ISID 2022: Fungal Resistance, Diagnostics, and Therapy Updates

The session focussed on the estimation of burden of serious human fungal infection in Malaysia, pulmonary aspergillosis management, and the outbreak and control of Candida auris.

Globally, 300 million people are affected by severe fungal infection, 25 million are at high risk of dying or loss of vision and there are almost 1.6 million deaths due fungal infection. Cryptococcal meningitis is the highest life-threatening fungal infection, pneumocystis pneumonia, disseminated histoplasmosis, aspergillosis and invasive candidiasis. In Asia, the burden of fungal disease is the highest due to the tropical environment, inadequately trained healthcare professionals and misuse of broad spectrum antibiotics. A study conducted across 60 countries (including Malaysia) to study the burden of fungal infection (2018) has shown that in Malaysia recurrent vaginal candidiasis is very common. In Japan, there are remarkably high cases of esophageal candidiasis in those without HIV and low rates of aspergillosis. Peru and Malaysia have high numbers of fungal asthma. Asia faces a challenge in the reporting of cases due to poor access to biomarkers tests and PCR. This elicits the need for proper laboratory support. In addition, clinicians too face challenges such as lack of formal training in medical mycology, lack of laboratory support for galactomannan assay and azole therapeutic drug monitoring, inability to use drug of choice due to high cost.

The WHO has released a fungal priority pathogens list to guide, research and development and public health action. It highlights 3 primary areas –

1. Strengthening laboratory capacity
2. Sustainable investment, research,development  and innovation
3. Public health interventions.

The burden of pulmonary aspergillosis (PA) and histoplasmosis is quite high. Pulmonary aspergillosis and tuberculosis may sometimes appear to have similar symptoms. The IDSA criteria for PA is 3 months of chronic pulmonary symptoms/chronic illness, progressive radiographic abnormalities with cavitation, pleural thickening and fungal ball. The GOLD standard for diagnosis is the aspergillus specific-IgG. Simple aspergillosis can be treated with surgical resection, in asymptomatic cases azoles can be given, chronic cavitary and fibrosing PA is treated with voriconazole or itraconazole > 6 months.

Global warming has been changing the fungal etiology worldwide. Candida auris is able to withstand high temperatures as compared to other related species. As compared to other Candida species, C auris predominantly exists in a haploid state. C. auris has high level resistance to azoles and some to amphotericin B and infection control is a challenge. This can be curbed by limiting antibacterial and antifungal overuse. During the COVID-19 pandemic, there have been increased incidence of candidemia associated with a higher mortality as compared to non-COVID patients. In addition, the interval of time to positive culture was 14 days in patients with COVID-19 as compared to non-COVID patients. Another infection that has serious consequences is acquiring aspergillosis in the ICU. Developing aspergillosis after influenza considerably increases the mortality rate. In sequential infections, irrespective of the first infection by a bacteria, fungi or a virus, there is an alteration of the immune system which is termed as immunomodulation. All these factors contribute to a challenge in infection management.

SS16 International Society for Infectious Diseases (ISID) Congress 2022, 17^th-20^th Nov. 2022, Malaysia