Burden of invasive fungal infections in developing countries - PowerPoint Presentation

Slide1

Burden of invasive fungal infections in developing countries

Arunaloke Chakrabarti

Professor & In-Charge

Center for Advanced Research in Medical Mycology

& WHO Collaborating Center

Professor & Head, Department

of Medical Microbiology

Postgraduate Institute of Medical Education & Research

Chandigarh – 160012, India

Slide2

Outline

Do we have true assessment on burden?What are the challenges in developing countries?

What is the magnitude of the problem in population or specific groups of patients?

Where are we regarding Big ‘3’ in developing countries?

Unique epidemiology for certain diseases in developing countries

Slide3

Prevalence of HAI – 15.5/100 patients, double than developed countries

The incidence in BSI – 34.2/1000 patient-days, triple the rate of USA

Risk of infection – 2-20 times more to industrialized nations, WHO,2008

Slide4

True burden of invasive fungal infections in developing countries

Persons having symptoms

Symptoms & signs non-specific

Sample submitted to lab

Doctor collects sample

Persons goes to doctor

Case reported

Lab identifies the pathogen

No obligatory reporting

Competence of diagnosis limited

Very few mycology lab

Sample from deep-tissue difficult

Patient visit to doctor low or late

Therefore, it is impossible to know the true burden

However, we predict high burden of fungal infections

Slide5

Why we predict high burden of fungal disease in developing countries?

Tropical environment with >50% of world’s population

Large economically

deprived section

Malnutrition

Attend the hospital late in the course of disease

Quackery

practice

Misuse of steroids & antibiotics

over the counter

Construction

activities in hospital & maintenance

Climate changes – Tsunami

Slide6

One infection that may be diagnosed easily, supports it

Cryptococcal

meningitis in HIV

Park

et al

. AIDS 2009; 23: 525

Slide7

One infection that may be diagnosed easily, supports it

Cryptococcal

meningitis in HIV

Sloan DJ.

Clin

Epidemiol

2014; 6:169

Slide8

Slide9

Mortality in HIV in sub-Saharan Africa

Park

et al

. AIDS 2009; 23: 525

Slide10

Slide11

Cryptococcosis

Developed nations

Developing nations

North America

Europe

Latin America

Africa

South East Asia

0.05-0.5

0.5-5

5-25

Rate/10

5

/yr

0.05-0.5

0.5-5

5-25

Rate/10

5

/yr

Spain 0.03

Austria 0.06

Ukraine 0.22

France 0.15

UK 0.16

Canada 0.05

Chile 0.12

Trinidad 3.7

Brazil 0.2

Jamaica 5.0

Nigeria 1.0

Tanzania 6.0

Senegal 1.2

Zambia 7.1

Sri Lanka 0.05

Vietnam 0.15

Korea 0.07

Nepal 0.6

Kenya 20.0

China 0.17

Indonesia 23

USA 1.3

New Zealand 0.3

Australia 6.4

Singapore 0.62

India 1.52

Thailand 4.2

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide12

Concern

The overwhelming number of cases

& the enormous

influence of

cryptococcosis

on early mortality

underscore a major failure of health care provision in developing countries, where there is

too little access to effective antifungal therapy

, including the

tools to control increased intracranial pressure, too few clinical initiatives involving meaningful clinical research, & inadequate investment

from public health, industry, government, private foundation & other funding sources - Peter G Pappas

Editorial,

Clin

Infect Dis 2010; 50: 345

Slide13

Which data are available in developing countries?

Pan country hard data like France, Australia, Iceland is absent in developing countries

GAFFI-LIFE initiated country-wise data

It is mere estimation from published studies

Localized active surveillance in population

Fungal

rhinosinusitis

prevalence in north India

Multicentric

active surveillance

Candidemia data in many countriesMulticentric laboratory surveillanceCandidemia

data by Asian Fungal Working Group

Passive surveillance

Not available as the disease is not notifiable

Slide14

Invasive mycoses in developing countries

Endemic (dimorphic) mycosesOpportunistic fungal infections

Slide15

Dimorphic fungal infections

HistoplasmosisBlastomycosisCoccidioidomycosis

Paracoccidioidomycosis

Penicilliosis

Sporotrichosis

Slide16

A new challenge

38y/F, native of Nepal, cleaner of farmhousePresented with weight loss, mild fever, dyspnoea, left chest painShe had multiple skin lesions on face and body (non-tender, non-itching)

