pulmonary aspergillosis pneumothorax and secondary bacterial complications occurred. Despite this the patient has demonstrated positive clinical effect continuing antifungal and antibiotic therapy (in accordance with the sensitivity of microorganisms) with accompanying therapy by the third month since the diagnosis of aspergillosis. The remission of autoimmune hepatitis has been observed. **Conclusion.** It should be taken into consideration that immunocompromised patients even without leukopenia/agranulocytosis and short period of immunosuppressive therapy are at risk of development fungal infection. GM testing demonstrates its usefulness for early diagnosis *Aspergillus spp.* A comprehensive approach to diagnosis and alertness of doctors for fungal infection can improve the detection of cases of aspergillosis.

P324

**Challenges in the management of fusariosis in oncology patients: a single-centre series of 27 cases**

R. Ito¹, K. Ibrahim¹, P. Bonazzi¹, J. De Almeida Junior², M. Santiago¹, A.C. Da Silva¹, M. Vieira¹, M. Freire¹, D. Silva³, M. Martins³, M. Szeszs³, L. Bonfietti³, J. Pereira¹, V. Rocha², M.D.P. Diz¹, P. Hoff¹, M. Melhem³, E. Abdala¹

¹Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil, ²Hospital da Clinicas da Universidade de Sao Paulo, Sao Paulo, Brazil, ³Instituto Adolfo Lutz, Sao Paulo, Brazil

**Objectives:** This study aims to describe clinical, epidemiological and laboratorial aspects of fusariosis in cancer patients.

**Methods:** We retrospectively identified patients from an oncology hospital with proven fusariosis, according to the EORTC/MSG modified criteria, since January 2011 to January 2018. Demographic, clinical and laboratorial data from patients were obtained. Mortality rates at 30 and 90 days were evaluated.

**Results:** Twenty-seven cases were identified. Median age was 55 years and 15 were female. Most patients had haematological malignancies (81.5%) and neutropenia (88.9%). All patients received chemotherapy and/or corticosteroids in the last 3 months. Eighteen had disseminated disease, 7 had fungaemia alone and 2 had localized skin infection. Out of 18 patients with disseminated fusariosis, 13 had skin involvement, 8 had pulmonary disease and 5 had sinusitis. Fourteen patients received a lipid formulation of amphotericin B and voriconazole, 10 amphotericin B alone and 3 died before treatment. Species identification was performed in 10 isolates, and all of them were from *F. solani* species complex. Six isolates had susceptibility profile to antifungals and all had MIC ≥8 mg/L to azoles; two isolates had MIC ≥2 mg/L to amphotericin. Mortality rates at 30 and 90 days were 51.9% and 63.0%, respectively. At 90 days, no patients with solid tumor or fungaemia had survived

**Conclusion:** Haematological malignancies, neutropenia, and the use of immunosuppressive therapies were the conditions most associated to fusariosis in cancer patients. Disseminated disease was the most common clinical presentation. Most patients received combined therapy, once the best therapeutic option has not yet been defined, and due to identification of isolates with high MICs to azoles and amphotericin. Mortality rates were higher in solid tumor patients and those with fungaemia alone.

P325

**Epidemiology of Pneumocystis jirovecii pneumonia and (non-)use of prophylaxis in three tertiary care hospitals.**

A. Dunbar¹, A. Schauwvlieghe², S. Algoe¹, J. Van Hellemond³, M. Reynders⁴, S. Vandecasteele⁵, J. Boelens⁶, P. Depuydt⁷, B. Rijnders¹

