BACKGROUND: Fungal meningitis outbreaks are rare and entail high mortality rates. Beginning May 2023, we investigated fungal meningitis caused by Fusarium solani species complex occurring in U.S. patients who received epidural anesthesia in Matamoros, Mexico. METHODS: Early epidemiological information suggested U.S. patients with suspected fungal meningitis had undergone mostly cosmetic procedures under epidural anesthesia performed in two Matamoros clinics. U.S. patients known to have received surgery at these clinics during January 1-May 13, 2023, (clinic closures date) were identified and notified by public health officials. Epidemiological and clinical data were used to update diagnostic and clinical guidance for outbreak response, including use of the experimental antifungal fosmanogepix. Whole genome sequencing was conducted on outbreak isolates. RESULTS: U.S. public health officials attempted to contact 233 potentially exposed U.S. residents who underwent surgeries, mostly cosmetic, in Mexico, reaching 170 (73%). Of those, 104 (61%) reported receiving epidural anesthesia and were therefore considered potentially at risk for fungal meningitis. At least 30/104 (29%) at-risk patients received a diagnostic lumbar puncture; 24 (23 women, 17 Hispanic or Latino) were diagnosed with fungal meningitis, and six were not. Twelve (50%) with fungal meningitis died. All cases involved epidural anesthesia administered by the same anesthesiologist in Mexico. Whole genome sequencing showed that patient isolates of Fusarium from the two implicated clinics in Matamoros, Mexico, were genetically closely related. CONCLUSIONS: Clinicians should maintain suspicion for fungal meningitis in patients with negative bacterial culture, viral culture and molecular testing with a history of epidural anesthesia for any reason.

BACKGROUND: Updated benchmark data on invasive fungal disease (IFD) in solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT) recipients are necessary to increase clinical recognition and inform treatment and prevention strategies. We estimated IFD incidence and potential risk factors in transplant recipients in a large US commercial health insurance database. METHODS: We observed patients who received SOT or HCT during 2018-2022 until IFD development, disenrollment, or database end date (July 31, 2023). We calculated incidence (per 1000 person-years) and time to IFD development, comparing demographic features and underlying conditions for IFD versus non-IFD patients. RESULTS: Overall, 9143 patients received an SOT (5667 kidney, 2025 liver, 759 heart, 650 lung, 39 pancreas, 3 intestine), and 5693 patients received an HCT (3519 autologous, 2114 allogeneic, 60 unspecified type). Among SOT patients, 360 developed an IFD (incidence: 21.0 [per 1000 person-years]). Mold infections had the highest incidence (7.1), followed by unspecified mycoses (3.9) and endemic mycoses (3.3). Among HCT patients, 292 developed an IFD (incidence: 28.5), with higher incidence among allogeneic (58.4) versus autologous (12.8) HCT recipients; among all HCT recipients, unspecified mycoses had the highest incidence (8.3), then pneumocystosis (7.6), and mold infections (6.7). Median time to IFD was 173.5 days for SOT recipients and 197.5 days for HCT recipients. IFD risk varied substantially by transplant type, region, and certain underlying conditions. CONCLUSION: Our results suggest that IFDs remain an important cause of infection among SOT and HCT recipients, particularly later in the posttransplant period, and highlight the need for prevention strategies.

We polled infectious disease specialists about cryptococcal antigen screening for patients initiating HIV antiretroviral therapy. Of 215 respondents, 33% reported typically obtaining screening for patients with CD4 counts <200 cells/mm(3) and 63% for counts <100 CD4 cells/mm(3). Uncertainty about cryptococcal antigen screening benefits and recommendations suggests opportunities for education and increased screening.

