Introduction: New fungal species are increasingly reported in immunocompromised patients. Saprochaete clavata (S. clavata), an ascomycetous fungus formerly called Geotrichum clavatum, is intrinsically resistant to echinocandins and is often misidentified.Objective: We describe a cluster of seven S. clavata infections in hospitalized hematology patients who developed this rare fungemia within a span of 11 months. Three of the seven patients died. Identification of the isolates was determined only with the Saramis database of VitekMS system and sequencing of the internal transcribed spacer (ITS) region. Clonal relatedness of the isolates was determined by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) analysis; clonal correlation between the strains was investigated by means of phylogenetic analysis, based on single-nucleotide variants (SNPs). Clinical presentation, 1-3 β-Dglucan (BG) and galactomannan (GM) antigen results and analysis of possible sources of contamination are also described with a prospective case-control study of the outbreak.Results: MALDI-TOF MS-Vitek (bioMerieux, Marcy l'Etoile, France) failed to identify the six isolates, while SARAMIS (bioMerieux, Marcy l'Etoile, France) identified the isolates as S. clavata. Initially, Vitek 2 identified the strains as Geotrichum capitatum in two of the seven cases. Molecular identification gave 99% homology with S. clavata. BG was positive in three out of six patients (range 159 to >523 pg/ml), GM results were always negative. All the isolates were resistant to echinocandins (anidulafungin, micafungin, and caspofungin) and Fluconazole, but susceptible to Flucytosine and Voriconazole. One isolate showed acquired resistance to Flucytosine and Amphotericin Frontiers in Microbiology | www.frontiersin.org 1 January 2020 | Volume 11 | Article 84Lo Cascio et al.Saprochaete clavata Outbreak Investigation Strategy B during treatment. Both the correlation-based dendrograms obtained by MALDI-TOF MS (Bruker Daltonics) and MS-Vitek not only clustered six of the seven bloodstream infection (BSI) isolates in the same group, but also showed their strong relatedness. Phylogenetic analysis using SNPrelate showed that the seven samples recorded during the investigation period clustered together. We observed a split between one case and the remainder with a node supported by a z-score of 2.3 (p-value = 0.021) and 16 mutations unique to each branch.Conclusion: The use of proteomics for identification and evaluation of strain clonality in outbreaks of rare pathogens is a promising alternative to laborious and time-consuming molecular methods, even if molecular whole-genome sequencing (WGS) typing will still remain the reference method for rare emergent pathogens.

We report an outbreak of linezolid-resistant Staphylococcus haemolyticus strains (MIC 32 mg/L) in patients admitted to the Verona University Hospital Intensive Care Unit. The strains proved to be clonally related at pulsed field gel electrophoresis. All the strains showed the G2576T mutation responsible for linezolid-resistance and retained their resistance even after several passages on antibiotic-free medium. After a decade of linezolid use, multifocal emergence of linezolid resistance in coagulase-negative staphylococci has become an important matter of concern and mandates stricter control over the use of this antibiotic in order to preserve its clinical utility.

Bloodstream infections (BSIs) after chemotherapy or hematopoietic stem cell transplantation (HSCT) are a leading cause of morbidity and mortality. Data on 154 BSIs that occurred in 111 onco-hematological patients (57 hematological malignancies, 28 solid tumors, and 26 non-malignant hematological diseases) were retrospectively collected and analyzed. Monomicrobial Gram-positive (GP), Gram-negative (GN), and fungal BSIs accounted for 50% (77/154), 38.3% (59/144), and 3.2% (5/154) of all episodes. Polymicrobial infections were 7.8% (12/154), while mixed bacterial–fungal infections were 0.6% (1/154). The most frequent GN isolates were Escherichia coli (46.9%), followed by Pseudomonas aeruginosa (21.9%), Klebsiella species (18.8%), and Enterobacter species (6.3%). Overall, 18.8% (12/64) of GN organisms were multidrug-resistant (seven Escherichia coli, three Klebsiella pneumoniae, and two Enterobacter cloacae), whereas GP resistance to glycopeptides was observed in 1% (1/97). Initial empirical antibiotic therapy was deemed inappropriate in 12.3% of BSIs (19/154). The 30-day mortality was 7.1% (11/154), while the bacteremia-attributable mortality was 3.9% (6/154). In multivariate analysis, septic shock was significantly associated with 30-day mortality (p = 0.0001). Attentive analysis of epidemiology and continuous microbiological surveillance are essential for the appropriate treatment of bacterial infections in pediatric onco-hematological patients.