¹Department Of Infectious Diseases, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands, ²Department Of Hematology, Erasmus Medical Center, Rotterdam, Netherlands, ³Medical Microbiology, Erasmus Medical Center, Rotterdam, Netherlands, ⁴Clinical Microbiology, AZ St-Jan Brugge-Oostende Hospital, Bruges, Belgium, ⁵Nephrology And Infectious Diseases, AZ St-Jan Brugge-Oostende Hospital, Bruges, Belgium, ⁶Laboratory Medicine, Ghent University Hospital, Ghent, Belgium, ⁷Intensive Care, Ghent University Hospital, Ghent, Belgium
**Objectives:** Pneumocystis jirovecii pneumonia (PCP) is caused by the fungus *Pneumocystis jirovecii* (PJ) and is almost exclusively diagnosed in severely immunocompromised patients. While in the recent past the vast majority of PCP-cases were diagnosed in patients with HIV, this is no longer the case in resource-rich countries with unrestricted access to HIV care. The benefit of prophylaxis against PJ has been convincingly demonstrated for patients with HIV and a CD4 T-cell count <200 cells/mm but the benefit of prophylaxis is less well established for other patient groups. This study aimed to describe the epidemiology of PJP in recent years and assess how many patients with PCP did or did not receive appropriate prophylaxis in the months preceding the infection.

**Methods:** A multicenter retrospective study was performed in 3 Belgian and Dutch tertiary care centers: Erasmus MC, University Medical Center in Rotterdam, AZ Sint-Jan in Bruges and UZ Gent in Ghent. A list of patients that underwent broncho-alveolar lavage sampling for PCP testing with an in-house PJ PCR was retrieved from the 3 microbiology labs. An in-house PJ PCR was used in each of the centers with a cycle threshold (Ct) value of <29 (Rotterdam and Bruges) or <31 (Ghent) considered a *probable* PCP. For patients with a positive PJ PCR but above this threshold a predefined case definition was used to classify patients as follows: a *possible* case of PCP had to fulfill all 3 of the following criteria; 1. PCR Ct value <35 and 2. Clinico-radiological diagnosis compatible with PCP and 3. Patient died or patient received PCP therapy and survived. Patient files from all PCR+ patients were reviewed to determine whether the patient fulfilled the PCP case definition and if antimicrobial prophylaxis had been provided prior to PCP. Disease specific guidelines (NIH AIDS, ECIL, ASOT, local hospital guidelines) were used to evaluate if prophylaxis was indicated. Fisher's exact test, t-test or Mann-Whitney U tests were used as appropriate.

**Results:** From 2012 to 2018, 482 patients with positive PCR PJ of respiratory samples were reviewed. 278 were excluded mostly because CT value was>35 (n = 247). Other reasons were age<18, insufficient clinical data available, other respiratory sample than BAL. Of the remaining 204, 153 had a probable (n = 90) or possible (n = 63) PCP. The remaining 51 were considered colonized (table 1). PCP patients were HIV negative in 74%. Only 11 (7%) of PCP cases had received prophylaxis, despite that 133 (87%) had an indication for prophylaxis according to guidelines.
<table><caption>Table 1:</caption><thead><tr><th>BASELINE CHARACTERISTICS</th><th>ALL PATIENTS</th><th>CASES PCP</th><th></th></tr></thead><tbody><tr><td>TOTAAL</td><td>204</td><td>153</td><td>OUTCOME</td></tr><tr><td>AGE (YEARS) [SD]</td><td>60</td><td>57(16)</td><td>ICU, (YES) [%]</td></tr><tr><td>SEX(MAN), N(%)</td><td>140</td><td>106(62.3)</td><td>MEDIAN ICU DURATION, DAYS [IQR]</td></tr><tr><td>HIV+, N(%)</td><td>41</td><td>39(25.5)</td><td>MEDIAN MV DURATION, DAYS [IQR]</td></tr><tr><td>HIV-, N(%)</td><td>163</td><td>114(74.5)</td><td>MISSING, N</td></tr><tr><td>HEMATOLOGY, N</td><td>66</td><td>50(32.7)</td><td>MEDIAN HOSPITAL STAY TOTAL, DAYS [IQR]</td></tr><tr><td>SOLID ORGAN TRANSPLANTATION, N</td><td>25</td><td>22(14.4)</td><td>MISSING, N</td></tr><tr><td>OTHER PATIENTS*, N</td><td>72</td><td>42(28.5)</td><td>MEDIAN HOSPITAL STAY AFTER PCP DIAGNOSE, DAYS [IQR]</td></tr><tr><td>CORTICOSTEROID USE*, YES (%)</td><td>104</td><td>83(71.9)</td><td>MISSING, N</td></tr><tr><td>CORTICOSTEROID DURATION IN DAYS, MISSING, N</td><td>30(15-31)</td><td>30(15-33)</td><td>HOSPITAL MORTALITY(%)</td></tr><tr><td>MEDIAN DOSE (MG/DAY) [IQR] MISSING, N</td><td>23.6[0.0-40.0]</td><td>24.5[12.5-40.0]</td><td>THERAPY, (YES) [%]</td></tr><tr><td>PROPHYLAXIS USE, [YES] [%]</td><td>14</td><td>11(7.2)</td><td>THERAPY MISSING, N</td></tr><tr><td>TYPE OF PROPHYLAXIS</td><td></td><td></td><td></td></tr><tr><td>1. COTRIMOXAZOLE, N(%)</td><td>8</td><td>5(3.3)</td><td>1. COTRIMOXAZOLE, N(%)</td></tr><tr><td>2. OTHER, N(%)</td><td>6</td><td>6(3.9)</td><td>2. THERAPY+ADJUNCTIVE CORTICOSTEROID, N(%)</td></tr><tr><td>PROPHYLAXIS INDICATION, MISSING</td><td>134</td><td>133(86.9)</td><td>3. CLINDAMYCINE +PRIMAQUINE, N(%)</td></tr><tr><td></td><td>5</td><td>3</td><td>4. ATOVAQUON, N (%)</td></tr><tr><td></td><td></td><td></td><td>5. DAPSON+TRIMETROPIM, N(%)</td></tr><tr><td></td><td></td><td></td><td>6. PENTAMIDINE, N(%)</td></tr><tr><td></td><td></td><td></td><td>MEDIAN THERAPY DURATION, DAYS [IQR] MISSING, N</td></tr></tbody></table>