Background: Antifungal therapeutic drug monitoring (TDM) is critical for individualized, precision treatment and prevention of fungal infections, but previous research has highlighted low TDM utilization rates, potentially reflecting long turnaround times, complex testing logistics, results interpretation, and cost. Objectives: To inform strategies to increase antifungal TDM use, we assessed TDM-related knowledge, attitudes, and practices among infectious disease (ID) physicians and pharmacists. Methods: We summarized findings from three structured focus group discussions (FGD)—two with six ID physicians each and one with six pharmacists—during March 2024. Open-ended discussions were held regarding awareness of and experiences with fungal infections and TDM, perceptions of antifungal TDM such as potential benefits, barriers, and challenges to conducting antifungal TDM, and information needs about antifungal TDM. We conducted qualitative transcription-based analysis to identify themes. Results: Six themes emerged from FGDs: (1) variable knowledge and experience with antifungal TDM among participants, (2) the importance of close collaboration between physicians and pharmacists during the TDM process, (3) the main motivators driving TDM use were improving treatment outcomes, preventing toxicity, and addressing pharmacokinetic variability, (4) the perception that antifungal resistance was unrelated to TDM, (5) key barriers were a lack of comprehensive clinical guidelines, long lab testing turnaround times, complex testing logistics, and high costs, and (6) a need for additional clinical data on TDM's impact on outcomes. Conclusions: Our findings can inform efforts to increase TDM use by addressing barriers to practice. Development of evidence-based clinical guidelines and improvements in testing infrastructure across practice settings could increase antifungal TDM use. Published 2025. This article is a U.S. Government work and is in the public domain in the USA.

PROBLEM/CONDITION: Candidemia, a bloodstream infection caused by Candida spp., is a common cause of health care-associated bloodstream infections in the United States. Candidemia is associated with substantial health care costs, morbidity, and mortality. PERIOD COVERED: 2017-2021. DESCRIPTION OF SYSTEM: CDC's Emerging Infections Program (EIP), a collaboration among CDC, state health departments, and academic partners, was used to conduct active, population-based laboratory surveillance for candidemia at city or county sites located in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee), representing a combined population of approximately 21.5 million persons, or 7% of the U.S. population in 2019. Connecticut began reporting cases on January 1, 2019, and conducts statewide surveillance. Although candidemia is not a nationally notifiable condition, cases of Candida auris infection are nationally notifiable, and cases of candidemia caused by C. auris could be included in both national case counts and EIP surveillance. A culture-confirmed candidemia case is defined as a positive blood culture for any Candida sp. from a resident in the surveillance catchment area. Subsequent positive blood cultures for Candida within 30 days of the initial positive culture (index date) in the same patient are considered part of the same case. Clinical laboratories serving each catchment area report candidemia cases, and trained surveillance officers abstract information from medical charts for all cases. Corresponding isolates are sent to CDC for species confirmation and antifungal susceptibility testing. RESULTS: A total of 7,381 candidemia cases were identified during the surveillance period (2017-2021). The overall incidence was 7.4 cases per 100,000 population. Across age groups, sexes, racial and ethnic groups, and surveillance sites, incidence was generally stable or increased slightly from 2017 to 2021, with the lowest overall incidence in 2019 (6.8) and the highest in 2021 (7.9). In 2021, candidemia incidence was highest in patients aged ≥65 years (22.7) and infants (aged <1 year) (8.0). Incidence was higher in males (8.7) compared with females (7.0) and higher in non-Hispanic Black or African American (Black) patients (12.8) compared with non-Black patients (5.6). Incidence was highest in Maryland (14.5), followed by Tennessee (10.1) and Georgia (10.0); incidence was lowest in Oregon (4.8). Increases occurred in the percentage of cases classified as health care onset (52.2% in 2017 to 58.0% in 2021). Overall, among 7,381 cases (in 6,235 patients), 63.7% occurred in patients who had a central venous catheter, 80.7% involved recent systemic antibiotic receipt, and 9.0% occurred in patients who had a history of injection drug use. The percentage of cases with a positive SARS-CoV-2 test during the 90 days before or after the index date increased from 10.4% in 2020 to 17.7% in 2021. From 2017 to 2021, the percentage of cases involving an intensive care unit stay before the index date increased from 38.3% to 44.9%. Echinocandins (e.g., micafungin) were used as treatment in 49.8% of cases, and azoles were used in 47.7%. The all-cause in-hospital mortality rate was 32.6%; this increased from 26.8% in 2019 to 36.1% in 2021. Overall, Candida albicans accounted for 37.1% of cases, followed by Candida glabrata (30.4%) and Candida parapsilosis (13.5%); however, C. glabrata was the most frequent species in California (38.4%) and Maryland (32.9%). Candida auris infections accounted for 0.4% of cases. Among 6,576 Candida isolates for which interpretive breakpoints exist and isolates were available for testing, 5.6% were fluconazole resistant, and <1% were echinocandin resistant. Antifungal resistance was stable for all antifungals tested across years. INTERPRETATION: Candidemia remains an important health care-associated infection. The disproportionate incidence among older adults, males, and Black patients is consistent with previous reports, and the overall incidence of candidemia has not changed substantially compared with previous EIP findings based on data collected during 2012-2016 (8.7 per 100,000 population). The higher mortality rate associated with candidemia during 2020-2021 likely reflects consequences of the COVID-19 pandemic, including strained health care systems and an increased population of patients who were susceptible to candidemia because of COVID-19-related critical illness. PUBLIC HEALTH ACTION: Strict implementation of measures to prevent health care-associated bloodstream infections is important to help prevent candidemia cases. Health care officials and providers should be vigilant for candidemia as a complication of critical illness. Continued surveillance is needed to monitor for emerging populations at risk for candidemia and changes in antifungal resistance patterns, which can help guide antifungal treatment selection.