A nosocomial cluster of Candida guillermondii fungemia ( n=5 episodes) occurred in a surgical unit over a 2-week period. The five infected patients had received parenteral nutrition through central lines and three of them had catheter-related candidemia. All of the isolates were resistant to 5-flucytosine (MIC >32 microg/ml) and they had strictly related fingerprints, as generated by randomly amplified polymorphic DNA analysis. Although no isolate of Candida guillermondii was recovered from other clinical, surveillance or environmental samples, nosocomial spread of this yeast stopped following the reinforcement of infection control measures. Candida guillermondii may require an intravascular foreign body to cause fungemia, but the outbreak reported here shows that it can be transmitted nosocomially and cause epidemics.

We report on a case of cutaneous infection caused by Alternaria infectoria in a cardiac transplant recipient. A rapid molecular diagnosis was obtained by sequence analysis of the internal transcribed spacer domain of the 5.8S ribosomal DNA region amplified from colonies developed on Sabouraud medium. Treatment consisted of a combination of systemic antifungal therapy, first with amphotericin B and then with itraconazole.Skin diseases in immunocompromised patients are being increasingly encountered, and the range of causative microorganisms is expanding. Alternaria spp., together with other species of the genera Bipolaris, Curvularia, and Exserohilum, are grouped together with dematiaceous fungi because of the formation of grey to black colonies on culture despite the absence of pigmented elements in tissues. All are anamorphs of ascomycetes of the order Pleosporales. They have a worldwide distribution; are commonly isolated from plants, soil, and indoor air environments; and produce large, airborne conidia. Alternaria spp. have been involved in human infections, and their importance as opportunistic pathogens is increasing among immunocompromised patients, especially in transplant recipients (5, 6, 10, 12). Clinically they are more often encountered as traumatic mycoses. It should be noted that cutaneous mycoses caused by such fungi are characterized by brownish hyphal elements in tissue, whereas subcutaneous mycoses often consist of large, hyaline, yeast-like cells. Identification at the species level can be clinically meaningful as long as the possibility of interference with therapy regimens of different degrees of melanization and the occurrence of chlamydospores or meristematic growth has not been excluded. Alternaria alternata and Alternaria infectoria are the most common species found in the clinical setting, but the lack of pigmentation has frequently led to the misidentification of isolates of these species. Molecular identification is a tool that PCR assays have successfully introduced into the armamentarium for the diagnosis of invasive fungal infections. Detection and analysis of the internal transcribed spacer (ITS) domain of the 5.8S ribosomal DNA (rDNA) region are currently proving to be a powerful tool for rapid and precise laboratory diagnoses (2), even if microscopic morphology and a number of additional tests are necessary to confirm the identification. This paper reports on the usefulness of PCR and DNA typing to identify A. infectoria as the causative agent of diffuse skin infections in a cardiac transplant recipient. Case report.A 49-year-old agricultural worker from Verona, Italy, underwent cardiac transplantation for dilated cardiomyopathy. Ten months after the transplant he developed a nodule on his right arm, and several months later nodules also appeared on his left leg. The patient did not recall any local skin trauma occurring since the transplant. A punch biopsy specimen was taken from the leg lesion for histological examination. No dyspnea or fever was present. Routine laboratory t...