Abstract
Urinary tract infections (UTIs) caused by Trichosporon are a significant concern for hospitalized patients and those with weakened immune systems. This narrative review study aims to provide a comprehensive overview of UTIs caused by Trichosporon, including its frequency, risk factors, laboratory diagnostic aspects, drug resistance, and the importance of accurate identification in clinical settings. A search of international databases was conducted to identify relevant studies, and it was found that Trichosporon asahii, specifically the G1 type, is the predominant causative agent of UTIs among various Trichosporon species. Prolonged hospitalization and immunosuppressive drug use were identified as significant risk factors for this fungal infection. Conventional methods for laboratory identification are commonly used. Still, rapid and accurate tools such as Matrix-Assisted Laser Desorption-Ionisation-Time of Flight Mass Spectrometry (MALDI-TOF MS) and DNA sequencing can improve the diagnostic process. Against all T. asahii isolates for which this triazole, polyene, and echinocandin were tested, voriconazole demonstrated the most potent in vitro activity, while amphotericin B had high MIC values and echinocandins had inherent resistance. This review provides valuable insights into the clinical significance and management of UTIs caused by Trichosporon.
Key Words: Microbial sensitivity test, Cutaneotrichosporon, Trichosporon, Urinary Tract Infections
Introduction
A urinary tract infection (UTI) is an umbrella term used to describe infections affecting any part of the urinary tract. This includes infections of the bladder, urethra, kidneys, and other associated structures (1). There are an estimated 130 to 175 million cases of UTIs that occur globally (2). In hospital-acquired infections, the occurrence of UTIs was evaluated and found to be 12.9% in the United States, 19.6% in Europe, and 24% in developing nations (3). Urologists must not underestimate the importance of urinary tract infections (UTIs), considering their significant increase in occurrence in recent decades. The elevated frequency of UTIs, as well as the associated morbidity and mortality, signifies a critical challenge, particularly in developing countries (4). The occurrence of UTIs is strongly influenced by age and gender (5). During the year 2019, the age-standardized mortality rate (ASMR) attributable to UTIs stood at 3.13 per 100,000 individuals (6). UTIs are known to negatively affect patients' quality of life and impose a substantial clinical and economic burden. UTIs caused by bacteria and yeasts are a prevalent form of infection that is observed globally (7). UTIs caused by yeasts are predominantly instigated by Candida species, followed by Trichosporon species and other fungi may also be responsible for such infections (8–10). Trichosporon species are causative agents of surface infections such as white piedra, affecting hair at diverse anatomical sites (11–13). These species have also been gaining recognition as opportunistic pathogens that can result in invasive diseases (Trichosporonosis), particularly in patients with weakened immune systems (14,15). The outlook for patients suffering from invasive trichosporonosis is a matter of great concern, as various studies have reported crude mortality rates ranging from 42% to 87% (16,17). In a recent taxonomic review, 20 distinct species were identified within the genus through analysis of IGS1 rDNA sequences (18). Within the group of 20 distinct species, Trichosporon asahii, T. asteroides, T. inkin, T. ovoides, and T. faecale have been reported to cause infections in humans. The primary culprit responsible for invasive trichosporonosis, an emerging infectious disease and UTIs is T. asahii (19–21). Based on the revised taxonomic scheme introduced in 2015, T. cutaneum, T. dermatis, T. jirovecii, and T. mucoides have undergone reclassification and are now classified under the genus Cutaneotrichosporon. Cutaneotrichosporon species are frequently encountered in both human and animal sources, including clinical specimens, and certain strains have been linked to opportunistic infections (18). UTIs caused by T. asahii are atypical invasive infections and have been infrequently reported in medical literature. These infections are typically observed in hospitalized patients (21). In a study conducted by Sabharwal in 2010, it was observed that T. asahii was the predominant fungus in patients with UTIs who also had diabetes (22). The prevalence of medically significant species like Trichosporon spp. that are infrequently encountered has risen in recent years due to various reasons. These include the higher incidence of degenerative and cancerous diseases, greater exposure of patients to immunosuppressive drugs, chemotherapy, and broad-spectrum antibiotics, and increased use of invasive medical procedures like urinary or intravenous catheters, endoscopic forceps, and arteriovenous grafts (14,16,17,23–26). A considerable number of cases of breakthrough trichosporonosis have been frequently observed in immunocompromised patients, particularly following the use of ineffective antifungal therapies such as amphotericin B, echinocandins, and, less commonly, triazoles (16). Trichosporon is a newly emerging infection that has been increasingly observed in invasive forms, which is alarming. This fungus exhibits inherent resistance to conventional antifungal treatments, rendering it even more severe. Appropriate and timely diagnosis and management are vital in managing this infection effectively (15). T. asahii is an emerging opportunistic infection and the predominant pathogenic fungus within its genus, causing urinary tract infections in individuals with weakened immune systems (27,28). Although these cases are rarely documented in scientific literature, more information is needed to understand the risk factors, potential complications, and susceptibility of different species to antifungal drugs.