Dermatophytosis (also called ringworm or tinea infection) is a common, contagious superficial infection of the skin, hair, or nails caused by dermatophyte molds. Historically, clinicians have considered dermatophytosis as a mild, easy-to-treat condition; however, the epidemiology of dermatophytosis has changed dramatically in the past decade because of the emergence of dermatophyte strains causing increasingly severe and difficult-to-treat infections. We review three recently emerged dermatophytes of public health concern: Trichophyton indotineae, which is causing outbreaks of frequently terbinafine-resistant and difficult-to-treat tinea in South Asia, with cases also reported across six continents; Trichophyton mentagrophytes genotype VII (TMVII), associated with oral and anogenital tinea infections particularly among men who have sex with men in France and the United States; and terbinafine-resistant Trichophyton rubrum, noted as a cause of difficult-to-treat tinea infections, although data are limited. We discuss practical considerations for identifying these pathogens, which relies on DNA sequencing or MALDI-ToF rather than on morphological characteristics. Additionally, we highlight the importance of antifungal susceptibility testing and practical laboratory considerations. Finally, we emphasize the importance of increased adoption of diagnostic testing for suspected dermatophyte infections, as well as the development of rapid, accurate, and affordable dermatophyte testing methods to help improve diagnostic accuracy and judicious antifungal use. Overall, the emergence of severe and antifungal-resistant dermatophyte infections poses a global public health concern. Clinical microbiologists can play a crucial role in addressing this threat by familiarizing themselves with techniques for identifying emerging dermatophyte species and performing antifungal susceptibility testing to guide patient management, monitor trends, and inform future public health interventions. Copyright © 2025

We report an extensive, terbinafine-resistant (squalene epoxidase F397L mutation) Trichophyton indotineae infection in a previously healthy businessman from São Paulo, Brazil. The patient had previously traveled to France, Spain, and the United States. Clinician awareness, laboratory testing capacity, and surveillance are essential to prevent T. indotineae spread and inform healthcare practices.

