The Argentinian landscape of mycological diagnostic capacity and treatment accessibility

Abstract

Immunosuppressed patients, transplant recipients, and those with acute or chronic respiratory disease are at increased risk for invasive fungal infections in Argentina. Although the national public system guarantees universal access to health care for all citizens, little is known about the quality of available diagnostic and treatment armamentaria for invasive fungal infections in the country. Between June and August 2022, infectious disease clinicians from each of the 23 provinces and the Autonomous City of Buenos Aires were contacted to describe local access to fungal diagnostic tools and antifungal agents. The information collected included different aspects such as hospital characteristics, patients admitted and wards, access to diagnostic tools, estimated infection incidence, and treatment capacity. Thirty responses were collected from facilities throughout Argentina. Most institutions were governmental (77%). A mycology department was available in 83% of them. Histopathology was available in almost 93% of the sites, while automated methods and galactomannan tests were available in 57%, each; 53% of the sites had access to MALDI-TOF-MS through regional reference laboratories, and PCR was present in 20% of the sites. Susceptibility testing was available in 63% of the laboratories. Candida spp. (24%), Cryptococcus spp. (20%), Aspergillus spp. (18%), and Histoplasma spp. (16%) were described as the main pathogens. Fluconazole was the only antifungal agent available in all institutions. This was followed by amphotericin B deoxycholate (83%) and itraconazole (80%). If an antifungal agent was not available onsite, then 60% of the patients could receive adequate antifungal treatment within the first 48 h upon request. Although there are no significant differences in access to diagnostic and clinical management of invasive fungal infections among the Argentinean centres studied, national awareness-raising initiatives led by policymakers could help to improve their general availability.

Introduction

Argentina is a country in South America with a population of >45 million inhabitants.¹ Large parts of the population are at risk for invasive fungal infections,² including immunosuppressed patients,^3,4 intensive care patients,⁵ or solid organ and haematopoietic cell transplant recipients.^6–8 The number of smokers⁹ and people with chronic lung disease,¹⁰ as well as the incidence of respiratory viral infections, such as influenza¹¹ or severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2),^5,12,13 led to an increased incidence of invasive fungal infections. Argentina also has a wide range of climates. This environmental heterogeneity includes tropical areas where the presence of endemic invasive fungal infections is prevalent, in particular, caused by Coccidioides spp., Histoplasma spp., Paracoccidioides spp., or Sporothrix spp.^14–16 Endemic invasive fungal infections may also be diagnosed in patients travelling to neighbouring countries where endemic mycoses are also a threat,^14,17 such as Bolivia, Brazil, Chile, Paraguay, Peru, or Uruguay. Moreover, invasive fungal infections caused by multidrug-resistant pathogens due to intrinsic or acquired resistance have been described in the country,^18–20 including the first candidemia due to Candida auris in late 2022.²¹

Argentina has a nationwide, universally accessible public healthcare system, but there may be limitations, for example, due to underfunding.^22,23 Access to the private network may not be an alternative for many patients with low incomes.²⁴ A lack of resources in the healthcare system versus a large number of patients at risk may hinder access to appropriate diagnostic tools and antifungal treatments.²⁵

Therefore, we aimed to monitor the current status of diagnostic and treatment tools for invasive fungal infections in Argentina in order to establish a targeted pathway to optimize clinical management of invasive fungal infections and facilitate rapid access to diagnosis and treatment for patients at risk.

Methods

Infectious disease clinicians from the 23 Argentinian provinces and the Autonomous City of Buenos Aires were invited to participate by email and telephone. The questionnaire (approved by the Ethics Committee of Sanatorio Allende, Córdoba, Argentina) covered different relevant aspects to evaluate the diagnostic and treatment capacity of invasive fungal infections, such as (a) hospital basic characteristics, (b) type of admitted patients and hospital wards, (c) interaction details between clinicians and microbiologists, (d) access to relevant diagnostic tools, (e) estimated invasive fungal infections incidence, and (f) treatment capacity. If participants had to provide feedback on their satisfaction level, a Likert scale was used, from 1 (very bad) to 6 (excellent). A Likert scale for frequency was also used, from 1 (never) to 6 (always). Before analysis, the answers from every participant were validated to ensure data coherence and completeness.

Participating institutions were grouped according to (a) predominantly urban versus rural provinces by population density, (b) type of endemic area by most prevalent endemic mycosis, (c) number of hospital beds, (d) admission of HSCT and/or SOT patients, (e) gross domestic product (GDP) following data from the National Institute of Statistics and Census of Argentina (INDEC, by its Spanish abbreviation),²⁶ and (f) ownership state versus private.