Imaging of chest – bilateral lobular consolidation with necrotic component (enhancing) on

lt

upper lobe &

mediastinal

lymphadenopathy

Clinically thought

tuberculosis, sputum –

neg

; HIV – positive

CT guided FNAC & skin biopsy

Slide17

A new challenge

Culture, microscopic morphology & molecular identification confirmed it as

Emmonsia

pasteuriana

Patient was treated with amphotericin B for 2 weeks followed by itraconazole

Slide18

Slide19

Paracoccidioidomycosis

Queiroz-Telles

&

Escuissato

.

Semin

Resp

Crit

Care Med 2011; 32: 764;

Veira

et al

. Rev

Soc

Bras Med Trop 2014; 47: 63: Lopez-Martinez

et al

. Mycoses 2014; 57: 525

Slide20

Paracoccidioidomycosis

Ballissimo

-Rodrigues

et al

. Am J Trop Med

Hyg

2011; 85: 546;

Veira

et al. Rev

Soc Bras Med Trop 2014; 47: 63

Reporting the disease in high-endemic area

Improvement in disease control & prevention

Health education among farmers

Increased rural exodus

Slide21

Penicilliosis marneffei

Endemic area with large number of cases

Slide22

Penicilliosis

Penicilliosis

in Vietnam

Lee

et al

.

Clin

Infect Dis 2011; 52: 945

Prevalent in South-east Asia, mainly in HIV infected population

Exact prevalence not known

Ranking

3

rd

after tuberculosis & Cryptococcus meningitis in Thailand; after PCP & tuberculosis in Hong Kong

Incidence has come down after anti-retroviral therapy

Duong TA.

Clin

Infect Dis 1996; 23: 125

Slide23

Opportunistic fungal infections

Slide24

Autopsy data at out center (PGI, Chandigarh, India)

1983-2008 (26

years)

IFIs:

2.4% (365/15,040)

Slide25

Hematological malignancies & transplantation

Slide26

Allogenic

transplant

Ref.- Mycoses. 2015 Jun;58(6):325-36

Biol

Blood Marrow Transplant 20 (2014) 872e880

Clin

Microbiol

Infect 2013; 19: 745–751

Biol

Blood Marrow Transplant. 2015 Jun;21(6);1117-26

Bone Marrow Transplant. 2015 Aug 17. Bone Marrow Transplant. 2004 Feb;33(3):311-5

Clinical Infectious Diseases 2009; 48:265–73

Clinical Infectious Diseases 2007; 45:1161–70

Slide27

IFI in AML/MDS patients

Ref.-

Am. J. Hematol. 88:283–288, 2013.

Eur

J

Haematol

. 2008 Nov;81(5):354-63

Clin

Microbiol

Infect 2013; 19: 745–751

Tumour

Biol. 2015 Feb;36(2):757-67

PLoS

ONE. 2015

10(6

): e0128410

.

Undergoing chemotherapy

Post transplant

Slide28

Liver transplant

Ref.-

Clinical Infectious Diseases 2010; 50:1101–1111

Transplant Proc. 2014

 Sep;46(7):2314-8

Clin

Microbiol

Infect 2013; 19: 745–751

Tumour

Biol. 2015 Feb;36(2):757-67

Ann Transplant. 2012 Dec 31;17(4):59-63 Chang Gung Med J. 2008 Jan-Feb;31(1):74-80

Slide29

Renal transplant

Ref.-

J Clin Med Res. 2015;7(6):

371-378

Clinical Infectious Diseases 2007; 45:1161–70

Mem

Inst

Oswaldo

Cruz. 2011 May;106(3):339-45

Nephrol

Dial Transplant. 1993;8(2):168-72

Clinical Infectious Diseases 2010; 50:1101–1111

Slide30

Heart transplant

Ref.- Clinical Infectious Diseases 2010; 50:1101–1111 Am J Infect Control.

