bioinformatic analyses, and real-time PCR experiments demonstrated the over-expression of all these
genes in culture media containing dihydroxybenzoate.

**Conclusion:** Results obtained in this study confirm that *Scedosporium* species exhibit the enzymatic arsenal to degrade natural complex molecules and are capable to open aromatic rings. This may explain their presence in polluted environments, but one may also consider these enzymes as virulence factors since it has been suggested a link between the ability to use aromatic compounds and the propensity of these fungi to cause cerebral infections in receptive hosts.

P214

Fusarium keratitis with poor prognosis: a report of four cases.

H. Chouaieb¹, A. Yaacoub¹, W. Mili², S. Ismail¹, M. Ghorbel², A. Fathallah¹

¹Parasitology Mycologie Laboratory, Farhat Hached university hospital, Sousse, Tunisia,

²Ophthalmology Department, Farhat Hached University Hospital, Sousse, Tunisia

Case Report:

**Introduction and objective** Keratitis caused by *Fusarium* species, a sight-threatening disease, is difficult to treat because *Fusarium spp* are highly resistant to most antifungals. Our objective was to describe four cases of Fusarium keratitis with poor prognosis.

**Methods** Direct microscopic examination of corneal scrapings and culture on Sabouraud-dichloramphenicol medium were performed. The identification of fungi was based on macroscopic and microscopic characteristics of culture.

**Results** All patients were male and the median age was 53, 5 years (range: 38-70). The predisposing factors were corneal trauma by a vegetative matter in three cases (75%), past history of herpetic keratitis in one case (25%) and steroid use in one case (25%). Direct microscopic examination was positive in 75% of cases and culture was positive in all cases. Culture grew *Fusarium solani* (50%) and *Fusarium solani/Fusarium chlamydosporium* (50%). It is important to mention that the two patients with *Fusarium solani/Fusarium chlamydosporium* keratitis were hospitalized in the same room; the first one was referred to ophthalmology department for *Fusarium* keratitis, when the second one developed the infection during his hospitalization. On the other hand, the antifungal susceptibility of the two strains were identical, so, it is quiet likely that the second patient was contaminated by the first one. Three patients underwent surgery and received antifungal therapy. One patient was treated by topical Amphotericin B associated to oral Itraconazole, the second received topical Amphotericin B, topical Betadine and oral Voriconazole and the third patient was treated by diluted Betadine, topical and oral Voriconazole. The fourth patient was lost to follow-up; he was discharged against medical advice. In most cases, the outcome was adverse.

**Conclusion** Keratomycosis is a severe disease that can lead to severe visual loss and even loss of the eye. Prompt diagnosis and early treatment are needed to avoid complications.

P215

Candida blankii as an emerging pathogen of cystic fibrosis patients

Y. Borzova¹, O. Voronina², N. Ryzhova², M. Kunda², E. Aksenova², O. Simonova³, D. Davletgareeva⁴,
I. Suslova⁴, T. Bogomolova¹, O. Skorbunova⁴, N. Klimko⁵, N. Vasilyeva⁴

¹Department of Medical Microbiology, North-Western State Medical University named after. I.I. Mechnikov, Sant-Petersburg, Russian Federation, ²N.F. Gamaleya National Research Center of Epidemiology and Microbiology, Ministry of Health of Russia,, Moscow, Russian Federation, ³National Medical Research Center for Children's Health, Ministry of Health, Moscow, Russian Federation, ⁴Kashkin Research Institute of Medical Mycology, North-Western State Medical University named after. I.I. Mechnikov,, Sant-Petersburg, Russian Federation, ⁵Department of Clinical Mycology, Allergy and Immunology, North-Western State Medical University named after.

I.I. Mechnikov, Sant-Petersburg, Russian Federation

**Objectives:** *Candida blankii* is emerging pathogen for children, and can be important for patients with cystic fibrosis (CF). Publications about *C. blankii* in CF patients are limited.
**Methods:** Tracheal aspirate and sputum of 255 CF children 0-18 years old were analyzed by DNA extraction, amplification of ITS1-5.8SrDNA-ITS2 fragments of Fungi genomes, Sanger sequencing and identification of sequences using BLAST NCBI. Massively parallel sequencing of amplicons based on the MiSeq Illumina platform was used for some samples. Bioproject PRJNA545010 was published in GenBank.

**Results:** *C. blankii* was revealed in the samples of two patients (P). P1 was 12 years old when *C. blankii* was detected in microbiome containing *Pseudomonas aeruginosa*, *Mycobacteroides abscessus*, but dominating bacteria were *Streptococcus* spp. The month later *C. blankii* was replaced by *C. sake*. In response to the therapy microbiome cleared of *M. abscessus*, but saved *P. aeruginosa*. The year later fungi and *P. aeruginosa* were not revealed in the low airway sample of P1. P2 has *C. albicans* and *P. aeruginosa* in the low airway sample at 7 years. Dominating bacteria were *Streptococcus* spp. At 8 years, when P2's conditions worsened, *C. blankii*, *P. aeruginosa* and *Capnocytophaga* spp. as main bacteria were revealed. Active therapy eliminated *P. aeruginosa*, but did not influence on *C. blankii*. The year later *C. blankii* accompanied *Staphylococcus aureus* and *P. aeruginosa* in P2 microbiome.

**Conclusion:** Repeated isolation of *C. blankii* from low airway samples of CF patient suggests the possibility of respiratory tract colonization by *C. blankii*.

P216

**The mortality attributable in Candidemia to C. auris is higher than other Candida species: Myth or reality?**

C. Alvarez Moreno¹, S.E. Morales-López², G.J. Rodriguez³, J.Y. Rodriguez³, E. Robert⁴, C. Picot⁵, C.M. Parra-Giraldo⁶, P. Le Pape⁷

¹Universidad Nacional De Colombia, Bogotá, Clínica Universitaria Colombia, Colsanitas, Colombia, bogota, Colombia, ²Universidad Popular del Cesar, Valledupar, Colombia, valledupar, Colombia, ³Cesar, Cimce, Cl. c #d -, Valledupar, Cesar, Colombia, ⁴Ea1155 Iicimed, Nantes University Hospital, NANTES, France, ⁵Pontificia Département de Parasitologie-Mycologie, Université de Nantes, Nantes Atlantique Universités, EA1155-IICiMed, Faculté de Pharmacie, Nantes, France, Dantes, France, ⁶Unidad de Proteómica y Micosis Humanas, Grupo de Enfermedades Infecciosas Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá D.C, Colombia, Bogota, Colombia, ⁷Ea1155 Parasitology And Mycology Department, Nantes University, Nantes, France

**Objectives:** *Candida auris* has emerged as a major threat in the healthcare setting, having caused invasive infections outbreaks around the world. Besides, it has been proved difficult to treat due to its multidrug-resistant nature and mortality rates have varied significantly among 30-60% in candidemia(1-2). However, the overall attributable mortality rate related to candidemia is unclear, nor is there any difference with other candida species (*Candida non-auris*). We investigated epidemiological, clinical and laboratory features of patients with candidemia to evaluate the mortality by *C. auris* or *C. non-auris*.

**Methods:** A case-control study was conducted between 2013 and 2017 in 12 hospitals of Valledupar, Colombia comparing 22 cases of *C. auriscandidemia* with 52 of *C. non-auris*. All isolates of candidemia were recovered to confirm identification by automated matrix-assisted laser desorption/ionization time of flight (MALDI-TOF MS) (Bruker Daltonik, Bremen, Germany) and susceptibility to widely used antifungals was determined with Sensititre Yeast One® AST plates (Thermo Fisher Scientific). Appropriate antifungal therapy was defined according to the antimicrobial susceptibility tests, for the case of *C. non-auris* the CLSI M27-A3 breakpoints were used, in the case of Amb, resistant isolates were defined as isolates with MIC> 1 µg / mL. For *C. auris*, breakpoints recommended by the CDC were used. The risk factors, clinical and microbiological characteristics and outcomes of patients with *C. auris* and *C. non-auris* candidemia (CAC) were compared. Odds ratio and corresponding 95% confidence intervals were calculated using EPI Info 7™.

**Results:** Seventy four patients of candidemia were enrolled. Total number of 22 cases (29.7%) and 52 controls (*C. albicans*, 21.6%; *C. parasilopsis*, 21.6%; *C. tropicalis*, 21.6%; *C. glabrata*, 1.4%) were included and analyzed in this study. The comparison of the main clinical and epidemiological variables is
summarized in Table 1. Previous fluconazole exposure was significantly higher in *C. auris* candidemia patients (OR 3.3: 1.15-9,5). *In vitro* antifungal susceptibility of *Candida* species isolates is presented in Table 2. Most *C. auris* isolates were resistant to fluconazole (86.3%) and amphotericin B (59%) while *C. non-auris* isolates were in general susceptible (fluconazole resistant, 1.9%; Amphotericine B resistant, 3.8%). No isolates resistant to echinocandins were detected. The average time to start antifungal therapy was 3.6 days. Sixty three (85.1%) patients received adequate antifungal therapy, without significant differences between the two groups (*C. auris* Vs *C. non-auris*; 86.4% vs 84.6%, respectively). The crude mortality at 30 and 90 days of candidemia was up to 37.8% and 40.5%, respectively. However, there was no difference in mortality both at 30 and 90 days, between the group with candidemia by *C. auris* and by *C. non-auris*, 31.8% vs 42.3% (OR 0.6; 95% IC 0.24-1.97) and 36.4% and 42.3% 0,77 (0,27-2,1).

**Conclusion:** Mortality due to candidemia is similar between *C. auris* and *C. non-auris* in this study. Appropriate antifungal therapy in both groups could contribute to finding no differences in outcomes. A high resistance to Anfo B was evidenced as previously described in Colombia(3).
<table><caption>Table 1. Clinical characteristics and outcomes of patients with *Candida auris* or *C. no auris* Candidemia. Valledupar, Colombia</caption><thead><tr><th></th><th>total</th><th>%/(range)SD</th><th>Candida auris</th><th>%/(range)SD</th><th>C. no auris</th><th>%/(range)SD</th><th>OR (95% IC)</th></tr></thead><tbody><tr><td>n</td><td>74</td><td>100%</td><td>22</td><td>29,7</td><td>52</td><td>70,3</td><td></td></tr><tr><td>Age (years), median</td><td>38,2 (0-88) SD</td><td>28,7</td><td>42,9 (0-77)</td><td></td><td>34 (0-88)</td><td></td><td>NA</td></tr><tr><td>Gender, male</td><td>44</td><td>59,5</td><td>12</td><td>54,5</td><td>32</td><td>61,5</td><td>0,3 (0,66-2,09)</td></tr><tr><td>Diabetes mellitus</td><td>9</td><td>12,2</td><td>4</td><td>18,2</td><td>5</td><td>9,6</td><td>0,6 (0,7-3,04)</td></tr><tr><td>Hematological malignancy</td><td>2</td><td>2,7</td><td>0</td><td>0,0</td><td>2</td><td>3,8</td><td>NA</td></tr><tr><td>Renal failure</td><td>21</td><td>28,4</td><td>9</td><td>40,9</td><td>12</td><td>23,1</td><td>0,1(0,8-3,5)</td></tr><tr><td>Dialysis</td><td>11</td><td>14,9</td><td>6</td><td>27,3</td><td>5</td><td>9,6</td><td>0,06(0,8-3,8)</td></tr><tr><td>Pancreatitis</td><td>3</td><td>4,1</td><td>2</td><td>9,1</td><td>1</td><td>1,9</td><td>0,08(0,9-5,4)</td></tr><tr><td>Solid tumor</td><td>8</td><td>10,8</td><td>3</td><td>13,6</td><td>5</td><td>9,6</td><td>0,16(0,8-44)</td></tr><tr><td>Mechanical ventilation</td><td>46</td><td>62,2</td><td>16</td><td>72,7</td><td>30</td><td>57,7</td><td>0,16(0,76-3,1)</td></tr><tr><td>Blood transfusion</td><td>39</td><td>52,7</td><td>13</td><td>59,1</td><td>26</td><td>50,0</td><td>1,44 (0.5-3.9)</td></tr><tr><td>HIV</td><td>5</td><td>6,8</td><td>3</td><td>13,6</td><td>2</td><td>3,8</td><td>0,04(0,99-5,32)</td></tr><tr><td>Central venous catheter</td><td>60</td><td>81,1</td><td>20</td><td>90,9</td><td>40</td><td>76,9</td><td>0,13(0,74-3,3)</td></tr><tr><td>Urinary catheter</td><td>51</td><td>68,9</td><td>18</td><td>81,8</td><td>33</td><td>63,5</td><td>0,09(0,81-3,4)</td></tr><tr><td>Abdominal surgery</td><td>24</td><td>32,4</td><td>7</td><td>31,8</td><td>17</td><td>32,7</td><td>0,09(0,82-3,9)</td></tr><tr><td>Parenteral nutrition</td><td>29</td><td>39,2</td><td>6</td><td>27,3</td><td>23</td><td>44,2</td><td>0,47 (0.154-1.4)</td></tr><tr><td>Use of costicosteroids</td><td>8</td><td>10,8</td><td>2</td><td>9,1</td><td>6</td><td>11,5</td><td>0,13(0,26-8,7)</td></tr><tr><td>Use of antibiotics</td><td>68</td><td>91,9</td><td>19</td><td>86,4</td><td>49</td><td>94,2</td><td>0,3(0,07-2,9)*</td></tr><tr><td>Previous use of fluconazole</td><td>23</td><td>31,1</td><td>11</td><td>50,0</td><td>19</td><td>36,5</td><td>3.3 (1.15-9,5)</td></tr><tr><td>Duration (days) of hospitalization before candidemia, median (range)</td><td>18,4 (0-55) SD</td><td>13,4</td><td>21 (0-55) SD</td><td>17,4</td><td>17,3 (0-48) SD</td><td>11,3</td><td></td></tr><tr><td>Treatment</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No antifungal treatment</td><td>9</td><td>12,2</td><td>2</td><td>9,1</td><td>7</td><td>13,5</td><td>0.6 (0.12-3.35)</td></tr><tr><td>Fluconazole</td><td>22</td><td>29,7</td><td>1</td><td>4,5</td><td>21</td><td>40,4</td><td>0.07 (0.08-0.56) **</td></tr><tr><td>Caspofungine</td><td>36</td><td>48,6</td><td>19</td><td>86,4</td><td>17</td><td>32,7</td><td>13.03 (3.3-50)***</td></tr><tr><td>Amphotericin B</td><td>4</td><td>5,4</td><td>0</td><td>0,0</td><td>4</td><td>7,7</td><td></td></tr><tr><td>Antifungals combination</td><td>3</td><td>4,1</td><td>0</td><td>0,0</td><td>3</td><td>5,8</td><td></td></tr><tr><td>Time to Initiation of antifungal therapy</td><td>3,6 (-1-34) SD</td><td>4,6</td><td>3 (1-6) SD</td><td>1,8</td><td>4 (-1-34) SD</td><td>4,5</td><td></td></tr><tr><td>Adequate antifungal treatment</td><td>63</td><td>85,1</td><td>19</td><td>86,4</td><td>44</td><td>84,6</td><td>1,1 (0,27-4,8)</td></tr><tr><td>30-day mortality rate</td><td>28</td><td>37,8</td><td>7</td><td>31,8</td><td>21</td><td>40,4</td><td>0.6 (0.24-1.97)</td></tr><tr><td>90-day mortality rate</td><td>30</td><td>40,5</td><td>8</td><td>36,4</td><td>22</td><td>42,3</td><td>0,77(0,27-2,1)</td></tr></tbody></table>

<table><caption>Table 2. Antifungal susceptibilities of *Candida auris* clinical isolates of 12 hospitals, northern region of Colombia, 2016-2017</caption><thead><tr><th>N°</th><th>AFG</th><th>MCF</th><th>CAS</th><th>FCS</th><th>PSC</th><th>VRC</th><th>ISV</th><th>FLC</th><th>AMPHOB</th></tr></thead><tbody><tr><td>1</td><td>0,12</td><td>0,12</td><td>0,06</td><td>0,12</td><td>0,25</td><td>0,5</td><td>0,5</td><td>32</td><td>2</td></tr><tr><td>2</td><td>0,25</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,25</td><td>0,5</td><td>0,5</td><td>64</td><td>2</td></tr><tr><td>3</td><td>0,06</td><td>0,06</td><td>0,06</td><td>&lt;0,06</td><td>0,5</td><td>1</td><td>0,5</td><td>128</td><td>2</td></tr><tr><td>4</td><td>&lt;0,015</td><td>0,015</td><td>0,015</td><td>&lt;0,06</td><td>0,12</td><td>0,25</td><td>0,25</td><td>64</td><td>2</td></tr><tr><td>5</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,25</td><td>1</td><td>0,5</td><td>128</td><td>2</td></tr><tr><td>6</td><td>0,12</td><td>0,12</td><td>0,06</td><td>&lt;0,06</td><td>0,12</td><td>0,25</td><td>0,25</td><td>32</td><td>2</td></tr><tr><td>7</td><td>0,06</td><td>0,03</td><td>0,03</td><td>&lt;0,06</td><td>0,03</td><td>0,03</td><td>0,06</td><td>16</td><td>0,5</td></tr><tr><td>8</td><td>&lt;0,015</td><td>0,015</td><td>0,015</td><td>&lt;0,06</td><td>0,015</td><td>0,12</td><td>0,06</td><td>128</td><td>1</td></tr><tr><td>9</td><td>&lt;0,015</td><td>0,015</td><td>0,015</td><td>&lt;0,06</td><td>0,12</td><td>0,25</td><td>0,25</td><td>128</td><td>1</td></tr><tr><td>10</td><td>&lt;0,015</td><td>&lt;0,008</td><td>&lt;0,008</td><td>&lt;0,06</td><td>0,015</td><td>0,015</td><td>0,03</td><td>32</td><td>0,5</td></tr><tr><td>11</td><td>&lt;0,015</td><td>0,015</td><td>&lt;0,008</td><td>&lt;0,06</td><td>0,03</td><td>0,12</td><td>0,12</td><td>128</td><td>0,5</td></tr><tr><td>12</td><td>0,06</td><td>0,03</td><td>0,03</td><td>&lt;0,06</td><td>&lt;0,008</td><td>0,03</td><td>0,06</td><td>32</td><td>0,5</td></tr><tr><td>13</td><td>0,06</td><td>0,06</td><td>0,06</td><td>&lt;0,06</td><td>0,25</td><td>1</td><td>0,5</td><td>256</td><td>2</td></tr><tr><td>14</td><td>0,12</td><td>0,12</td><td>0,06</td><td>&lt;0,06</td><td>0,12</td><td>0,5</td><td>0,25</td><td>32</td><td>2</td></tr><tr><td>15</td><td>0,03</td><td>0,03</td><td>0,03</td><td>&lt;0,06</td><td>0,25</td><td>0,5</td><td>0,25</td><td>64</td><td>2</td></tr><tr><td>16</td><td>0,06</td><td>0,06</td><td>0,03</td><td>&lt;0,06</td><td>0,25</td><td>0,5</td><td>0,5</td><td>128</td><td>2</td></tr><tr><td>17</td><td>0,03</td><td>0,03</td><td>0,015</td><td>&lt;0,06</td><td>0,12</td><td>0,25</td><td>0,25</td><td>64</td><td>1</td></tr><tr><td>18</td><td>0,03</td><td>0,06</td><td>0,03</td><td>&lt;0,06</td><td>0,25</td><td>0,5</td><td>0,25</td><td>64</td><td>2</td></tr><tr><td>19</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,06</td><td>0,25</td><td>0,5</td><td>0,5</td><td>256</td><td>4</td></tr><tr><td>20</td><td>0,15</td><td>0,03</td><td>0,03</td><td>&lt;0,06</td><td>0,03</td><td>0,06</td><td>0,06</td><td>4</td><td>1</td></tr><tr><td>21</td><td>0,06</td><td>0,12</td><td>0,06</td><td>0,06</td><td>0,06</td><td>0,06</td><td>0,25</td><td>4</td><td>2</td></tr><tr><td>22</td><td>0,015</td><td>0,015</td><td>0,015</td><td>&lt;0,06</td><td>0,03</td><td>0,06</td><td>0,12</td><td>128</td><td>1</td></tr><tr><td>MIC Range</td><td>&lt;0,015 a 0,25</td><td>&lt;0,008 a 0,12</td><td>&lt;0,008 a 0,12</td><td>&lt;0,06 a 0,12</td><td>&lt;0,008 a 0,5</td><td>0,015 a 1</td><td>0,03 a 0,5</td><td>4 a 256</td><td>0,5 a 4</td></tr><tr><td>MIC50</td><td>0,06</td><td>0,03</td><td>0,03</td><td>&lt;0,06</td><td>0,12</td><td>0,25</td><td>0,25</td><td>64</td><td>2</td></tr><tr><td>MIC90</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,12</td><td>0,25</td><td>1</td><td>0,5</td><td>128</td><td>2</td></tr></tbody></table>

AFG, anidulafungin; MCF, micafungin; CAS, caspofungin; FCS, flucytosine; PSC, Posaconazole; VRC, voriconazole; ISV, Isavuconazole; FLC, fluconazole; AMB, amphotericin B; MIC50, minimal inhibitory concentration for 50% of yeast; MIC90, minimal inhibitory concentration for 90% of yeast; susceptibility to d antifungals was determined with Sensititre Yeast One® AST plates.

<footnote>* p value 0.02; **p value 0.005; ***p value 0.00007 Fischer exact Test</footnote>
N. Vasilyeva¹, O. Pinegina², I. Vybornova¹, G. Chilina³, S. Apalko⁴, S. Scherbak⁴, I. Pchelin⁵, A. Taraskina⁵

¹Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I.Mechnikov, St. Petersburg, Russian Federation, ²Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russian Federation, ³Kaschkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I. Mechnikov, Saint-Petersburg, Russian Federation, ⁴City Hospital No. 40, Saint Petersburg, Russian Federation, ⁵Kashkin Research Institute Of Medical Mycology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation

**Objectives:** The yeast *Candida auris* is an emergent nosocomial pathogen. In October, 2017, the first case of candidaemia due to *C. auris* in Russia has been diagnosed. A large series of isolates was published from Moscow. However, the source of the pathogen and its spreading to other Russian cities remained obscure. Our objective was to provide genetic characteristic and describe antifungal drug susceptibility profiles of *C. auris* clinical isolates from Russia.

**Methods:** For the study, a total of six *C. auris* strains were available. Four originated from Moscow and two originated from St. Petersburg. We identified isolates by ribosomal ITS region sequencing. Whole genome sequence of one isolate was obtained by Illumina MiSeq technology. Antifungal susceptibility testing was performed using colorimetric Sensititre YeastOne YO10 broth dilution panels.

**Results:** For the first Russian *C. auris* isolate from Moscow, we obtained whole genome sequence. It clustered within Indian/Pakistani clade with isolates from Indian subcontinent. The earliest *C. auris* isolate from outside Moscow was obtained in St. Petersburg in March, 2019. All six studied isolates, including two strains from St. Petersburg, harbored exactly the same ITS region genotype (MK829041). Also, antifungal drug susceptibility profiles were highly similar. All isolates were resistant to fluconazole, but susceptible to echinocandins and amphotericin B.

**Conclusion:** Currenty, *C. auris* is being detected in two Russian cities. The spreading clone has Indian/Pakistani origin, probably independent from known outbreaks outside Indian subcontinent.

P218

Candida auris in China

G. Liang

Department Of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science, Nanjing, China

**Objectives:** Since 2009, *Candida auris* has been spreading globally, which is a serious threat to human health and has attracted the international attention. We analyzed the epidemiological trend and pathogenic characteristics of Candida auris in China and try to discover the problem behind and put forward the reasonable strategies to provide useful information for prevention and treatment of the diseases.

**Methods:** We reviewed all Candida auris cases reported from China by searching Pubmed, EMbase, Wanfang and CNKI; also deeply speculated the hidden clinical problems in China.