The identification of T. asahii in urine culture specimens from hospitalized patients is a therapeutic challenge due to the absence of clearly defined and specific guidelines for clinical interpretation and treatment (16). Moreover, the testing for antifungal susceptibility lacks standardization, and there is an absence of interpretive epidemiological cut-off values for minimal inhibitory concentrations that can differentiate non-wild type Trichosporon isolates (29). Due to the lack of comprehensive research on the frequency of urinary tract infections caused by Trichosporon, a review of all Trichosporons isolated from the urine of patients around the world during the last four decades will be conducted in this study. By analyzing patient demographics, geographical location, and other contributing factors, patterns and trends can be identified, precise statistics on the prevalence of these infections can be obtained, major risk factors can be identified, and the susceptibility of various Trichosporon species to commonly used antifungal drugs can be evaluated based on global research findings.
Materials and methods
For this narrative review, a thorough electronic search was performed on international databases to collect pertinent studies published before May 16, 2023. The search was conducted on reputable platforms such as PubMed, Scopus, Google Scholar, and Web of Science. Several specific search terms, such as "urinary tract infection", "urinary tract infections", "UTI", "urine", "funguria", "Trichosporon" and "Cutaneotrichosporon" were utilized in various combinations during each database search.
Results
Study Selection
The study collected a total of 729 articles from designated databases, which were then subjected to a deduplication process. This resulted in 492 unique articles that were considered suitable for further scrutiny and analysis. The study excluded articles written in languages other than English, as well as review papers, case reports, conference proceedings, letters, books, editorials, and notes. The main objective was to focus exclusively on original research articles for the purpose of analysis. Following a thorough examination of the titles and abstracts of the 492 remaining original papers, 46 articles were chosen to advance into the primary phase of the study.
Study Characteristics
This narrative review analyzed 46 articles. These findings are summarized in Table 1 and cover a 33-year period from 1989 to 2022 (Table 1). Asia has been the site of 45.65% of the studies, while America accounts for 30.43%. Following these regions in terms of frequency of study are Europe and Africa. A majority of research studies (60.8%) were carried out in the period starting from 2010 and continuing until the present time.
Table 1.
The detailed information presented in the 46 included studies.