2010 Mar;38(2):162-3

Clinical

Infectious Diseases 2007;

45:1161–70

Transplantation Proceedings, 42, 952–954 (2010

)

Slide31

Lung transplant

Ref.- Clinical Infectious Diseases 2010; 50:1101–1111

Clin Transplant 2015: 29: 311–318

Transplantation Proceedings, 40, 822–824 (2008)

Slide32

The big ‘3’

Candidiasis

Aspergillosis

Mucormycosis

Slide33

Candidiasis

Slide34

Candidemia – comparing to global scenario

0.8/1000

discharges

J

Clin

Microbiol

, 2004; 42: 1519

0.09-0.36/1000

admissions

Emerg

Infect Dis., 2006; 12: 1562

0.2-0.5/1000

discharges

J

Clin

Microbiol

2005; 43:1829 & 4434

1-12/1,000

admissionsJpn J Med Mycol 2008; 49: 165

India & Brazil – candidemia rate 7-20 times more common

2.49/1000

admissionJ Clin Microbiol, 2006; 44: 2816

Slide35

Developed nations

Austria 2.6

Netherland 2.6

Australia 1.87

Canada 4.8

Belgium 5.0

Ukraine 5.0

New Zealand 4.27

UK 7.5

Ireland 6.3

Spain 10.7

1-3

3-6

6-9

>9

Rate/10

5

/yr

France 3.8

Nigeria 0.6

Argentina 1.1

Korea 1.5

Sri Lanka 2.3

Developing nations

Zambia 4.0

Kenya 5.0

Egypt 5.0

Israel 5.0

Jordan 5.0

Trinidad 5.0

DR 5.0

Jamaica 5.0

Chile 5.0

China 5.0

Mongolia 5.0

Vietnam 5.0

Singapore 5.1

Saudi Arabia 10.0

Thailand 13.3

Indonesia 63.0

Brazil 249

India 540

1-3

3-6

6-65

66-250

>250

Rate/10

5

/yr

Candidemia

North America

Europe

Latin America

Africa

Middle East

South East Asia

USA 8.0

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Denmark 8.6

Atlanta 19.75

Nordic 1.4

Slide36

Candidemia in Asia (2010-2011)

Country

No. of hospitals

No. of

candidemia

Incidence/1000 discharges

China

9

310

0.38

Hong Kong

1

30

0.25

Singapore

1

73

0.15/1000 patient days

Thailand

3

130

1.31

India

3

333

1.94

Taiwan

6

1104

2.93

Total

25

1601

1.22

ICU

25

370

11.7

Tan

et al.

Clin

Microbiol

Infect 2015;

online

20

June

2015

Slide37

SIHAM

Candidemia Network

April 2011 – Sept 2012

27 Centres:

11 Government sector

16 Private sector

1400

Candidemia

cases:

858 Males

542 Females

Mortality

Overall 40.0%

attributable 22.8%

6.51

candidemia cases/

1000 ICU admissions

Chakrabarti

et al.

Intensive Care Med 2015; 41: 285

Slide38

Time to Candidemia (ICU Days)

Right skew &

Mean: 10.8 days

Western data -

23 days

China-Scan study

10days

Guo

et al

. J Antimicrob Chemother

2013; 68: 660

Slide39

Spectrum of non-albicans Candida

species

Quindos

G. Rev

Iberoam

Micol

2014; 31: 42

Slide40

Candidemia data in six Asian countries

Tan

et al.

Clin

Microbiol

Infect 2015;

online

20

June 2015

Slide41

Comparison of C. tropicalis candidemia across regions

Slide42

Candida

species isolated during recent study on 27 ICUs

Slide43

Intra-abdominal candidiasis

Candida in acute pancreatitis

Chakrabarti

et al.

Surgery

today 2007; 37: 207-11

Fungal infection of necrotizing pancreatitis has worst outcome that those of bacterial infection

335 patients with acute pancreatitis investigated

True infection in 22 (6.6%),

possible infection in 19 (5.7%)

Grade E pancreatitis, prophylactic fluconazole, sepsis are significant risk factor

Lead to ↑hospital stay & mortality (51%)