**Results:** First, there are more than 19 cases has been recorded in China. Second, immunosuppressor and Long-term use of broad-spectrum antibiotics may be the high risk. Thirdly, fifteen cases was reidentified as Candida auris by PCR and sequencing the ITS and D1/D2 regions which was misidentified as C. haemulonii by Vitek. Fourth, both Azole-resistant and non-Azole-resistant Candida auris was found. Fiveth, the infection by Candida auris can not be effective diagnosed and identified timely 3 years ago in the most third-grade class-A hospital in China, but now it is being improved because of popularized MALDI-TOF equipment.

**Conclusion:** The situation of Candida auris infection may be much severer than expected because of the misidentification especially in high-risk groups and more attention has been paid and better medical conditions has been strengthened for the Challenges ahead.

P219
**Candida auris** Candidemia in a Tertiary Care Centre in North India: Rapid Identification from Direct Blood Culture Positive Samples by MALDI-TOF MS and Analysis of Risk Factors

R.S.K. Marak¹, S. Yadav², A.K. Dixit²

¹Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India,
²Microbiology, sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

**Objectives:** To identify the *Candida auris* from direct positive blood cultures by MALDI-TOF MS and analyse the risk factors associated with this multidrug resistant yeast- *Candida auris*

**Methods:** A prospective study was conducted from February 2017 to January 2018 by taking 8 ml of positive blood cultures. After multiple washings and treating with triton X, it was directly subjected to the MALDI-TOF MS assay. The clinical data of candidemia cases due to *C. auris* were determined for significant associated risk factors with *C. auris* infection.

**Results:** Of the 122 candidemia cases reported during the study, 23 (18.85%) were due to *C. auris*; being the 3rd most common species after *C. tropicalis* and *C. parapsilosis*. The age ranged from 4-day old neonate to 80 years old and there was female preponderance (n = 13). MALDI-TOF MS was able to rapidly identify all *Candida auris* species on the same day when the blood culture was flagged positive thereby shortening the time for species identification by MALDI-TOF MS from culture. The underlying risk factors significantly associated with *C. auris* candidemia were diabetes mellitus, underlying respiratory illness, gastrointestinal surgery, prior antifungal exposure. Mortality was seen in 60.8%. All isolates were resistant to fluconazole (MIC ≥ 64µ/ml).

**Conclusion:** *Candida auris* is a recently described agent of fungemia that poses a serious global health threat. *C. auris* infection has been observed across India and notable for its antifungal resistance; often multidrug-resistant. *C. auris* is difficult to identify; polymerase chain reaction, DNA sequencing and MALDI-TOF MS can correctly identify it. *C. auris* known to cause outbreaks in healthcare settings and therefore, it is important to quickly identify *C. auris* in a hospitalized patient and the healthcare facilities can take special precautions to prevent its spread.

P220

Epidemiology of Cryptococcal antigenemia among HIV infected patients in southwestern, Nigeria
2018

O.B. Odegbemi¹, H.O. Dada-Adegbola², I. Adeoye¹, S.A. Fayemiwo³

¹Epidemiology And Medical Statistics, University of Ibadan, Ibadan, Nigeria, ²Medical Microbiology And Parasitology, University of Ibadan, Ibadan, Nigeria, ³Medical Mycology Unit, Division Of Infection, Immunity And Respiratory Medicine, School Of Biological Sciences, University of Manchester, Manchester, United Kingdom

**Objectives:** Cryptococcal antigenemia occurs in Nigeria, but the magnitude of this disease remains unclear. This study was carried out i. To determine the prevalence of Cryptococcal antigen (CrAg) among HIV-seropositive subjects ii. To determine the prevalence of CrAg among HIV-seronegative subjects and iii. To assess the relationship between CD4 count and CrAg in HIV-seropositive subjects attending Adeoyo Maternity Teaching Hospital, Yemetu, Ibadan

**Methods:** It was hospital based case-control study using simple random sampling. Semi-structured interviewer administered questionnaire was used to collect data from subjects and retrospective review of CD4 count records in HIV infected subjects. Five millilitres venous blood was collected from each participant. Serum CrAg testing was done using CrAg Lateral Flow Assay. Data was analyzed using descriptive statistics and bivariate analysis at 5% confidence level.

**Results:** One hundred and fourteen HIV-seropositive individuals (cases) and 228 HIV-seropositive individuals (controls) were recruited. Mean age of cases was 41.2 ± 10.0 years and 85 (74.6%) were females while mean age of controls was 38.9 ± 13.7 years (68.4%) were females. The prevalence of CrAg among cases was 11.4% and 7.0% among controls. Cases were about two times more likely to test positive for CrAg. However, the association was not statistically significant (OR: 1.71, 95%CI: 0.79 - 3.68). Individuals with CD4 counts of ≤100 cells/µl were 20 times more likely to have positive serum cryptococcal antigen than individuals with CD4 counts >100 cells/µl (OR: 20.3, 95%CI: 5.23-78.9).
**Conclusion:** This study demonstrated significant prevalence of Cryptococcal antigenemia among the study population; however, prevalence was higher among cases. Screening for CrAg should therefore be part of routine tests amongst all confirmed HIV-seropositive subjects, since asymptomatic cryptococcal antigenemia predicts impending cryptococcal infection with probable mortality.

P221

High prevalence of *Fusarium proliferatum* isolates from onychomycosis and antifungal susceptibility pattern

I. Haghani¹, M. Shams-Ghahfarokhi², A. Dalimi Asl³, M. Abastabar⁴, T. Shokohi⁴, M.T. Hedayati⁴, M. Fathi³

¹Medical Mycology, Mazandaran university of Medical sciences, Sari, Iran, ²Department Of Mycology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran, ³Department Of Parasitology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran, ⁴Department Of Medical Mycology, Invasive Fungi Research Center, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran, Sari, Iran

**Objectives:** Onychomycosis refers to any fungal infection of the nail and is usually caused by dermatophytes; however, non-dermatophyte molds (NDM) and yeasts are increasingly recognized as the pathogens accounting for nail disease. Regarding this, the present study was conducted to describe the molecular epidemiology of *Fusarium* onychomycosis in the North of Iran.

**Methods:** To this end, 257 nail samples collected from the Iranian patients clinically suspected of onychomycosis were subjected to direct microscopy, calcofluor white staining, and fungal culture. The characteristics of *Fusarium* isolates were further identified at a species level by determining multi-locus sequences for internal transcribed spacer and translation elongation factor 1 alpha

**Results:** According to the results, *Fusarium* species were isolated from 27 patients with onychomycosis. Based on previous partial genes analysis, the recognized species in our study were among the members of *F. fujikuroi* species complex (n = 14), *F. solani* species complex (n = 12), and *Fusarium incarnatum-equiseti* species complex (n = 1). In the present study, *F. proliferatum* was the dominant *Fusarium* species isolated from the samples. With regard to the increased prevalence of *Fusarium* onychomycosis and the intrinsic resistance of these agents to a broad range of antifungals, it is necessary to correctly identify *Fusarium* species. Our results were indicative of a change in the epidemiology of *Fusarium* species isolated from onychomycosis. The minimum inhibitory concentration (MIC) of luliconazole and lanoconazole ranged within 0.001 to - 1 µg/mL and their geometric mean MICs were 0.0103 and 0.0343 µg/mL against *Fusarium* species, respectively.

**Conclusion:** The increased prevalence of *Fusarium* onychomycosis and the intrinsic resistance of these infectious agents to a broad range of antifungals have highlighted the importance of the accurate identification of *Fusarium* species. According to the results of the present study, it seems that the epidemiology of *Fusarium* species isolated from onychomycosis has been changed. In addition we conclude that luliconazole and lanoconazole demonstrate potent activity against *Fusarium* species isolated from onychomycosis. These compounds are accordingly promising for the treatment of superficial fusariosis such as onychomycosis.

P222

Fungal disease burden: an underestimated health challenge in Cote d'Ivoire

D. Koffi¹, B. Ira¹, A.O. Toure¹, R. Jambou¹, D. Denning²

¹Parasitology And Mycology, ABIDJAN, Côte d'Ivoire, ²University of Manchester, Manchester, United Kingdom

**Objectives:** Due to limited access to more powerful diagnostic tools, there are few data on the burden of fungal infections in Cote d'Ivoire, despite a high HIV and TB burden and many cutaneous diseases. Here we estimate the burden of serious fungal infections in this sub-Saharan country.

**Methods:** National demographics were used to perform a PubMed search and retrieve all published articles on fungal infections in Cote d'Ivoire and countries bordering West Africa. When no data
existed, risk populations were used to estimate frequencies of fungal infections, using previously described methodology by LIFE (www.LIFE-Worldwide.org).

**Results:** The population of Cote d'Ivoire is around 24 millions; 37% are children, and 9% are >65 years. Tinea capitis in children is common, measured at 13,9% in the last epidemiological study (2013). Considering the prevalence of HIV infection (2.7% of the population, a total of ~500,000) and a hospital incidence of 6% of cryptococcosis, it is estimated that 3726 patients per year develop cryptococcosis. For pneumocystosis, it is suggested that 6023 new cases occur each year with the prevalence of 14,1% in paediatric HIV infection. An estimated 1567 new cases of chronic pulmonary aspergillosis occur after pulmonary tuberculosis (a 5 year prevalence of 4938 cases (20.3/100,000). Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) were estimated in 104/100,000 and 151/100,000 respectively, in 1,100,000 adult asthmatics. Vulvovaginal candidiasis (VVC) is common and recurrent VVC affects ~6% of women in their fertile years - 407,000 women. An unknown number develop candidaemia and invasive aspergillosis. There are no incidence data on fungal keratitis, histoplasmosis and chromoblastomycosis, although some cases of mycetoma and histoplasmosis have been reported.

**Conclusion:** The present study indicates that around to 6.8% (1.6 million) of the population is affected by a serious fungal infection, predominantly tinea capitis in children and rVVC in women. These data should be used to inform epidemiological studies, diagnostic needs and therapeutic strategies in Cote d'Ivoire.

P223

**Frequency and molecular epidemiology of Aspergillus isolated from patients with suspicion of respiratory fungal infection**

M. Oliveira¹,², H. Simões³, C. Verissimo¹, R. Sabino¹

¹Infectious Diseases, National Health Institute Dr. Ricardo Jorge, Lisbon, Portugal, ²Animal Biology Department, Faculty of Sciences of the University of Lisbon, Lisbon, Portugal, ³Infectious Diseases, National Health Institute, Lisbon, Portugal

**Objectives:** The aim of this study was to determine the frequency of *Aspergillus* detected in respiratory samples from a cohort of patients with suspicion of fungal infection of the respiratory tract as well as to determine the susceptibility to azoles of the isolates from the *Fumigati* section.

**Methods:** A retrospective study was performed involving samples obtained from 16 hospitals covering different districts of continental Portugal and Azores islands. One hundred and eighty-seven respiratory samples (101 bronchoalveolar lavage fluids, 52 bronchial lavages, 27 bronchial secretions, 6 expectorations and 1 bronchial aspirate) were collected between November 2011 and December 2017 from a cohort of 146 patients with suspicion of respiratory fungal infection (ages ranging from 20 to 87 years old). Demographic and clinical data were recorded. Detection of *Aspergillus* was done by culture, immunoenzimatic assay and/or molecular techniques. *Aspergillus* molecular identification to species level was performed by sequencing of the calmodulin and β-tubulin genes. To detect possible resistance to azoles, isolates belonging to section *Fumigati* were inoculated into Sabouraud dextrose agar media supplemented with 1 µg/ml or 4 µg/ml of voriconazole, 4 µg/ml of itraconazole and 0.5 µg/ml of posaconazole and their growth was observed and recorded after 7 days of incubation at 27°C. Doubtful results were confirmed when possible by E-test and by real-time multiplex PCR for the detection of mutations in the Cyp51A gene.

**Results:** Fifty-seven (39.0%) of the studied patients were positive for *Aspergillus*. From the cases with a positive culture (n = 58) the species were identified by sequencing and belonged to six different sections. The most frequently isolated was the section *Nigri* (42.1%) followed by the *Fumigati* (33.3%) and *Flavi* sections (8.6%). Regarding the species, the most frequent was *A. niger sensu stricto* (33.9%) followed by *A. fumigatus sensu stricto* (32.1%). Nine cryptic species were also identified which frequency was 21.4%. In order to study the frequency of azole resistance in *Fumigati* isolates collected from the samples of this cohort as well from other biological products, 52 isolates - *Aspergillus fumigatus* sensu stricto (n = 45), *A. lentulus* (n = 4), *A. udagawae* (n = 2) and *A. pseudofelis* (n = 1) - were tested. The tested *A. fumigatus sensu stricto* isolates did not show resistance to azoles. An *A. udagawae*
strain revealed low susceptibility to voriconazole (MIC was not determined due to loss of strain viability). An *A. pseudofelis* strain also showed decreased susceptibility to voriconazole (MIC = 1 µg/ml) as well as to and itraconazole (MIC = 2 µg/ml).

**Conclusion:** In this study, the genus *Aspergillus* was frequently isolated in the respiratory samples tested and a high number of cryptic species was detected. Although resistance to azoles was not a problem identified in the tested isolates, determination of the *in vitro* susceptibility profile and molecular identification of the *Aspergillus* species is essential to improve the diagnosis and management of aspergillosis since several cryptic species have intrinsic resistance to antifungal drugs.

P224

Epidemiological analysis of a large *Tinea* epidemic in schools of a city in the northern suburbs of Paris, France

S. Brun, Y. Vingataramin, M. Akhoundi, M. Lintanf, C. Bruel, A. Izri

Parasitology-mycology, Avicenne Hospital, Bobigny, France

**Objectives:** The main goals of this investigation were i) to identify the causative agents of a large *Tinea* epidemic in several schools of a city in the northern suburbs of Paris, France, and ii) to determine the epidemiological factors which played an important role in dissemination of this dermatophyte infection.

**Methods:** Following a report to the Parasitology-Mycology Department of Avicenne hospital (Bobigny, France) regarding a possible *Tinea* epidemic in two schools of Clichy-sous-Bois city (northern-suburbs of Paris), all the children of these schools were screened for dermatophytosis by clinical and mycological examinations. Some children from other schools of this city and members of their families came to the same laboratory for dermatophytosis screening. Suspected lesions of hair or skin were sampled by scraping and swabbing for mycological diagnosis and demographic data were recorded in parallel. A dermatophytosis case was determined by positive direct microscopic examination (presence of fungal filaments or spores in hair or scales) and/or positive dermatophyte culture. A map of the cases repartition was realised. Next, in order to evaluate the intra- and interspecific genotypic relationships among *T. tonsurans* isolates, they were subjected to sequencing of two fragments of the alkalin protease 1 (ALP1) gene. The obtained sequences were aligned using the Basic Local Alignment Search Tool (BLAST) and compared to the sequences deposited in GenBank.

**Results:** During 15 months, 122 individuals (coming from 12 schools of the city and members of their families) were sampled and 139 samples were analysed for mycological direct microscopic examinations and mycological cultures. Ninety-three (70%) samples (79 scalp and 14 skin samples) were positive for dermatophyte culture or direct examination in 82 (67%) individuals. *Trichophyton tonsurans* was isolated in 60 samples (87%), followed by *Microsporum audouinii* (4 isolates), *Trichophyton rubrum* (4) , *Trichophyton soudanense* (1) and *Microsporum canis* (1). The infected individuals had an age ranging from 3 months to 53 years with an average of 8 years old. All of these infected individuals were living in houses that, together with their schools, are located in an area of less than 1 km². Most of them were originated or had parents coming from sub-Saharan Africa, followed by Haiti and North Africa. According to the sequence analysis of ALP1 gene, the *T. tonsurans* isolates all shared the same nucleotide sequences, but were different from the only sequence available in GenBank coming from USA.

**Conclusion:** This study presents likely the largest *Tinea* epidemic recorded not only in France but also in Europe, with a large majority of infections caused by *T. tonsurans*. The genotypic analysis of the *T. tonsurans* isolates revealed the circulation of a unique strain in this city of the northern suburbs of Paris, distinct from the strain described in USA. The high population density together with the high poverty rate of this city are of the major factors, beside the high transmission rate of *T. tonsurans*, that have facilitated the transmission of the dermatophytes between the individuals in a same family and a same district, as well as in schools.
P226

Presence of *Malassezia furfur* in the cutaneous microbiome of preterm infants in a Neonatal Intensive Care Unit

R.T.F. Moreira<fnref n="1" />, D.P. Silva<fnref n="1" />, F.C.A. Maranhão², I.F. Moreira³, F.I.R. Farias³, J. Alvarez⁴, S.D.A. Coutinho⁴

¹Nursery School, Federal University of Alagoas, Maceió, Brazil, ²Biological Sciences Institute, Federal University of Alagoas, Maceió, Brazil, ³Medicine Faculty, Federal University of Alagoas, Maceió, Brazil, ⁴Post-graduation Program In Environmental And Experimental Pathology, Paulista University, São Paulo, Brazil

**Objectives:** In humans, the colonization of the skin by yeasts belonging to the genus *Malassezia* starts from the birth. They usually live in commensalism but may become pathogenic depending on predisposing factors and may cause superficial mycoses. Although in a lower percentage, *M. pachydermatis* and *M. furfur* are responsible for serious invasive infections in man. In outbreaks of fungemia reported in neonatal intensive care units (NICU), the neonates showed prematurity, low birth weight, multiple comorbidities and parenteral nutrition with lipid supplementation. The aim of this study was to investigate the occurrence of *Malassezia* spp. in the cutaneous microbiome of low and extremely low birth weight neonates hospitalized in a neonatal intensive care unit.

**Methods:** Forty newborns, gestational age between 21 and 34 weeks, weight between 405 and 1,430 grams, hospitalized in a NICU of a public hospital in the city of Maceió, Brazil, were evaluated. Using sterile swabs, samples from the oral and nasal cavities, axilla, inguinal and anal areas of the neonates were collected at the time of admission to the unit, which did not exceed 12 hours postpartum. The samples from the same areas were collected after 48 h, 96 h, and then twice a week until the discharge resulting from clinical improvement or death, making a total of 192 clinical samples. The samples were seeded on Dixon's medium and microbial colonies were phenotypically characterized using standard biochemical tests. After extraction of DNA, the strains were submitted for 26S rDNA gene PCR amplification. Subsequently, the RFLP analysis using the restriction enzymes BtsCI and HhaI was performed on PCR products. The standard strain *Malassezia furfur* CBS-1878 was used as a positive control.

**Results:** Eight preterm infants (20% - 8/40), weighing between 585 and 1,344 g, presented the colonization by *Malassezia* sp from 48 h of life. Some newborns showed colonization from the 1st to the 6th week, before they left the NICU. There was a higher frequency of *Malassezia* in the axillae and anal region, followed by the nasal cavity and inguinal area. The difficulty in culture maintenance was observed and some strains failed to survive after the first isolation, making a total of 12 characterized strains. The biochemical phenotypic behavior of the 12 strains was similar and consistent with *M. furfur*. These strains submitted to PCR showed bands between 500 and 600 bp and presented the same pattern of bands in the RFLP analysis indicating *M. furfur*.

**Conclusion:** This study demonstrated the colonization by *M. furfur* in different sites of the cutaneous microbiome of preterm infants in NICU. Since the infections caused by these yeasts are less frequent, these agents are mostly neglected. However, our findings reveal the need for monitoring low and extremely low birth weight neonates, as this yeast may be pathogenic, as described in malasseziosis outbreaks in NICUs. It is worth to note that adequate isolation and cultivation techniques should be employed since most species of the genus *Malassezia* are lipid-dependent and do not grow in the media usually employed for fungal isolation.

P227

Cryptococcosis in HIV-infected patients in Madagascar: high prevalence and mortality

R.A. Rakotoarivelo<fnref n="1" />, M. Raberahona², T. Rasamoelina³, A. Rabezanahary⁴, F.A. Rakotomalala³, T. Razafinambintsoa², T. Bénet⁵, P. Vanhems⁶, M.J.D.D. Randria², L. Romanò⁷, M. Cogliati⁸, M. Cornet⁹, M.R. Andrianarivelo³

<footnote n="1">¹Service des Maladies Infectieuses, Hôpital Universitaire Tambohobe, Faculté de Médecine, Université de Fianarantsoa, Fianarantsoa, Madagascar, ²Service des Maladies Infectieuses, Hôpital</footnote>
Universitaire Joseph Raseta Befelatanana, Antananarivo, Madagascar, ³Centre d'Infectiologie Charles Mérieux, Université Ankatso, Antananarivo, Madagascar, ⁴Service de Pneumologie, Hôpital Régional de Reference, Toamasina, Madagascar, ⁵Service d'Hygiène, Epidémiologie et Prévention, Hospices Civils de Lyon, Lyon, France, ⁶Laboratoire des Pathogènes Emergents, Fondation Mérieux, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France, ⁷Laboratorio di Micologia Medica, Dipartimento di Scienze Biomediche per la Salute, Universita degli Studi di Milano, Milano, Italy, ⁸Laboratorio di Micologia Medica, Dipartimento di Scienze Biomediche per la Salute, Universita degli Studi di Milano, Milano, Italy, ⁹Université Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Grenoble, France, Grenoble, France

**Objectives:** In Madagascar, the epidemiology of cryptococcosis is poorly documented. The main objective was to estimate its prevalence in HIV-infected patients and to describe the fungal isolates and the patient outcome

**Methods:** An observational study was conducted in the hospitals of Antananarivo (central highlands) and Toamasina (eastern coast). Consecutive HIV-infected adults with CD4≤ 200/µl were enrolled between November 2014 and December 2016. The serum crytococcocal antigen (CrAg) was screened using a lateral flow immunoassay (IMMYCrAg ®). In case of positive result and clinically suspected cryptococcal meningoencephalitis (CM), a lumbar puncture was performed to evaluate the presence of CrAg in the cerebrospinal fluid (CSF), as well as India ink staining and culture. The isolates were identified using MALDI-ToF and genotyped. Antifungal susceptibility was evaluated using the E-test. A high-dose oral fluconazole (at least 1200/day) was given for 10-12 weeks followed by 200 mg/day. Adjusted prevalence ratios (aPR) based on multivariate robust variance Poisson regression, and 90-days survival based on Kaplan-Meier method were used

**Results:** Overall, 129 patients were included, median age was 37 years. At baseline, the median CD4 count was 83 cells/µl, 62.8% had a CD4 count <100 cells/µl and 38.1% were on ART. Overall, 17 patients had a serum CrAg-positive (CrAg+) and 112 CrAg-negative (CrAg-). CrAg+ patients were more likely than CrAg- patients to present low CD4 cells count 38 Vs 86; p = 0.018). Among the 17 CrAg+ in serum, 14 had a CSF CrAg+ of which 13 yielded *Cryptococcus* spp. in culture. After multivariate regression, adjusted on CD4 count, previous ART initiation (aPR = 0.4, 95% CI: 0.2-0.9) and presence of neck pain (aPR = 15.7, 95% CI: 3.4-72.1) were associated with CM. The prevalence of cryptococcal infection was 13.2% (95%CI 7.9-20.3) and that of CM was 10.9% (95%CI 6.1-17.5). The prevalence of cryptococcal infection in Toamasina (20%) was not different from the one in Antananarivo (11.1%) (p = 0.21). The mortality rates were 70.6% and 71.4% for cryptococcal infection and CM, respectively. Survival was significantly higher for CrAg- patients as compared with CrAg+ (p = 0.049, Log-rank test). All 17 clinical isolates obtained from CSF (13 at baseline and 4 during follow-up) were identified as *Cn* var. *grubii*. The 13 initial isolates were genotyped and belonged to the VNI type (3 isolates), the rarer but also globally distributed VNII type (4 isolates) and a hybrid intra-varietal type VNI/VNII (6 isolates). All three molecular types were found in Antananarivo whereas only VNI/VNII was found in Toamasina. Among the 13 *Cn* var. *grubii* strains, 2 acquired fluconazole resistance after 4 and 5 months of exposure, respectively.