| Row | Year of Publication | Country | No. of Positive Yeast Cultures | Frequency% | Isolates Distribution | Diagnostic Methods | Sex | MeanAge(Years) | Risk Factors | Reference [Number] |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2022 | Thailand | * | * | T. asahii (51)T. inkin (1)Trichosporon spp. (1) | MALDI-TOFDNA-Sequencing (IGS1)Conventional | NA | NA | Hospitalization (53) | (30) |
| 2 | 2021 | Turkey | 1442 | 6.9% | T. asahii (100) | MALDI-TOF MS | M (68)F (32) | 69.94 | ICU (82) | (31) |
| 3 | 2021 | Brazil | * | * | T. asahii (157) | DNA-sequencing (IGS1) | NA | NA | NA | (32) |
| 4 | 2021 | India | * | * | Trichosporon spp. (15) | VITEK MS | NA | NA | NA | (33) |
| 5 | 2020 | Iran | 7 | 14.3% | T. asahii (1) | DNA-sequencing (ITS) | M (1) | 67 | Kidney transplantation (1) | (34) |
| 6 | 2019 | India | 11 | 18.2% | Trichosporon spp. (2) | Conventional | NA | NA | Burn patients (2) | (35) |
| 7 | 2019 | Egypt | 41 | 4.9% | C. mucoides (2) | VITEK 2 | NA | NA | Cancer (2) | (36) |
| 8 | 2019 | Mexico | 51 | 15.7% | T. beigelii (8) | VITEKConventional | NA | NA | NA | (37) |
| 9 | 2019 | Iran | 135 | 3% | T. asahii (4) | DNA-sequencing (ITS) |
M (1)F (3) | 41.5 | Diabetes Mellitus (3)Renal Failure (1) Hospitalization (3) |
(38) |
| 10 | 2018 | Mexico | * | * | T. asahii (33) | API 20CDNA-Sequencing (IGS1)Conventional | NA | NA | NA | (39) |
| 11 | 2018 | Taiwan | 508 | 0.6% | T. asahii (3) | NA | NA | NA | NA | (40) |
| 12 | 2018 | Turkey | * | * | T. asahii (68) | MALDI-TOF MSVITEK MSDNA-sequencing (IGS1) Conventional |
M (43)F (25) | 65 | Hospitalization (68)ICU (63%)Urology ward (14%)Nephrology ward (12%) Oncology ward (5%) Hematology clinic (4%) Neurology ward (2%)Chronic disease (68)Urinary Catheter (51) |
(41) |
| 13 | 2018 | Spain | 155 | 0.6% | T. asahii (1) | MALDI-TOFAPI 32CConventional | NA | Over 80 Years Old | Hospitalization (1) Above 80 years (1) | (42) |
| 14 | 2017 | Korea | 14 | 14.3% | T. asahii (2) | VITEK 2 Conventional | NA | NA | NA | (43) |
| 15 | 2017 | Taiwan | 19 | 5.3% | Trichosporon spp. (1) | Conventional | NA | NA | Hospitalization (1)Urinary Catheter (1) | (44) |
| 16 | 2016 | Brazil | * | * | T. asahii (9) | DNA-sequencing (IGS1) | NA | NA | NA | (45) |
| 17 | 2015 | Brazil | 54 | 3.7% | Trichosporon spp. (2) | VITEK 2Conventional | NA | NA | NA | (46) |
| 18 | 2015 | Egypt | 23 | 8.7% | T. beigelii (2) | Conventional | NA | 25-85years old | Urinary Catheter (2)Bladder cancer (2) | (47) |
| 19 | 2014 | India | 123 | 3.3% | Trichosporon spp. (4) | Conventional | NA | NA | NA | (48) |
| 20 | 2014 | Brazil | * | * | T. asahii (20) | DNA-sequencing (IGS1) | NA | NA | NA | (49) |
| 21 | 2014 | Korea | 159 | 5.0% | Trichosporon spp. (8) | Conventional | NA | Over 18 Years Old | Urinary Catheter (8) | (50) |
| 22 | 2014 | Argentina | * | * |
T. asahii (9) Trichosporon spp. (1) |
DNA-sequencing (IGS1, ITS, D1/D2) | NA | NA | Hospitalization (10) | (51) |
| 23 | 2014 | Spain | * | * | T. asahii (32) | VITEK 2 DNA-sequencing (IGS, ITS) | M (26)F (6) | 85 | Urine drainage bag (32)Hospitalization (32) Antibiotic therapy (32) Pneumonia (12) Sepsis (8) Kidney diseases (6) Cancer (1) ICU (1) |
(52) |
| 24 | 2014 | India | 337 | 2.1% | Trichosporon spp. (7) | VITEK 2 | NA | NA | Chronic liver disease (7)Urinary Catheter (7) | (53) |