-: all HIV+ patients, see frequencies for different patient group at table 4.

-: corticosteroid use and dose only for the HIV - patients.

-: other prophylaxis sort: atovaquone and pentamidine.

-: prophylaxis was indicated by Center of Disease Control and prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. European Conference on Infections in Leprosia and American Society of Transplantation in HIV positive, hematology patients and solid organ transplant patients and according to Trasus MC guidelines.

-: Other patients: lung diseases (11), patients with malignancy other than hematology (11), (metastatic brain tumors (6), dermatology patients (4), auto immune diseases (4), rheumatoid arthritis (2), hyperthyroidism (1), mental health patient (1), missing (2)
**Conclusion:** The vast majority of patients diagnosed with PCP had not received prophylaxis and therefore the infection could be considered at least partially preventable. In regions where HIV testing and treatment is available without restrictions, PCP is mainly diagnosed in non-HIV immunocompromised patients. Strategies to improve awareness of and compliance with antimicrobial prophylaxis guidelines in immunocompromised patients are urgently needed.

P326

**Prospective evaluation of Mucorales DNA qPCR detection in serum for early diagnosis of mucormycosis: First results from the ModiMucor study**

L. Millon¹, D. Caillot², A. Berceanu³, H. Gbaguidi-Haore⁴, V. Letscher-Bru⁵, F. Dalle⁶, B. Denis⁷, S. Bretagne⁸, A. Alanio⁹, D. Boutoille¹⁰, F. Morio¹¹, F. Lanternier¹², M.-E. Bougnoux¹³, F. Botterel¹⁴, T. Chouaki¹⁵, A. Charbonnier¹⁶, F. Ader¹⁷, D. Dupont¹⁸, S. Rocchi¹⁹, E. Scherer¹⁹, R. Herbrecht²⁰