Purpose of Review: This review summarizes current literature about the disability burden of the fungal neglected tropical diseases (NTDs) sporotrichosis, chromoblastomycosis, eumycetoma, and paracoccidioidomycosis. The review highlights current knowledge gaps in global settings and describes available tools that could be adopted to fill these gaps. Recent Findings: Sporotrichosis, chromoblastomycosis, and eumycetoma often present initially as skin lesions that can become progressively disfiguring, lead to stigmatization, and cause various sequalae affecting health and function. Chronic paracoccidioidomycosis can have systemic involvement and commonly results in impaired pulmonary function, which can limit activities of daily living and employment capacity. Use of standardized tools to quantify disability with fungal NTDs has been limited to date. Standardized tools to measure the impacts on quality of life and mental health are available and have been used for similar patient populations, including persons with other fungal diseases and persons with non-fungal skin NTDs. Summary: Fungal NTDs can be disabling. Improved understanding of the quality of life and mental health consequences might lead to greater awareness of the burden of fungal NTDs and enhance health planning to address the health and rehabilitation needs of persons affected by these diseases. © This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2025.

We used metagenomic next-generation sequencing (mNGS) to investigate an outbreak of Fusarium solani meningitis in US patients who had surgical procedures under spinal anesthesia in Matamoros, Mexico, during 2023. Using a novel method called metaMELT (metagenomic multiple extended locus typing), we performed phylogenetic analysis of concatenated mNGS reads from 4 patients (P1-P4) in parallel with reads from 28 fungal reference genomes. Fungal strains from the 4 patients were most closely related to each other and to 2 cultured isolates from P1 and an additional case (P5), suggesting that all cases arose from a point source exposure. Our findings support epidemiologic data implicating a contaminated drug or device used for epidural anesthesia as the likely cause of the outbreak. In addition, our findings show that the benefits of mNGS extend beyond diagnosis of infections to public health outbreak investigation.

In a commercial claims database analysis, <0.5% of patients with inflammatory bowel disease or rheumatoid arthritis developed an invasive fungal infection (IFI) within 1 year of initiating tumor necrosis factor-alpha therapy. Histoplasmosis was the most common IFI type. Overall IFI incidence varied based on region, underlying conditions, and use of certain immunosuppressive medications.

The epidemiology of allergic bronchopulmonary aspergillosis (ABPA) in the United States is not well-described. To estimate national ABPA prevalence among patients with asthma or cystic fibrosis, characterize ABPA testing practices, and describe ABPA clinical features, treatment, and 6-month outcomes. We used the 2016-2022 Merative™ MarketScan® Commercial/Medicare and Multi-State Medicaid Databases to identify cohorts of patients with 1) asthma, 2) cystic fibrosis (CF), and 3) ABPA. We calculated ABPA prevalence per 10,000 patients with asthma or CF, assessed diagnostic testing for ABPA among patients with severe asthma, and described features of patients with ABPA using diagnosis and procedure codes. The overall ABPA prevalence among patients with asthma was 2.8/10,000 (Commercial/Medicare) and 1.0/10,000 (Medicaid). ABPA prevalence increased with asthma severity (Commercial/Medicare: mild 1.3, moderate 9.3, severe 70.6, Medicaid: mild 0.3, moderate 2.4, severe 32.4). Among patients with CF, ABPA prevalence was 183.7/10,000 (Commercial/Medicare) and 134.6/10,000 (Medicaid). Among patients with severe asthma, 10.3% (Commercial/Medicare) and 7.4% (Medicaid) received total immunoglobulin E testing, which is recommended for ABPA diagnosis. Among all patients with ABPA (Commercial/Medicare: n = 1,564, Medicaid: n = 410), ABPA treatments included inhaled corticosteroids (>70%), systemic corticosteroids (>62%), and antifungals (>18%). Patients with ABPA and Medicaid were more likely to experience hospitalization (45.1% vs. 22.5% of patients with Commercial/Medicare insurance) and respiratory failure (18.5% vs. 10.9%). This analysis provides initial estimates of national ABPA prevalence. Further studies could identify potential barriers to ABPA testing and investigate potential factors affecting payer-related differences in ABPA burden.