| 25 | 2012 | China | * | * | T. asahii (23) | VITEK 2DNA-sequencing (IGS1, ITS) | M (17)F (6) | 80 | ICU (23)Systemic antibiotics (14) Urinary Catheter (14) Diabetes mellitus (8)High blood pressure (7) Heart failure (5)Chronic Diseases (2) | (54) |
| 26 | 2012 | Taiwan | * | * |
T. asahii (8) T. montevideense (2)C. dermatis (1)C. cutaneum (1)T. japonicum (1) |
DNA-sequencing (ITS, D1/D2)API 32C VITEK | NA | NA | NA | (55) |
| 27 | 2011 | Korea | 93 | 1.1% | T. asahii (1) | VITEK 2 | NA | NA | Burn patients (1) Urinary Catheter (1) | (56) |
| 28 | 2011 | Brazil | 27 | 3.7% | T. beigelii (1) | VITEK 2 | NA | NA | Urinary Catheter (1)Hospitalization (1) | (57) |
| 29 | 2010 | Turkey | * | * | T. asahii (23) | API 20CRep-PCR | M (10)F (5) | 44 | Hospitalization (15) Urinary Catheter (15) | (58) |
| 30 | 2009 | Poland | * | * | T. asahii (22) | ATB Expression | NA | NA | Kidney transplantation (21) Simultaneous pancreas Kidney transplantation (1) |
(59) |
| 31 | 2009 | Taiwan | * | * | T. asahii (9)C. dermatis (1)T. montevideense (1) | DNA-sequencing (IGS1)API 32CConventional | NA | NA | Hospitalization (11) | (25) |
| 32 | 2009 | Qatar | * | * |
T. asahii (6) T. faecale (1) |
DNA-sequence (LSU, ITS) VITEK 2API 32CConventional | M (5)F (2) | 47.1 | Pyuria (7)Hematuria (1) | (60) |
| 33 | 2009 | Poland | 12 | 8.3% | Trichosporon spp. (1) | API 32C Conventional |
NA | NA | hematological malignancies (1) | (61) |
| 34 | 2009 | Turkey | 28 | 3.6% | Trichosporon spp. (1) | Conventional | NA | NA | ICU (1) | (62) |
| 35 | 2008 | Brazil | * | * | T. asahii (8) | API 20CConventional | NA | NA | ICU (8) | (63) |
| 36 | 2008 | Brazil | * | * | T. asahii (3) | DNA-sequencing (IGS1, ITS) | NA | NA | Hospitalization (3) | (64) |
| 37 | 2007 | India | 145 | 5.5% | T. beigelii (8) | Conventional | NA | NA | Hospitalization (8) | (65) |
| 38 | 2007 | Brazil | 100 | 3% | T. asahii (3) | Conventional | NA | 0-7years old | Hospitalization (3)Candiduria (3) | (66) |
| 39 | 2005 | Kuwait | * | * | T. asahii (19) | VITEK 2DNA-sequencing (ITS) | NA | NA | Cancer (4)Kidney failure (1)Kidney transplantation (1)Severe burns (1)Hemi-colectomy (1)Low birth weight (1) | (67) |
| 40 | 2005 | Spain and Argentina | * | * |
T. asahii (2) C. jirovecii (1) |
DNA-sequencing (IGS1, ITS)Conventional | NA | NA | Hospitalization (3) | (68) |
| 41 | 2000 | Canada | * | * | T. beigelii (11) | Conventional | M (8)F (3) | 42 | Immunosuppressive drugs (11) Kidney transplantation (11)broad-spectrum antibiotics (6) Urinary Catheter (5) |
(69) |
| 42 | 1993 | Japan | 39 | 10.2% | Trichosporon spp. (4) | Conventional | NA | NA | NA | (70) |
| 43 | 1992 | India | 9 | 11.1% | C. cutaneum (1) | Conventional | NA | NA | Acute leukemia patients (1) | (71) |
| 44 | 1992 | Saudi Arabia | 302 | 0.3% | T. beigelii (1) | API 20CConventional | NA | NA | Hospitalization (1) | (72) |
| 45 | 1989 | USA | * | * | T. beigelii (15) | VITEK | M (11)F (4) | 18-85years old | Hospitalization (15) Urinary Catheter (15) | (73) |
| 46 | 1966 | USA | 179 | 1.1% | C. cutaneum (2) | Conventional | F (2) | NA | NA | (74) |
* Trichosporon and cutaneotrichosporon were the sole microorganisms identified in the urine samples within the statistical population of these studies.
A restricted number of studies have specifically explored UTIs attributed to Trichosporon. Nevertheless, this narrative review encompasses a number of original investigations that documented the identification of Trichosporon isolates derived from urine samples.