¹Parasitology - Mycology - Umr6249 Cnrs Chrono-environnement, University Hospital Besançon, Besançon, France, ²Clinical Haematology, University Hospital of Dijon, Dijon, France, ³Hematology, University Hospital Jean Minjoz, BESANCON, France, ⁴Infectious Risk Control, University Hospital Jean Minjoz, BESANCON, France, ⁵Parasitology-mycology, University Hospital of Strasbourg, Strasbourg, France, ⁶Parasitology-mycology, University Hospital Dijon, Dijon, France, ⁷Tropical And Infectious Diseases Department, Lariboisière Saint-Louis Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), PARIS, France, ⁸Mycology, Saint Louis hospital, Paris, France, ⁹Paris-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, ¹⁰Tropical Infectious Diseases, University Hospital of Nantes, Nantes, France, ¹¹Ea1155 Iicimed, Nantes University Hospital, NANTES, France, ¹²Infectious Diseases, Necker hospital, Paris, France, ¹³Parasitology Mycology, APHP Hôpital Necker-Enfants-Malades, Paris, France, ¹⁴Parasitologie-mycologie, CHU Henri MONDOR, Créteil, France, ¹⁵Parasitology-mycology, University Hospital of Amiens, Amiens, France, ¹⁶Haematology, University Hospital of Amiens, Amiens, France, ¹⁷Infectious Diseases, University hopital of Lyon, Lyon, France, ¹⁸Parasitology And Medical Mycology / Umr 5292, Université Lyon 1 / Hospices Civils de Lyon, Lyon, France, ¹⁹Mycology - Umr6249 Cnrs Chrono-environnement, University Hospital Besançon, Besançon, France, ²⁰Hematology, CHU de Strasbourg, Strasbourg, France

**Objectives:** Early initiation of specific treatment is essential to improve prognosis of mucormycosis. Several retrospective studies have reported that qPCR detection of Mucorales DNA in serum could anticipate the diagnosis of mucormycosis by an average of 8 days in hematological patients and in critically ill burn patients¹⁻⁴. Modimucor is a French prospective multicentre study (9 university hospitals) that aims to assess the performance (sensitivity, specificity, positive and negative predictive values and likelihood ratios) of the circulating DNA detection test for the diagnosis of mucormycosis in comparison to CT scan imaging, histopathology, microscopy and culture.

**Methods:** Patients with risk factors for invasive mold infection (IMI) such as patients with hematological diseases, burns diabetes, solid organ transplantation, trauma, or diabetes, and patients diagnosed with mucormycosis were enrolled prospectively. Serum samples were collected twice-a-week, and Mucorales PCR were performed at the time of serum sampling, in each center, as previously described¹. Clinical data and biological data were collected up to 6 months after enrollment. An interlaboratory quality control was done to ensure uniformity of the assays. Data analysis was performed using STATA 14 software.

**Results:** Were included 250 patients with suspicion of invasive fungal infection from January 2015 to June 2017 (Strasbourg *n* = 156; Dijon *n* = 39; Besançon *n* = 21; APHP Saint Louis *n* = 10; APHP Necker *n* = 9; Nantes *n* = 9; APHP Mondor *n* = 3; Amiens *n* = 2; Lyon *n* = 1). Classification of patients according to EORTC/MSG criteria was as follows: 47 probable (*n* = 13) or proven (*n* = 34) mucormycoses, 64 probable or proven aspergilloses, 5 other probable or proven IMI (fusariosis *n* = 2; scedosporiosis *n* = 2; histoplasmosis *n* = 1). A very low interlaboratory variation of the Mucorales PCR results was observed (SD = 1,8 cycles [range 1.3 ; 2.9]). At least one serum with positive Mucorales PCR was found for 35/47 patients with proven or probable mucormycosis. Among the 12
PCR-negative patients, 4 were given liposomal amphotericin B for more than 10 days at the date of serum sampling, and 3 patients had only a positive direct examination, without positive culture. Twenty-two patients with possible IMI had at least one positive Mucorales PCR. Sensitivity, specificity, positive and negative predictive values were 74.5% (35/47), 89.2% (181/203), 61.4% (35/57) and 93.8% (181/193), respectively. In addition, positive and negative likelihood ratios were 6.8 and 0.28, respectively. The first PCR-positive sample was observed in average 6.5 days [range 0-22; median = 4] before the sampling date of the first mycological positive specimen, and 7 days [range 0-44; median = 4] before the first imaging criteria.