**Conclusion:** Prevalence of cryptococcal infections and CM in HIV-infected patients in Madagascar were 13.2% and 10.9% respectively. The point-of-care LFA CrAg test confirmed to be reliable and cost effective for the diagnosis. Challenges to facilitate access to more effective molecules to treat patients with CM include reducing administrative formalities linked to drug importation and increasing priorities to implement national control programs.
**Methods:** Initially, we identified all published data on serious fungal infections in the country. We have used the model proposed by LIFE (Leading International Fungal Education) to estimate the burden of infections where no local data exist.

**Results:** Tajikistan is the low-income (GDP Per Capita is 800 USD) country in Middle Asia with a population of 8.9 million people. 5% of the population lives on less than 1.9 USD a day and 54% live on less than 5.5 USD a day. There are 2,813,903 adult (15-50 yrs.) women in Tajikistan who comprise 32% of the population. It was estimated that 168,834 Tajik women develop recurrent vulvovaginal candidiasis (>=4 episodes/year). The number of HIV positive patients is 15,000; 10,067 (67%) of them do not receive antiretroviral therapy. We estimate 1,253 patients with oesophageal candidiasis and 4,530 patients with oral candidiasis annually, 27 cases of cryptococcal meningitis and PCP is approximated at 216 cases annually. According to our estimations there are 1,040 cases of chronic pulmonary aspergillosis (CPA) as a sequel of TB. Due to the fact, that CPA may occur as a consequence of multiple other pulmonary conditions, the total prevalence of 4,161 cases was estimated. We have estimated 6,008 cases of ABPA and 7,930 cases of SAFS; 196 annual deaths from asthma provides us with an estimation of 137 fungal asthma deaths annually. We have estimated 445 cases of candidemia a year applying a low European rate. There are approximately 205 cases of invasive aspergillosis in immunocompromised patients annually and 1,388 cases in patients with COPD which gives us a total of 1,593 cases of invasive aspergillosis annually.

<table><thead><tr><th rowspan="2">Infection</th><th colspan="5">Number of infections per underlying disorder per year</th><th rowspan="2">Rate/100K</th><th rowspan="2">Total burden</th></tr><tr><th>None</th><th>HIV/AIDS</th><th>Respiratory</th><th>Cancer/Tx</th><th>ICU</th></tr></thead><tbody><tr><td>Oesophageal candidiasis</td><td>-</td><td>1,253</td><td>-</td><td>-</td><td>-</td><td>14.0</td><td>1,253</td></tr><tr><td>Oral candidiasis</td><td>-</td><td>4,530</td><td>-</td><td>-</td><td>-</td><td>51.0</td><td>4,530</td></tr><tr><td>Candidemia</td><td>-</td><td>-</td><td>-</td><td>312</td><td>134</td><td>5.0</td><td>445</td></tr><tr><td>Candida peritonitis</td><td>-</td><td>-</td><td>-</td><td>-</td><td>67</td><td>0.8</td><td>67</td></tr><tr><td>Recurrent vaginal candidiasis (4x/year +)</td><td>168,834</td><td>-</td><td>-</td><td>-</td><td>-</td><td>3,794</td><td>168,834</td></tr><tr><td>ABPA</td><td>-</td><td>-</td><td>6,008</td><td>-</td><td>-</td><td>67.5</td><td>6,008</td></tr><tr><td>SAFS</td><td>-</td><td>-</td><td>7,930</td><td>-</td><td>-</td><td>89.1</td><td>7,930</td></tr><tr><td>Fungal asthma deaths</td><td>-</td><td>-</td><td>137</td><td>-</td><td>-</td><td>1.5</td><td>137</td></tr><tr><td>Chronic pulmonary aspergillosis</td><td>-</td><td>-</td><td>4,161</td><td>-</td><td>-</td><td>234</td><td>4,161</td></tr><tr><td>Invasive aspergillosis</td><td>-</td><td>-</td><td>-</td><td>205</td><td>1,388</td><td>17.9</td><td>1,593</td></tr><tr><td>Cryptococcal meningitis</td><td>-</td><td>27</td><td>-</td><td>-</td><td>-</td><td>0.3</td><td>27</td></tr><tr><td>Pneumocystis pneumonia</td><td>-</td><td>216</td><td>-</td><td>-</td><td>-</td><td>2.4</td><td>216</td></tr><tr><td>Fungal keratitis</td><td>?</td><td>-</td><td>-</td><td>-</td><td>-</td><td>?</td><td>?</td></tr><tr><td>Tinea capitis</td><td>?</td><td>-</td><td>-</td><td>-</td><td>-</td><td>?</td><td>?</td></tr><tr><td><strong>Total burden estimated</strong></td><td><strong>168,834</strong></td><td><strong>6,026</strong></td><td><strong>18,099</strong></td><td><strong>517</strong></td><td><strong>1,589</strong></td><td></td><td><strong>196,778</strong></td></tr></tbody></table>

**Conclusion:** According to our estimations, there are 196,778 (2.21% of the population) people suffering from serious fungal infections in Tajikistan. Hence, improving diagnostics is the first step of understanding a scale of the fungal burden and the foundation of addressing the problem of serious fungal infections.

P229

## Cases of Mycetoma reported from a Histopathology laboratory of Pakistan: Two years' Experience

M. Zeeshan¹, S. Fatima¹, M.O. Arif², J. Farooqi¹,³, A. Arsalan¹, K. Jabeen¹,²,⁴, A. Zafar³

¹Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, ²Dow University of Health Science, Karachi, Pakistan, ³Pathology And Laboratory Medicine, Aga Khan University, Karachi-KHI, Pakistan, ⁴Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, Pakistan

**Objectives:** Mycetoma is a chronic granulomatous infection that is found worldwide and is endemic in tropical and subtropical regions. Occurrence of mycetoma varies in different regions as per environmental temperature and rainfall in that particular area. The exact prevalence of this disease is largely unknown, though estimates are available for various countries. (van de Sande. 2013). Pakistan is a tropical country with diverse climatic conditions. Our green and lush north-eastern border consists of agricultural land is shared with Indian Punjab. South eastern part is close to Indian desert of Rajasthan, and the western border with Iran and Afghanistan is arid. There are multiple
reports published from various regions of India as well as Iran. There is dearth of information regarding the frequency of mycetoma, both eumycetoma and actinomycetoma, from Pakistan. The objective of this study was to find out the number of cases reported during year 2017 and 2018 from histopathology department of Aga Khan University Hospital laboratory, a tertiary care hospital laboratory also providing diagnostic services to outside patients

**Methods:** Retrospective data of subcutaneous surgical tissue biopsies with positive findings of mycetoma were retrieved from hospital laboratory database from the years 2017-2018. Site of lesion, age, gender, type of mycetoma and geographical location of patients were analyzed. The data was entered and descriptive epidemiologic assessment was carried out using MS excel 2013

**Results:** Total 30 cases of mycetoma reported in these two years. Eumycetoma was reported in the majority of the cases 25/30 (83%) while actinomycetoma in 4/30 (13%). In one case, both entities of mycetoma were detected in a single lesion (3%). Our cohort was all adults with age range of 25-60 years. Eumycetoma cases were mostly observed in male 18/25 (72%) whereas Actinomycetoma cases were mostly seen in females 3/4 (75%). In eumycetoma anatomical site involvement were predominantly lower extremities 22/25 (88%) followed by hand in rest of the other cases. All the reported cases of actinomycetoma had foot involvement only. In majority of cases tissue specimen culture was not performed 23/30 (77%). Out of 7 specimens only 2 were culture positive for fungal etiological agents (29%)

**Conclusion:** In view of our data, we can definitely describe the presence of mycetoma in Pakistan. However, there is a desperate need of national registry to report cases and creating strong liaison between dermatologists, radiologist, surgeons and clinical microbiology laboratory and Histopathologist, so that burden of the disease may be estimated. Only then can we stress upon our national health authorities to prioritize this neglected disease by improving patients' access to specialized facilities for better management.

P231

**Radiological and microbiological profile of patients with allergic bronchopulmonary aspergillosis presented in outpatient pulmonary clinics of Karachi-Pakistan**

M. Irfan¹, N. Iqbal¹,², K. Jabeen³, S. Awan⁴, A.B.S. Zubairi⁴

¹Medicine, Aga Khan University, Karachi, Karachi, Pakistan, ²Medicine, Jinnah Medical and Dental College, Karachi, Pakistan, Pakistan, ³Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, Pakistan, ⁴Medicine, Aga Khan University, Karachi, Karachi, Pakistan, Pakistan

**Objectives:** There is limited data available on microbiology and radiographic features in patients with allergic bronchopulmonary aspergillosis (ABPA) from Pakistan. The aim of the study is to determine the radiological and microbiological profile of patients visited outpatient pulmonary clinic of a tertiary care hospital of Karachi Pakistan

**Methods:** A retrospective study was conducted at pulmonary outpatient clinics, Aga Khan University Hospital, Karachi, Pakistan from January 2017 to December 2018. Patient with ABPA was enrolled using ISHAM criteria, data was collected on microbiology and radiology features.

**Results:** A total 7759 asthmatic patients presented at outpatient pulmonology clinics, 245 were labelled as ABPA, 167 patients fulfilled the inclusion criteria and 91(54.5%) were female (mean age 41.9 ± 13.0 years). High resolution CT scan (HRCT) chest was done in 126, out of these 104(82.5%) patients had bronchiectasis. Central bronchiectasis was noted in 98(94.2%), Mucus plugging in 71(56.3%) and hyperinflation seen in 30(23.4%) patients. Microbiological testing was available in 103(61.7%). The commonest bacterial pathogen isolated was *Pseudomonas aeruginosa* 32(31.1%) followed by *Hemophilus influenzae* 16(15.5%) and *Morexella catarrhalis* 7(9.7%). While among fungal cultures commonest isolated fungas was *Aspergillus fumigatus* 17(23.6%) followed by *Aspergillus flavus* 16(22.2%) and *Aspergillus Niger* 11(15.3%). Co infection (bacterial and fungi) isolated in 18(17.45%) patients.

**Conclusion:** Extensive bronchiectasis was noted in our cohort of patients with ABPA that leads to frequent bacterial exacerbation. *Pseudomonas aeruginosa* was found to be common among bacterial pathogens. Early diagnosis can prevent lung damage.
P232

# Epidemiology and outcomes of patients with invasive mould infections: a retrospective observational study at Karolinska University Hospital, 2010 - 2014

A. Böhlin-Wiener¹,², A. Szakos³, L. Klingspor²

¹Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden, ²Laboratory Medicine, Karolinska Insitutet, Stockholm, Sweden, ³Pathology And Cytology, Karolinska University Hospital, Stockholm, Sweden

**Objectives:** To investigate the epidemiology and outcomes of invasive mould infections (IMI) during 2010-2014, compared to 2005-2009 (1).

**Methods:** Patients with proven or probable IMI were included. Data regarding patient baseline characteristics, underlying diseases, types of transplant, infecting mould species, sites of infection, antifungal therapies, etc were extracted from patient journals. Outcome was 90-days and 1-year survival post diagnosis.

**Results:** A total of 127 (vs 100) patients were included, an increase by 27% compared to the previous period. The rise in incidence occurred mainly during 2010-2011 (Fig 1). The majority, 54% (vs 66%) were in the age group 18-65 and 30% (vs 24%) were over 65 years old. Males predominated with 57% (vs 60%). Most isolates were *Aspergillus* spp, *n* = 59 (vs 75) followed by *Mucorales* spp, *n* = 14 (vs 9) and *Fusarium* spp, *n* = 8 (vs 3). In *n* = 7 cases (vs 10), more than one mould was isolated. An additional *n* = 45 had a positive galactomannan antigen test. Lungs were the most often affected organ, 92% (vs 88%) and haematological malignancies (HM) were the most common underlying diseases, 71% (vs 70%). In total, 431 (vs 354) allogeneic Haematopoietic Stem Cell Transplants (HSCT) were performed during the study period, of which 6.5% (vs 7.6%) developed IMIs. Following diagnosis, 75% (vs 87%) received antifungal therapy, usually voriconazole, 53% and liposomal amphotericin B, 38%. Breakthrough infections occurred in 33% of the cases in spite of prophylaxis, mainly posaconazole, 59% and caspofungin, 24%. The 90-days overall survival remained basically unchanged, 48% (vs 49%), but with significant yearly variations (Fig 2). The allogeneic HSCT and HM cohorts had highest overall survival rates, 68% respectively 55% (vs 37% respectively 43%). The 1-year overall survival declined to 35% (vs 46%) with lowest rate 13% in 2012.

<figure><img src="image_66.png" /></figure>

**Conclusion:** There were no significant changes in patient characteristics, mould epidemiology or underlying diseases. Survival rates improved for the HM and allogeneic HSCT cohorts. The yearly variations in mortality rates coincide with construction work around the hospital, notably with periods of intense blasting. During these periods there was also an increase in the incidence of IMIs.
<figure><img src="image_67.png" /></figure>

(1).Klingspor L, et al: Epidemiology and outcomes of patients with invasive mould infections: a retrospective observational study from a single center (2005-2009). Mycoses. 2015 Aug; 58(8):470-7

P233

Epidemiology of candidemia and their antifungal susceptibility in our University Hospital from
2014 to 2018

M. Vannini¹, F. Lieutier², S. Emery², N. Retur², L. Hasseine¹

¹Laboratoire De Parasitologie Mycologie, CHU DE NICE, NICE, France, ²Service Pharmacie, CHU DE NICE, NICE, France

**Objectives:** Given the differences between local epidemiologies, we have to know our fungal epidemiology, in order to adapt our antifungal strategies. The purpose of this study is: 1. to identify the epidemiology and antifungal susceptibilities of candidemia over 5 years; 2. to evaluate the anti-fungal treatment and to see the survival in the third month (M3) of the patients after the diagnosis of fungemia.

**Methods:** This study was retrospective, conducted from January 2014 to December 2018. All patients who had at least one positive fungal blood culture were included. A single blood culture per patient was taken into account with a study of the MICs (Molecules tested: amphotericin B, caspofungin, voriconazole and fluconazole).

**Results:** In total, 306 *Candida* blood culture isolates were obtained from 280 patients (39 in 2014, 62 in 2015, 72 in 2016, 60 in 2017 and 47 in 2018). The three most common *Candida* spp isolated from blood cultures were *Candida albicans* (44%), *Candida glabrata* (22%) and *Candida parapsilosis* (13%). Any resistance to the four tested antifungals is observed for *C. albicans* and *C.parapsilosis*. However, resistance was observed for *C. glabrata* in 10% for amphotericin B, 28% for voriconazole, and 15% for fluconazole. In 2% and 75%, there is respectively a resistance and an intermediate susceptibility to caspofungin. For the time being, the antifungal treatment was recovered for 170 patients. Among them, 67%, 26% and 5% received respectively caspofungin, fluconazole and ambisome. 2% have not received antifungal treatment, because they were at the end of their life. Evolution at M3 was reported and the mortality rate was 32%. Candidemia has probably a role in 51% of them.

**Conclusion:** We report an overall increase in candidemia but a constant distribution of *C. albicans*, *C. parapsilosis* and *C. glabrata*. The lack of antifungal resistance for *C. albicans* and *C. parapsilosis* for candidemia suggests a possibility of treatment with fluconazole as a first-line in our hospital, without waiting for the results of the antifungal susceptibilities. We have also to analyse the possible nosocomial etiology, and the link between antifungal resistance, and the cause of death of those patients.

P234

Presence of Malassezia pachydermatis in the cutaneous microbiome of humans cohabiting with dogs
J. Alvarez¹, L. Camargo², C. Corsini², J. Neves¹, S.D.A. Coutinho¹

¹Post-graduation Program In Environmental And Experimental Pathology, Paulista University, São Paulo, Brazil, ²Veterinary Hospital, Paulista University, São José dos Campos, Brazil

**Objectives:** *Malassezia* species are yeasts that are inhabitants of the cutaneous microbiome of animals and men; however, they can eventually cause infections. In dogs, *M. pachydermatis*, a zoophilic and non-lipid-dependent species, particularly causes otitis and dermatitis. Although malasseziosis is not considered zoonotic, it was suggested the disease may be transmitted to neonates by the professionals of intensive care units (ICU) who have dogs. No data on the exchange of *Malassezia* species between animals and men who have close contact are available. The aim of this study was to isolate and identify *M. pachydermatis* from the cutaneous microbiome of dog owners and compare with that of people who do not have contact with animals.

**Methods:** A total of 15 dogs with otitis and/or dermatitis caused by *M. pachydermatis* and their owners were selected. We collected three clinical samples of each owner (total 45 samples) from the upper trunk, scalp, and behind the ears. At the same time, three clinical samples were collected from 24 people (total 72 samples) of the same regions, who did not have any contact with animals. The samples were seeded on Dixon's medium and the isolates obtained were inoculated on Sabouraud dextrose agar. Cultures that grew only on the Dixon's medium were considered lipid-dependent *Malassezia* species and those on Sabouraud dextrose agar were considered as *M. pachydermatis*. For genus confirmation, DNA was extracted and 26S rDNA was amplified using the polymerase chain reaction. The standard strain *M. pachydermatis* CBS-1879 was used as a positive control.

**Results:** The presence of *Malassezia* spp. in the people living with dogs (80.0% - 12/15) and those who not living with animals (83.3% - 20/24) was similar (Table 1). *Malassezia* spp. were isolated from 37.8% (17/45) and 58.3% (42/72) of clinical samples from those cohabiting with dogs and those who were not, respectively (Table 1). *Malassezia pachydermatis* was the most common species in the cutaneous microbiome of the owners found in 52.9% (9/17) of the isolates, whereas lipid-dependent *Malassezia* spp. were isolated from 47.1% (8/17) (Table 1). *Malassezia pachydermatis* was isolated from the three sites sampled, scalp, upper trunk, and behind the ears. Only lipid-dependent *Malassezia* (100.0% of the isolates) was found in people who did not cohabit with dogs, *M. pachydermatis* was not isolated from these people (Table 1). "Dog cohabitation" has a statistically significant effect on the presence of *M. pachydermatis* in the cutaneous microbiome of the owners (*p* < 0.05).

<table><caption>**Table 1 – Presence of *Malassezia pachydermatis* in the cutaneous microbiome of dog owners and people who do not have contact with animals.**</caption><thead><tr><th rowspan="2"></th><th colspan="2">Dog owners</th><th colspan="2">People without contact with animals</th></tr><tr><th>Absolute Number</th><th>%</th><th>Absolute Number</th><th>%</th></tr></thead><tbody><tr><td>Total people</td><td>15</td><td>100.0</td><td>24</td><td>100.0</td></tr><tr><td>Positive people</td><td>12</td><td>80.0</td><td>20</td><td>83.3</td></tr><tr><td>Total samples</td><td>45</td><td>100.0</td><td>72</td><td>100.0</td></tr><tr><td>Positive samples</td><td>17</td><td>37.8</td><td>42</td><td>58.3</td></tr><tr><td>Malassezia pachydermatis</td><td>9</td><td>52.9</td><td>-</td><td>-</td></tr><tr><td>Lipodependent Malassezia</td><td>8</td><td>47.1</td><td>42</td><td>100.0</td></tr></tbody></table>

**Conclusion:** *Malassezia pachydermatis* was associated with the nosocomial outbreaks of fungemia in neonates hospitalized in ICUs, with the possibility of transmission occurring by health professionals who were having dogs and carried the yeast to the ICU. However, limited literature exists on the association of close cohabitation with dogs or other pets with the human microbiome. Our results
show that there is a change in the *Malassezia* spp. in the cutaneous microbiome of people cohabiting
with dogs, thus significantly increasing the presence of a zoophilic strain of *M. pachydermatis*.

P235

"zygomyco.net": 15 years of a global mucormycosis registry of the joined ECMM/ISHAM Working Group on zygomycosis.

A. Skiada¹, M. Drogari-Apiranthitou², G. Petrikkos³

¹1st Dpt. Of Medicine, Laiko Hospital, Athens University, Athens, Greece, ²Infectious Diseases Research Laboratory, 4th Department Of Internal Medicine, General University Hospital “Attikon”, School of Medicine, University of Athens, Athens, Greece, ³Infectious Diseases, School of Medicine, European University of Cyprus, Nikosia, Cyprus

**Objectives:** Taking into consideration the challenges related to epidemiology, treatment and outcome of mucormycosis, a Working Group (WG) on Zygomycosis was initially formed in ECMM, in 2004. It aimed to create a registry by collecting mucormycosis cases from European countries. From 2008 onwards the WG expanded under also the auspices of the ISHAM and it now includes participants from all over the world. The aims of this project are: 1) to conduct a prospective international registration of patients with mucormycosis using a well-established global network, 2) to collect and molecularly identify mucormycetes and tissue specimens from the patients enrolled in order to establish an international archive that will be used in future studies and 3) to provide information about this rare but devastating disease and enhance the collaboration of physicians and researchers all over the world.

**Methods:** Definitive and probable mucormycosis cases from each participating country were initially prospectively recorded in standardized case report forms (CRFs) and sent to the study coordinator. Since the creation of the registry platform (www.zygomyco.net) participants can submit cases directly. Isolated mucormycetes are identified at the participating institutions and molecular identification, if not available, is performed at an appointed laboratory (National Centre for Mycology, Madrid, Spain). In absence of culture data, paraffin-embedded tissues are sent to an appointed laboratory for PCR. Appropriate statistical methods are used for univariate and multivariate analysis.

**Results:** The WG on zygomycosis has organized 3 international fora on zygomycosis, co-organized international workshops, and meetings are regularly held. As an ongoing study, results are being presented at conferences and related papers are published. During 2005-2007, 230 cases were submitted and analyzed. The first analysis (A. Skiada et al., Clin Microbiol Infect 2011;17:1859-1867) has shown a wide variation regarding underlying diseases, clinical presentations, fungal species and treatment modalities in different countries. These observations have increased our understanding of the risk for transmission and diversity of this disease, which may lead to increased suspicion, earlier diagnosis and appropriate management. The analysis has also contributed to issuing guidelines on the diagnosis and treatment of mucormycosis. More than 300 further cases have been added during 2008-2018, from more than 15 countries, Brazil, India, Iran, Lebanon and the USA included.

**Conclusion:** The existence of the ECMM/ISHAM Working Group on Zygomycosis and its official website and registration platform, provide the means for a network of investigators, including many experts, to interact, exchange information and hopefully improve the outcome of mucormycosis. Focus on more detailed information on the development of the disease according to various underlying conditions and mucoralean species involved is a future perspective, as a tool for the construction of predictive risk models for patients at risk. This project can also be a powerful tool for the assessment of novel diagnostic procedures, therapeutic modalities and efficacy of new antifungals.

P236

First report on the isolation of five new geophilic Arthroderma species in hedgehogs

S. Uhrlass¹, D. Rimek², V. Hubka³, W. Schroedl⁴, M. Reuschel⁵, H. Muetze¹, D. Koch¹, C. Krueger¹, Y. Graeser⁶, P. Nenoff¹
¹Partnership Dr. C. Krueger & Prof. P. Nenoff, Laboratory of medical microbiology, Roetha OT Moelbis, Germany, ²Gesundheitsschutz, Thueringer Landesamt für Verbraucherschutz, Bad Langensalza, Germany, ³Laboratory Of Fungal Genetics And Metabolism, Institute of Microbiology ASCR, Prague, Czech Republic, ⁴Ag Mykologie, Institut für Bakteriologie und Mykologie, Leipzig, Germany, ⁵Klinik Für Heimtiere, Reptilien, Zier- Und Wildvögel, Stiftung Tierärztliche Hochschule, Hannover, Germany, ⁶Institut Für Mikrobiologie Und Hygiene, Universitätsmedizin – Charité, Berlin, Germany

**Objectives:** During the last years an increase of rare and new dermatophytes in human beings, but also in animals has been observed in routine diagnostics of mycological laboratories, not at least due to the significantly improved molecular identification methods. The conventional diagnostics includes native preparation plus fungal culture. Today, molecular methods, e. g. polymerase chain reaction (PCR), in particular an in-house- PCR-ELISA, are completing mycological diagnostics.

