Understanding acquisition and evolution of antifungal resistance in chronic respiratory disease

烟曲霉是一种霉菌，可引起广泛的临床综合征。A.烟曲霉的感染主要取决于病原体和宿主免疫反应之间的相互作用，从无症状的定殖到危及生命的感染。侵袭性曲霉病（IA）是A.烟曲霉感染主要影响免疫功能低下的患者，而免疫功能亢进可导致过敏性支气管肺曲霉病（ABPA），其特征是进行性气道破坏和粘液嵌塞。患有既存慢性呼吸道疾病（例如支气管扩张，包括囊性纤维化（CF））的患者特别容易感染和对A过敏。烟熏。在这些个体中，A.烟曲霉可导致肺空洞形成或预先存在的空洞（足菌肿）的感染、ABPA发展或称为气管支气管炎的气道限制性感染。越来越多的人认识到A的致病和破坏作用。慢性呼吸道疾病中的烟曲霉菌。全球估计慢性肺曲霉病约为300万例。最近在英国估计约有300，000例支气管扩张患者中显示了非CF支气管扩张症中支气管扩张症相关疾病的高患病率。在高达约20%的CF患者中显示了与支气管炎相关的肺部疾病（例如ABPA、支气管炎、定植），并显示与住院率增加相关。慢性阻塞性肺疾病是侵袭性曲霉菌病的重要危险因素，病死率高，三唑类药物是治疗慢性呼吸道疾病曲霉菌相关感染和过敏的最常用抗真菌药物。然而，在过去的十年里，关于A.烟曲霉多重三唑耐药（MTR），随后治疗失败，死亡率增加。在慢性呼吸道疾病患者中，我们发现耐唑类A。烟曲霉约15%。在大多数这些分离株中，环境驱动的突变（TR 34）是耐药的原因;然而，慢性呼吸道疾病个体中MTR的获得和演变途径尚不清楚。A.然而，烟曲霉MTR分离物的出现，提出了在未来霉菌活性唑类可能不再有效的现实可能性。在慢性呼吸道疾病中，感染和耐药性的早期检测是结果的关键。检测A。然而，烟曲霉和MTR的鉴定受到当前真菌培养诊断的局限性和抗性检测的阻碍，所述真菌培养诊断具有差的灵敏度，所述抗性检测耗时、劳动密集且昂贵。通过本项目，我们的目的是验证一种新的快速检测方法（TR 34-LAMP）来检测A。烟曲霉和MTR分离株，并推进我们对MTR在慢性呼吸道疾病中的演变的理解。TR 34-LAMP检测试剂盒将用于检测A。直接在慢性呼吸道疾病患者的痰中检测烟曲霉菌和MTR，同时分析大型特征明确的支气管扩张患者队列中MTR的患病率。这种检测方法有可能通过基于“芯片实验室”的形式实现准确、低成本、快速、即时检测A。烟曲霉为了进一步了解A.烟曲霉MTR在慢性呼吸道疾病中的应用，一种前瞻性的全基因组测序方法将用于分析纵向A.烟曲霉分离株来自2个不同临床和地理位置的开始抗真菌治疗的慢性呼吸道疾病患者。将进行全面的环境和队列采样，以分析A的获得和演变。烟曲霉这些信息将为慢性呼吸道护理的未来感染控制和抗菌药物管理策略提供重要信息。

Aspergillus fumigatus is a mould that can cause a wide spectrum of clinical syndromes. The effects of A. fumigatus depend largely on the interplay between the pathogen and host immune response ranging from asymptomatic colonisation to life-threatening infection. Invasive aspergillosis (IA), the most severe form of A. fumigatus infection, predominantly affects immunocompromised patients while immune hyperactivity that can lead to allergic bronchopulmonary aspergillosis (ABPA), characterised with progressive airway destruction and mucus impaction. Patients with pre-existing chronic respiratory disease (e.g. bronchiectasis including cystic fibrosis (CF)) are particularly susceptible to infection and allergy to A. fumigatus. In these individuals, A. fumigatus can result in lung cavity formation or infection of pre-existing cavities (mycetoma), ABPA development, or airway limited infection called tracheobronchitis. There is an increasing recognition of the causative and destructive role of A. fumigatus within chronic respiratory disease. Global estimates of chronic pulmonary aspergillosis are ~3 million cases. A high prevalence of Aspergillus-associated disease in non-CF bronchiectasis has recently been shown with ~300,000 bronchiectasis patients estimated in the UK. Aspergillus-associated lung disease (e.g. ABPA, bronchitis, colonisation) has been shown in up to ~20% of individuals with CF and has been shown to be associated with an increased hospitalisation rate. Chronic obstructive pulmonary disease remains a significant risk factor for development of invasive aspergillosis with high mortality.Triazoles are the most widely used antifungal agents in treatment of Aspergillus-related infection and allergy in chronic respiratory disease. Over the last decade, however, there has been increasing reports of A. fumigatus multiple tri-azole resistance (MTR) with subsequent treatment failure and increased mortality. Within individuals with chronic respiratory disease we have shown a prevalence of azole resistant A. fumigatus of ~15%. In the majority of these isolates, an environmentally driven mutation (TR34) is the cause of resistance; however the route of acquisition and evolution of MTR within individuals with chronic respiratory disease is as yet unclear. The rapid emergence and global spread of A. fumigatus MTR isolates, however, has raised the realistic possibility that in the future mould-active azoles may cease to be effective.Early detection of infection and resistance is key to outcome within chronic respiratory disease. Detection of A. fumigatus and MTR, however, is hampered by limitations in current fungal culture diagnostics which have poor sensitivity, and resistance detection, which is time-consuming, labour-intensive and costly. Through this project, we aim to validate a novel rapid assay (TR34-LAMP) to detect A. fumigatus and MTR isolates and advance our understanding of the evolution of MTR in chronic respiratory disease. The TR34-LAMP assay will be used to detect A. fumigatus and MTR directly in sputum from individuals with chronic respiratory disease whilst analysing prevalence of MTR in a large well-characterised cohort of bronchiectasis patients. This assay has the potential through a 'lab-on-a-chip' based format to enable accurate, low-cost, rapid, point-of-care detection of A. fumigatus MTR. To further understand the genomic evolution and acquisition of A. fumigatus MTR in chronic respiratory disease, a prospective whole genome sequencing approach will be used to analyse longitudinal A. fumigatus isolates from individuals with chronic respiratory disease starting antifungal therapy across 2 distinct clinical and geographical sites. Comprehensive environmental and cohort sampling will be performed to analyse acquisition and evolution of A. fumigatus MTR. This information will critically inform future infection control and antimicrobial stewardship strategies across chronic respiratory care.