Risk Factors
Individuals afflicted with various types of cancer, receiving chemotherapy treatment, displaying neutropenia, experiencing severe burns or cystic fibrosis, or diagnosed with advanced kidney failure, as well as those with compromised immune systems, are more susceptible to the development of severe trichosporonosis (75–77). In a 2015 study, it was discovered that UTIs caused by Trichosporon had an occurrence rate of 6% within the intensive care unit (ICU) over two years. Furthermore, these infections were found to be associated with a significant mortality rate of 20% (9). Based on the findings of the studies, hospitalization, utilization of urinary catheters, receipt of organ transplants, and administration of antibiotic therapy are identified as the prevalent risk factors for urinary trichosporonosis.
Diagnosis
Yeast-like colonies are obtained through culturing on sabouraud dextrose agar. These colonies exhibit a cream-colored appearance, which may eventually transition to a yellowish-grey hue. The colonies possess significant wrinkling, with the center appearing heaped and folded. Additionally, they tend to adhere to and cause cracking of the agar surface. The process of diagnosing the condition is complicated as it involves identifying a yeast-like organism in a clinical sample (78). The use of direct examination is not always helpful for making a conclusive diagnosis since it does not commonly exhibit arthroconidia and has histological similarities with Candida. Nevertheless, this organism can be differentiated from Candida through its thinner hyphae and pseudohyphae and its slight staining with Gomori methenamine silver (GMS) stain (79). The intergenic spacer 1 (IGS1) region of the gene is an essential factor in the precise and distinct identification of different Trichosporon species (80,81). During a research investigation analyzing 45 clinical isolates and three reference isolates of Trichosporon species, assessments that focused on both the internal transcribed spacer (ITS) region and the intergenic spacer 1 (IGS1) region successfully distinguished all 48 isolates (80). The molecular identification of Trichosporon species in clinical samples obtained from Indian patients has been accomplished using the IGS1 region (82). In a reverse line blot (RLB) hybridization and rolling circle amplification (RCA)-based assay, accurate identification of Trichosporon species was achieved utilizing species-specific probes directed towards the ITS region and the D1/D2 domain. This technique exhibited 100% specificity in identifying the species when compared to DNA sequencing results from the ITS region, D1/D2 domain of the 28S rRNA gene, and IGS1 region (81). Successful management of invasive trichosporonosis infections is contingent on the diagnostic method's sensitivity and timeliness.
Identification Method and Species Distribution
After conducting a statistical analysis of several studies, it has been observed that 170 cases out of 4013 instances of yeast urinary tract infections are linked with diverse Trichosporon species. These species have been identified to be responsible for causing such infections, thus indicating the high occurrence and significance of UTIs caused by Trichosporon-related strains. Because there is a scarcity of literature examining urinary tract infections caused by Trichosporon, no temporal boundaries were imposed during the search process. Nevertheless, certain investigations focused solely on candiduria or other microbial urinary infections, which meant that Trichosporon was only identified at the level of genus and not down to the specific species. Furthermore, some studies had limited access to precise identification tools, leading them to limit their identification of Trichosporon to the genus level. Over time, multiple methods have been utilized to identify Trichosporon at the genus or species level. In the past, identification techniques were primarily limited to morphology, microscopic and macroscopic examination, and different sugar fermentation tests. Over time, the progress in microbial identification techniques used in research and medical labs has led to the implementation of advanced methods like VITEK 2, MALDI-TOF MS, and DNA sequencing for better identification of various Trichosporon species. These techniques have greatly improved the accuracy of identification. Having analyzed and consolidated the statistical data reported in multiple studies, our findings indicate that T. asahii is the predominant type of Trichosporon detected from urine, with T. beigelii, Cutaneotrichosporon cutaneum (formerly named T. cutaneum), and C. mucoides (formerly named T. mucoides) following in descending order (Chart 1) (31,34-38,40,42-44,46-48,50,53,56,57,61,62,65,66,70 -72,74).
Fig 1.
The variability of distinct Trichosporon/Cutaneotrichosporon species obtained from urine across 25 investigations.
Genotype of T. asahii
To identify the genotype of T. asahii isolates obtained from urine, a total of nine studies were conducted. The results revealed that more than 69% of the T. asahii isolates belonged to genotype type I (G1) while genotypes G3 and G7 were found to be the subsequent most common genotypes (Chart 2) (30,32,39,41,45,51,52,54,64).
