Al harboured the same genotype of multi-triazole resistant A. fumigatus, isolated on two different occasions which raises concern on the exposure of hospitalized patients to this resistant genotype. In this context it is pertinent to mention that previously multi-triazole resistant TR34/L98H A. fumigatus isolates have been reported from patients attending the outpatient departments of VPCI who were never exposed to azoles [22]. In addition multi-triazole resistant A. fumigatus has also been isolated from admitted patients of VPCI. The presence of A. fumigatus resistant to medical triazoles poses a threat to immunocompromised patients as alternative therapy is limited. Snelders et al. reported that TR34/L98H isolates from clinical and environmental origins were cross resistant to five triazole DMIs fungicides, propiconazole, bromuconazole, tebuconazole, epoxiconazole and difenoconazole and thus supporting the hypothesis that exposure of A. fumigatus to azole fungicides in the environment causes cross resistance to medical triazoles. [21]. Furthermore, these investigators also reported that these five triazole DMIs showed very similar molecule structures to the medical triazoles and adopted a similar TKI-258 lactate biological activity conformation while docking the target enzyme and exhibit activity against wild type A. fumigatus but not against multi-triazole resistant TR34/L98H A. fumigatus [21]. Similarly, in the present study four of the five (bromuconazole, tebuconazole, epoxiconazole and difenoconazole) triazole DMIs known to have similar molecule structures as medical triazoles showed significantly higher MICs for multi triazole resistant TR34/L98H A. fumigatus from environmental and clinical samples than those of wild type strains (Table 2). In addition, metconazole and hexaconazole also showed high MICs for multi-triazole resistant A. fumigatus isolates with the TR34/ L98H mutation. Attention is called to the report of Serfling et al., who used the maize anthracnose fungus Colletotrichum graminicola model get ADX48621 system to study the acquisition of azole resistance and investigated whether isolates that were resistant to an agricultural azole show cross-resistance to azoles and antifungal agents of other chemical classes used in medicine [30]. Their in-vitro data revealed that C. graminicola was able to efficiently adapt to medium containing azoles, and strains adapted to tebuconazole were less sensitive to all agricultural and medical azoles tested than the nonadapted control strain. Likewise, azole cross-resistance was observed for yeast isolates from the oropharynx of human immunodeficiency virus-infected patients to agricultural azole drugs and for those from environmental sources to medical azole drugs [31]. It is remarkable that all of the environmental and clinical TR34/ L98H A. fumigatus isolates in 1527786 India had the same microsatellite genotype. Although the environmental isolates originated from geographically diverse regions of northern, eastern and southern parts of India were separated from each other by about 2000 Km, they harboured an identical short tandem repeat (STR) pattern. The possibility of contamination during handling of samples was ruled out by processing of the samples by different laboratorypersonnel in two different laboratories in India and the Netherlands. Furthermore, we had reported earlier that two clinical TR34/L98H A. fumigatus isolates originating from two azole naive patients, who were residents of Bihar and Delhi, shared the same STR patte.Al harboured the same genotype of multi-triazole resistant A. fumigatus, isolated on two different occasions which raises concern on the exposure of hospitalized patients to this resistant genotype. In this context it is pertinent to mention that previously multi-triazole resistant TR34/L98H A. fumigatus isolates have been reported from patients attending the outpatient departments of VPCI who were never exposed to azoles [22]. In addition multi-triazole resistant A. fumigatus has also been isolated from admitted patients of VPCI. The presence of A. fumigatus resistant to medical triazoles poses a threat to immunocompromised patients as alternative therapy is limited. Snelders et al. reported that TR34/L98H isolates from clinical and environmental origins were cross resistant to five triazole DMIs fungicides, propiconazole, bromuconazole, tebuconazole, epoxiconazole and difenoconazole and thus supporting the hypothesis that exposure of A. fumigatus to azole fungicides in the environment causes cross resistance to medical triazoles. [21]. Furthermore, these investigators also reported that these five triazole DMIs showed very similar molecule structures to the medical triazoles and adopted a similar conformation while docking the target enzyme and exhibit activity against wild type A. fumigatus but not against multi-triazole resistant TR34/L98H A. fumigatus [21]. Similarly, in the present study four of the five (bromuconazole, tebuconazole, epoxiconazole and difenoconazole) triazole DMIs known to have similar molecule structures as medical triazoles showed significantly higher MICs for multi triazole resistant TR34/L98H A. fumigatus from environmental and clinical samples than those of wild type strains (Table 2). In addition, metconazole and hexaconazole also showed high MICs for multi-triazole resistant A. fumigatus isolates with the TR34/ L98H mutation. Attention is called to the report of Serfling et al., who used the maize anthracnose fungus Colletotrichum graminicola model system to study the acquisition of azole resistance and investigated whether isolates that were resistant to an agricultural azole show cross-resistance to azoles and antifungal agents of other chemical classes used in medicine [30]. Their in-vitro data revealed that C. graminicola was able to efficiently adapt to medium containing azoles, and strains adapted to tebuconazole were less sensitive to all agricultural and medical azoles tested than the nonadapted control strain. Likewise, azole cross-resistance was observed for yeast isolates from the oropharynx of human immunodeficiency virus-infected patients to agricultural azole drugs and for those from environmental sources to medical azole drugs [31]. It is remarkable that all of the environmental and clinical TR34/ L98H A. fumigatus isolates in 1527786 India had the same microsatellite genotype. Although the environmental isolates originated from geographically diverse regions of northern, eastern and southern parts of India were separated from each other by about 2000 Km, they harboured an identical short tandem repeat (STR) pattern. The possibility of contamination during handling of samples was ruled out by processing of the samples by different laboratorypersonnel in two different laboratories in India and the Netherlands. Furthermore, we had reported earlier that two clinical TR34/L98H A. fumigatus isolates originating from two azole naive patients, who were residents of Bihar and Delhi, shared the same STR patte.