Slide44

Candida peritonitis

0.1-0.5

0.5-1

1-1.5

Rate/10

5

/yr

Developed nations

Developing nations

0.1-0.5

0.5-1

1-1.5

1.5-2

Rate/10

5

/yr

Canada 0.8

UK 0.14

Ukraine 0.75

Belgium 0.75

Ireland 1.0

Netherland 0.9

Spain 1.25

Austria 0.9

Argentina 0.4

Jamaica 0.75

Trinidad 0.75

DR 0.75

Chile 0.8

Nigeria 0.2

Egypt 0.8

Zambia 2.0

Kenya 2.0

Saudi Arabia 1.6

Jordan 0.8

North America

Europe

Latin America

Africa

Middle East

South East Asia

Sri Lanka 0.3

Korea 0.75

China 1.4

Singapore 1.4

Mongolia 2.0

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide45

Aspergillosis

Slide46

Invasive aspergillosis

- magnitude

No hard systematic data available

Leading cause of IFI in Thailand

(J Med Assoc Thai 2007; 90: 895),

Korea

(Transplant Infect Dis 2010; 12: 309)

Autopsy data – 1% of all autopsies & 42% of all invasive mycoses

Also occurs in so called

immunocompetent host (6-14%)

A. flavus

more prevalent in eye, CNS infections & fungal sinusitis

in tropical climate

Slide47

Invasive

Aspergillosis

Developed nations

Developing nations

North America

Europe

Latin America

Africa

Middle East

South East Asia

1-5

5-10

10-15

Rate/10

5

/yr

1-5

5-10

10-15

Rate/10

5

/yr

Canada 2.0

Sri Lanka 1.0

Nigeria 0.1

Netherland 3.4

Spain 2.7

Ukraine 1.42

France 1.6

Jordan 1.3

DR 0.8

Chile 1.7

Brazil 4.5

Austria 4.1

New Zealand 4.9

Belgium 6.1

Ireland 7.0

UK 8.15

Kenya 0.6

Egypt 10.7

Saudi Arabia 7.6

Thailand 1.4

Mongolia 3.1

Korea 3.5

Nepal 4.0

Singapore 7.6

China 11.9

Vietnam 15.9

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide48

Chronic pulmonary aspergillosis - underlying diseases

Uncommon underlying diseases

Rheumatoid arthritis with pulmonary nodules (3%)

Ankylosing

spondylitis (rarely)

Thoracic surgery (5%)

Asthma (2%)

Radiotherapy to the thorax or chest wall

Invasive pulmonary aspergillosis

Cannabis lungPneumoconiosisHistoplasmosisSilicosis

Common underlying diseasesPulmonary tuberculosis (16%)

Nontuberculous mycobacterial infection

(14%)

Allergic bronchopulmonary aspergillosis ± asthma

(12%)

Treated lung cancer

(10%)

Pneumothorax (often related to a bulla)

(10%)

Chronic obstructive pulmonary disease (10%)Community acquired pneumonia requiring hospitalization (8%)Sarcoidosis (stage II/III) (7%)

Smith et al Eur

Respir J 2011; 37: 865-872

Slide49

Chronic pulmonary

Aspergillosis

Developed nations

Developing nations

Europe

Latin America

Africa

Middle East

South East Asia

1-15

15-50

50-175

Rate/10

5

/yr

1-15

15-50

50-175

Rate/10

5

/yr

Ireland 3.1

Austria 4.7

UK 5.8

Spain 9.18

Brazil 6.2

Trinidad 8.2

Argentina 8.5

Jamaica 11.2

Tanzania 24.0

Egypt 1.6

Senegal 35.0

Kenya 144.0

Sri Lanka 13.0

Thailand 20.1

India 24.0

China 19.5

Belgium 22.7

Ukraine 109.1

New Zealand 15.7

Chile 25.0

DR 52.0

Nigeria 43.0

Zambia 173.3

Saudi Arabia 3.4

Jordan 5.4

Nepal 24.2

Mongolia 42.0

Vietnam 61.0

Korea 146.1

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide50

Global burden of CPA

Denning

et al

. Bull WHO 2011; 89: 864

Slide51

CPA burden in India

Total population in 2011

1,210,569,573

Incident TB cases

2,130, 602

Annual pulmonary TB case alive at 1 year

1,438,157

Estimated annual CPA cases after PTB

92,042 (7.6/100,000)

5-year estimated CPA prevalence

290,147

5-year estimated CPA prevalence

rate

24/100,000

Agarwal et al.

