The study sample sizes ranged from 14 to 513. Twenty-nine articles, 16 with clinical samples only, 4 with environmental samples only, and 9 with a mixture of clinical and environmental samples, were included in the meta-review (Fig. 1). The characteristics of included articles have been summarized in Table 1. Twenty-one studies determined the fungi type by partial beta-tubulin DNA sequencing, six by morphology, and the other two were pre-defined isolates. The method of measuring antifungal resistance in 27 studies was based on the CLSI-M38 guideline and in two cases was based on the EUCAST standard.[17, 18] Table 2 outlines data on sources of clinical samples of included studies. The most common sample sources for clinical studies were broncho-alveolar lavage (BAL), ear, sputum, sinus, and nail. Environmental studies mainly sampled paddy field soils, hospital garden soils, hospital air (indoor and outdoor), and medical equipment. Table 3 summurizes a comprehensive report of antifungal resistance data. Of eighteen meta-analyses, five showed complete homogeneity (I2 = 0%), ten showed heterogeneity (I2 > 75%), and three showed relative homogeneity (I2 < = 75%). Among most studies examining the CYP51 gene as a mechanism of Aspergillus resistance, approximately half of resistant isolates carried the TR34/L98H mutation.[19–22] Several studies have reported that less than half of resistant isolates were mutated.[23, 24] A small proportion of resistant isolates had TR46/ Y121F/T289A mutation.[19–24] As Aspergilli fumigati and flavi are the most prevalent species,[25] we briefly reviewed their antifungal susceptibility results below. A summary of other meta-analysis results and additional information on other species has been shown in Table 4. Forest plots representing resistance rates of included studies and their pooled resistance rates have been indicated in Fig. 2, Fig. 3, and Fig. 4. The forest plots have data on the prevalence of A. fumigatus resistance to itraconazole (Fig. 2), A. fumigatus resistance to voriconazole (Fig. 3), and A. flavus resistance to itraconazole (Fig. 4). Other forest plots from the meta-analysis have been included in the supplementary data.
Table 1
Authors, publication dates, settings and methods used in included studies
Code | Author | Publication date | Study period | Setting | Speices identification | AFST method | Mutations | Number of samples |
N01[31] | Badiee P. | 2022 | 2018–2021 | Env, Cln | PBT DNA sequencing | CLSI M38 | - | 233 (191 Cln; 42 Env) |
N02[32] | Xue Xu | 2021 | 2015–2018 | Cln | PBT DNA sequencing | CLSI M38 | - | 48 |
N03[33] | Yassin Z. | 2021 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 14 |
N04[34] | Vaghar Z. | 2021 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 163 |
N05[35] | Gharaghani M. | 2020 | - | Cln | Morphology | CLSI M38 | - | 90 |
N06[19] | Ahangarkani F. | 2020 | 2017–2018 | Env | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 44) TR46/ Y121F/T289A (n = 3) | 300 |
N07[25] | Chadeganipour M. | 2020 | 2010 – 2018 | Cln | PBT DNA sequencing | CLSI M38 | - | 132 |
N08[36] | Ardi P. | 2020 | 2017–2019 | Cln | PBT DNA sequencing | CLSI M38 | - | 35 |
N09[20] | Taheri Rizi Z. | 2020 | - | Env, Cln | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 10) TR46/ Y121F/T289A (n = 7) | 354 (218 Cln; 138 Env) |