For this narrative review, we describe recent high-profile and severe outbreaks of emerging fungal infections, emphasizing lessons learned and opportunities to improve future prevention and response efforts. Several themes and challenges remain consistent across a diverse array of fungal outbreaks, including the multidisciplinary need for improved diagnostic testing to determine species and perform antifungal susceptibility testing, clinical awareness, and optimization of antifungal use. Recent outbreaks exemplify the growing promise of non-culture-based tools in identifying fungal outbreaks and improving responses, although access remains limited. Culture-based tools remain critical for performing antifungal-susceptibility to guide therapy.

During 2016-2022, Medicare part D beneficiaries filled 8,674,460 clotrimazole-betamethasone dipropionate prescriptions. Annual rates were stable (30.9 prescriptions/1,000 beneficiary-years in 2022, enough for one in every 33 beneficiaries). Diagnostic testing was infrequent, particularly among internal medicine, family medicine, and general practitioners, suggesting potential opportunities to improve diagnostic and prescribing practices.

Antifungal-resistant dermatophyte infections have recently emerged as a global public health concern. A survey of US infectious diseases specialists found that only 65% had heard of this issue and just 39% knew how to obtain testing to determine resistance. Increased clinician awareness and access to testing for antifungal-resistant dermatophytosis are needed.

BACKGROUND: Pityriasis versicolor (PV), a cutaneous fungal infection, most commonly affects adolescents and young adults and is associated with hyperhidrosis and humid weather. Understanding other factors associated with PV might help improve diagnostic and treatment practices. OBJECTIVES: PV's associations with patient demographics, comorbidities and medication exposures were assessed using the All of Us Database, a large, diverse, national database from the United States. METHODS: A case-control study with multivariable analysis was performed. RESULTS: We identified 456 PV case-patients and 1368 control-patients. PV case-patients (vs. control-patients) were younger (median age [years] (standard deviation): 48.7 (15.4) vs. 61.9 (15.5); OR: 0.95, CI: 0.94-0.96) and more likely to be men versus women (42.8% vs. 33.9%, OR: 1.45, CI: 1.16-1.79) and Black (19.5% vs. 15.8%, OR: 1.35, 95% CI: 1.02-1.80) or Asian (4.6% vs. 2.7%, OR: 1.86, CI: 1.07-3.24) versus White. PV case-patients more frequently had acne (5.3% vs. ≤1.5%, OR: 5.37, CI: 2.76-10.48) and less frequently had type 2 diabetes mellitus (T2DM) (14.7% vs. 24.7%, OR: 0.52, CI: 0.39-0.70) and hypothyroidism (OR: 10.3% vs. 16.4%, OR: 0.59, CI: 0.42-0.82). In multivariable analysis, PV odds were significantly higher in those with acne and lower in those with T2DM, older age and female sex. CONCLUSIONS: Our results may be used as a basis for future studies evaluating whether acne treatment may decrease PV risk. Physicians could educate patients with acne about PV, including strategies to control modifiable PV risk factors, such as avoidance of hot and humid environments and avoidance of use of topical skin oils.

BACKGROUND: Five organs (heart, right lung, liver, right, and left kidneys) from a deceased patient were transplanted into five recipients in four US states; the deceased patient was identified as part of a healthcare-associated fungal meningitis outbreak among patients who underwent epidural anesthesia in Matamoros, Mexico. METHODS: After transplant surgeries occurred, Fusarium solani species complex, a fungal pathogen with a high case-mortality rate, was identified in cerebrospinal fluid from the organ donor by metagenomic next-generation sequencing (mNGS) and fungal-specific polymerase chain reaction and in plasma by mNGS. RESULTS: Four of five transplant recipients received recommended voriconazole prophylaxis; four were monitored weekly by serum (1-3)-β-d-glucan testing. All five were monitored for signs of infection for at least 3 months following transplantation. The liver recipient had graft failure, which was attributed to an etiology unrelated to fungal infection. No fungal DNA was identified in sections of the explanted liver, suggesting that F. solani species complex did not contribute to graft failure. The remaining recipients experienced no signs or symptoms suggestive of fusariosis. CONCLUSION: Antifungal prophylaxis may be useful in preventing donor-derived infections in recipients of organs from donors that are found to have Fusarium meningitis.