PLoS

One 2014; 9: e114745

Slide52

Fungal rhinosinusitis in India

Recent study in north India – 1.4% adult suffer from CRS,

8.1% of them are FRS (0.11% of population)

Slide53

Mucormycosis

Slide54

1983-2008 (26

years)

IFIs:

2.4% (365/ 15,040)

Mucormycosis: 0.6%

Our Institute data

(Courtesy Prof. A Das)

1969-1994 (26

years)

IFIs: 2.9% (17,064/5,94,263

)

Mucormycosis: 0.1%

1989-2003 (15

years)

IFIs:

31% (314/1017)

MD Anderson, Hematology malignancy

Chamilos

G

et al

.

Haematologica

2006; 91: 986

Japan, National data

Yamazaki T

et al

. JCM 1999; 37: 1732

Mucormycosis

Slide55

Mucormycosis

Developed nations

Developing nations

North America

Europe

Latin America

Africa

Middle East

South East Asia

0.02-0.2

0.2-2

2-20

Rate/10

5

/yr

0.02-0.2

0.2-2

2-20

Rate/10

5

/yr

Spain 0.04

France 0.1

Netherland 0.2

Austria 0.3

Korea 0.02

Vietnam 0.12

Sri Lanka 0.2

Nepal 0.3

Ukraine 0.2

Ireland 0.2

Canada 0.12

Brazil 2.1

Kenya 0.2

Senegal 0.2

Jordan 0.02

China 0.2

Singapore 0.2

India 14.0

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide56

Mucormycosis

India – reported highest incidenceNext common - brazilReported in tsunami survivors

(Andresen

et al.

Lancet 2005; 365: 876; Snell &

Tavakoli

Plast

Reconsstr Surg 2007; 119: 448) Majority cases in India, China are associated with diabetes

(Slain & Chakrabarti Med Mycol 2012; 50: 18)

Slide57

35 cases of consecutive 22,316 diabetics (1.6 cases/1000 diabetics

); 48.6% diabetic ketoacidosisThe mean informed duration of diabetes was 6.7±4.6 y before acquiring mucormycosis

Compliance

to anti-diabetic therapy is also poor

23% patients in our study were ignorant of underlying diabetes before reporting with

mucormycosis

in our

hospital

(Chakrabarti A et al.

Postgrad

Med J

2009; 85: 573-581)

Slide58

Prevalence of mucormycosis in diabetics in India

Computational model

Reviewed all literature for past five decades (1960-2012)

Prevalence -

0.14/1000 population

– ranges - 137,807 & 208,177, mean - 171,504 (SD: 12,365.6; 95% CI: 195,777-147,688) –

70 times to generally accepted rates

Attributable mortality

- mean of 65,500/year

(38.2%) [Chakrabarti et al. Poster number 1044, 23rd ECCMID, Berlin, 2013].

Slide59

Chakrabarti & Singh. Mycoses 2014; 57 (Suppl. 3) 1-6

Human pathogenic

Mucorales

in different series

India

India

Europe

France

Italy

Slide60

Apophysomyces elegans

Rhizopus homothallicus

Saksenaea vasiformis

Thamnostylum lucknowense

Asian garden has many new flowers!

Slide61

Pneumocystis

Developed nations

Developing nations

North America

Europe

Latin America

Africa

South East Asia

0.1-1

1-10

10-100

Rate/10

5

/yr

0.1-1

10-100

>100

Rate/10

5

/yr

1-10

Ireland 0.8

UK 0.9

Spain 3.4

Ukraine 13.5

France 1.0

Belgium 1.1

Canada 0.2

New Zealand 1.55

Chile 4.3

Brazil 39.6

Trinidad 30.0

Jamaica 41.0

Egypt 0.15

Tanzania 22.0

Senegal 9.4

Nigeria 48.0

Korea 0.42

Nepal 1.3

Vietnam 0.67

Thailand 2.6

Kenya 70.0

Zambia 230.0

Singapore 1.6

China 1.8

Posters: ICAAC 2014 (Washington DC)

ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen) ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)

Slide62

Certain unique fungal diseases in developing countries

Slide63

Slide64

Distribution of Pythiosis

Pythiosis

in Thailand

Slides courtesy –

Ariya

Chindanporn

Slide65

Trichosporonosis

After Japan frequently encountered in Thailand, TaiwanThailand

6% of all

fungemia

cases

& cannot be distinguished from candidemia

(

Anunnatsiri

et al. Int J Infect Dis 2009; 13: 90)