Antifungal Susceptibility Patterns:
In vitro antifungal susceptibility testing (AFST) was performed on T. asahii isolates obtained from urine during studies published before May 16, 2023. The isolates were tested for susceptibility to amphotericin B, 5-flucytosine, 6 triazole, and 3 echinocandin using the broth dilution method according to Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines, Epsilometer Test (E-test), and the VITEK 2 system. The results are summarized in Table 2 (20,30,31,45,49,52,58,63,64).
Table 2.
The summary of all data reporting antifungal susceptibility patterns of T. asahii isolated from urine during studies published before May 16, 2023 (studies without raw data of MIC are not included).
| MethodIncubation time | No. of isolates with available data | Antifungal agent | (MIC) values (μg/mL) | ||
|---|---|---|---|---|---|
| MIC range | MIC50 | MIC90 | |||
| CLSI M2748-h | 345 | AMB | 0.062- ≥ 16 | 2 | 4 |
| 345 | FCZ | 0.25- ≥ 64 | 2 | 8 | |
| 328 | VCZ | ≤ 0.015 -2 | 0.062 | 0.125 | |
| 257 | PSZ | 0.015-2 | 0.25 | 1 | |
| 137 | ITZ | 0.015-8 | 0.25 | 0.5 | |
| 100 | ISZ | ≤ 0.008-2 | 0.12 | 0.25 | |
| 100 | MYC | >8 | >8 | >8 | |
| 8 | 5FC | 16-32 | 16 | 32 | |
| E-test48-h | 55 | AMB | 0.062- ≥ 32 | 2 | 8 |
| 55 | FCZ | 0.25-64 | 4 | 16 | |
| 55 | ITZ | 0.032-32 | 0.5 | 4 | |
| 32 | VCZ | 0.008-0.75 | 0.062 | 0.125 | |
| 32 | CAS | ≥16 | ≥16 | ≥16 | |
| 32 | 5FC | ≥32 | ≥32 | ≥32 | |
| EUCAST EDef 7.148-h | 35 | AMB | 0.5- 8 | 1 | 2 |
| 35 | FCZ | 2-32 | 8 | 8 | |
| 35 | ITZ | 0.125-1 | 0.5 | 1 | |
| 35 | VCZ | 0.125-1 | 0.25 | 1 | |
| 35 | CAS | ≥16 | ≥16 | ≥16 | |
| 35 | 5FC | 2-64 | 8 | 16 | |
| 3 | PSZ | 0.125-0.25-0.5 | * | * | |
| 3 | MYC | 16 | * | * | |
| 3 | ANF | 16 | * | * | |
| 3 | RAV | 0.125-0.5-4 | * | * | |
| VITEK 2 system | 32 | AMB | ≤0.25-2 | 0.5 | 1.0 |
| 32 | FCZ | 2.0-16.0 | 2.0 | 8.0 | |
| 32 | VCZ | ≤0.12-1.0 | 0.1 | 0.3 | |
| 32 | CAS | ≥4.0 | ≥4.0 | ≥4.0 | |
| 32 | 5FC | ≤1.0-8.0 | 4.0 | 8.0 | |
MIC: Minimum Inhibitory Concentration, AMB: Amphotericin B, FCZ: Fluconazole, VCZ: Voriconazole, PSZ: Posaconazole, ITZ: Itraconazole, ISZ: Isavuconazole, MYC: Micafungin, 5FC: 5-Fluorocytosine CAS: Caspofungin, ANF: Anidulafungin, RAV: Ravuconazole
Fig 2.
The diversity of distinct T. asahii genotypes across a given population.