**Conclusion:** This prospective study confirms the good performance of serum Mucorales PCR for early diagnosis of mucormycosis. This assay with an acceptable time frame and a reasonable cost helps to anticipate the diagnosis of mucormycosis and is becoming essential in the clinical diagnosis of mucormycosis. 1.Millon L. Clin Infect Dis, 2013; 2.Millon L. Clin Microbiol Infect 2016; 3.Caillot D. Open Forum Infect Dis, 2016; 4.Legrand M. Clin Infect Dis 2016

P327

Cryptococcal Infections among Human Immunodeficiency Virus /Acqiiref Immune Deficiency Syndrome (HIV/AIDS) Patients Accessing HAART Treatment in Ibadan

I. Adebiyi<fnref n="1" />,<fnref n="2" />, V. Ogunleye<fnref n="2" />

**Objectives:** Cryptococcosis occurs in man and animals in almost all the regions of the world. People with AIDS are particularly vulnerable to this infection. In particular, a higher mortality due to the infection is said to be associated with a CD4+ count less than 200cells/µL. Although Nigeria has the second highest number of people living with HIV globally, there is paucity of data on the prevalence of cryptococcal infections among this people. This study aimed to determine the burden of cryptococcal infections among HIV/AIDS patients accessing highly active antiretroviral therapy (HAART) treatment in Ibadan as well as determine the CD4+ count associated with cryptococcal infections in this locality.

**Methods:** Adult male and female HIV/AIDS patients accessing HAART treatment at the President's Emergency Plan for AIDS Relief (PEPFAR) clinic in Ibadan with CD4+ count less than 200cells/µL were enrolled into the study. Other HIV/AIDS patients with CD4+ count higher than 200cells/µL but who had a high index of cryptococcal meningitis were screened at the attending physician's request. A cryptococcal antigen test was performed on blood samples from patients with CD4+ count less than 200cells/µL and CSF samples from patients referred by the attending physician. The CSF samples were also cultured on Sabouraud Dextrose Agar culture media to isolate the organism.

**Results:** 200 HIV/AIDS patients were enrolled in the study. The mean CD4+ count was 145.2cells/µL and 49% of participants were newly diagnosed and had not commenced HAART. The overall prevalence of cryptococcosis was 2%. All positive samples were from patients referred by the attending physician. All positive samples were from patients with CD4+ higher than 200cells/µL. 100% of patients with cryptococcosis were already receiving HAART.

**Conclusion:** Cryptococcosis was found in HIV/AIDS patients with CD4+ count higher than 200cells/µL. Hence timely and appropriate cryptococcal screening in HIV/AIDS patients could help reduce cases of and mortality due to cryptococcal infection and also guide treatment needs. Cryptococcal screening should always be implemented for HIV/AIDS patients with low CD4+ counts regardless of symptoms or receipt of HAART to identify asymptomatic infected patients. It is also important to promptly screen HIV/AIDS patients with CD4+ count higher than 200cells/µL with a high index of cryptococcal meningitis.

P328

Disseminated phaeohyphomycosis associated to Tuberculosis in a pregnant woman

G. Mhamdi<fnref n="1" />, M. Kilani<fnref n="1" />, R. Abdelmalek<fnref n="1" />, A. Berriche<fnref n="1" />, B. Kilani<fnref n="1" />, L. Ammari<fnref n="1" />, H. Tiouiri Benaissa<fnref n="1" />, A. Kallel<fnref n="2" />, **K. Kallel**<fnref n="2" />, I. Chelly³, S. Haouet³, S. Boukriba⁴, H. Mizouni⁴

<footnote n="1">¹Department Of Medical Microbiology, University College Hospital, Ibadan, Ibadan, Nigeria,</footnote>

<footnote n="2">²Department Of Medical Microbiology, University College Hospital, Ibadan, Nigeria</footnote>
¹Department Of Infectious Diseases, The Rabta hospital, Tunis, Tunisia, ²Department Of Parasitology-mycology, The Rabta hospital, Tunis, Tunisia, ³Department Of Anatomopathology, The Rabta hospital, Tunis, Tunisia, ⁴Department Of Radiology, The Rabta hospital, Tunis, Tunisia