Majority cases in ICUs, with malignancies, CVC, antibiotic exposure (Ruan et al. CID 2009; 49: e11)

Taiwan

(

Ruan

et al

. CID 2009; 49: e11)

84% positive for

T.

asahii, then T. dermatis, T montevideense

Other than fungemia, pulmonary, soft tissue infection & meningitis

Slide66

Cladophialophora

bantiana brain abscess

Place

No. of cases

Male/ Female

Immuno

-compromised

Mortality

DAmB

LAmB

Vorico-nazole

Asia

71

(India

62)

79:21

34%

53%

50%

8%

16%

Other than Asia

53

66:39

49%

79%

47%

22%

20%

Chakrabarti

et al

. Med

Mycol

2015 (in press)

Slide67

Fusariosis in Brazil

High rate of IFI in AML &

myelodysplasia

(n=237), HSCT (n=700)

Nucci

et al

.

Clin

Microbiol

Infect 2013; 19: 745

Slide68

Stories of outbreaks

Slide69

Outbreaks of unusual fungemia in India

Pichia anomala (379 babies)

Kodamaea ohmeri

(38 cases)

Candida

auris

/haemulonii

Pichia

fabianii

(21 cases)

C. guilliermondiiC. lusitaniaeC. dubliniensisC. inconspicuaC. famata

C. rugosa

C. norvegensis

Slide70

Pichia anomala fungemia outbreaks

Series

Place of outbreak

No. of patients

Type of patients

Murphy

et al.

, 1986

Liverpool, UK

8

Pediatric

Yamada

et al.

, 1995

Japan

4

Pediatric

Thuler

et al.,

1997

Rio de Janeiro,

Brazil

24

Pediatric

Chakrabarti

et al.

,

2001

Chandigarh, India

379

Pediatric

Aragao

et al., 2001

Sao Paulo, Brazil

8Pediatric

Kalenic et al.

, 2001Croatia

8Adult

Mestroni

et al.

, 2003

La Plata, Argentina

4

Adult

Pasqualotto

et

al

., 2003

Brazil

17

Pediatric

Kalkanci

et al

., 2010

Ankara, Turkey

4

Pediatric

Slide71

Reasons for majority outbreaks

High yeast hand carriage rate (46-80%)Horizontal transmissionToo many patients in hospital

Compromise in

healthcare

Slide72

From Sir Ganga

Ram Hospital – C. haemulonii (15.5%) of all candidemia cases (Oberoi JK,

et al

. Indian J Med Res 2012; 136: 997-1003)

Sensitivity – AMB – 28%, FLU – 0%, ITR – 0%, VOR – 64%

Extremes of age, central line, mechanical ventilation, malignancy are significantly associated

Next, Max hospital – 14 cases of

C. haemulonii

fungemia

Then, PGIMER, Chandigarh – multiple cases; MIC

50 – AMB – 16g/ml, FLU – 64, ITR – 4, VOR – 8Sequencing showed majority of the isolates are

C.

auris

Candidemia network – 5.2% isolates from 19 of 27 ICUs

Candida

auris

(

haemulonii

) in India

Slide73

C. auris - a new threat in developing countries

Slide74

Summary

Prevalence of fungal disease is vey high with unique spectrum of agentsAmong endemic fungi,

penicilliosis

&

paracoccidioidomycosis

are restricted in developing countries

Prevalence of opportunistic fungal infection is alarming

Among yeast,

C. tropicalis

& C. parapsilosis more commonAspergillosis – real incidence not known;

A. flavus prevalent in tropical areaMucormycosis – high incidence in India, Brazil, China; association with diabetes; wide spectrum of agents

Slide75

Summary

P. insidiosum, C. bantiana

,

Fusarium

,

Trichosporon

infections are common in certain geographical location

Outbreaks due to unusual fungi are disturbing

A

wareness among clinicians is still lacking; few laboratories in majority countriesEpidemiology of candidiasis indicates requirement of adequate resourcing for infection control

Slide76

Future need

More awarenessDiagnostic mycology lab. in every tertiary center

We need clinical mycologists

Training program across developing countries

Mycology research

Systematic epidemiology study

Thank you!