Typically, Trichosporon infections are treated with triazole antifungal agents and amphotericin B (16). Based on growth evaluation conducted at 48 hours, it was found that the majority of strains had a MIC90 value equal to or greater than 1 µg/mL for amphotericin B. Previous investigations have indicated that amphotericin B demonstrates insufficient fungicidal activity and restricted in vivo efficacy, with evidence of in vitro resistance (83). In vitro studies comparing the MIC values of various azole antifungal agents, such as voriconazole, itraconazole, posaconazole, isavuconazole, ravuconazole and fluconazole, were conducted. Results indicated that triazole antifungal agents demonstrated similar and low MIC values at 48 hours, whereas fluconazole displayed higher MIC values compared to other azole agents. Among the triazole drugs, voriconazole showed the best in vitro activity against clinical isolates of T. asahii and is considered as the first-line therapy, particularly for hematological patients. The MIC results revealed that all the strains tested had MIC values exceeding 4 mg/L for the echinocandins drug. Furthermore, Trichosporon species showed innate resistance to echinocandins and were found to be unaffected by this class of drugs (17). 5-Flucytosine, a drug commonly used to treat fungal infections, is ineffective against Trichosporon. Nevertheless, certain studies indicate that administering a combination of 5-flucytosine and amphotericin B can lead to favorable outcomes in the treatment of trichosporonosis (84). The findings propose that the concomitant administration of echinocandin and amphotericin B may exhibit synergistic antifungal properties (85). Previous studies have indicated that the broth dilution method and the VITEK 2 system reveal comparable results for the susceptibility testing of amphotericin B, 5-flucytosine, fluconazole, voriconazole, and caspofungin with no discrepancies exceeding a two-dilution difference in MIC50 and MIC90 (86). The E-test is a feasible method for routine laboratory use; however, its results have been found to deviate from previous findings particularly in the case of 5-flucytosine and itraconazole, which appear to be anomalous. Lemes et al. have also reported significant inconsistencies between the E-test and CLSI methodologies regarding 5-flucytosine and itraconazole (87).
Conclusion
Trichosporon species infections, primarily arising from endogenous microbial populations, present a heightened threat to individuals with weakened immune systems or those confined to ICUs. This increased risk can be attributed to factors such as microbial translocation across the gastrointestinal mucosa and the presence of indwelling catheters.
Various factors, including patient age, length of hospital stay, pre-existing medical conditions, invasive medical procedures, immune status, and other variables, play a role in determining the occurrence and severity of invasive fungal infections (IFIs) such as Trichosporonosis.
The traditional methods used to identify fungi based on their physiological and morphological characteristics are not only time-consuming but also often inadequate. However, the introduction of molecular techniques such as polymerase chain reaction (PCR) with species-specific primers has revolutionized fungal infection diagnosis by providing a simpler, more specific, and faster approach. These molecular methods offer high sensitivity and specificity, enabling the differentiation of closely related species with precision and accuracy.
Due to a scarcity of studies concurrently investigating the drug sensitivity and genotypic frequency of Trichosporon isolates derived from urine specimens, our ability to explore the correlation between drug sensitivity and genotype was hindered. While certain studies solely examined the drug sensitivity of Trichosporon isolates acquired from urine, and other studies focused on determining the prevalence of diverse genotypes of T. asahii obtained from similar urine samples, there exists a notable dearth of research encompassing both aspects together. Consequently, we were unable to elucidate the association between drug sensitivity and genotype in this context.
Accurate identification of Trichosporon species is crucial to administer appropriate and effective treatment. This is because different species of Trichosporon exhibit varying levels of susceptibility to antifungal medications. Additionally, timely diagnosis and prompt initiation of treatment are of utmost importance for patients affected by trichosporonosis. Based on the existing data, it appears that the sensitivity of Trichosporon strains obtained from urine samples towards antifungal agents is subject to variation, which can be attributed to both the species and the type of drug utilized in the analysis. However, additional investigations are warranted to comprehensively elucidate the drug susceptibility patterns of Trichosporon strains isolated from urinary sources. Furthermore, it is worth noting that T. asahii, a specific species within the Trichosporon genus, demonstrates high resistance to the antifungal drug amphotericin B.
The isolation of various Trichosporon species from urine, specifically in immunocompromised patients and ICU admissions, necessitates comprehensive research efforts. These studies aim to achieve multiple objectives, including investigating the prevalence of Trichosporon infections in urine samples, employing molecular and sequence-based methods for identifying Trichosporon species, gathering accurate epidemiological data, and performing antifungal susceptibility testing for commonly used antifungal drugs. Such efforts can provide a clear, precise, and broader understanding of the management and treatment of this infection.
Acknowledgments
None.
Data Availability
There is no additional data separate from available in cited references.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Conflict of Interest
The authors declared no conflict of interest.
Ethics Approval:
Not applicable
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