**Methods:** Recently, between April and September 2018, a survey of the health of hedgehogs was performed in the city of Hanover, Germany. Altogether 50 European hedgehogs were included in this study. Skin and sting samples from the animals were collected, and mycological investigation was done as described before. A minor part of hedgehogs showed clinical signs of a dermatomycosis, most animals were, however, asymptomatic. For confirmation of cultural dermatophyte isolates, sequencing of the Internal Transcribed Spacer (ITS) region of the rDNA, and the Translation Elongation Factor (TEF)-1α gene was performed.

**Results:** The following dermatophytes were isolated from the hedgehogs: *Trichophyton erinacei* (8), *Arthroderma* (A.) *crocatum* (4), *A. quadrifidum* (2), *A. insingulare* (1), *A. chiloniense* (1) and *A. tuberculatum* (1). Based on their macro architecture, their microscopic features, and their genetic characteristics, all from hedgehogs isolated strains were compared with each one or two clinical isolates of the respective *Arthroderma* species. These reference strains were isolated from human skin samples, e.g. scrapings, nail samples, and hair roots, achieved between 2016 to 2018. Clinical diagnoses were tinea manuum, tinea corporis, tinea capitis, and tinea unguium.

**Conclusion:** Meanwhile, both the here described new animal isolates from hedgehogs, but also the human strains of different *Arthroderma* species are deposited at the deposited at the „Deutsche Sammlung von Mikroorganismen und Zellkulturen" (DSMZ, German Collection of Microorganisms and Cell cultures), Brunswick, Germany. The DNA sequences (ITS and TEF-1α) of all strains are available now at the gene bank of the National Center for Biotechnology Information (NCBI) in Bethesda, Maryland, USA.

P237

Epidemiology, Clinical characteristics, and Outcome of adult Candidemia in a Chinese tertiary hospital: from 2008 to 2015

L. Zhang¹, Z. Liu¹, T. Li¹, M. Xiao², Y. Wang², Y. Xu²

¹Department Of Infectious Disease, Peking Union Medical College Hospital, Beijing, China,

²Department Of Clinical Laboratory, Peking Union Medical College Hospital, Beijing, China

**Objectives:** The aim of this study was to assess the epidemiology, clinical characteristics, risk factors and outcome of candidemia patients in a tertiary hospital.

**Methods:** A retrospective observational study of all cases of candidemia which occurred during hospitalization was carried out in a tertiary hospital including 6 intensive care units (ICUs), 22 medical and 24 surgical wards in Beijing, China(2008-2015). Demographic and clinical data were collected from the database of the patient's medical records. Chi Square test (or Fisher's Exact Test when expected frequencies were less than 5) and multivariate logistic regression models were used to identify the risk factors associated with the higher mortality during hospitalization.

**Results:** A total of 192 episodes of candidemia were identified in 181 patients(male 102,female 79, mean age 58.96±17.86). All cause mortality during hospitalization was 64/181 (35.4%), and attributable mortality was 50/181 (27.6%). Multivariate analysis showed that age≥65 years, ICU hospitalization and polymicrobial bloodstream infections were independently associated with a higher risk of crude mortality. *Candida albicans* was the predominant specie 100/192(52.1%) followed
disseminated disease. The objective of this study was to describe clinical manifestations, treatment and outcome of patients with culture-proven *Coccidioides immitis* infections in San Diego, California, United States, an area endemic to *Coccidioides immitis*.

**Methods:** We performed a retrospective chart review of medical records of all patients with culture-proven *Coccidioides immitis* infection at UCSD between 5/01/2017 - 12/31/2018 (1 1/2 year period). The study was approved by the UCSD Human Research Protection Program.

**Results:** A total of 11 cases with detection of *Coccidioides immitis* in culture were identified (Table). Of 11 cases, 10 were evaluable, and of those 1 had chronic coccidioidomycosis and 9 had proven acute infection. Of those with acute infection, 56% (5/9) had traditional risk factors for coccidioidomycosis infection including African American race, immunosuppressive state, lung transplant status, HIV/AIDS, and type II diabetes mellitus, while the remaining 4/9 lacked traditional risk factors. Five of 9 (56%) had primary coccidioidomycosis of the lungs and 4/9 (44%) disseminated disease. Of those who received antifungal therapy, 3/7 (43%) received combination therapy and 4/7 (57%) monotherapy with fluconazole. At 180 days, 5/9 (56%) were alive, 3/9 (33%) deceased, and 1/9 (11%) lost to follow-up. Of those who were not alive at 180 days, 1/3 (33%) had disseminated disease and 2/3 (67%) primary coccidioidomycosis, both who were on immunosuppressive therapy.

**Conclusion:** Culture-proved *Coccidioides immitis* infection occurred in a variety of hosts, with 44% lacking typical risk factors for infection. Disseminated coccidioidomycosis infection occurred in 44%; of these, 50% lacked traditional risk factors and 75% were alive at 180 days.

P239

**Positive fungal culture in tissue specimens from burns patients: Data from a tertiary care hospital laboratory in Pakistan**

K. Jabeen¹, S. Umar², N. Shaheen², M. Khan³, J. Farooqi²

¹Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, Pakistan, ²Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, ³Medical College, Aga Khan University, Karachi, Pakistan

**Objectives:** Due to defective skin barrier burns patients are at great risk of development of fungal wound infections. Fungi are frequently cultured from tissue specimens from these patients either singly or in combination with bacteria. Spectrum of fungal wound infection in burns patients from Pakistan has not been reported previously. We evaluated positive cultures from burn wounds samples received at a tertiary care hospital laboratory in Karachi, Pakistan. Positivity rate of fungal isolation within these cases and spectrum of yeast and filamentous mold was reported.

**Methods:** We reviewed laboratory data of tissue and wound samples received for bacteriological assessment from burn patients at the Aga Khan University Hospital laboratory, Karachi, Pakistan from September 2017-March 2018. Specimens were inoculated on chocolate agar and sheep blood agar with colistin and nalidixic acid incubated in 5% CO2, a triplate with MacConkey agar, Mannitol salt agar and Sabouraud's dextrose agar incubated in ambient environment, and sheep blood agar incubated in anaerobic environment. All cases were incubated at 37°C and pus and tissue samples were also enriched by inoculating in cooked meat broth. Clinical and demographic information recorded on the worksheet at the time of clinical reporting was collected for the study. Frequencies were computed to describe the data.

**Results:** A total of seventy positive tissue cultures from burn patients were identified over the study period. These specimens were received for 36 male patients and 34 female patients with age ranging from eight months to eighty five years (average: 15.5 year). Of these, 26 (37%) had growth of either filamentous mold (17 cases) or *Candida species* (11 cases). Two cases had growth of both mold and yeast. *Aspergillus flavus* was the most common mold (9 cases) followed by *Fusarium* species (3 cases) and *Lichtheimia corymbifera* (2 cases). *Candida tropicalis* was the most common yeast (5 cases) followed by *Candida parapsilosis* (3 cases). There was a concomitant bacterial growth in 19 cases predominantly of *Staphylococcus aureus* (13 cases), *Pseudomonas aeruginosa* (8 cases) and other Gram negative rods (6 cases).
**Conclusion:** High rate of fungal isolation from burn wound infection was seen in this study despite less optimal culture techniques. The findings in our study are consistent with the global increase in incidence of fungal infections in burn wounds. High index of suspicion of fungal infections by clinicians and revision of culture protocols in burn patients may be warranted for optimal management of these patients.

P240

Fungal isolation from wound samples submitted for culture at a tertiary care hospital laboratory in Karachi, Pakistan

J. Farooqi¹, A. Ladak², N. Shaheen³, K. Jabeen⁴

¹Pathology And Laboratory Medicine, Aga Khan University, Karachi-KHI, Pakistan, ²Medical College, Aga Khan University, Karachi, Pakistan, ³Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, ⁴Pathology And Laboratory Medicine, Aga Khan University, Karachi, Pakistan, Pakistan

**Objectives:** Skin and Soft tissue infections rank the fourth most common infections worldwide. These often emerge from chronic wounds, traumatic implantation and surgical wounds. Bacteria are the most common isolated organisms from such wounds. However, recently, many centers across the world have started to report an increase in fungal isolates, possibly due to excessive use of antibiotics and expansion in host risk factors. This study aims to present the frequency of reported fungal isolates in patients with skin and soft tissue infections and relate the incidence of these infections with concomitant risk factors.

**Methods:** We reviewed laboratory slips of all tissue and pus samples received for bacteriological assessment at the Aga Khan University, Hospital clinical laboratory from mid-September till to mid-October 2018. All samples were inoculated on Chocolate Agar and Sheep Blood Agar with colistin and nalidixic acid incubated in 5% CO₂, a triplate with MacConkey Agar, Mannitol Salt Agar and Sabouraud's Dextrose Agar incubated in ambient environment, and Sheep Blood Agar incubated in anaerobic environment. All cases were incubated at 37°C and also enriched by inoculating in Cooked Meat Broth. Clinical information recorded on the worksheet at the time of clinical reporting was collected for the study. Any missing information was filled in from the in-house hospital information management software if available. Variables such as patient age, location, gender, relevant medical history, type and site of wound, microbial isolates and drug resistance were collected. Frequencies were computed to describe the data.

**Results:** We reviewed a total of 140 patients' information over the study period. Our study population consisted of 48.6% (n = 68) females and 51.4% (n = 72) males with the median age of 30.5 years. Of the 140 samples submitted, 76.4% (n = 107) were culture positive; pathogens were isolated from 81.3% of these (n = 87), and 9.3% yielded fungi. The categories of lesions included accidental wounds [8.6% (n = 12)], burn and blast injuries [2.9% (n = 4)], diabetic wounds [7.9% (n = 11)], nosocomial infections [15% (n = 21)], skin and soft tissue infections [57% (n = 80)] and unknown [8.6% (n = 12)]. The fungal isolates were spread across all categories of lesions. Skin and soft tissue infections had the highest number of fungal isolates (n = 4) while diabetic wounds had none. Yeasts (*Candida* species) were most commonly isolated (n = 4), followed by *Fusarium* species (n = 3), *Aspergillus* species (n = 2), *Bipolaris* species (n = 2) and *Curvularia* species (n = 1).

**Conclusion:** Our center has reported a high number of fungal isolates over the short study period. Our study raises the question of identifying underlying causes that has led to this high number of fungal isolates reported in just one month from samples sent only for bacterial culture. Moreover, centers across the region should be educated about the rising fungal load in the population especially wound samples. Setting an additional fungal isolation medium may be life saving for patients with severe necrotizing fungal wound infections.

P241

Subcutaneous Mucormycosis – Beyond Rhizopus and Mucor species
C. Sebastian¹, R. V¹, J. Mathew², J. Savio²

¹Microbiology, St.John's Medical College, Bangalore, India, ²Microbiology, St. John's Medical College, Bangalore, India

**Case Report:** Introduction The *Mucorales, Apophysomyces* and *Saksenaea* species are unusual human pathogens that are reported with increasing frequency as a cause of subcutaneous infection in previously healthy patients following trauma or invasive procedures. Identification of these species in a routine laboratory is challenging due to their difficulty in sporulation. Special techniques for inducing sporulation must be employed for their identification. Objective To report 4 cases of subcutaneous mucormycosis due to the *mucorales - Apophysomyces* and *Saksenaea* species **Case 1** 25 years old farmer presented with necrotising fasciitis of the entire back following religious self-flagellation. Microscopic examination of the tissue revealed aseptate hyphae. Culture yielded a mucorale that was identified as *Apophysomyces variabilis*. Patient condition improved with wound debridement and liposomal Amphotericin B. He was discharged on Posaconazole. **Case 2** A 30 year old male patient, diabetic since 6 months presented with submandibular swelling of 10 days duration following an injury to the neck. Pus sample revealed aseptate hyphae. Culture isolate was identified as *Apophysomyces* species on culture. **Case 3** 55 years old patient presented with persistent fever and necrotising fasciitis of the right leg. It all started following a bite by a pig 15 days back. He was not a known case of diabetes mellitus but was diagnosed on admission. The tissue sample yielded *Apophysomyces elegans* on culture. **Case 4** 25 years old retro positive patient presented with a gluteal abscess following an intramuscular injection. The fungal culture of the tissue sample yielded *Saksenaea vasiformis*. **Conclusion** Mucormycosis is an angio-invasive infection which is rapidly progressive and associated with a high morbidity and mortality. *Rhizopus* species is the most common mucoralean worldwide causing mainly rhino-orbito-cerebral mucormycosis. Genera other than *Rhizopus* like *Apophysomyces* and *Saksenaeae* are associated with cutaneous and subcutaneous manifestations. More and more cases are presently being diagnosed in developing countries like India where the at-risk population of diabetic patients and other immunocompromised states are continually on the rise. 39 cases of mucormycosis were reported from our laboratory in the last 2 and a half years, from January 2017 to May 2019. 34 were rhino-orbito-cerebral mucormycosis caused by *Rhizopus* species. Of the 5 cases of subcutaneous mucormycosis, 3 were caused by *Apophysomyces* species and one each by *Saksenaea vasiformis* and *Rhizopus arrhizus* respectively. All three *Apophysomyces* species were identified as *Apophysomyces elegans* in our laboratory. However sequencing at PGIMER Chandigarh has confirmed one of them as *A.variabilis*. Two of the four cases were diabetic patients and one was retro positive. All the four patients gave a history of trauma. In a country like India, mucormycosis should be considered in patients presenting with non healing wound especially following a trauma, even in young adults as they may be silent diabetics.

P242

**Changing trends in genus and species distributions of clinical fungal strains: An evaluation of ten-year data from a tertiary care center in Turkey**

D. Gulmez, A.K. Sığ, N. Akar, S. Duyan, S. Arikan-Akdagli

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

**Objectives:** Opportunistic fungal infections may develop due to a wide variety of fungal species. Changes in species distribution profiles are reported from many centers and occasionally reflect an increase in rates of antifungal drug-resistant or -less susceptible species. The aim of this retrospective evaluation is to determine the fungal species and their relative isolation rates in the last ten years in our center with a specific focus on bloodstream yeast isolates and mould growth from lower respiratory tract specimens.

**Methods:** Fungal strains isolated from clinical samples from 2009 to 2018 were included. Isolation and identification were done by standard mycological methods. Fungal growth in all sample types was evaluated and repetetive growths from the same type of specimens were excluded. Isolated
fungal species were analysed in course of time and with respect to the specimen types. Distribution
of species in five-year periods (2009-2013 vs. 2014-2018) was compared by z test.

**Results:** A total of 23046 specimens sent to the laboratory during the study period revealed fungal growth. Excluding the episodes of repetetive growth, 17239 fungal strains were isolated from 15465 clinical samples. Total number of specimens and isolates markedly increased in time, from 757 and 819 in 2009 to 2511 and 2875 in 2018, respectively. Urinary tract (n = 7164, 46%) and lower respiratory tract (n = 4523, 29%) were the most common fungal isolation sites followed by blood (specimens from peripheral vein and catheter, n = 1076, 7%). For all specimen types, most common species were *Candida albicans* (58%) and *Candida glabrata* species complex (SC) (12%). Among moulds, *Aspergillus fumigatus* SC (51%) was the most common. Per the yeast species isolated from blood cultures (Figure 1), isolation rate of *C.albicans* decreased from 48% to 44% (p = 0.186) and that of *C.glabrata* SC increased from 10% to 15% (p = 0.014) in 2014-2018 as compared to 2009-2013. No significant change was observed in species distribution of isolates from sterile specimens other than blood. Distribution of mould genera from lower respiratory tract specimens is shown in Figure 2. Although *A.fumigatus* SC was always the most common, its rate of isolation decreased from 63% in 2009-2013 to 46% in 2014-2018 (p<0.001). In the same time intervals, isolation of *Aspergillus* species other than *A.fumigatus* SC increased from 26% to 34% (p = 0.145) and moulds other than *Aspergillus* (*Penicillium* spp., Order Mucorales, *Scedosporium* spp., *Alternaria* spp., *Paecilomyces* spp., dematiaceous fungi and unidentified moulds) increased from 11% to 20% (p = 0.185).
<figure><img src="image_68.png" /><figcaption>**Figure 2:** Distribution of moulds isolated from lower respiratory tract specimens</figcaption></figure>

<figure><img src="image_69.png" /></figure>

**Conclusion:** In our center, while the most commonly isolated yeast and mould species display a usual profile, species distribution is diverse. Evaluation of bloodstream yeast isolates revealed a decrease of *C.albicans* and an increase in *C.glabrata* SC, which appears as a recent change. Significance of increase in rate of *C.glabrata* SC remains noteworthy also with respect to potential resistance or decreased susceptibility to antifungal agents. Isolation of less common mould genera from lower respiratory tract samples remains remarkable.
"Attikon", School of Medicine, University of Athens, Athens, Greece, ³Department Of Plastic Surgery, Thriasio General Hospital of Elefsis, Elefsis, Athens, Greece, ⁴Department Of Pathology, Thriasio General Hospital of Elefsis, Elefsis, Athens, Greece, ⁵Laboratory Of Microbiology, Thriasio General Hospital of Elefsis, Elefsis, Athens, Greece

**Case Report:**

**Objectives:** Cutaneous mucormycosis after major trauma may cause devastating morbidity and death if not treated promptly and appropriately. The presentation of this case report aims to sensitize health care professionals for the potential occurrence of cutaneous mucormycosis after natural disasters.

**Methods:** Case report: A previous healthy 75-year-old woman was trapped in her flooded home during the flood in Mandra, Attica, Greece, which occurred on 15/11/2017. She remained four hours under water until rescued. She was transferred to the Emergency department (ED) of a General Hospital with dyspnoea and type-I acute respiratory failure (ARF) due to near-drowning. The patient had also multiple blunt injuries with skin rupture in both lower extremities. At the ED she received treatment for ARF consisting of oxygenation, tracheal aspiration, bronchodilators and antibiotics. Her wounds were surgically cleaned and sutured and tetanus immune globulin was administered. The Glasgow Coma Scale score (GCS) was evaluated at 13/15 and the patient was admitted to the Pneumology department for further treatment. At day 2 post-admission clinical improvement was documented, but on day 3 her consciousness level deteriorated (qSOFA score >2) with onset of fever and low blood pressure. The antibiotic scheme was changed. Upon re-evaluation of the leg wounds, development of necrotic eschars at the wound margins was observed. On day 4 the patient was put on mechanical ventilation (GCS<8/15), underwent extensive tissue debridement and liposomal amphotericin B 10mg/kg/24h was added to the antibiotic scheme on suspicion of mucormycosis. Excised tissue was sent to the Pathology and Clinical Microbiology departments for histological examination and culture.

**Results:** The patient was transferred to a high dependency unit (HDU), however, on day 5 she suffered severe cardiovascular collapse while the infection on both legs had progressed over a large area. The patient's family denied consent for bilateral hip disarticulation. The patient died on day 6 after hospital admission. Histology revealed fungal hyphae typical for Mucorales.

**Conclusions:** Mucormycosis should be always suspected in victims of natural disasters. Infection can progress rapidly, requiring early therapy with antifungals, frequent inspection of the wounds and repeated surgical debridement. Early primary wound closure should be avoided.

P244

**The burden of serious fungal diseases in Sudan**

M.T. Albirair¹, A.H. Fahal², D. Denning³,⁴

¹Blue Nile National Institute for Communicable Diseases (BNNICD), Wad Madani, Sudan,
²Mycetoma Research Center, University of Khartoum, Khartoum, Sudan, ³University of Manchester, Manchester, United Kingdom, ⁴National Aspergillosis Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom

**Objectives:** Sudan is a large north-African country with a population of about 40 million. Apart from mycetoma which is a substantial problem, the burden of fungal infections in Sudan is not well documented. Serious fungal infections are increasing with more immunocompromised patients, longer lives and a high frequency of respiratory diseases. The aim of this study was to estimate the burden of serious fungal infections in Sudan.

**Methods:** Epidemiological data reporting fungal infection rates in Sudan and nearby countries together with population estimates for general and specific at-risk patient groups were acquired. We used previously described deterministic modelling to estimate national incidence or prevalence.

**Results:** HIV rates are low in Sudan and we estimated 231, 1,378 and 3,568 cases with cryptococcal meningites, *Pneumocystis* pneumonia and oesophageal candidiasis, respectively. Asthma affects an estimated 480,000 adults, and 11,400 and 15,048 people were estimated to have allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS)
respectively, probably with some overlap between them. We estimated 1,085 cases of all forms chronic pulmonary aspergillosis (CPA) with 50% assumed to occur post tuberculosis or are misdiagnosed as TB. We estimated 354 cases of invasive aspergillosis complicating leukaemia, HIV and lung cancer. There are no COPD prevalence data. In the absence of local data, we have estimated candidaemia at 5/100,000 or 2,000 cases. We estimated ~530,000 women to be affected by recurrent vulvovaginal candidiasis (RVVC). As many as 3.6 million school-age children suffer from tinea capitis, based on a 21% rate. Mycetoma is a particular problem in Sudan and a minimum of 1.81/100,000 inhabitants or about 700 estimated cases are found there, predominantly eumycetoma. No reliable data exist on fungal keratitis, histoplasmosis or mucormycosis.

**Conclusion:** Our study revealed about 4.1 million (10.5%) of the Sudanese population suffer from serious fungal infections yearly with about 15,633 affected by life-threatening invasive fungal infections. Improvements in fungal disease diagnosis and management is required in Sudan.

P245

**Global epidemiology of mucormycosis: Preliminary analysis of the cases submitted to the zygomyco.net registry during the last 10 years**

A. Skiada¹, J. Chander², N. Klimko³, P. Hamal⁴, S. Dolatabadi⁵, M. Drogari-Apiranthitou⁶, C. Lass-Flörl⁷, S. Kanj⁸, K. Lagrou⁹, V. Arsic-Arsenijevic¹⁰, S. Zimmerli¹¹, G. Petrikkos¹²

¹¹st Dpt. Of Medicine, Laiko Hospital, Athens University, Athens, Greece, ²Department Of Microbiology, Government Medical College Hospital, Chandigarh, India, ³Department Of Clinical Mycology, Allergology And Immunology, North-Western State Medical University n.a. I.I. Mechnikov, Saint-Petersburg, Russian Federation, ⁴Department Of Microbiology, Palacký University, Faculty of Medicine and Dentistry and University Hospital Olomouc, Olomouc, Czech Republic, ⁵Faculty Of Engineering, Sabzevar University of New Technology, Sabzevar, Iran, ⁶Infectious Diseases Research Laboratory, 4th Department Of Internal Medicine, General University Hospital “Attikon”, School of Medicine, University of Athens, Athens, Greece, ⁷Div Hygiene & Med. Microbiology, Med. Univ. Innsbruck, Innsbruck, Austria, ⁸Division Of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon, ⁹Laboratory Of Clinical Bacteriology And Mycology, Department Of Microbiology And Immunology, Excellence Center For Medical Mycology (ecmm), KU Leuven, Leuven, Belgium, ¹⁰Medical Mycology Reference Laboratory, Faculty of Medicine University of Belgrade, Belgrade, Serbia, ¹¹Department Of Infectious Diseases, Inselspital, Bern University Hospital, University Of Bern, University Hospital of Bern, Bern, Switzerland, ¹²Infectious Diseases, School of Medicine, European University of Cyprus, Nikosia, Cyprus

**Objectives:** Mucormycosis is an invasive fungal infection with high morbidity and mortality. Due to its rarity, registries are an important tool, used to collect information about risk factors, diagnosis and treatment of this potentially lethal infection. The aim of this study was to perform a preliminary analysis of the cases submitted to zygomyco.net, the ECMM/ISHAM Working Group on Zygomycosis global registry, during a 10-year period (2008-2018).