N10[10] | Mohamadnia A. | 2020 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 45 |
N11[37] | Hivary S. | 2019 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 67 |
N12[17] | Zarrin M. | 2018 | - | Env, Cln | Pre-defined isolates | EUCAST | - | 58 (9 Cln; 45 Env) |
N13[21] | Falahatinejad M. | 2018 | 2013–2016 | Env, Cln | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 9) | 79 (50 Cln; 29 Env) |
N14[38] | Kamali Sarwestani Z. | 2018 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 43 |
N15[22] | Vaezi A. | 2018 | - | Env | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 2) | 108 |
N16[39] | Vaezi A. | 2018 | - | Env, Cln | PBT DNA sequencing | CLSI M38 | - | 81 (36 Cln; 45 Env) |
N17[40] | Nasrolahi A. | 2017 | - | Cln | PBT DNA sequencing | CLSI M38 | - | 160 |
N18[41] | Zargaran M. | 2017 | - | Env | Morphology | CLSI M38 | - | 40 |
N19[42] | Raiesi O. | 2017 | 2014–2015 | Cln | Morphology | CLSI M38 | - | 122 |
N20[23] | Mohammadi F. | 2016 | 2010–2014 | Cln | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 8) TR46/ Y121F/T289A (n = 6) | 172 |
N21[24] | Nabili M. | 2016 | 2012–2015 | Env, Cln | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 9) | 513 (213 Cln; 300 Env) |
N22[18] | Mohammadi F. | 2016 | 2014 | Cln | PBT DNA sequencing | EUCAST | - | 170 |
N23[43] | Khodavaisy S. | 2016 | - | Env, Cln | PBT DNA sequencing | CLSI M38 | - | 199 (171 Cln; 28 Env) |
N24[44] | Hoseinnejad A. | 2016 | 2013–2015 | Env, Cln | PBT DNA sequencing | CLSI M38 | - | 400 (150 Cln; 250 Env) |
N25[45] | Hojatinia H. | 2015 | - | Env, Cln | Pre-defined isolates | CLSI M38 | - | 40 (20 Cln; 20 Env) |
N26[46] | Nemati S. | 2014 | 2011 – 2012 | Cln | Morphology | CLSI M38 | - | 100 |
N27[47] | Kazemi A. | 2012 | 2011 | Cln | Morphology | CLSI M38 | - | 50 |
N28[1] | Badali H. | 2013 | - | Env | PBT DNA sequencing | CLSI M38 | TR34/L98H (n = 5) | 150 |
N29[48] | Hashemi J. | 2011 | 2009–2010 | Cln | Morphology | CLSI M38 | - | 50 |
ECV, Epidemiologic Concentration Value; Cln, Clinical; Env, Environmental; PBT, Partial Beta Tubulin; PCR, Polymerase Chain Reaction; AFST, Antifungal Seseptibility Testing |
Table 2
Isolation sources of Aspergillus in Studies with clinical specimens
Code | Spp | BAL | Biopsy | Pharynx | Trachea | Sputum | Sinus | Nail | Ear | Nose | Eye | Skin | CSF |
N01[31] | A. flavus | 35 | - | - | - | 17 | - | - | 13 | - | 1 | - | - |
A. fumigatus | 8 | - | - | - | 6 | - | - | - | - | 1 | - | - |
A. niger | 16 | - | - | - | 10 | - | - | 28 | - | 4 | - | - |
A. terreus | 7 | - | - | - | - | - | - | 6 | - | - | - | - |
Others | 2 | - | - | - | 1 | - | - | 1 | - | - | - | - |
N04[34] | Total† | 11 | 3 | - | - | 8 | 26 | - | 3 | - | - | 14 | - |
N05[35] | Total† | - | - | - | - | - | - | - | 90 | - | - | - | - |
N07[25] | Total† | 51 | - | - | - | - | 21 | 40 | 12 | - | 7 | 1 | - |
N08[36] | Total† | 22 | - | - | - | - | 13 | - | - | - | - | - | - |
N10[10] | A. nidulans | 3 | 4 | - | - | - | - | - | - | - | - | - | - |
A. terreus | 27 | 1 | - | 5 | - | - | - | - | - | - | - | - |
Others | 4 | 2 | - | - | - | - | - | - | - | - | - | - |
N13[21] | Total† | 31 | 9 | - | - | - | 8 | 2 | - | - | - | - | - |
N16[39] | Total† | 7 | 3 | 3 | - | 8 | 1 | 14 | - | - | - | - | - |
N21[24] | Total† | 144 | 9 | - | - | - | 24 | 12 | 24 | - | - | - | - |