**Case Report:** Introduction: The phaeohyphomycosis are superficial or deep mycosis that occur due to pigmented frequently opportunistic fungus. We are reporting a case of co-infection, deep phaeohyphomycosis and tuberculosis in a 7 months pregnant patient unknowingly immunosuppressed. Observation: The patient is Mrs Y.S. 24 years old, admitted for convulsions. The diagnosis of cerebral and lymph node tuberculosis was held because of right hemi-body convulsions, a positive quantiferon, an evocative lymph node aspiration cytology and the presence of tuberculomas on the cerebral MRI. The patient received a quadruple antitubercular treatment. In two months, there was recurrence of the seizures and persistence of a left abscessed cerebral lesion with an important edema contrasting with the disappearance of a big number of tuberculomas in MRI control. The examination found a discreet right mowing, no meningeal syndrome and a firm cervical lymph node of 1,5 cm. The HIV serology was negative. We have maintained the antitubercular treatment and associated a corticosteroid therapy. A complement of surgical exeresis was realised for treatment and diagnosis purposes. She developed two cervical renitent lymph nodes and new seizures. The CT Scan identified a numerous parenchymal pulmonary nodes some of which are excavated, many necrotic cervical lymph nodes and the reappearance of the cerebral lesion at surgical site. The lymph node puncture aspirated greyish pus containing mycelian filaments. The molecular biology identified *Arthrocladium*. The anatomopathology study of cerebral abscess confirmed both tubercular and mycosic co-infection. We have associated Amphotericin B and Itraconazole. The evolution was slowly favorable. Conclusion: phaeohyphomycosis is a rare pathology with a difficult diagnosis. The prognosis is dark for the systematic forms. The treatment is medico-surgical.

P329

**Mechanisms of Ibrutinib-dependent susceptibility to invasive aspergillosis**

D. Armstrong-James¹, A. Bercusson¹, L. Herta Gonzales¹, A. Warris²

¹Nhli, Imperial College London, London, United Kingdom, ²Mrc Centre For Medical Mycology, University of Aberdeen, Aberdeen, United Kingdom

**Objectives:** Patients receiving Ibrutinib, a small molecule inhibitor of Bruton's tyrosine kinase (Btk), are at increased risk of invasive and disseminated aspergillosis. Given the increasing use of this drug as front-line treatment for haematological malignancies, better understanding of the mechanistic basis for this risk is urgently required. Whilst Btk is recognised as an important tyrosine kinase in B cell receptor signalling pathways, we and others have shown an important role for Btk in macrophage-based phagocytic responses to *Aspergillus fumigatus* and *Candida albicans*. Furthermore, Ibrutinib is also known to inhibit other TEC kinases such as TEC, which is important for macrophage responses to *Candida albicans*. Our objective was to characterise the impact of Ibrutinib on macrophage behaviour during *A. fumigatus* exposure.

**Methods:** Human monocyte-derived and alveolar macrophages, or murine J774A.1 macrophages, [AB1] were infected with *A. fumigatus* after treatment with Ibrutinib and the impact on phagocytosis, cell signalling, fungal killing and cell death responses assayed using a combination of imaging, western blotting and cell death kinetic assays. Selected findings were confirmed to be Btk-specific by siRNA.

**Results:** We show that Ibrutinib is a potent inhibitor of both NFAT and NFκB responses in human macrophages during infection with *A. fumigatus*. We show that *A. fumigatus* induces human macrophage Btk phosphorylation and that Btk depletion impairs NFAT and NFκB responses in human macrophages. Furthermore, Ibrutinib strongly inhibited macrophage necrosis in response to infection. Our findings in a human in vitro model suggest Btk involvement in a TLR9-dependent endosomally driven pathway in accordance with previous findings in our murine model. How this mediates fungal dissemination is currently unknown.
**Conclusion:** These observations suggest that defects in macrophage Btk signalling contribute to susceptibility to pulmonary aspergillosis. We are currently developing in vivo models to further study the effects of ibrutinib on outcomes from pulmonary aspergillosis.