Data are presented as frequencies and percentages. Proportions are presented in contingency tables and compared using Fisher’s exact test. P-values <.05 were considered statistically significant. SPSS v27.0 was used for statistical analyses (SPSS, IBM Corp., Chicago, IL, USA).

Results

Between June and August 2022, 30 answers were received from institutions from 14/23 (60.9%) Argentinian provinces and the Autonomous City of Buenos Aires, gathering the 85.2% of the national population (Fig. 1).

General description

Fifteen (50.0%) sites had at least 200 beds, most of them in urban areas (n = 17/30, 56.7%) (Tables 1 and Supplementary Table 1). Almost half of these sites serve as reference centres for coccidioidomycosis (n = 13/30, 43.3%), and 10 (33.3%) for paracoccidioidomycosis and sporotrichosis. In areas where Coccidioides spp. was the main endemic fungus, most of the sites had between 100 and 200 beds (n = 7/13, 53.8%), while a capacity of >200 beds was most common in Paracoccidioides spp. + Sporothrix spp. endemic areas (n = 8/10, 80.0%; P = .027) (Tables 1 and Supplementary Table 2). Most of the sites were state-owned (n = 23, 76.7%). Eleven (36.7%) sites were performing HSCT (6/30, 20.0%) or SOT (10/30, 33.3%) (Table 1 and Supplementary Tables 1 and 3).

All institutions had an onsite microbiology laboratory, with a specific mycology section available in 83.3% (n = 25/30) of them, and a trained mycologist in 22/30 (73.3%). Interaction between clinicians and laboratory was always perceived as good to excellent (Table 1).

Invasive fungal infection diagnosis

Histology was available in almost every site (n = 28/30, 93.3%), although it was used infrequently to occasionally in 21 (70.0%) of them. Access to automated methods (i.e., VITEK^®) and galactomannan tests were reported from 17 (56.7%) sites each. Enzyme-linked immunosorbent assay (ELISA)-based galactomannan tests were used for the detection of infections due to Aspergillus spp. and were more commonly available in larger hospitals as compared to the small ones, where reactive stripes of immunochromatographic assays were more common (P < .001) (Tables 1 and Supplementary Table 1). The main target of galactomannan tests were patients with neutropenic fever (n = 27/28, 96.4%). They could get tested in every hospital, with some limitations in those institutions in areas with a GDP < 6000 US$ (P = .026) (Table 1 and Supplementary Table 3). Cryptococcus spp. antigen testing was available in 21 (70.0%) sites and Histoplasma spp. antigen tests for urine in 11 (36.7%). Access to Aspergillus spp. serology for antibody detection was reported from 12 (40.0%) laboratories. Half of the sites had access to matrix-assisted laser desorption/ionization mass spectrometry (MALDI-TOF-MS) (n = 16/30, 53.3%), mainly in urban areas (P = .010) (Table 1 and Supplementary Table 2), with a GDP > 10 000 US$ (P = .013) (Table 1 and Supplementary Table 3) through regional reference laboratories. Access to PCR was given in 20.0% (n = 6/30) of the sites. Nineteen (63.3%) institutions could run susceptibility tests on fungal pathogens (Table 1).

The turnaround time for any initial diagnostic test result was considered as excellent solely in institutions with >200 beds (P = .020) (Table 1 and Supplementary Table 1). The overall turnaround time for the final diagnosis was below 7 days in one-third of the laboratories (n = 11/30, 36.7%), but for six (20.0%) centres, it was >21 days, mainly in non-endemic areas (n = 3/6, 50.0%, P = .013) (Table 1 and Supplementary Table 2).

Estimated invasive fungal infection incidences and mortality rates

Overall, an incidence of 447 invasive fungal infections within the year immediately before the survey completion was estimated due to fungi of major concern, mainly due to Candida spp. (n = 108/447, 24.2%), Cryptococcus spp. (n = 89/447, 19.9%), Aspergillus spp. (n = 79/447, 17.7%), and Histoplasma spp. (n = 73/447, 16.3%) (Table 1). However, pathogen distribution varied depending on the setting (Supplementary Tables 1–3 and Fig. 2A). Candida spp. were the most common pathogens overall (108/447, 24.2%). In endemic areas of Paracoccidioides spp. and Sporothrix spp., Candida spp. and the endemic fungi were equally incident (n = 44/196, 22.4%, each). In non-albicans Candida spp., we could also observe varying distributions based on the setting. Candida glabrata and C. parapsilosis were the most prevalent non-albicans species overall (n = 10/30, 33.3%, each) (Supplementary Tables 1–3 and Fig. 2B).