**Methods:** In order to submit a case, a participant must register to the site (www.zygomyco.net), giving his name, country of origin and e-mail address. Participants in the study can submit cases online in electronical CRFs. Alternatively, they can download a paper form and send it to the coordinators. The required data include demographics, underlying conditions, mode of transmission, clinical presentation, diagnosis, treatment and outcome. In order to be included in the study the case must pertain to a probable or proven case of mucormycosis. A data review committee reviewed all submitted cases.

**Results:** During the study period 365 cases were submitted from 16 countries (Austria, Belgium, Brasil, Czech Republic, Greece, India, Iran, Italy, Lebanon, Netherlands, Romania, Russia, Serbia, Switzerland, United Kingdom and USA). The largest proportion of cases (34%) were submitted from India. The analysis was done in the 330 cases which were complete. Sixty-two % of the patients were male. The mean age was 45y (range 1 month to 81 years). Underlying conditions were diabetes mellitus (37%), hematological malignancies (30%), other malignancies (7%), bone marrow transplantation (9%), solid organ transplantation (6%) and trauma (9%). Neutropenia was present in
25%. The main sites of infection were lungs (35%), sinus/orbital/cerebral region (34%), soft tissue (16%), disseminated (12%) and gastrointestinal (3%). Diagnosis was made only by histopathology in 11%, only by direct examination in 3%, only by culture in 7%, and with combined methods in the rest. Cultures were positive in 74.5% of cases (*Rhizopus* spp. 56%, *Lichtheimia* spp. 15%, *Mucor* spp. 8%, *Apophysomyces* spp. 6%, *Rhizomucor* spp. 4%, *Saksenaea* spp. 2%, *Syncephalastrum* spp. 2%, *Cunninghamella* spp. 1% and unspecified Mucorales 6%. Treatment was performed only by surgery in 3%, only by antifungals in 37% and by combined approach in 44%. In the remaining 16% of patients, either the diagnosis was made post-mortem or the patients declined treatment and left the hospital against medical advice. Crude mortality was 41%.

**Conclusion:** This is a preliminary analysis of the cases submitted to zygomyco.net in the period 2008 to 2018. A wide range of clinical presentations, underlying diseases and isolated species was observed. Diagnosis is still difficult in many parts of the world and mortality remains high. Further analysis of the data is going to highlight the differences occurring in various countries and the risk factors associated with mortality.

P246

**Isolation and phenotypic characterization of *Sporothrix brasiliensis* from cats with suspected sporotrichosis**

T. Maschio-Lima¹, M. Marques², B. De Almeida¹, T. Lemes¹, L. Bianco¹, M. Caetano¹, N. Brizzotti², C. Silva², J. Fernandes², E. Castilho², J.P. Siqueira², M. Almeida²

¹UNESP, São José do Rio Preto, Brazil, ²FAMERP, São José do Rio Preto, Brazil

**Objectives:** To confirm cases of suspected sporotrichosis in felines in the municipality of São José do Rio Preto, Brazil, by isolating and identifying the *Sporothrix* spp. in clinical samples of symptomatic animals; and to evaluate the clinical and epidemiological factors associated with the disease.

**Methods:** In a 15 months period (August 2017 to November 2018), 114 samples of secretion and/or biopsy of lesions from symptomatic cats were collected at the Center for Zoonoses Control and analyzed using traditional mycological techniques. Phenotypic features of the isolates were used to differentiate the species of the *Sporothrix schenckii* complex (*S. schenckii* var. *schenckii*, *S. brasiliensis*, *S. globosa*, *S. mexicana*, *S. luriei*, *S. albicans*). These features include presence or not of sessile pigmented conidia, colony growth rates at 30°C and 37 °C, and assimilation of sucrose and/or raffinose. Epidemiological aspects of the cats, which all had clinical suspicion of the disease, were analyzed based on the information presented in research sheets filled in at the time of collection by veterinarians.

**Results:** Regarding the origin of the animals, 65.79% (75) of the cats were erring, 23.68% (27) domiciled, and 10.53% (12) fully domiciled. Most of the animals (99, 86.84%) were adults; 91 (79.82%) were males, and 23 (20.17%) were castrated. Multiple skin lesions were present in 82 (71.92%) animals, 67% (55) of them exclusively ulcerated. Indication of euthanasia was given to 66 (57.89%) cats. In relation to the mycological analyses, 83 (72.80%) samples were positive for fungus, exhibiting characteristics of the genus *Sporothrix*, i.e. creamy wrinkled colonies that become blackened due to the production of melanin, and septate hyphae with conidiophores giving rise to conidia in the shape of a daisy flower. The analyses revealed that the 83 isolates showed morphophysiological profiles characteristic of *S. brasiliensis*.

**Conclusion:** Considering the short period of analysis, and that the samples were provided from a single center, it is evident the high occurrence of feline sporotrichosis in the municipality of São José do Rio Preto, Brazil, caused by *S. brasiliensis*. The high percentage of positivity in adult, uncastrated and erring male felines highlights the need to create control measures in this city.

P247

**CauSTR – A rapid multiplex microsatellite typing tool for the multi-drug resistant yeast *Candida auris***

E. Then¹, A. De Jong¹, A. Ruiz-Gaitan²,³, A. Al-Hatmi¹,⁴, R. Ben-Ami⁵,⁶, O. Kurzai⁷,⁸, B. Gerrits Van Den Ende¹, F. Hagen¹,⁹,¹⁰
¹Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands, ²Severe Infection Research Group, Medical Research Institute La Fe, Valencia, Spain, ³Department Of Clinical Microbiology, La Fe University and Polytechnic Hospital, Valencia, Spain, ⁴Ministry Of Health, Directory General of Health Services, Ibri, Oman, ⁵Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel, ⁶Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel, ⁷National Reference Center For Invasive Mycoses, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany, ⁸Institute For Hygiene And Microbiology, Julius Maximilian University of Wuerzburg, Wuerzburg, Germany, ⁹Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands, ¹⁰Department Of Dermatology, Jining No. 1 People's Hospital, Jining, China
**Objectives:** Since the first description of *Candida auris* as a novel yeast pathogen it has quickly conquered hospital environments causing colonization of patients that ultimately can lead to bloodstream infections. During the past decade *C. auris* has been reported from 25 countries and a development of multi-drug resistance has been observed. Molecular epidemiological typing studies using whole genome sequencing, amplified fragment length polymorphism fingerprinting and multi-locus sequencing typing all identified four lineages linked to geographic regions. The aim was to develop a rapid and cost-effective molecular typing tool that relies on genetic diverse microsatellite loci.

**Methods:** The genome of *C. auris* strain B8441 (GenBank GCA_002759435.2) was used to search for repetitive loci using Tandem Repeat Finder (https://tandem.bu.edu/trf/trf.html). This resulted in 34 candidate loci that were tested by conventional PCRs using the CDC *C. auris* reference set. Nine microsatellite loci remained and were subsequently tested on a larger set of 92 *C. auris* isolates (India *n* = 28, Oman *n* = 24, Spain *n* = 13, Israel *n* = 11, Germany *n* = 6, Korea and Saudi Arabia *n* = 2 each, and *n* = 1 for Austria, Belgium, Japan, Kuwait, Switzerland and the Netherlands). Three multiplex PCRs were developed using fluorescently labeled primers to detect and differentiate the loci when analyzed on an ABI3730xL Genetic Analyzer.

**Results:** The genome size of *C. auris* strain B8441 is 12.366 Mbp and contains 2,374 microsatellites ranging from 1 bp repeat units up to a 461 bp repeat unit. Based on other fungal genomes it was expected that the smaller microsatellite units of 1–10 bp represent the majority of the microsatellites. But surprisingly, as can be observed in Figure 1, those with a repeat unit of 12, 15 and 18bp are more common than those containing 2–10bp repeat units. The final panel consisted of six tri-nucleotide, one with tetra-nucleotide, one nona-nucleotide and one undeca-nucleotide loci. The Simpson's diversity index *D* ranged from 0.5387–0.8120 for individual loci, when all nine loci were considered. Fifty-two genotypes were observed with a Simpson's *D* of 0.9656. The isolates from the endemic regions (India, Oman) were found to be clonal, while those from nosocomial outbreaks (Israel, Spain) could be linked to two different endemic regions. Single reported cases from Europe could be mostly
linked to the South East C. *auris* population.

<figure><img src="image_70.png" /><figcaption>**Figure 1.** A selection of microsatellite types that occur at least ten times in the C. *auris* genome are shown. The number in each box stands for the size of the repeat unit and the size of the box represents the relative abundance of these specific repeat units.</figcaption></figure>

**Conclusion:** Microsatellite loci are abundantly present in the C. *auris* genome but surprisingly the most variable repeat units (2–10bp) are sparsely distributed. The developed nine-loci microsatellite typing panel ‘CauSTR’ in this study is able to rapidly differentiate the four recognized lineages previously identified by other molecular methods and to observe subtle differences within C. *auris*.

P248

Molecular characterization and epidemiology of *Histoplasma* isolates from Uruguay

M. Carbia¹, B. Gerrits Van Den Ende², N. Fernández³, M. Setropawiro², F. Hagen²,⁴,⁵

¹Parasitology And Mycology, Instituto de Higiene, Montevideo, Uruguay, ²Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands, ³Sección Micología De La División Infectología, Hospital de Clínicas “José de San Martín”, Buenos Aires, Argentina, ⁴Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands, ⁵Department Of Dermatology, Jining No. 1 People's Hospital, Jining, China

**Objectives:** Histoplasmosis is an invasive fungal infection, often encountered in HIV-positive subjects, caused by members of the genus *Histoplasma*. Historically three varieties were recognized within the single known pathogenic *Histoplasma* species, namely *H. capsulatum* variety *capsulatum*, variety *duboisii* (African histoplasmosis) and variety *farciminosum* (Equine histoplasmosis). However, a recent taxonomic revision based on whole genome sequencing, phenotypic and clinical data differentiated *H. capsulatum* var. *capsulatum* into four species: *H. capsulatum sensu stricto*, *H. mississippiense*, *H. ohiense* and *H. suramericana*. This study was initiated to retrospectively investigate the epidemiology of *Histoplasma* in Uruguay.

**Methods:** Forty-two clinical *Histoplasma* isolates obtained from 42 cases, collected during 1963-2019 and preserved at the Instituto de Higiene, Montevideo, Uruguay, were included. A set of 25 isolates that includes the four newly recognized *Histoplasma* species was used as reference. Fourteen patients (33.3%) were found to be HIV-positive, 12 (28.6%) had other underlying diseases/predisposing factors, 1 (2.4%) was immunocompetent and for the remaining 15 cases (35.7%) no clinical data was available. *Histoplasma* DNA was extracted using the CTAB-protocol and subsequently subjected to multi-locus sequence typing (partly sequencing of ITS, ARF, OLE, H-anti, M-anti and 60S) and
amplified fragment length polymorphism fingerprinting. The mating-type *MAT1-1* and *MAT1-2* was determined by conventional PCR.

**Results:** There was a nearly equal distribution of mating-type *MAT1-1* and *MAT1-2* isolates, randomly distributed over time and among Uruguayan patients. By AFLP fingerprinting and multi-locus sequence typing it was observed that all Uruguayan isolates clustered together. However, based on the former molecular typing tool it appears that all these isolates were clonal while with the sequence-based approach more subtle clustering was observed. With both molecular tools the Uruguayan *Histoplasma* isolates clustered closely together with the reference strain of *H. suramericana*.

**Conclusion:** Using AFLP fingerprinting and multi-locus sequencing typing a set of 42 *Histoplasma* isolates from Uruguay was found to belong to the newly described species *H. suramericana*. There was no link observed between the clinical background versus the molecular characteristics of the studied isolates.

P249

The Burden of Serious Fungal Infections in Azerbaijan

A. Osmanov¹, D. Denning¹,², R. Huseynov³

¹Global Action Fund for Fungal Infections, Geneva, Switzerland, ²Manchester Academic Health Science Centre, Manchester, United Kingdom, ³Azerbaijan Medical University, Baku, Azerbaijan

**Objectives:** We aim to calculate the burden of serious fungal infections in Azerbaijan.

**Methods:** We have performed search on published papers of serious fungal infections. Where no published data existed, we used population at-risk to identify burden of serious fungal infections. Our estimations were based on the model developed by LIFE (Leading International Fungal Education).

**Results:** Azerbaijan is in the South Caucasus region with the population of 9.8 M people and GDP per capita of 5,805 USD. There are 4,051,310 adult women (15-55 yrs) in Azerbaijan, so it was estimated that 176,961 women suffer from recurrent vulvovaginal candidiasis (rVVC) which is defined as = > 4 episodes/year. There are 8,000 PLHIV which is most likely an underestimate; 54% of them do not receive antiretroviral therapy. Hence, we estimate 2,673 and 1,291 patients with oral and oesophageal candidiasis respectively. There are probably 16 cases of cryptococcal meningitis and 64 cases of *Pneumocystis* pneumonia annually which is likely to be an underestimate. We have estimated 902 cases of chronic pulmonary aspergillosis (CPA) as a sequel of TB and 2,707 cases of CPA complicating other conditions such as pneumothorax, emphysema, and sarcoidosis; which results in the total of 3,609 cases of CPA. Based on asthma prevalence there are approximately 4,188 patients with allergic bronchopulmonary aspergillosis (ABPA) and 5,528 with severe asthma with fungal sensitisation (SAFS). We used a low European rate to estimate invasive candidiasis cases and there are approximately 493 and 74 with candidemia and invasive candidiasis respectively. We have estimated approximately 111 patients with invasive aspergillosis and 20 patients with mucormycosis.

<table><thead><tr><th rowspan="2">Infection</th><th colspan="5">Number of infections per underlying disorder per year</th><th rowspan="2">Rate/100K</th><th rowspan="2">Total burden</th></tr><tr><th>None</th><th>HIV/AIDS</th><th>Respiratory</th><th>Cancer/Tx</th><th>ICU</th></tr></thead><tbody><tr><td>Oesophageal candidiasis</td><td>-</td><td>1,291</td><td>-</td><td>-</td><td>-</td><td>13.0</td><td>1,291</td></tr><tr><td>Oral candidiasis</td><td>-</td><td>2,673</td><td>-</td><td>-</td><td>-</td><td>27.1</td><td>2,673</td></tr><tr><td>Candidemia</td><td>-</td><td>-</td><td>-</td><td>345</td><td>148</td><td>5.0</td><td>493</td></tr><tr><td>Candida peritonitis</td><td>-</td><td>-</td><td>-</td><td>-</td><td>74</td><td>0.8</td><td>67</td></tr><tr><td>Recurrent vaginal candidiasis (4x/year +)</td><td>176,961</td><td>-</td><td>-</td><td>-</td><td>-</td><td>3,588.75</td><td>176,961</td></tr><tr><td>ABPA</td><td>-</td><td>-</td><td>6,008</td><td>-</td><td>-</td><td>42.5</td><td>4,188</td></tr><tr><td>SAFS</td><td>-</td><td>-</td><td>7,930</td><td>-</td><td>-</td><td>56.0</td><td>5,528</td></tr><tr><td>Chronic pulmonary aspergillosis</td><td>-</td><td>-</td><td>3,609</td><td>-</td><td>-</td><td>36.6</td><td>3,609</td></tr><tr><td>Invasive aspergillosis</td><td>-</td><td>-</td><td>36</td><td>75</td><td>-</td><td>1.12</td><td>111</td></tr><tr><td>Cryptococcal meningitis</td><td>-</td><td>25</td><td>-</td><td>-</td><td>-</td><td>0.25</td><td>25</td></tr><tr><td>Pneumocystis pneumonia</td><td>-</td><td>64</td><td>-</td><td>-</td><td>-</td><td>0.65</td><td>64</td></tr><tr><td>Mucormycosis</td><td>-</td><td>-</td><td>-</td><td>20</td><td>-</td><td>0.2</td><td>20</td></tr><tr><td>Fungal keratitis</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>?</td><td>?</td></tr><tr><td>Tinea capitis</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>?</td><td>?</td></tr><tr><td><strong>Total burden estimated</strong></td><td><strong>176,961</strong></td><td><strong>4,044</strong></td><td><strong>18,099</strong></td><td><strong>440</strong></td><td><strong>222</strong></td><td></td><td><strong>196,778</strong></td></tr></tbody></table>

**Conclusion:** We have estimated 195,026 (2% of the population) people in Azerbaijan with serious fungal infections. Providing diagnostics tools for fungal infection will lead to better understanding of this problem and will allow to highlight this problem at the national level.
P250

Disability and disease after indoor macrocyclic Trichothecenes mycotoxin and microfungal exposure: exposure variable analysis indicates unexpected significant relationship between immunosuppression and MTHFR detoxification defects.

I.H. Grant¹, J. Geller², H. Sabath³

¹Community Medicine, New York Medical College, Tarrytown, United States of America,

²Information Revelations, Montclair NJ, United States of America, ³International Environmental

Diagnostics Inc, Irvington NYw, United States of America

**Objectives:** Macrocyclic trichothecene mycotoxins are extremely toxic nanoparticulate exotoxins dangerous for all mammals, binding to surface dust where mold grow, aerosolized and inhaled if disturbed. They damage intracellular protein/DNA/RNA production and mitochondrial function causing premature cell death (apoptosis) on contact. A exotoxins, they remain toxic despite disinfection. They cause damage to mammalian skin, mucosa, phagocytes, neurons, and organs via systemic circulation after inhalation. Produced by *Stachybotrys* and *Trichoderma* water-damaged indoor environments, they are more potently toxic than T2-toxin and doxynivalenol (DON, vomitoxin) mainly produced by *Fusarium* on agricultural grains. **Objectives:** Determine: - Severe illness frequency due to indoor mold/mycotoxin exposure. - Specific exposure risks - The impact of genetically-impaired intracellular MTHFR detoxification capacity. - Conditions that predispose to opportunistic fungal infection with such exposures (e.g. mucosal injury, immunosuppression, malnutrition)

**Methods:** Prospectively monitored 51(21M,30F) adults and children exposed to 30 Trichothecenes-contaminated indoor-environments with comprehensive environmental-mycological and medical investigations, fungal IGGs, urine mycotoxins(MCTs: Aflatoxin, Gliotoxin, Ochratoxin A, Trichothecenes), immune parameters(neutrophils, lymphocyte subsets, monocytes, IGG, IGA, IGM, IGE, subclasses), immunosuppressants, nutritional deficiencies (protein, Vitamin D, zinc), genetic Methylenetetrahydrofolate reductase (MTHFR) single-nucleotide-polymorphisms C677T & A1298C. Disease Severity Outcomes(DS), Environmental Mold-Contamination Severity(EMCS), Hazardous Exposure Activities(HEA), Exposure Duration (ED), MCT/Trichothecenes exposure(MTC/TE), and clinical findings were stratified and analyzed. Biostatistical analysis(Pearson Correlation Coefficients) correlated DS with EMCS, HEA, ED, MCT/TE, mucosal Injury(MI), Neurological disease, Cell-mediated Immunodeficiencies(CMIs), combined cellular-immunoglobulin immunodeficiencies, mucosal injury (MI), mold-specific IGG response(M-IGG), MCT excretion and MTHFR defects.

**Results:**
<table><thead><tr><th>Outcomes</th><th>Disabled</th><th>20/51 (39%)</th><th>Permanently 9/20 (45%): 67% female</th></tr></thead><tbody><tr><td></td><td>Emergency Treatment</td><td>10/51 (20%)</td><td>70% female</td></tr><tr><td></td><td>Bedridden</td><td>8/51 (16%)</td><td>100% female</td></tr><tr><td></td><td>Hospitalized</td><td>5/51 (10%)</td><td>80% female</td></tr><tr><td></td><td>Bedridden</td><td>8/51 (16%)</td><td>100% female</td></tr><tr><th colspan="4">Disease & Symptom Frequencies</th></tr><tr><td></td><td>Bleeding</td><td>46/51 (90%)</td><td>56% female</td></tr><tr><td></td><td></td><td>ENT 43/51 (84%): 58% female</td><td></td></tr><tr><td></td><td></td><td>Pulmonary 8 63% male</td><td></td></tr><tr><td></td><td></td><td>GI 8 63% male</td><td></td></tr><tr><td></td><td>Mucosal Injury</td><td>42/51 (82%)</td><td>(17 severely/extremely ill)</td></tr><tr><td></td><td>• Nasal Symptoms</td><td>41/51 (80%)</td><td>61% female</td></tr><tr><td></td><td>• Ear/Nose/Throat Injury</td><td>39/51 (77%)</td><td>59% female</td></tr><tr><td></td><td></td><td>• 34 denuded nostril mucosa (62% female)</td><td></td></tr><tr><td></td><td></td><td>• 32 loss of nostril hairs (66% female)</td><td></td></tr><tr><td></td><td></td><td>• 17 ulcerated mucosa (53% female)</td><td></td></tr><tr><td></td><td>Neurologic</td><td>38/51 (75%)</td><td>66% female</td></tr><tr><td></td><td>• Cognitive impairment</td><td>36/51 (71%)</td><td>69% female</td></tr><tr><td></td><td>• Toxic Encephalopathy</td><td>17/51 (33%)</td><td>88% female</td></tr><tr><td></td><td>• Permanent Neurocognitive Damage</td><td>10/51 (20%)</td><td>70% female</td></tr><tr><td></td><td>Pain, severe unexplained</td><td>33/51 (64%)</td><td>64% female</td></tr><tr><td></td><td>Chronic Fatigue</td><td>32/51 (63%)</td><td>69% female</td></tr><tr><td></td><td>Cough</td><td>32/51 (63%)</td><td>67% female</td></tr><tr><td></td><td>Postnasal Drainage</td><td>31/51 (62%)</td><td>61% female</td></tr><tr><td></td><td>Pulmonary</td><td>30/51 (59%)</td><td>70% female</td></tr><tr><td></td><td>Burning</td><td>29/51 (57%)</td><td>59% female</td></tr><tr><td></td><td>Sinusitis</td><td>28/51 (55%)</td><td>57% female</td></tr><tr><td></td><td>GI</td><td>27/51 (53%)</td><td>56% female</td></tr><tr><td></td><td>Dermatological</td><td>26/51 (51%)</td><td>69% female</td></tr><tr><td></td><td>Headaches</td><td>19/51 (37%)</td><td>58% female</td></tr><tr><td></td><td>Muscles</td><td>19/51 (37%)</td><td>63% female</td></tr><tr><td></td><td>Joints</td><td>18/51 (35%)</td><td>61% female</td></tr><tr><td></td><td>Environmental Chemical Sensitivity</td><td>11/51 (22%)</td><td>64% female</td></tr></tbody></table>

<table><thead><tr><th colspan="2">Clinical Parameters</th></tr></thead><tbody><tr><td><strong>Immune Defects</strong></td><td><strong>50/51 (98%)</strong></td></tr><tr><td></td><td><strong>Innate Defects:</strong> 43/51 (84%) 61% female:<br>(Vitamin D defic 39/43 (91%), 5 under age 4 yrs.)</td></tr><tr><td></td><td><strong>Neutrophil Defects:</strong> 30/51 (62%) 67% female: Zinc 14<br>(77% female), Protein deficient 8 (63% female), Steroids<br>14 (79% female with 12 deteriorating after RX)</td></tr><tr><td><strong>Combined Innate -Neutrophil Defects</strong></td><td>47/51 (92%) 62% female</td></tr><tr><td><strong>Adaptive Immunoglobulin Deficiencies</strong></td><td>23/37 tested (62%) 65% female<br>IGA 9/23 (39%) 67% female<br>IGG Total Defic 6/37 (16%)<br>IGG Subclass Defic: 16/37 (43%)<br>IGM Defic 7/37 (19%)</td></tr><tr><td><strong>Genetic: MTHFR DEFECTS</strong></td><td><strong>48/51 (94%)</strong></td></tr><tr><td>A1298c Total 34</td><td>12 Heterozygous, 4 homozygous, 18 Compound<br>Heterozygous</td></tr><tr><td>C677T Total 32</td><td>9 Heterozygous, 5 homozygous, 18 Compound<br>Heterozygous</td></tr></tbody></table>

**CORRELATIONS:** Disease Severity based on formal disability classification/physical injury strongly correlated with Hazardous Activities (p = 0.000043), Neurological disease(p = .000263), Immunoglobulin deficiencies(p = .000923),Combined Cellular-Immunoglobulin Deficiencies (p = 0.00502), Environmental Mold Contamination(p = 0.007531) and Mucosal Injury-the main expected injury from Trichothecenes inhalation (p = 0.018034). Mucosal injury strongly correlated with Neurological damage(p = .026842) and combined cellular-immune defects(p = 0.026842). Combined Cellular-Immunoglobulin Deficiencies strongly correlated Hazardous Activities (p = .009464). Development of mold-specific IGGs correlated with environmental mold-contamination(p = 0.26842) and Urine Trichothecenes(p<.00001). Females were more often adversely affected. Environmental Exposure Hazardous Activities (especially unprotected mold-disturbance, uncontained construction/repairs, basement-living, HVAC-contamination and sewage-overflow) correlated with environmental Trichothecenes level(p = 046588), Combined Cellular Deficiencies(p = .038993) and immunoglobulin deficiencies(p = .005952). Environmental Mold Contamination correlated with Disease Severity(p = 007531), Hazardous Activities(p = 0.002153), Environmental Trichothecenes level(p = .00502), multiple environmental mycotoxins (p = .02207), Combined Cellular-Immunoglobulin Deficiencies(p = .04658),immunoglobulin deficiencies(p = .032448) and elevated mold IGGs(p = .026842). Environmental mycotoxin contamination correlated with urine mycotoxin
excretion (p = .046588). Environmental Trichothecenes contamination significantly correlated with Environmental Mold Contamination (p = .00502), Hazardous Activity (p = .046588) and Exposure Duration (p = .046588). Urine Macrocyclic Mycotoxin Score strongly correlated with the Environmental Mycotoxin Score (p = .046588).