P331

Ten year experience with fungal Infections in Acute Myeloid Leukemia in the Posaconazole Era

C. Marini, P. Chorão, R. Bergantim, E. Vale Aguiar, J. Cancela Pires, F. Trigo

Centro Hospitalar Sao Joao, Porto, Portugal

**Objectives:** Posaconazole prophylaxis in patients with acute myeloid leukaemia (AML) changed the paradigm of fungal infections (FI). AIMS: Description of FI and analysis of factors that might predispose to this type of infection in non-allotransplant AML patients in the posaconazole era.

**Methods:** Retrospective analysis of 217 consecutive non-M3 AML patients diagnosed between June 2008 and June 2018 in a tertiary center and treated with intensive chemotherapy regimens, including autologous transplantation when performed in these patients. Posaconazole prophylaxis was introduced since January 2009. Multivariate regression analysis was performed to identify characteristics related to FI.

**Results:** Median age at diagnosis was 51 years [19;71], 52% were females and all patients had an age-adjusted Charlson score ≤3. Genetic risk group according to the European Leukemia Net 2017 classification was favourable in 24%, intermediate in 43% and adverse in 22%. Twelve percent of patients (n = 26) had secondary AML. Patients were included from completed remission-induction intensive therapy up to transplant referral, the latter which occurred in 48% of patients (n = 104), with a global median follow-up of 7 months [1;132]. Autologous transplantation was performed in 15% of patients (n = 34). Fluconazole prophylaxis was administered in 7 patients, all others received posaconazole. There were 20 patients that had episodes of prophylaxis interruption, 14 during autotransplantation, 3 due to toxicity and 3 out of our protocol. During treatment, patients with no relapse presented a global median time of neutropenia of 69 days [26;421] whereas relapsed patients had a median of 104 days [30;356]. Ten percent of patients had >2 episodes of prolonged neutropenia (defined as ≥28 consecutive days of <500 neutrophils/microliter). Fungal infections were identified in 41 patients (19%), 3 of which were in the non-posaconazole group, and classified according to EORTC criteria, with 13 proven, 17 probable and 10 possible infections. In 32% of patients FI occurred during remission-induction (n = 13) of which 3 were diagnosed in the first week of neutropenia, 19% during consolidation treatment in first remission and 49% during relapse treatment (n = 20). Of the confirmed infections, 5 were aspergillosis, 3 candidemia, 2 by *Fusarium* and 1 mucormycosis. Probable infections had pulmonary origin with no microbiology isolate or serologic positivity but identified by typical radiologic evidence; of these, broncho-alveolar lavage and/or pulmonary biopsy was performed in 6 patients (35%) with negative results. For possible infections, antifungal therapy was initiated in a pre-emptive manner for high risk patients with persistent fever despite large spectrum antibiotics. In a multivariate analysis for the posaconazole group, patients with FI had a higher odds of having relapsed AML, refractory AML at first approach and >2 episodes of prolonged neutropenia during treatment (p<0.01, p = 0.01 and p = 0.012, respectively). There was no mortality related to FI in this cohort of patients.

**Conclusion:** Despite posaconazole prophylaxis, FI is still prevalent in AML patients. Infection during salvage treatment for refractory or relapsed disease and >2 previous periods of neutropenia exceeding 4 weeks should raise awareness for an increased risk of FI.

P332

Neuromeningeal cryptococcosis: experience of a department of infectious diseases

G. Mhamdi<fnref n="1" />, S. Bachrouch<fnref n="1" />, A. Berriche<fnref n="1" />, L. Ammari<fnref n="1" />, R. Abdelmalek<fnref n="1" />, B. Kilani<fnref n="1" />, H. Tiouiri Benaissa<fnref n="1" />,
A. Kallel², K. Kallel²

<footnote n="1">¹Department Of Infectious Diseases, The Rabta hospital, Tunis, Tunisia, ²Department Of Parasitology-mycology, The Rabta hospital, Tunis, Tunisia</footnote>