Identification to species level was possible in 27 (90.0%) institutions for Candida spp. and in 11 (36.7%) institutions for Aspergillus spp. An overall median mortality rate of 25% (IQR 25%–50%) was estimated for patients with invasive fungal infections, with a minimum of 10% and a maximum of 75% (Fig. 1).

Antifungal treatment

Participants were specifically asked about their routine for the treatment of Aspergillus spp. and Candida spp. infections. For aspergillosis, voriconazole (n = 12/30, 40.0%) and lipid-based amphotericin B formulations (n = 6/30, 20.0%) were the most common first-line antifungals. In candidiasis, fluconazole (n = 13/30, 43.3%) and echinocandins (n = 12/30, 40.0%) were the most frequently administered antifungals. Fluconazole was more common than echinocandins for the treatment of candidiasis in rural (P = .003) (Table 1 and Supplementary Table 2) and in public (P = .035) hospitals (Table 1 and Supplementary Table 3).

Amphotericin B deoxycholate (n = 25/30, 83.3%) was the most frequently available amphotericin B formulation, although with some limitations in non-endemic settings (n = 0.004). Fluconazole was the only azole available in all 30 institutions, and among mould-active triazoles, itraconazole was the most available (n = 24/30, 80.0%) (Supplementary Tables 1 and 2). Nevertheless, institutions in non-endemic areas (P = .041) (Supplementary Table 2) or hospitals with <100 beds (P = .015) (Supplementary Table 1) had some limitations in accessing itraconazole as compared to other sites. Availability of voriconazole was restricted in medium-sized institutions (P = .005). Half of the institutions (n = 16/30, 53.3%) had access to at least one echinocandin (Table 1 and Supplementary Table 1).

If an antifungal was not available to the onsite pharmacy, then 60.0% (n = 18/30) of patients could receive adequate antifungal treatment within 48 h upon request. However, the self-perception of the access–quality to them was bad to moderate half of the time (n = 15/30, 50.0%), especially in endemic areas (P = .004) (Table 1 and Supplementary Table 2) and middle-sized hospitals (P = .026) (Table 1 and Supplementary Table 1).

Discussion

Our survey observed a homogeneous access to either invasive fungal infection diagnostic or treatment tools among the participating Argentinian institutions. However, we did detect potential for improvement in several aspects, such as reduction in the turnaround time to assay results, the general availability of certain diagnostic tests, and the access to specific antifungals.

Most of the participating centres were located in urban areas, mainly in the cities of Buenos Aires, Córdoba, and Rosario, which are the cities in Argentina with the largest number of inhabitants, and thus, the largest number of healthcare institutions.¹ Different Argentinian climate zones have endemic fungi such as Coccidioides spp. (rural areas in the North-West, with predominance of Coccidioides posadasii over C. immitis), Histoplasma spp. (whole country), Paracoccidioides spp., and Sporothrix spp. (northeast, coastline, mainly Sporothrix schenckii and scarcely S. brasiliensis, probably linked to vicinity to Brazil) similar to other countries in the region,^14,15,17 which may increase the incidence of invasive fungal infections.

Most participants were affiliated to institutions from the public healthcare system, as this is the most extensive network in the country due to universal healthcare access.^22,25 This may guarantee that any patient from Argentina can have a similar access to diagnostic and treatment tools for invasive fungal infections.

Despite histology is accessible in nearly every institution, patients cannot benefit from it in most cases, as it is not performed routinely. Almost three in four laboratories use histology for the diagnosis of invasive fungal infections infrequently to occasionally. Even though histology is a highly recommended method to prove invasiveness of different fungal infections,^14,27–37 obtaining samples, especially from the lungs remains underused, and thus the eventual assessment by histology-based diagnosis. Galactomannan tests were used for the detection of infections due to Aspergillus spp. in 56% of sites, either as ELISA or reactive stripes, which is a lower availability than, for example, that in the Asian/Pacific (79%)³⁸ or European (94%) regions,³⁹ and similar to Africa (≥60%).⁴⁰ Although there was no significant difference in the access to galactomannan-based diagnostic tests in any setting, we observed that larger hospitals could run ELISA tests significantly more often than reactive stripes, the most common tests in smaller sites. The lower number of sample processing facilities in smaller hospitals can explain this difference, with ELISA being preferred for the management of large amounts of specimens. Despite all centres in areas with a GDP > 6000 US$ have access to galactomannan tests, this does not occur in the centres from areas with GDP < 6000 US$, which are mainly rural environments. Here, patients are at increased risk for diagnostic delays. Overall limitations in the access to Histoplasma spp. antigen tests for urine samples were observed too, despite this pathogen being endemic in the entire country, so as in the continent.^{14–17,41,42} Still, access levels to Histoplasma spp. antigen tests in Argentina (37%) were above the levels in Africa (5%),⁴⁰ Asia-Pacific, the Caribbean, and Latin America (22%, each),^38,41 or Europe (34%).³⁹ The costs of these test kits might be hampering a wider access. Overall access to MALDI-TOF-MS is low and with significant differences between centres, based in their geographical setting (urban versus rural) or the GDP of their province. A similar situation has been observed in previous research with data from other geographical settings.^38,40 Despite the use of MALDI-TOF-MS being cost-effective,^43,44 the initial investment to set-up the appliances may hinder the spread of its use in Argentina. At overall national level, Argentina appears to slowly progress towards the recommendations of the World Health Organization (WHO) and its list of essential in vitro diagnostics for invasive fungal infections.⁴⁵ Nevertheless, the access to such diagnostic tools can be already adequate in single hospitals.