**Conclusion:** Indoor exposure to macrocyclic Trichothecenes appears extremely hazardous. The high frequency of bleeding (90%), mucosal injury (82%), neurological damage (75%), pain (64%), chronic fatigue (63%), burning (57%), with expected respiratory/Gi /Dermatologic symptomatology is consistent with known Trichothecenes effects in animal models and military data. The high (94%) MTHFR methylation-defect incidence is striking compared to estimated USA 50-60% prevalence. MTHFR is a key intracellular detoxifying-enzyme protecting ribosomes/mitochondria RNA/DNA damage from Trichothecene injury via glutathione metabolism. Further investigation is needed to determine if Trichothecenes trigger genetic damage or autoimmunity. Urine macrocyclic Trichothecenes detection appears a useful marker for environmental macrocyclic Trichothecenes exposure. Public health education and epidemiological research are urgently needed to investigate correlation between environmental mold/mycotoxin exposure, multisystem illness, immunodeficiencies and female susceptibility.

P251

Survivors of candidemia without antifungal treatment

L. Hestvedt¹, P. Gaustad², C. Torp Andersen², F. Muller², I. Nordoy¹

¹Dept. Of Infectious Diseases, Oslo University Hospital, Oslo, Norway, ²Dept. Of Microbiology, Oslo University Hospital, Oslo, Norway

**Objectives:** Candidemia is associated with high mortality, which increases without antifungal treatment. The aim of this nationwide, retrospective study was to examine factors associated with 30-day survival in a subpopulation of candidemia patients who did not receive antifungal treatment.

**Methods:** We collected data by reviewing medical records from patients who were diagnosed with candidemia between January 1st 2008 and December 31st 2012. Age (at or below and above 65 years), sex, *Candida* species (*C. albians* vs. *C. glabrata*), predisposing illnesses (malignancy; gastrointestinal cancer, hematological malignancy or all other malignancy, organ transplantation, chronic obstructive pulmonary disease, diabetes mellitus, inflammatory bowel disease, intravenous drug users – IVDU) and health-care related risk factors (central venous catheter - CVC, urine catheter, mechanical ventilation, dialysis, abdominal surgery, neutropenia – neutrophils <0.5 x10⁹/L > 5 days, use of antibiotics, corticosteroids, chemotherapy, proton pump inhibitor –PPI or total parenteral nutrition-TPN) were recorded.

**Results:** In 144 candidemia patients (60.4% men, age 63.9 ± 16.2 years) not receiving any antifungal treatment, the overall 30-day survival rate was 36.8%. No significant difference was found between genders of untreated survivors (n = 53, 54.7% men, age 63.6±20.4) and untreated non-survivors (n = 91, 63.7% men, age 74.2±11.7). Overall significantly more of the patients < 65 years than ≥ 65 years survived without treatment (55.8% vs. 26.5%, p = 0.015). Of predisposing illnesses malignancies excluding hematological and gastro-intestinal cancers was significantly less common in untreated survivors compared to non-survivors (23.5% vs. 76.5%, p = 0.02). Of healthcare related risk factors the untreated survivors significantly less often were mechanically ventilated (34.5% vs. 65.5%, p = 0.049), less often had urine catheters (27.0% vs. 73.0%, p<0.001), received TPN (23.9% vs. 76.1%, p = 0.04) or PPI (28.4% vs. 71.6%, p = 0.03) compared to untreated non-survivors. Central venous catheters were more often removed in untreated survivors than in non-survivors (29.2% vs. 10.9%, p = 0.04). Untreated intravenous drug users (IVDU) (n = 9) all survived candidemia. No significant difference was seen between untreated survivors and non-survivors related to *C. albicans* or *C. glabrata* candidemia.

**Conclusion:** Patients surviving untreated candidemia were significantly younger, had less underlying malignancy and fewer risk factors for candidemia, in addition more often having their CVC removed than the patients who died without treatment. The prognosis in untreated candidemia is influenced by comorbidity and its subsequent treatment.
P252

**Mucormycosis – A clinicoepidemiological review of cases over 10 year**

M. O'Sullivan

Clinical Microbiology, Chrisitan Medical College, Vellore, Tamil Nadu, India

**Objectives:** **Objectives:** To study the epidemiology and outcomes of various agents causing mucormycosis in different clinical settings in a tertiary care hospital from South India.

**Methods:** **Patients and methods:** We reviewed details of 184 consecutive patients with culture-proven mucormycosis with consistent clinical syndrome and supporting features from September 2005 to September 2015.

**Results:** **Results:** The mean age of patients was 50.42 years; 70.97% were male. Unlike developed countries, *Rhizopus microsporus* (29/184; 15.7%) and *Apophysomyces elegans* (20/184; 10.8%) also evolved as important pathogens in addition to *Rhizopus arrhizus* in our setting. Paranasal sinuses (136/184; 73.9%) followed by musculoskeletal system (28/184; 15.2%) were the common areas of involvement. *A. elegans* typically produced skin and musculoskeletal disease in immune-competent individuals with trauma (12/20; 60%) and caused significantly lower mortality (P = 0.03). *R. microsporus* was more common in patients with haematological conditions (25% vs 15.7%) and was less frequently a cause for sinusitis than *R. arrhizus* (27.58% vs 10.9%). The overall mortality was 30.97%. Combination therapy with surgery and antifungals offered the best chance for cure.

**Conclusion:** **Conclusions:** Agents causing mucormycosis may have unique clinical and epidemiological characteristics.

P253

**Biliary Tract Candidiasis: an overview of the epidemiology in a general hospital**

I. Costales¹, L. Milian², E. Vallina¹, S. Martínez¹, A. Templado¹, J.A. Boga¹, T. Peláez¹

¹Servicio De Microbiología Y Parasitología, HUCA, Oviedo, Spain, ²Servicio De Microbiología Y Parasitología, CAUSA, Salamanca, Spain

**Objectives:** Infections of the biliary tract are a common gastrointestinal disorder. Infections caused by *Candida* spp. and other fungal species have increased their incidence in the last few years. Knowing the autochthonous epidemiology is advisable in order to ensure an effective empirical therapy and an optimal management of the patients.

**Methods:** Biliary tract samples from patients diagnosed with acute cholangitis from January 2017 to June 2019 were included in the study. We considered only one sample per patient and clinical episode. All isolates were identified using MALDI-TOF Biotyper® (Bruker Daltonics) methodology and yeast susceptibility testing were performed by Sensititre™ YeastOne® (Thermo Scientific, TREK Diagnostic systems, UK). In case of polyfungal infections, all yeast isolates were identified and susceptibility test was performed, but were considered as a single sample.

**Results:** From a total of 299 biliary samples analyzed, 80 of them (26.8%), corresponding to 65 patients, showed positive fungal growth. During the study period, the incidence of yeasts isolated from biliary tract increased from 2017 (0.49/1.000 admissions) to 2019 (0.95/1.000 admissions). The species most frequently recovered from biliary tract candidiasis episodes were *C. albicans* (56.25% of cases), *C. glabrata* (16.25%), *C. krusei* (6.25%), *C. tropicalis* (6.25%), *C. parapsilosis* (6.25%) and other yeasts (8.75%). The percentages of isolation of different yeasts isolated in the first and last year of the study were respectively as follows: *C. albicans* (70.6% vs 53%), *C. glabrata* (11.7% vs 23.6%), *C. krusei* (5.9% vs 11.8%), *C. tropicalis* (0% vs 16.7%), *C. parapsilosis* (0% vs 13.3%) and other yeasts (11.8% vs 23.5%). A total of 51 cases (78.46%) of biliary tract candidiasis were monofungal infections and 14 (21.54%) were polyfungal infections.

**Conclusion:** In our hospital, the incidence of biliary tract candidiasis increased during the study period probably due to an improvement of culture methods, as well as greater clinical suspicion requesting a micological analysis of bile samples. Globally, *C. albicans* was the most frequent yeast species isolated, followed by *C. glabrata*. However, a significant increase in potentially fluconazole resistant species (*C. glabrata* and *C. krusei*) occurs in the last year of the study.
P254

**Prevalence of severe asthma with fungal sensitization (SAFS) in European population.**

A. Iunovidova¹, N. Klimko², A. Sobolev¹

¹Department Of Clinical Mycology, Allergology And Immunology, North-Western State Medical University named after I.I, Mechnikov, Saint-Petersburg, Russian Federation, ²Department Of Clinical Mycology, Allergology And Immunology, North-Western State Medical University n.a. I.I. Mechnikov, Saint-Petersburg, Russian Federation

**Objectives:** SAFS can be defined as a continuum of fungal sensitization with asthma at one end and allergis bronchopulmonary aspergillosis at the other. The main goal was to determine the prevalence of SAFS in the European population due to insufficient data.

**Methods:** Incident case and population data were obtained for SAFS from the Surveillance, Epidemiology, and End Results between 2011 and 2018.

**Results:** Recent global estimates have found 10,000,000 cases of fungal asthma occur annually. The major assumptions made were based on previous studies of SAFS; severe asthma is thought to affect about 10% of adults and 33-70% are sensitised to fungi and that 2.77-2.90% of the population have asthma. Although the prevalence of SAFS is uncertain as this disease has been recently described it was conservatively estimated that 30% of patients with severe asthma have or develop SAFS. Patients with SAFS probably constitute a significant proportion (~50% estimated) of the nearly 0.5 million asthma related deaths worldwide. The burden of SAFS has been estimated to 4,125,428 (+-174,033) cases in 43 countries.

**Conclusion:** The diagnostic gap between estimated burden and recorded cases numbers provides a clear cut target to close, to improve patient outcomes. There is recognition of fungal infections as a major contributor to mortality of several conditions that emphasize the need for public health efforts in reducing the incidence and mortality of these infectious diseases.

P255

**Epidemiological aspects of superficial mycosis among arabic school children in two localities in Sénégal (Thies and Touba)**

A. Badiane, K. Diongue, M.C. Seck, M. Ndiaye, D. Ndiaye

Parasitology And Mycology, Université Cheikh Anta Diop de Dakar, Dakar, Senegal

**Objectives:** The objective of this study was to determine the prevalence of superficial mycosis in koranic schools of Thies and Touba, two cities located in western Senegal.

**Methods:** This study was conducted in children from seven (07) koranic schools in two cities of Senegal (Thies and Touba). A total of 210 children were recruited. For each child, depending on the lesions squama, hairs or nail pieces were collected using sterile material. Fungal pathogens were identified using direct examination with 30% Potassium Hydroxide (KOH) and culture on Sabouraud d'Addiction with chloramphenicol and actidone (cycloheximide).

**Results:** The most prevalent lesion was tinea capitis (90%). The culture was positive for 25.1% of the pupils. The species identified were Trichophyton soudanense (85.18%), Microsporum audouinii langeronii (9.25%), Trichophyton rubrum (3.70%), and Chrysosporium keratinophilum (1.85%). Among infected participants, children aged 3 to 10 years were more contaminated (53.70%), followed by the age group of 11 to 15 years (44.44%) and participants over the age of 15 were less infected (1.85%). The prevalence of infection was higher among boys (85.18%).

**Conclusion:** This study showed a fairly prevalence of superficial mycoses among koranic school children.

P256

**Infections by Mucoraceous moulds recorded during a period of twelve years.**

K. Samaras, A.-M. Markantonatou, E. Zarkada, E. Zachrou, T.-A. Vyzantiadis

First Department Of Microbiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
**Objectives:** Mucoraceous moulds are very common in natural environment. They may rarely be the cause of severe or even fatal infections in immunocompromised patients, patients with uncontrolled diabetes mellitus or patients bearing deep and dirty wounds. The aim of this study was to record the cases of infections by mucoraceous moulds, microbiologically diagnosed in our laboratory and to detect the existence of any possible specific feature of these infections.

**Methods:** A retrospective recording was performed of all similar cases tested by our laboratory during the last twelve years

**Results:** Eleven cases of mucoraceous mould infections were recorded (7 male, 4 female). The fungal pathogens isolated were: 9 *Rhizopus arrhizus*, 1 *Mucor circinelloides* and 1 *Saksenaea vasiformis*. Seven patients were immunocompromised, two were suffering from uncontrolled diabetes mellitus and two of them had deep, dirty wounds. Five of the aforementioned cases concerned culture plates sent to the laboratory for identification of the fungal isolate. As for the other six specimens, direct microscopy of the clinical sample was positive for all of them. In 8 cases, antifungal susceptibility testing was performed and the range of MICs was 0.003-16 µg/ml for amphotericin B and 0.75-12 µg/ml for posaconazole. The outcome was favourable for five patients. In nine out of the eleven cases the infection was presented in spring or autumn, seasons that in our country are characterized by mild to moderate temperatures and relatively high humidity.

**Conclusion:** All patients had at least one risk factor for mucormycosis. A seasonal distribution was noticed, something that has been noted by other authors too. Positive direct microscopy in all clinical samples demonstrates the great importance of the procedure which provides promptly very characteristic images and contributes to the initiation of targeted treatment which may be life saving.

P257

Molecular Epidemiology of Histoplasmosis in Germany

D. Wilmes, H.L. Losert, H. Leibhan, J. Gerkrath, V. Rickerts
Fg16-mycology, Robert Koch Institute, Berlin, Germany

**Objectives:** Histoplasmosis is a systemic fungal infection caused by obligate pathogenic fungi of the genus *Histoplasma*. Autochthonous infections in wild and domesticated animals document the presence of Histoplasma in the environment in Germany. The aim of this study is to characterize the molecular epidemiology of Histoplasmosis in Germany by multilocus sequence typing (MLST) of *Histoplasma* cultivated from patients diagnosed in Germany and to compare them to strains characterized by a modified MLST from infected animals in Germany.

**Methods:** Since the year 2000, we participated to the diagnosis of 76 human cases (mean = 4/year) and 10 animal cases (7 cats, 3 badgers) of proven and probable infection. Twenty-two *Histoplasma* strains cultivated at our Laboratory, including two CBS reference strains were typed using a 4 gene scheme (arf, H-anti, ole and tub) previously described by Kasuga (1). Concatenated sequences were aligned with reported sequences of worldwide isolates. Then a modified MLST for formalin fixed paraffin (2) embedded samples was performed on pathology blocks from veterinary samples. Neighbour joining trees were constructed to demonstrate relationships using the Geneious software suite.

**Results:** All four genes could be sequenced for 16 of 22 isolates while the amplification of the ole gene failed for 6 isolate. The phylogenetic analysis demonstrated clustering of the German patient isolates with previously defined clades (African: *n* = 7; Latin American: *n* = 7; Bat associated clade1: *n* = 1; Netherlands: *n* = 1) corresponding to the patients travel history. Of note, 3 patient isolates clustered with the Eurasian clade, in which also 7 animal samples (5 cats and 1 badger) clustered, suggesting related organisms. Two of the patients had a travel history to Southeast Asia, while for one no travel history was reported.

**Conclusion:** Our study demonstrates that histoplasmosis in Germany is mostly imported from endemic regions including Latin America, Africa and Southeast Asia. However, clustering of human isolates and veterinary cases from Germany within the Eurasian clade suggest the presence of *Histoplasma* in the German environment. Further molecular studies on human and veterinary cases and environmental sampling are needed to define environmental niches.
P258

Burden of fungal infections in Morocco

B.E. Lmimouni¹, S. Azelmat², C. Hennequin³, D. Denning⁴

¹School Of Medicine And Pharmacy, University Mohamed The Fifth, Parasitology and Medical Mycology Lab, Military Teaching Hospital Mohamed the Fifth, Hay Riad, Rabat, Morocco,
²Parasitology And Medical Mycology, Military Teaching hospital Mohammed the Fifth, Rabat, Morocco,
³Parasitology-mycology, APHP, Hôpital St Antoine, Paris, France,
⁴University of Manchester, Manchester, United Kingdom

**Objectives:** We report for the first time in Morocco burden estimates of fungal infections. The aim of this study was to estimate the incidence and prevalence of fungal infection in Morocco.

**Methods:** We used the national demographic data and performed a PubMed and Scopus search to retrieve all published papers on fungal infections from Morocco. We have also modelled the likely burden of serious fungal infections using methodology previously published by LIFE.

**Results:** We report for the first time the main causes of these diseases in our country. Superficial mycoses and dermatophytic infection (onychomycosis, tinea capitis, others ...) are very commonly diagnosed, We have found 13,294 cases in the published papers. Deep fungal infection are less found in the literature. Modlelling shows higher rates for all infections where modelling is possible, especially for pulmonary fungal infections. Literature Modelling Infection Rate/100,000 Total burden Rate/100,000 Total burden Cryptococcal meningitis 0.32 115 0.7 252 Pneumocystis pneumonia 0.22 78 1.2 420 Invasive aspergillosis 0.88 315 1.9 674 Mucormycosis 0.01 4 0.2 72 Chronic pulmonary aspergillosis post TB 0.74 266 8.6 3085 Allergic bronchopulmonary aspergillosis (ABPA) 0.01 4 51 18,400 Severe asthma with fungal sensitization (SAFS) 0.28 100 67 24,292 Candidaemia 1.47 528 5 1800 Oral Candidiasis 0.25 90 22 7800 Mycetoma 0.11 40 Recurrent Candida vaginitis (>4x/year) 0.17 30 2755 496,000 Histoplasmosis 0.01 4 - - Skin dermatophytic infection 13.97 5031 - - Onychomycosis 14.08 5069 - - Tinea capitis 8.87 3194 - - Deep dermatophytosis 0.02 10 - - Total burden estimated 14522 551,400

**Conclusion:** A focus on improving the diagnosis and epidemiological data related to fungal infection is necessary in Morocco.

P259

Fusarium keratitis in the Netherlands (2005 – 2016).

C. Oliveira Dos Santos¹, E. Kolwijck¹, C. Eggink², P.E. Verweij³

¹Medical Microbiology (777), Radboud University Medical Center, Nijmegen, Netherlands,
²Ophthalmology, Radboud University Medical Center, Nijmegen, Netherlands,
³Medical Microbiology, RadboudUMC, Nijmegen, Netherlands

**Objectives:** Recognizing the clinical picture of fungal keratitis is difficult. As a consequence, the fungal diagnosis might be delayed due to primary therapy with antibacterial agents and topical corticosteroids, resulting in spreading of the fungus in the cornea which ultimately may lead to more severe infection and monocular blindness. There seems to be a trend of increasing incidence of fungal keratitis in the Netherlands, especially caused by *Fusarium* species. Here, we describe the epidemiology and clinical management of fungal keratitis in the Netherlands.

**Methods:** The Dutch national reference center for medical mycology has received *Fusarium* strains isolated from 89 Dutch fungal keratitis patients, in the period 2005 up to 2017. The clinical data was added in retrospect by the ophthalmologists. All *Fusaria* were identified up to genus level using conventional techniques and/or molecular techniques. Antifungal susceptibility testing was performed according to the method described by the EUCAST. The antifungal agents tested were amphotericin B, voriconazole and natamycin. Susceptibility to the antisepticum chlorhexidine was also tested.

**Results:** In this period there was a mean incidence of *Fusarium* keratitis of 0.5 (range 0 – 1.5) per million per year. The male to female ratio was 1:3 (p = 0.014). The use of contact lenses in this cohort was high; 92.9% of patients with reported use or non-use of contact lenses. The time between start of
symptoms to the diagnosis of fungal keratitis was significantly longer in the group with therapy failure opposed to the group with restored vision; respectively 22 days versus 15 days (p = 0.024). The need of a corneal transplantation or enucleation of the affected eye occurred in 27 cases (n = 20 [22.5%] resp. n = 7 [7,9%]). Enucleation occurred in patients with delayed diagnosis of the fungal culprit (>14 days after start symptoms). The mean visual acuity was moderately impaired with a logMAR of 0.8 (95% CI 0.6 – 1) at the time of isolation of the *Fusarium* strain. The final visual outcome had an average logMAR of 0.2 (95% CI 0.1 – 0.3), the equivalent of mild visual impairment. The treatment strategies differed greatly between the cases. Of note, five patients were treated with chlorhexidine 0.02% monotherapy after *Fusarium* was isolated with good results; 4 patients had a successful outcome. The most frequently isolated species was *F. oxysporum* (n = 22, 24.7%) followed by *F. solani sensu stricto* (n = 16, 18%) and *F. petroliphilum* (n = 8, 9%). The lowest MICs were obtained with amphotericin B followed by natamycin, voriconazole, and chlorhexidine.