Among 207 914 multimember households with a tinea case, a secondary case was diagnosed in another household member in 8.5%. Excluding same-day diagnoses (20%), the median time from index case to first secondary case was 138 days. To prevent household tinea transmission, appropriate treatment and strategies to reduce environmental contamination are needed.

In this part 1 of a 2-part continuing medical education series, the epidemiology, clinical features, and diagnostic methods for fungal skin neglected tropical diseases (NTDs), which include eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis, are reviewed. These infections, several of which are officially designated as NTDs by the World Health Organization (WHO), cause substantial morbidity and stigma worldwide and are receiving increased attention due to the potential for climate change-related geographic expansion. Domestic incidence may be increasing in the setting of global travel and immunosuppression. United States dermatologists may play a central role in early detection and initiation of appropriate treatment, leading to decreased morbidity and mortality.

In this part 2 of a 2-part continuing medical education series, the management, outcomes, and morbidities for fungal skin neglected tropical diseases (NTDs), including eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis are reviewed. While fungal skin NTDs are associated with poverty in resource-limited settings, they are more often associated with immunosuppression and global migration in the United States. These infections have a high morbidity burden, including disfigurement, physical disability, coinfection, malignant transformation, mental health issues, and financial impact. For most fungal skin NTDs, management is difficult and associated with low cure rates. Dermatologists play a central role in initiating appropriate treatment early in disease course in order to improve patient outcomes.

Tinea capitis is a fungal infection of the scalp and hair caused by dermatophyte molds, that most often affects children and may also affect adults. Previous estimates suggest that between 3% and 11% of all tinea capitis cases worldwide occur in adults, although updated epidemiological studies are needed to reassess the prevalence of tinea capitis in adult populations specifically. Postmenopausal adult women are most often affected by tinea capitis, with African American or Black women particularly at risk. Adults who experience crowded living conditions, who live in close proximity to animals, who are immunosuppressed, and/or who live in households with affected children are at greatest risk of infection. Tinea capitis can be non-inflammatory or inflammatory in nature, and the subtype affects the extent and severity of clinical symptoms. Fungal culture and potassium hydroxide preparations are the most commonly used diagnostic tools. Trichoscopy, defined as dermoscopic imaging of the scalp and hair, is a useful adjunct to the physical examination. The mainstay of therapy is oral antifungal therapy, and topical therapy alone is not recommended. Since tinea capitis infection is uncommon in adults, there are no widely accepted treatment guidelines. Rather, the same medications used for tinea capitis infection among children are recommended for adults at varying doses, including griseofulvin, and terbinafine, and, less commonly, itraconazole and fluconazole. The prognosis for tinea capitis in adults is typically excellent when prompt and adequate treatment is administered; however, delayed diagnosis or inadequate treatment can result in scarring alopecia. Over the past decade, dermatophyte infections resistant to treatment with topical and oral antifungal agents have emerged. While tinea capitis infections resistant to antifungal therapy have been rarely reported to date, antifungal resistance is rising among superficial fungal infections in general, and antifungal stewardship is necessary to ensure that resistance to treatment does not develop among dermatophytes that cause tinea capitis.

In 2 large health insurance claims databases, cryptococcosis prevalence was 3.4 cases per 100 000 commercially insured patients and 6.5 per 100 000 Medicaid patients. Prevalence was higher among males, non-Hispanic Black patients, and residents of the Southern United States, likely reflecting the disproportionate burden of HIV in these populations.