Similar to the regional levels of Africa (63%)⁴⁰ and the Caribbean and Latin America (61%),⁴¹ 63% of the participating laboratories have the capacity to perform susceptibility tests on patient samples; still with improvement potential as compared to Asia/Pacific (84%)³⁸ or Europe (94%).³⁹ Yet, in many cases, the access to susceptibility testing is limited to Candida spp., while resistance for Aspergillus spp. or even endemic fungi can only be performed in a low number of centres, and often not as a routine. This facilitates the treatment with suboptimal or even inadequate antifungals and the potential development of new resistance in circulating fungal strains, which has been already described in Argentina.²⁰

Despite 90% of the institutions could identify Candida spp. to a species level, the same was not applicable for Aspergillus spp. Only reference laboratories can run these analyses in moulds,⁴⁶ which may hamper the beneficial effect for the patients and endanger an adequate clinical management of aspergilloses, as not all these species are equally susceptible to the same antifungal treatments.^34,37

The turnaround time for an initial diagnosis was considered excellent only in few of the largest institutions (>200 beds), likely related to the capacity of these centres to process their samples in a shorter time. As for the final diagnosis, evaluated as the number of days needed to obtain conclusive results, centres from non-endemic areas were the only ones that reported waiting times >21 days. A lower incidence of invasive fungal infections in these centres might be causative for such numbers, as these sites are more likely to have reduced diagnostic capacity for invasive fungal infections in general, and patients have to be transferred to larger institutions, mainly in the capital city of Buenos Aires. This is particularly common in smaller laboratories and in rural areas, as their general capacity is lower, and they need to outsource most mycological testing.

Equally to the data observed in other geographical settings,^{38–41, 47}Candida spp. are considered as the fungi responsible for the largest number of invasive fungal infections in Argentina. Of note, five Candida spp. have been recently classified as medium to critical priority fungal pathogens by the WHO⁴⁸:C. albicans, C. auris, C. glabrata, C. parapsilosis, and C. tropicalis. However, regarding the infections due to Histoplasma spp. (16%), classified as high-priority fungus by the WHO,⁴⁸ the numbers in Argentina are larger than in Africa (13%),⁴⁰ Asia/Pacific (14%),³⁸ and Europe (4%),³⁹ which is explained by its endemicity in the country.^2,14–17,42 Nevertheless, the incidence is lower as compared to the overall regional levels in the Caribbean and Latin American region (48%),⁴¹ likely caused by the higher prevalence of Histoplasma spp. infections in Brazil. Interestingly, in hospitals from areas with a GDP < 6000 US$, Cryptococcus spp. incidence was higher as compared to the national average. Late human immunodeficiency virus (HIV) diagnosis is a major concern in Argentina. Particularly, in areas with lower GDP, the unaffordability of the antiretroviral treatment might also promote a health status with more associated comorbidities in patients living with HIV.^49,50 For example, this could trigger a progression of the infection and the potential appearance of opportunistic infections like cryptococcosis,⁵¹ mainly due to Cryptococcus neoformans, a pathogen of critical priority according to the WHO.⁴⁸

For the treatment of aspergillosis, more than half of the sites reported first-line use of voriconazole or amphotericin B, in line with international guideline recommendations.^34,37 Nevertheless, the elevated price of antifungals in Argentina might lead to an antifungal step-down to the cheapest options, especially from liposomal amphotericin B to the more toxic deoxycholate formulation. In the case of candidiasis, fluconazole was the first option in rural areas (which is not an adequate treatment for fluconazole-resistant Candida spp.),^19,52 whereas echinocandins were the chosen option in the urban ones. Access to the most appropriate treatment in all settings would improve management quality, likely reduce mortality rates, and limit selective pressure on pathogens. This is especially relevant as the major limitation for the access to appropriate antifungal treatment in Argentina, similarly to other countries, appears to be the drug acquisition costs.^53,54 General access to mould-active triazoles is limited in Argentina. For example, for itraconazole, the first line or alternative to first-line antifungal for endemic pulmonary coccidioidomycosis, histoplasmosis, paracoccidioidomycosis, and sporotrichosis,¹⁴ there are significant differences between settings.