<table><caption>Table. Molecularly identified fusarial keratitis isolates and their susceptibility profile including chlorhexidine (only identified strains are depicted, n=78).</caption><thead><tr><th rowspan="2">Fusarium species complex and species (n)</th><th colspan="1">MIC* % [mode (range)]</th><th colspan="4">MIC* mg/L [mode (range)]</th></tr><tr><th>CHX</th><th>CHX</th><th>AMB</th><th>VCZ</th><th>NAT</th></tr></thead><tbody><tr><td><strong>F. solani</strong> species complex - FSSC (32)</td><td>0.003 (0.0015-0.006)</td><td>16 (8-32)</td><td>2 (0.5-16)</td><td>8 (4-16)</td><td>8 (4-16)</td></tr><tr><td><em>F. solani</em> (16)</td><td>0.006 (0.0015-0.006)</td><td>32 (8-32)</td><td>2 (1-16)</td><td>8 (4-16)</td><td>8 (4-16)</td></tr><tr><td><em>F. petroliphilum</em> (8)</td><td>0.0015 (0.0015-0.006)</td><td>8 (8-32)</td><td>2 (0.5-4)</td><td>8 (4-16)</td><td>4 (4-8)</td></tr><tr><td><em>F. keratinoplasticum</em> (7)</td><td>0.003 (0.0015-0.006)</td><td>16 (8-32)</td><td>4 (2-4)</td><td>4 (4-16)</td><td>4 (4-8)</td></tr><tr><td><em>F. falciforme</em> (1)</td><td>0.006</td><td>32</td><td>2</td><td>16</td><td>8</td></tr><tr><td><strong>F. oxysporum</strong> species complex - FOSC (22)</td><td>0.0015 (0.0002-0.013)</td><td>8 (1-64)</td><td>2 (0.25-16)</td><td>4 (2-16)</td><td>8 (4-8)</td></tr><tr><td><em>F. oxysporum</em> (22)</td><td>0.0015 (0.0002-0.013)</td><td>8 (1-64)</td><td>2 (0.25-16)</td><td>4 (2-16)</td><td>8 (4-16)</td></tr><tr><td><strong>F. fujikuroi</strong> species complex - FFSC (15)</td><td># (0.0008-0.013)</td><td># (4-64)</td><td>2 (1-4)</td><td>4 (1-8)</td><td>8 (2-8)</td></tr><tr><td><em>F. proliferatum</em> (7)</td><td>0.0008 (0.0008-0.013)</td><td>4 (4-64)</td><td>1 (1-4)</td><td>4 (2-8)</td><td>8 (4-8)</td></tr><tr><td><em>F. verticillioides</em> (2)</td><td># (0.0008-0.003)</td><td># (4-16)</td><td># (1-2)</td><td># (1-2)</td><td># (2-8)</td></tr><tr><td><em>F. lactis</em> (3)</td><td>0.0015 (0.0015-0.003)</td><td>8 (8-16)</td><td># (0.5-4)</td><td># (2-8)</td><td>8</td></tr><tr><td><em>F. sacchari</em> (1)</td><td>0.0015</td><td>8</td><td>2</td><td>1</td><td>8</td></tr><tr><td><em>F. ramigenum</em> (1)</td><td>0.003</td><td>16</td><td>4</td><td>1</td><td>4</td></tr><tr><td><em>F. musae</em> (1)</td><td>0.003</td><td>16</td><td>2</td><td>4</td><td>8</td></tr><tr><td><strong>F. dimerum</strong> species complex - FDSC (7)</td><td>0.0015 (0.0015-0.003)</td><td>8 (8-16)</td><td>2 (0.5-2)</td><td>8</td><td>4 (4-16)</td></tr><tr><td><em>F. dimerum</em> (7)</td><td>0.0015 (0.0015-0.003)</td><td>8 (8-16)</td><td>2 (0.5-2)</td><td>8</td><td>4 (4-16)</td></tr><tr><td><strong>F. equiseti-incarnatum</strong> species complex - FIESC (1)</td><td>†</td><td>†</td><td>1</td><td>8</td><td>†</td></tr><tr><td><em>F. equiseti</em> (1)</td><td>†</td><td>†</td><td>1</td><td>8</td><td>†</td></tr><tr><td><strong>Ambrosia Fusarium</strong> complex - AFC (1)</td><td>0.006</td><td>32</td><td>2</td><td>16</td><td>8</td></tr><tr><td><em>F. ambrosium</em> (1)</td><td>0.006</td><td>32</td><td>2</td><td>16</td><td>8</td></tr></tbody></table>

**Conclusion:** In our population trauma is not the main route of infection. An important risk factor in the Netherlands seems to be the use of contact lenses. When correct diagnosis and antifungal treatment is delayed the risk of losing the affected eye is great. The lack of a specific national guideline is reflected in the greatly varying treatment strategies. Chlorhexidine seems to be a good addition to the therapeutic options.

## P260

### Fungal invasive infections after kidney transplant: a monocenter study

M. Zaidan¹, Z. Mechref¹, M. Frank-Soltysiak², D.-P. Nguyen², A. Durrbach¹, A. Angoulvant³,⁴

¹Nephrology, Hôpital Bicêtre, APHP, Le Kremlin Bicêtre, France, ²Dim Hups / Aiph Wind, Hôpital Bicêtre, APHP, Le Kremlin Bicêtre, France, ³Génétique Quantitative et Évolution – Le Moulon, INRA – Université Paris-Sud – CNRS – AgroParisTech, Gif-sur-Yvette, France, ⁴Mycology-parasitology, Hôpital Bicêtre, APHP, Le Kremlin Bicêtre, France

**Objectives:** Invasive fungal infections constitute an important cause of morbidity and mortality in solid organ transplantation recipients. Epidemiology of invasive fungal infections (IFI) after kidney transplantation in the modern era of immunosuppression is poorly described. We aim to describe the IFI epidemiology in our centre.

**Methods:** We retrospectively analyzed the epidemiology of IFI in a single-center cohort of kidney transplant adult recipients between January 2011 and December 2018.

**Results:** There were 1646 kidney transplanted patients hospitalized during the study period; 68 (4%) cases of IFI were identified. Sex ratio (M/F) was 1.1 and mean age 63 years (44 – 77). IFI occurred 12 (1-144) months after transplantation, in patients with immunosuppressive therapy containing tacrolimus, mofetil mycophenolate and corticosteroids. 100% of them had renal insufficiency, 68% had diabetes and 50% were neutropenic at the time of the IFI diagnosis. *A. fumigatus* proven or probable invasive aspergillosis (IA) was the leading cause (n = 28, 1.7 %) followed by pneumocystosis

<footnote>*NIC, minimal inhibitory concentration; AMB, amphotericin B; VCZ, voriconazole; POS, posaconazole; MCZ, miconazole; NAT, natamycin; SFC, 5-fluorocytosin; CHLX, cNothexidine; CAS, caspofungin.</footnote>

<footnote>†Mode not calculable (even numbers).</footnote>

<footnote>‡Susceptibility testing was not performed</footnote>
(n = 20, 1.22%), candidemia (n = 15. 0.92%) and other IFI (n = 6 (0.3%). Urinary source was identified in 77% of patients with candidemia. C. albicans (60%) was the leading species followed by C. glabrata and C. parapsilosis (20% each). Loss of graft occurred in 20% of them. Mortality was 50%, 40% and 10% for IA, candidemia and pneumocystosis respectively

**Conclusion:** In our centre IFIs, excepted pneumocystosis, were associated with high mortality rates in renal transplant patients. IA was the most common and was associated with the higher mortality. Candidemia occurred rarely but was associated with high mortality and loss of graft rates.

P261

**Prevalence and biotypes of vulvovaginal Candidiasis among reproductive-age women in Sarajevo.**

S. Kotoric Keser¹, A. Pilav², S. Bektaş¹, D. Hodžić¹, A. Obradović Balihodžić¹

¹Microbiology, P.I. INSTITUTE FOR PUBLIC HEALTH OF CANTON. SARAJEVO, Dr. Mustafe Pintola 1/III 71 000 Sarajevo, Sarajevo, Bosnia and Herzegovina, ²Social Medicine, P.I. INSTITUTE FOR PUBLIC HEALTH OF CANTON. SARAJEVO, Dr. Mustafe Pintola 1/III 71 000 Sarajevo, Sarajevo, Bosnia and Herzegovina

**Objectives:** The study aimed to determine the prevalence of VVC among reproductive-age women attending the Institute for Public Health of Canton Sarajevo. And to know the fungal profile/biotypes of vulvovaginal candidiasis using *Candida CHROMagar*.

**Methods:** This is a 4-month cross-sectional study performed at the Department of Medical Microbiology of the Institute for Public Health of Canton Sarajevo. A pair of high vaginal swab and endocervical swab samples was collected from each of 213 individual participating subjects. They were separately inoculated on Sabouraud's dextrose agar and incubated aerobically at 33°C for 48 hours and Candida CHROMagar. Infection with Candida species was diagnosed by microscopy of a saline wet mount, Gram-stained smear and colony growth on SDA and Candida CHROMagar.

**Results:** Of the 213 sampled, 109 were positive for candidiasis giving a prevalence rate of 51.1%. Candidiasis was observed mostly among the 20- to 30-year age-group. The ages of the women ranged from 16 to 45 years with a mean of 26.8 (standard deviation ± 4.93). Women aged 26–30 years recorded the highest prevalence of 37.6% (41/109). Candida albicans was the most prevalent species isolated in 85.3% of the women followed by Candida crusei 12.8% and Candida parapsilosis 1.83%.

**Conclusion:** High prevalence rate of vulvovaginal candidiasis among females in Sarajevo and the predominant agent is *Candida albicans*. In addition, correct identification of *Candida species* could play an important role in management and treatment of VVC.

P262

**Cryptococcal antigenemia in HIV-uninfected patients with stroke in Nigeria**

S.A. Fayemiwo¹, O. Makanjuola¹, F. Bongomin², J. Nwaokenye³, R. Akinyemi⁴, S. Diala⁴, M. Faniyan⁵, M. Owolabi⁴

¹Department Of Medical Microbiology & Parasitology, College of Medicine, University of Ibadan, Ibadan, Nigeria, ²Department Of Medical Microbiology And Immunology, Gulu University, Kampala, Uganda, ³Department Of Medical Microbiology & Parasitology, University College Hospital, Ibadan, Nigeria, ⁴Centre For Genomic And Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria, ⁵Department Of Medicine, University of Ibadan, Ibadan, Nigeria

**Objectives:** Stroke continues to be a leading cause of morbidity and mortality globally. Infections have been associated with stroke occasionally, but are not considered to be a direct cause, and so they are not often included in the traditional stroke workup and management. Sub-Saharan Africa also has the highest incidence, prevalence, and fatality from stroke in the world. Cryptococcal infections occur globally and in a wide variety of individuals, ranging from those who are severely immunocompromised to those who are assumed to be immunocompetent. Recurrent strokes secondary to cerebral infarction may occur and has been reported in immunocompetent persons following reactivation of a latent infection. The study aimed to determine the prevalence of
Cryptococcal antigenaemia in stroke patients, to identify risk factors for Cryptococcal antigenaemia in stroke patients and to compare Cryptococcal infection among stroke and non-stroke patients.

**Methods:** The Stroke Investigative Research and Education Network (SIREN) project, which this study was a part of, is a multicentre, multidisciplinary, case-control study carried out in Ghana and Nigeria. One of the objectives of this extensive study is to evaluate the risk factors of stroke in blacks in Sub-Saharan Africa. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. A simple random sampling was used to select blood samples of 50 stroke patients and 50 controls from the study population. Inclusion criteria were stroke patients and controls who were HIV negative confirmed by HIV testing. Serum from study participants was tested for the presence of Cryptococcal antigen with the Cryptococcal Antigen Lateral Flow Assay (LFA) (Dynamiker Cryptococcal Antigen Lateral Flow Assay (LFA)), a point-of-care test for the diagnosis of Cryptococcosis.

**Results:** Ninety-nine HIV-uninfected patients (50 cases and 49 controls) constituted the study population. Majority of the participants were males (n = 69, 70%), with a median age of 57 (range: 33-86) years. 36 (n = 50, 72%) for cases and 22 (n = 49, 44.9%) were hypertensive while six (n = 50, 12%) for cases and 14 (n = 49, 28.6%) were diabetic. Overall, CrAg was positive in 16% (n = 16) of the participants. Similar proportions of the cases and controls were CrAg positive (18% vs. 14%, p = 0.786). 8(n = 9, 89%) for cases and 3 (n = 7, 43%) hypertensive participants were CrAg positive. Death rates was the same between CrAg positive and CrAg negative patients (13% Vs 13%, p = 1.000 by Fisher's exact test). Multinomial Logistic Regression DM (odds ratios, 0.77 (95%CI: 0.55-1.08); p = 0.130).

**Conclusion:** Cryptococcal Infectious causes should be considered in the differential and work up of stroke in certain patient populations, especially in Sub-Saharan Africa, and appropriate treatments should be initiated to minimize adverse stroke-related outcomes.

P263

## Epidemiological, diagnosis and management of mycetoma cases in three hospital centers from 2008 to 2018 in Senegal

D. Sow¹, M. Ndiaye², L. Sarr³, P. Diousse², F. Ly², B.T. Faye⁴, K. Sylla⁴, S. Ranque⁵, B. Faye⁴

¹Service De Parasitologie-mycologie/section De Biologie, UFR Sciences de la Santé, Université Gaston Berger, Saint-Louis, Senegal, ²Service De Dermatologie, Faculté de médecine, UCAD, Dakar, Senegal, ³Service D'orthopédie, Faculté de médecine, UCAD, Dakar, Senegal, ⁴Service De Parasitologie, Faculté de médecine, UCAD, Dakar, Senegal, ⁵IHU-Méditerranée Infection, Marseille, France

**Objectives:** Mycetoma is a neglected tropical disease, characterized by the formation of tumor like-swellings and grains. This disease transmitted through subcutaneous tissue is caused by a range of actinomycetes (actinomycetoma) and fungi (eumycetoma). Treatments for eumycetoma are unsatisfactory leading to high amputation rates. Senegal represents one of the country where the disease is highly endemic. However, many mycetoma cases are underdiagnosed/misdiagnosed due to the lack of informations in health workers and at the community level. The purpose of this study is to generate accurate data of the geographical distribution of Mycetoma spp. cases and their management in hospital settings in Senegal.

**Methods:** In this retrospective study we report epidemiologic, clinical, diagnostic and therapeutic data of mycetoma observed in three hospital centers in Senegal in a 10 year-period (2008 to 2018).

**Results:** A total of 193 cases were included in the study. One hundred and sixty two patients (83.5%) were recruited in two hospitals of the capital Dakar and the other patients (16.5%) were diagnosed in Thiès region located at 70km from Dakar. Most of the cases (47.2%) were eumycetoma followed by 36.8% for actinomycetoma cases and 16.1% undetermined form. The mean age was 38.3 years and the patients were predominately aged between 15 and 45 years (68.4%). There was a male predominance with a sex ratio of 2.94 and most patients were agricultural workers. One hundred fifty six patients (80.8%) have used local and oral phytotherapy before attending hospital with sometimes an evolution beyond 10 years (19.1%). The main affected localization was lower limbs
(90.6%) and most of the patients had lesions over 10cm. Grains were observed in 85% cases including white (25.6%) and yellow (4.3%) grains. The diagnosis was difficult in many cases without positive results in direct microscopy, culture and histopathology explaining that 16.1% remained undetermined. In most of cases, actinomycetoma form were treated with cotrimoxazole plus amoxicillin/clavulanic acid plus streptomycin while eumycetoma cases were treated with terbinafin. The surgery was done in 100 cases (51.8%) including amputation performed in 45 patients.

**Conclusion:** This study has shown the difficulty of the diagnostic of mycetoma in Senegal, the delay in management cases and the lack of adequate therapeutic tools. The baseline data provided will contribute to the establishment of a surveillance system, in the context of advocating for much more attention.

P264

**Clinical and Microbiological Characterization of *Candida parapsilosis* complex Infection in a**
**Tertiare Care Hospital from Cali, Colombia**

A. Ceballos-Garzon¹,², L. Martinez³, C.M. Parra-Giraldo², A.M. Sanz Montealegre³, D.M. Martinez³, F. Rosso Suarez³

¹Department Of Parasitology And Medical Mycology Of The University Of Nantes., Universite de Nantes, Nantes, France, ²Unidad de Proteómica y Micosis Humanas, Grupo de Enfermedades Infecciosas Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá D.C, Colombia, Bogota, Colombia, ³Centro de investigaciones clínicas Fundación Valle del Lili, Cali, Colombia

**Objectives:** To determine the association between the resistance of *C. parapsilosis* complex to Fluconazole and adverse clinical outcomes in patients hospitalized in the Valle del Lili Foundation.

**Methods:** An observational prospective study was conducted. The study included patients with *C. parapsilosis* complex (CPC) isolations attended at Valle del Lili Foundation (FVL) from 2016 to 2017. The 55 strains were identified by MALDI-TOF MS. Minimal inhibitory concentrations (MIC) were determined by broth microdilution (M27 A3 CLSI). Statistical univariate analysis was performed; differences between resistant cases and non-resistant cases were assessed through U Mann-Whitney test, Pearson chi-2 test or Fisher exact test

**Results:** 55 patients had CPC isolations during the study period: 18 newborns, 13 children, and 24 adults. Most isolations were from blood cultures (n = 31) (14 of them newborns), bronchoalveolar lavage (n = 9), peritoneal fluid (n = 8), and catheter tips (n = 3). The resistance was 36%. 52 strains were *C. parapsilosis* s.s., of them, 20 were FCZ resistant; 3 strains were *C. orthopsilosis*, all of them FCZ sensitive. The MIC50 = 1 µg/ml and MIC90 = 16 µg/ml. Patients with previous antifungal treatment had a higher risk of FCZ resistance (RR: 2.14, 95% IC 1.07-4.26). The mortality brute rate was 30%, patients with renal failure death risk (RR: 2.8, 95% CI: 1.4-6.9), heart disease (RR: 3.14, 95% CI: 1.4-6.9), and hemodialysis (RR: 2.97, 95% CI: 1.38-6.4). Candidemia was present in 50% of deaths among children with parenteral nutrition
<figure><img src="image_71.png" /><figcaption>**Figure 1.** Minimal inhibitory concentrations (MIC) to *C. parapsilosis* complex (n = 55). Strains ATCC 6258 and ATCC 22019 was used as a control.

**Graphical analysis of the mass spectra obtained by MALDI-TOF MS**</figcaption></figure>

<figure><img src="image_72.png" /><figcaption>**Figure 2.** Graphical analysis of mass spectra obtained by MALDI-TOF MS of cytoplasmic protein extracs from clinical isolates of *C. parapsilosis* complex.</figcaption></figure>

**Conclusion:** Fluconazole resistance in CPC has increased in the last decade. Newborns receiving parenteral nutrition had a higher proportion of CPC fungemia, we also found higher mortality rates among this population

P265

**Characterisation and Antifungal Susceptibility of *Cryptococcus* species Isolated from Rodents**

N.N. Tirkey, K. Singh

Animal Mycology Laboratory, Zoology, Mmv, Banaras Hindu University, VARANASI, India

**Objectives:** Rodents are recognized as intermediate hosts of zoonotic diseases that represent a serious threat to human health. *Cryptococcus* is an opportunistic fungal pathogen found worldwide and causes life-threatening meningoencephalitis especially in immunocompromised host. In this view, the present study was conducted to investigate the role of rodents in the epidemiology of cryptococcosis caused by *Cryptococcus neoformans*.

**Methods:** Rodents (*Rattus rattus*, *Mus musculus castaneus*, *Mus musculus domesticus*) were trapped from the city of Varanasi, India (eastern Uttar Pradesh). After behavioural and clinical examinations, they were euthanized. The organs were removed aseptically for histopathology and isolation of fungi. For isolation, homogenates were cultured on Sabouraud's dextrose agar (SDA). The isolates were then grown in Staib's and tobacco agar medium. In addition, all isolates were identified on the basis of different biochemical tests such as germ tube test, urease test and canavanine-glycine-bromothymol blue (CGB) test. Further, molecular characterization was carried out by using PCR and
DNA sequence analysis. *In vitro* antifungal susceptibility profiles of *Cryptococcus* strains were performed by using broth microdilution method recommended by CLSI (2009) M27-A3.

**Results:** Out of 20 screened, 2 rodents were positive for *Cryptococcus* spp. At the necroscopy, there were no pathological lesions. *Cryptococcus* species were isolated from the lungs, kidney, brain and blood of the animals. The isolates were subjected to germ tube test and pseudohyphae were not observed after 24 hrs of incubation at 37°C in mammalian serum, therefore the test was considered as negative. The presence of brown colonies on Staib's and tobacco agar media confirmed that the isolated pathogen is *Cryptococcus*. Further the isolates of *Cryptococcus* were tested for urease production using Christensen urea citrate agar medium in which all isolates were found to hydrolyse urea rapidly and reddish pink colour was obtained confirming it to be *Cryptococcus neoformans*. All isolates were negative for Canavanine glycine bromothymol blue (CGB) as they failed to produce a colour change in the medium. Molecular analyses showed that these isolates were *C. neoformans*. Histological sections of lungs stained with haematoxylin and eosin stain revealed the presence of *C. neoformans* like encapsulated cells. In *in vitro* antifungal testing, isolates were found susceptible to amphotericin B.

**Conclusion:** All the rodents screened are synanthropic. As they were found positive for *C. neoformans*, they could be a potential threat for human health. Therefore wide epidemiological survey should be conducted.

P266

Prevalence and characterization of otomycosis among patients attending Ear, Nose and Throat clinics at Abia State University Teaching Hospital, Aba, South Eastern Nigeria

A. Ngwogu¹, K. Ngwogu²

¹Medical Microbiology, Abia State University Uturu, Aba, Nigeria, ²Histopathology, Abia State University Uturu, Aba, Nigeria

**Objectives:** Otomycosis or Fungal Otitis External is a superficial infection of the outer ear canal. This could lead to complications involving the middle ear. The prevalence of otomycosis has been studied in several parts of the world. It is seen more frequently as an opportunistic infection in Immunocompromised people and those with ear injury. This study was carried out to determine for the first time, the prevalence of otomycosis in patients attending the Ear, Nose and Throat (ENT) Clinics at Abia State University Teaching Hospital (ABSUTH), Aba, South Eastern Nigeria and to isolate and characterize fungal agents responsible for otomycosis.

**Methods:** A total of 380 patients presented at the ENT Clinics during the period of study. Out of this number, 100 samples were collected from those patients who presented with symptoms of ear infection (pruritis, otalgia, otorrhea and hypacusis) by the ENT Consultant Physician. Patients with other types of ear disorders other than otitis media and otitis externa and patients under antibiotic therapy within the last 2 weeks were excluded from the study. Demographic characteristics of the patients were noted. The samples which consisted of swabs and scrapings were examined in 10% potassium hydroxide solution and cultured on Sabouraud Dextrose Agar containing Chloramphenicol. Fungal growth were identified using slide culture techniques and physiological tests which include growth on some cspecialized media, germ tube test, urease test, growth in Corn Meal Agar Containing Tween 80, nitrate assimilation, sugar assimilation and sugar fermentation tests.

**Results:** Out of the 100 samples examined, (68% males and 32% females) were positive for fungal structures both in microscopy and culture. Males were significantly more affected than females in the ratio of 19: 4 (P<0.01). Although ear infection was highest within the age group 1-10 years, fungal infection was highest within the age group 31- 40 years. Otomycosis was highest amongst outdoor, unskilled labourers (8%), followed closely by students (6%) and lowest among civil servants (2%). The aetiologic agents isolated were Candida albicans (13%), Candida tropicalis (5%), Aspergillus fumigatus (3%) and Aspergillus niger (2%).

**Conclusion:** This study has shown for the first time that fungi are implicated in ear infections in ABSUTH. The prevalence of otomycosis in the present study is high. Clinical follow up with
mycological diagnosis are important since symptoms (pruritis, otalgia, otorrhea and hypacusis) are not specific. In fact many cases of otomycosis are clinically misdiagnosed as otitis media leading to chronicity. Laboratory diagnosis and management of otomycosis though challenging is very important. This is to detect the causative organism and avoid wrong prescription of drugs. Recurrences are common in immunocompromised patients than in immunocompetent patients. General practitioners, otologists and laboratory personnel should remain alert for otomycosis. Diagnosis of ear infections should not be made on clinical diagnosis only, it should be confirmed by laboratory diagnosis. Specimens must be collected by an experienced Medical Personnel by aid of otoscope. The frequent use of earphones, pricking the ear with hard objects, and traumatic attacks on the ear are factors that could predispose to otomycosis.

P267

Six Year Surveillance Study of Scedosporium and Lomentospora Isolates Collected from Humans
in the United States (2012 - 2018)

S. Bauman, C. Gibas, C. Sanders, D. Mccarthy, H. Patterson, N. Wiederhold

Fungus Testing Laboratory, The University of Texas Health Science Center at San Antonio, San Antonio, United States of America

**Objectives:** *Scedosporium* species and *Lomentospora prolificans* are increasing causes of invasive infections in immunocompromised hosts, and many isolates have reduced susceptibility or are resistant to available antifungals. This is especially true for isolates of *L. prolificans*, which are often resistant to all clinically available antifungal agents. Although these fungi can be common colonizers in patients with cystic fibrosis, invasive infections can occur, as can breakthrough infections in persistently neutropenic and or lymphopenic patients, as well as lung transplant recipients. Our objective was to evaluate the species distribution and antifungal susceptibility patterns of *Scedosporium* and *Lomentospora* clinical isolates in the United States over a 6-year period.

**Methods:** The electronic database of our reference mycology laboratory (Fungus Testing Laboratory, UT Health San Antonio) was queried for *Scedosporium/Pseudallescheria/Lomentospora* isolates received between September 2012 and October 2018. Fungal species identification was performed when requested by observation of phenotypic characteristics combined with DNA sequence analysis of ITS rDNA and the calmodulin gene. Antifungal susceptibility testing was performed by broth microdilution according to the CLSI M38 standard.

**Results:** 1376 isolates were received over this 6-year period. The overall species distribution as well as the distribution of species identified by our laboratory are shown in Table 1. Overall, *S. apiospermum* was the most prevalent species, followed by *S. boydii* and *L. prolificans*, and these 3 species accounted for ~89% of the isolates received. Voriconazole had the most potent *in vitro* activity of the azoles and amphotericin B tested against *Scedosporium* species (Voriconazole geometric mean [GM] MIC range 0.79 – 0.83 mg/L Table 2). In contrast, the activity of isavuconazole was markedly reduced (GM MIC range 6.25 – 6.68 mg/L). Caspofungin and micafungin also demonstrated *in vitro* activity against *Scedosporium* species, although the clinical relevance of the minimum effective concentration (MEC) is unknown. The *in vitro* potency of all agents was reduced against *L. prolificans*. However, greater variability was observed when all isolates were included in the analysis versus those that our laboratory identified, especially for *L. prolificans*, which is considered to be pan-resistant to clinically available agents. This suggests possible misidentification of species, which may be due to reliance on phenotypic characteristics.
<table><caption>Table 1. Species distributions of *Scedosporium*, *Pseudallescheria*, and *Lomentospora prolificans* isolates from the United States (2012 – 2018).</caption><thead><tr><th>Species</th><th>Number (all isolates)</th><th>Percentage (all isolates)</th><th>Number (ID confirmed)</th><th>Percentage (ID confirmed)</th></tr></thead><tbody><tr><td><i>S. minutisporum</i></td><td>2</td><td>0.15%</td><td>2</td><td>0.84%</td></tr><tr><td><i>P. angusta</i></td><td>2</td><td>0.15%</td><td>2</td><td>0.84%</td></tr><tr><td><i>S. aurantiacum</i></td><td>7</td><td>0.51%</td><td>4</td><td>1.68%</td></tr><tr><td><i>S. dehoogii</i></td><td>7</td><td>0.51%</td><td>5</td><td>2.10%</td></tr><tr><td><i>P. ellipsoidea</i></td><td>7</td><td>0.51%</td><td>5</td><td>2.10%</td></tr><tr><td><i>S. apiospermum</i> complex</td><td>102</td><td>7.41%</td><td>7</td><td>2.94%</td></tr><tr><td><i>S. boydii</i></td><td>121</td><td>8.79%</td><td>35</td><td>14.7%</td></tr><tr><td><i>L. prolificans</i></td><td>231</td><td>16.8%</td><td>43</td><td>18.1%</td></tr><tr><td><i>S. apiospermum</i></td><td>621</td><td>45.1%</td><td>135</td><td>56.7%</td></tr><tr><td><i>Scedosporium sp.</i></td><td>276</td><td>20.1%</td><td>---</td><td>---</td></tr></tbody></table>

<table><caption>Table 2. MIC/MEC values against *Scedosporium* species and *Lomentospora prolificans* as performed by CLSI broth microdilution methodology.</caption><thead><tr><th rowspan="2">Species</th><th colspan="2">S. apiospermum</th><th colspan="2">S. boydii</th><th colspan="2">S. dehoogii</th><th colspan="2">S. aurantiacum</th><th colspan="2">L. prolificans</th></tr><tr><th>Range</th><th>GM MIC</th><th>Range</th><th>GM MIC</th><th>Range</th><th>GM MIC</th><th>Range</th><th>GM MIC</th><th>Range</th><th>GM MIC</th></tr></thead><tbody><tr><td>Amphotericin</td><td>0.06-<br/>>16</td><td>3.83</td><td>0.5-<br/>>16</td><td>4.88</td><td>2-8</td><td>---</td><td>16</td><td>16</td><td>0.25-<br/>16</td><td>12.1</td></tr><tr><td>Caspofungin</td><td>≤0.015-<br/>>8</td><td>1.29</td><td>0.06-<br/>>8</td><td>1.09</td><td>1</td><td>---</td><td>---</td><td>---</td><td>1-8</td><td>6.85</td></tr><tr><td>Micafungin</td><td>≤0.015-<br/>>8</td><td>0.43</td><td>0.06-<br/>>8</td><td>0.45</td><td>0.25</td><td>---</td><td>4-8</td><td>---</td><td>0.25-<br/>>8</td><td>6.09</td></tr><tr><td>Itraconazole</td><td>0.25-<br/>>16</td><td>3.99</td><td>0.06-<br/>>16</td><td>3.16</td><td>4</td><td>---</td><td>---</td><td>---</td><td>0.5-<br/>>16</td><td>12.8</td></tr><tr><td>Posaconazole</td><td>0.125-<br/>>16</td><td>1.48</td><td>≤0.03-<br/>>16</td><td>1.39</td><td>1-2</td><td>---</td><td>2-4</td><td>---</td><td>1-16</td><td>12.2</td></tr><tr><td>Voriconazole</td><td>0.125-<br/>>16</td><td>0.83</td><td>0.125-<br/>>16</td><td>0.79</td><td>0.5-2</td><td>---</td><td>1</td><td>---</td><td>0.5-<br/>>16</td><td>10.6</td></tr><tr><td>Isavuconazole</td><td>0.5-16</td><td>6.25</td><td>0.5-<br/>>16</td><td>6.68</td><td>---</td><td>---</td><td>16</td><td>16</td><td>1-16</td><td>12.2</td></tr></tbody></table>

**Conclusion:** *Scedosporium* species and *Lomentospora prolificans* are not uncommon fungi cultured from patients in the United States. The species distribution we observed is similar to those reported in previous surveillance studies from other countries. Although voriconazole had the most potent *in vitro* activity, variability was observed among the different species, with reduced activity observed for all antifungals against *L. prolificans*.

P268

Molecular typing of isolates of *Microsporum canis* collected in Brasil

J. Neves¹, J. Alvarez², A.R. Molinar¹, M. Pasquetti¹, S.D.A. Coutinho², A. Peano¹

¹Department Of Veterinary Sciences, Sector Of Parasitology, University of Turin, Grugliasco, Italy,

²Post-graduation Program In Environmental And Experimental Pathology, Paulista University, São Paulo, Brazil

**Objectives:** *Microsporum canis* is the most common dermatophyte in cats and dogs. *M. canis* is diffused worldwide and plays an important zoonotic role. Methods able to characterize a pathogen at a strain level are expected to provide useful information to gain insight into the dynamics of disease transmission. Among methods proposed for strain typing of dermatophytes, the microsatellite (MS) multilocus typing method is considered one of the most powerful tool. MS are tandem-repeating DNA sequences comprised of 1-6 bp per repeating unit, that are polymorphic in populations due to their propensity for insertion/deletion mutation of multiples of the repeating unit during replication. Multiple loci are generally used, so that a multilocus genotype is obtained (multi-locus microsatellite typing – MLMT). This study was aimed to investigate the intra-specific variability of strains of *M. canis* isolated from different animal hosts and environment sites in Brasil, using a panel of 8 MS.

**Methods:** Fungal strains were collected in different locations in Brasil (mainly in the city of São Paulo), from cats, dogs and environment sites. Overall, 73 strains of *Microsporum canis* from 12 outbreak episodes were included in the genetic analyses. DNA was extracted using a commercially available kit (NucleoSpin® Tissue, Macherey-Nagel, Düren, Germany). PCR primers were designed against sequences flanking the MS detected by a BLAST (Basic Local Alignment Search Tool) search using the nucleotide sequence information assembled by the *Microsporum canis* CBS 113480 genome project
(http://www.broadinstitute.org/annotation/genome/dermatophyte_comparative/MultiHome.html). Primer sequences for the 8 MS markers recognized as the most polymorphic were custom synthesized (Applied Biosystems UK) with a fluorescent label attached to the 5' end of each forward primer. Microsatellite fragment analysis was performed using an ABI Prism 310 Genetic Analyzer (Applied Biosystems, FosterCity, CA) for capillary electrophoresis. The ML-MS genotypes for the Brasilian isolates were compared with the genotypes available in the database of the Departament of Veterinary Medicine of Turin, which includes more than 300 strains mainly sampled in Europe.

**Results:** Out of the analyzed strains, 5 different multilocus genotypes were detected. One genotype was more prevalent as it was shared by 11 strains coming from 9 episodes. Thus the genetic diversity was quite low, perhaps due to the fact that a restricted geographic area was sampled. A higher degree of diversity is instead present in the existing database.

**Conclusion:** These data allow enriching the database of MS profiles already available, which regards mainly strains isolated in Europe. Such an enrichment represents a key step to make the database a more and more powerful reference in the study of the dynamics of transmission of *M. canis*. Indeed, it must be pointed out that studies that report the same strain among all isolates from a suspected outbreak, occurring in a geographic region for which no baseline data on the degree of variation in the population exists, remain uninterpretable.

P269

**Genetic diversity of *Pneumocystis jirovecii* in a tertiary hospital in Spain**

L. Goterris Bonet¹, M. Guerrero Murillo¹, L. Pasic², A. Anton Pagarolas¹, J. Aguilar Company³, I. Ruiz-Camps³, M.T. Martin-Gomez¹

¹Microbiology, Vall d'Hebron University Hospital, Barcelona, Spain, ²Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, The University of Sydney, Sydney, Australia, ³Infectious Diseases, Vall d'Hebron University Hospital, Barcelona, Spain

**Objectives:** *Pneumocystis jirovecii* (PJ) is an opportunistic fungus that can be found in the respiratory tract of humans as an asymptomatic colonizer or as a cause of severe pneumonia (PJP) in immunocompromised patients. Establishing associations between genetic types and clusters of cases, clinical manifestation or underlying pathology is not easy as there is no consensus on the better typing scheme. The aim of this study is to apply two multi-locus sequence typing (MLST) protocols to ascertain their ability to discriminate the genetic diversity of colonized and infected immunocompromised patients visited at a tertiary referral hospital in Spain.

**Methods:** **Patients and samples:** From April 2014 to April 2018, consecutive respiratory tract samples with a positive result for *P. jirovecii* by PCR were included. Only 1 sample per patient and respiratory episode was studied. **Laboratory procedures:** Two different MLST protocols were carried out. Protocol A (http://mlst.mycologylab.org/pjirovecii) targeted the B-tubulin, dihydropteroate synthase (DHPS) and mitochondrial 26S rRNA (mt26S) loci. Protocol B is a newly developed scheme targeting the cytochrome B (cyt), mt26s and superoxide dismutase (SOD) loci (Pasic et al. Establishment and optimization of a combined MLST scheme for *Pneumocystis jirovecii*. 21st ISHAM Congress 2018, P-223). **Phylogenetic analyses:** The obtained sequences were depurated and collapsed before achieving phylogenetic analyses. The resulting trees were constructed computing genetic distances among patients for each protocol. Patients were categorized into PJP (green) or PJ colonized (red) groups.

**Results:** Samples from 35 pneumonia cases and 51 colonizations were included. Successful amplification rate was non-significantly different for protocol A (total 58.1%; 26/35[LG1] PJP and 24/51 colonizations) and B (total 72.1%; 26/35 PJP and 34/51 colonizations). As shown in figure 1, Protocol A allowed the identification of 11 sequence-types (ST) whereas protocol B was able to find 21 different ST. Both protocols agreed in finding no apparent clustering of cases in time or space. However, whereas Protocol A grouped 73.1 %[LG2] of pneumonia cases into a group of 7 closely related ST and 61% of colonization cases into the other 4 ST, no apparent correlation between illness and ST could be seen with protocol B.
<figure><img src="image_73.png" /><figcaption>Figure 1. Phylogenetic trees from MLST protocols including b-tubuline, DHPS and mt26S loci (A) and Cyt, SOD and mt26S (B). Patients were named by numbers and showed green (PJP) and red (PJ colonized)</figcaption></figure>

**Conclusion:** In the present study, two MLST protocols were carried out to describe PJ genetic diversity in our cohort. The two protocols provided complementary information: greater genetic diversity was documented with protocol B, whereas protocol A helped us to find sequence-types mostly associated with PJP or colonization. This study allowed us to demonstrate the absence of PJ outbreaks in our hospital during the study period.

P270

**Disability and disease after hazardous indoor exposure to airborne Stachybotrys spores: exposure variable analysis shows significant correlation with injury to mucosa, phagocytes and neurons.**

I.H. Grant<fnref n="1" />, J. Geller<fnref n="2" />, H. Sabath³

**Objectives:** While *Stachybotrys* is a mold that flourishes indoors with chronic water intrusion, its spores usually require physical disturbance of its colony growth or prolonged wetness to become airborne. The macrocyclic Trichothecenes mycotoxins in its spores are extremely toxic nanoparticulates dangerous for all mammals, damaging intracellular protein/DNA/RNA production and mitochondrial function causing premature cell death on contact: apoptosis. As exotoxins, they remain toxic despite disinfection, bind to dust causing damage to mammalian skin, mucosa, phagocytes, neurons, and organs via systemic circulation, especially with inhalation. **Objectives:** To determine: - The frequency of severe illness due to indoor airborne Stachybotrys spore exposure. - Specific exposure risks (fungi, hazardous exposure activities) - The impact of genetically-impaired intracellular MTHFR detoxification capacity. - Conditions that predispose to opportunistic fungal infection with such exposures (e.g. mucosal injury, immunosuppression, malnutrition)

**Methods:** Prospectively monitored 14 (7M, 7F) adults and children exposed to 5 documented Macrocyclic Trichothecenes-contaminated indoor-environments with airborne *Stachybotrys* spores with comprehensive environmental-mycological and medical investigations, fungal IGGs, urine mycotoxins (MCTs: Aflatoxin, Gliotoxin, Ochratoxin A, MT), immune parameters (neutrophils, lymphocyte subsets, monocytes, IGG, IGA, IGM, IGE, subclasses), immunosuppressants, nutritional deficiencies (protein, Vitamin D, zinc), genetic Methylenetetrahydrofolate reductase (MTHFR) single-nucleotide-polymorphisms C677T&A1298C. Disease Severity Outcomes (DS), Environmental Mold-Contamination Severity (EMCS), Hazardous Exposure Activities (HEA), Exposure Duration (ED), MCT/Trichothecenes exposure (MTC/TE), and clinical findings were stratified and analyzed.

<footnote n="1">¹Community Medicine, New York Medical College, Tarrytown, United States of America,</footnote>

<footnote n="2">²Information Revelations, Montclair NJ, United States of America, ³International Environmental</footnote>

<footnote>Diagnostics Inc, Irvington NYw, United States of America</footnote>
Biostatistical analysis (Pearson Correlation Coefficients) correlated DS with EMCS, HEA, ED, MCT/TE, mucosal Injury (MI), Neurological disease, Cell-mediated Immunodeficiencies (CMIs), combined cellular-immunoglobulin immunodeficiencies (CCIs), mucosal injury (MI), mold-specific IGG response(M-IGG) and genetic MTHFR deficiencies.

Results:

<table><thead><tr><th>Disability Outcomes</th><th>Disabled</th><th>5/14 (36%)<br>Permanently 3/5 (60%) 67% male</th></tr></thead><tbody><tr><td>Emergency Treatment</td><td></td><td>4/14 (29%) 50% female</td></tr><tr><td>Bedridden</td><td></td><td>2 100% female</td></tr><tr><td>Hospitalized</td><td></td><td>1 male</td></tr><tr><th colspan="3">Disease Frequencies</th></tr><tr><td>Mucosal Injury</td><td></td><td>11/14 (79%) 64% male (8 severely/extremely ill)</td></tr><tr><td>Nasal Symptoms</td><td>• Nasal Symptoms</td><td>9/14 (64%) 56% female</td></tr><tr><td>Ear/Nose/Throat Injury</td><td>• Ear/Nose/Throat Injury</td><td>ENT 11/11 (100%) 55% male<br>• 2 denuded nostril mucosa (62% female)<br>• 4 loss of nostril hairs (66% female)<br>• 4 ulcerated mucosa (53% female)</td></tr><tr><td>Pain, severe, unexplained</td><td></td><td>11/14 (79%) 55% male</td></tr><tr><td>Bleeding</td><td></td><td>10/14 (71%) 60% female<br>ENT 10/10 55% male<br>Pulmonary 4/10 50% male<br>GI 4/10 63% male</td></tr><tr><td>Neurologic</td><td></td><td>10/14 (71%) 50% male<br>• Cognitive impairment<br>• Toxic Encephalopathy<br>• Permanent Neurocognitive Damage</td></tr><tr><td>Burning</td><td></td><td>9/14 (64%) 67% male</td></tr><tr><td>Chronic Fatigue</td><td></td><td>9/14 (64%) 67% female</td></tr><tr><td>Cough</td><td></td><td>8/14 (59%) 63% female</td></tr><tr><td>Postnasal Drainage</td><td></td><td>8/14 (57%) 50% male</td></tr><tr><td>Pulmonary</td><td></td><td>7/14 (57%) 63% female</td></tr><tr><td>Dermatological</td><td></td><td>7/14 (50%) 71% female</td></tr><tr><td>Sinusitis</td><td></td><td>7/14 (50%) 57% male</td></tr><tr><td>Muscles</td><td></td><td>7/14 (50%) 57% female</td></tr><tr><td>Joints</td><td></td><td>7/14 (50%) 57% male</td></tr><tr><td>GI</td><td></td><td>6/14 (43%) 50% female</td></tr><tr><td>Headaches</td><td></td><td>6/14 (43%) 50% male</td></tr><tr><td>Environmental Chemical Sensitivity</td><td></td><td>3/14 (21%) 67% male</td></tr></tbody></table>

Clinical Parameters

Immune Defects

13/14 (93%)

Cell Mediated Immune Defects 13/14 (93%)

Immune Defects: 11/14 (79%) 55% male

(Vitamin D deficiency: 11/14 (79%) 55% male)

Neutrophil Defects: 12/14 (86%) 58% female; Zinc 6 (100% female); Protein deficient 3, Steroids 5 (60% female with 100% deteriorating after RX)

Combined Innate-Neutrophil Defects

13/14 (93%) 54% female

Immunoglobulin Deficiencies

10/12 tested (83%) 50% female

IGA 5/10 (50%) 60% female

IGG Total Defic 4/10 (40%)

IGG Subclass Defic 7/10 (70%)

IGM Defic 1/10

Combined CMI Immunoglobulin Defects

9/14 (64%) 56% female

None (minimally ill)

7/9 (78%) severely/extremely ill

Genetic:

MTHFR DEFECTS

13/14 (93%)

A1298c Total 10 (male 70%)

4 Heterozygous, 2 homozygous

4 Compound Heterozygous

C677T Total 3 (female 100%)

2 Heterozygous, 1 homozygous

4 Compound Heterozygous

**CORRELATIONS:** Disease Severity based on formal disability classification or physical injury strongly correlated with Hazardous Activities (p = 0.01819), Immune deficiencies (p = .046229). Environmental Exposure Exposure Hazards (especially unprotected mold disturbance, uncontained construction/repairs, basement living, HVAC contamination and sewage overflow) correlated with immunodeficiencies (p = .046229). Environmental contamination with multiple mycotoxins correlated with multiple mycotoxin urinary excretion (p = .026354). Duration of exposure correlated with urinary excretion of multiple mycotoxins (p = .006314) as well as Trichothecenes p = .00875). Urine Trichothecenes correlated with immunoglobulin deficiencies (p = .037285).

**Conclusion:** The high frequency of immune deficiencies (93%), mucosal injury and pain (79%), bleeding, and neurological damage (71%), burning and chronic fatigue (64%) with expected
respiratory/Gi /Dermatologic symptomatology in 50% is consistent with known Trichothecenes effects in animal models and military data. The high frequency of cell-mediated immune deficiency is consistent with invitro and in vivo research on Stachybotrys spores injuring phagocytes, supporting injury from inhalation of Stachybotrys spores. The high 94% MTHFR methylation-defect incidence is peculiarly striking compared to estimated USA 50-60% prevalence. MTHFR is a key intracellular detoxifying enzyme protecting ribosomes/mitochondria RNA/DNA damage from Trichothecene injury via glutathione metabolism. Further investigation is needed to determine if Trichothecenes trigger genetic damage. Urine macrocyclic Trichothecenes detection appears a useful marker for environmental macrocyclic Trichothecenes exposure. Public health education and epidemiological research are urgently needed to investigate correlation between environmental mold/mycotoxin exposure and immunodeficiencies.

P271

Two different involvement of Aspergillus fumigatus in the same case: endophthalmitis and lumbar spondylodiscitis

G. Dogan¹, O. Tunger¹, F. Kocoglu¹, C. Temiz², P. Temiz³, S. Senol¹, C.B. Cetin¹

¹Infectious Diseases And Clinical Microbiology, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey, ²Neurosurgery, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey, ³Pathology, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey

Case Report:

*Aspergillus* species are mold type fungi that commonly found in nature and especially for immunocompromised people can cause opportunistic infections. *Aspergillus*-induced endogenous endophthalmitis is a very rare ophthalmic emergency that can result in visual loss. Bone infections caused by *Aspergillus* species are also rare clinical manifestation especially occurs in immunocompromised patients. In this case report, two rare clinical conditions such as endogenous endophthalmitis and lumbar spondylodiscitis due to Aspergillus are reviewed.

A 39-year-old woman with no known underlying disease was admitted to the Ophthalmology Department with loss of vision in her left eye. Approximately two months ago, there was a history of antibiotic use (moxifloxacin) for pneumonia. No additional physical examination findings were detected in the patient. Laboratory tests revealed erythrocyte sedimentation rate 59 mm / h, leukocyte count 9.81 10³ / /L, hematocrit 34.2%, platelet count 552 10³ / /L, neutrophil count 7.53 10³ / /L, C-reactive protein 1 mg / dl. Vasculitis was detected in ocular angiography and corticosteroid therapy (prednisolone 32 mg) was started by consultation of Rheumatology Department. Lumbar puncture was performed after normal result of cranial MRI that performed for differential diagnosis of vasculitis, and CSF examination was normal. The patient had undergone vitrectomy because the complaint did not regress despite steroid treatment. Direct examination of the vitreous specimen revealed gram positive bacteria and fungi, and intravitreal Liposomal AMB treatment with intravenous liposomal amphotericin-B (LAMB) and moxifloxacin was initiated. *Aspergillus fumigatus* was grown in vitreous samples. Bronchoscopy was performed and there was no cultural growth in BAL samples. Parenteral antimicrobial treatment was completed and was discharged after 14 days. The patient who had low back pain and morning stiffness was hospitalized in Rheumatology with the preliminary diagnosis of ankylosing spondylitis and received 250 mg intravenous methylprednisolone treatment for 3 consecutive days. Due to the absence of sacroileitis in MR imaging and monitoring of L4-L5 spondylodiscitis, piperacillin tazobactam and daptomycin were started empirically. The patient was than hospitalized in Infectious Diseases. In the pathological examination of the lumbar spine, fungal hyphae were seen and LAMB (3 mg / kg) was added to the treatment because of the positive galactomannan antigen (GMA). The patient whose complaints had regressed and whose GMA was negative was discharged with oral voriconazole after 45 days use of LAMB and 7 days use of parenteral voriconazole. The patient underwent oral voriconazole therapy for 160 days during outpatient follow-up, and regression was detected in control magnetic resonance imaging. CONCLUSION: In immunosuppressive and immunocompetent patients, fungal agents