In the case of lack of a certain antifungal drug in stock, only 60% of the patients could benefit from its administration within the first 48 h since prescription, despite invasive fungal infections often being medical emergencies. Ideally, essential antifungals should be available onsite. Considering the WHO list of essential antifungals,⁵⁵ only fluconazole (100%), amphotericin B deoxycholate (83%), and itraconazole (80%) are available in at least 80% of institutions. This is a major hazard for those invasive fungal infections with a recommended first-line treatment based on antifungals such as echinocandins (53%), isavuconazole (33%), or voriconazole (60%).

Our study has certain limitations. The first is related to institution enrolment, as we did not receive data from every province. Still, data from the largest institutions in the country were collected, covering the 85% of the population and the densest areas. A longer recruitment timeline may have permitted the inclusion of additional institutions. Secondly, unlike in other similar initiatives of capacity mapping in invasive fungal infections, we did not ask about the use of therapeutic drug monitoring. Nonetheless, due to the reduced general access to triazoles, we hypothesize TDM use to be low. Finally, the results could have benefited from further depth in certain details, such as the access to the most novel diagnostic methods and the respective individual turnaround times (i.e., antigen testing, PCR, and serology) per pathogen. Further initiatives may need to include these aspects into research to improve the capacity mapping.

In conclusion, no significant interinstitutional differences are observed in Argentina regarding access to diagnostic and clinical management tools for invasive fungal infections. However, there are limitations in the availability of certain tests and antifungals. Increased funding and national awareness initiatives could be of help to improve the current status, especially in the least dense locations.

Acknowledgments

The authors thank all participating institutions for their utmost contributions and support to the project during the pandemic situation and to all the individuals and associations that have disseminated the link to the survey.

Authors acknowledge the utmost contribution of Nahir Daniela Anahí REYES, Adria MORALES, María Carolina OYOLA, Fernando A. MESSINA, Silvia ATORRI, Juan Manuel BERTONE, Sanra LAMBERT, Patricia COSTANTINI, Alejandra CUELLO, Lucas STEFANINI, Veronica ARCE, Valeria ALANIZ, Fernando CIKMAN, María Isabel GARZÓN, Leonardo MARIANELLI, Paula BERNACHEA, Miriam ANGÉLICA, Farias CASTELLANO, Damian LERMAN, María BANGHER, María Soledad FROLA, Gustavo A. MÉNDEZ, Graciana MORERA, Mariana RODRÍGUEZ RAIMONDO, Flavio LIPARI, Marcia GUERCI, Diego VARELA MAILLARD.

Author contributions

Fernando Riera (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing), Juan Pablo Caeiro (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing), Oliver A. Cornely (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing), and Jon Salmanton-García (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing).

Conflicts of interest

F.R. reports grants from Gador, Gilead, and Knight Tx, outside the submitted work.

O.A.C. reports grants or contracts from Amplyx, Basilea, BMBF, Cidara, DZIF, EU-DG RTD (101037867), F2G, Gilead, Matinas, MedPace, MSD, Mundipharma, Octapharma, Pfizer, Scynexis; consulting fees from Amplyx, Biocon, Biosys, Cidara, Da Volterra, Gilead, Matinas, MedPace, Menarini, Molecular Partners, MSG-ERC, Noxxon, Octapharma, PSI, Scynexis, Seres; honoraria for lectures from Abbott, Al-Jazeera Pharmaceuticals, Astellas, Grupo Biotoscana/United Medical/Knight, Hikma, MedScape, MedUpdate, Merck/MSD, Mylan, Pfizer; payment for expert testimony from Cidara; participation on a Data Safety Monitoring Board or Advisory Board from Actelion, Allecra, Cidara, Entasis, IQVIA, Janssen, MedPace, Paratek, PSI, Shionogi; a patent at the German Patent and Trade Mark Office (DE10 2021113007.7), all outside of the submitted work.

J.S.G. reports speaker honoraria from Gilead and Pfizer, outside of the submitted work.

References