N23[43] | Total† | 31 | 8 | - | - | - | 61 | - | 4 | 19 | - | 40 | - |
N24[44] | Total† | 17 | - | - | - | 2 | 4 | 3 | - | - | - | 2 | 2 |
N26[46] | Total† | - | - | - | - | - | - | - | 100 | - | - | - | - |
N27[47] | A. flavus | 5 | - | - | - | - | 18 | 2 | - | - | - | - | - |
A. fumigatus | 20 | - | - | - | 2 | 2 | - | - | - | - | - | - |
BAL, Broncho-Alveolar Lavage; CSF, Cerebro-Spinal Fluid |
†The term “Total” means that the study did not contain data of each species separately; instead, a total resistance rate was reported. |
Table 3
The prevalence of Aspergillus species resistance to different drugs
Code | Spp | n | ITC | VRC | AMB | POS | CFG | ANF | RAV | ISA | LAN | LUL | CLO |
N01[31] | A. flavus | 117 | 0 | 3.4 | 0 | 1 | 2.5 | - | - | 3.4 | - | 5 | - |
N02[32] | A. flavus | 38 | 0 | 0 | 0 | 0 | 0 | - | - | 0 | - | - | - |
N03[33] | A. flavus | 14 | - | - | - | - | 28.6 | - | - | - | - | - | - |
N04[34] | A. flavus | 42 | - | - | 5 | 0 | 0 | - | - | - | - | - | - |
N05[35] | A. flavus | 30 | 3.3 | - | - | - | 76.7 | - | - | - | - | - | - |
N07[25] | A. flavus | 32 | 9.4 | 9.4 | 0 | - | - | - | - | - | - | - | - |
N09[20] | A. flavus | 66 | 7.6 | 0 | 3 | 0 | - | 10.7 | - | - | - | - | - |
N17[40] | A. flavus | 5 | 0 | 0 | 0 | - | 0 | - | - | - | - | - | - |
N23[43] | A. flavus | 199 (171 Cln, 28 Env) | 1.1 (0.6 Cln, 3.6 Env) | 1.1 (0.6 Cln, 3.6 Env) | 3.6 (3 Cln, 7.2 Env) | 2.6 (2.4 Cln, 3.6 Env) | 0 | - | - | - | - | - | - |
N24[44] | A. flavus | 90 | 2.2 | 0 | - | - | - | - | - | - | - | - | - |
N25[45] | A. flavus | 40 | 0 | 0 | - | - | 0 | - | - | - | - | - | - |
N27[47] | A. flavus | 25 | 0 | - | 0 | - | - | - | - | - | - | - | - |
N29[48] | A. flavus | 40 | 25 | 0 | 7.5 | - | - | - | - | - | - | - | - |
N04[34] | A. fumigatus | 12 | 0.5 | 1 | - | 0 | - | - | - | - | - | - | - |
N06[19] | A. fumigatus | 63 | 87.3 | 27.8 | - | - | - | - | - | - | - | - | - |
N09[20] | A. fumigatus | 141 | 17.7 | 12 | 1.4 | 12.8 | - | - | - | - | - | - | - |
N12[17] | A. fumigatus | 54 (9 Cln, 45 Env) | - | 9.3 (0 Cln, 11.1 Env) | - | - | - | - | - | - | - | - | - |
N13[21] | A. fumigatus | 50 | 30 | - | - | - | - | - | - | - | - | - | - |
N15[22] | A. fumigatus | 11 | 36.6 | 27.8 | 0 | 0 | 0 | - | - | - | 0 | 0 | - |
N17[40] | A. fumigatus | 1 | 100 | 0 | 0 | - | - | - | - | - | - | - | - |
N20[23] | A. fumigatus | 172 | 3.5 | 3.5 | - | 0 | - | - | - | - | - | - | - |
N21[24] | A. fumigatus | 150 (71 Cln, 79 Env) | 6.7 (4.2 Cln, 8.9 Env) | 4.7 (2.8 Cln, 6.3 Env) | 0.7 (Cln) | 3.4 (2.8 Cln, 3.8 Env) | - | - | - | - | - | - | - |
N22[18] | A. fumigatus | 58 | 0 | 0 | - | 0 | - | - | - | - | - | - | - |
N26[46] | A. fumigatus | 7 | - | - | - | - | - | - | - | - | - | - | 71.4 |
N27[47] | A. fumigatus | 25 | 0 | - | 0 | - | - | - | - | - | - | - | - |
N28[1] | A. fumigatus | 41 | 12.2 | 12.2 | - | - | - | - | - | - | - | - | - |
N29[48] | A. fumigatus | 1 | 0 | 0 | 0 | - | - | - | - | - | - | - | - |
N05[35] | A. nidulans | 1 | 0 | - | - | - | 0 | - | - | - | - | - | - |
N10[10] | A. nidulans | 9 | 11.1 | 0 | 88.9 | 0 | 11.1 | - | 11.1 | 0 | - | - | - |
N02[32] | A. niger | 1 | 0 | 0 | 0 | 0 | 0 | - | - | 0 | - | - | - |
N04[34] | A. niger | 8 | - | - | - | 0 | 0 | - | - | - | - | - | - |
N05[35] | A. niger | 36 | 0 | - | - | - | 41.7 | - | - | - | - | - | - |
N07[25] | A. niger | 1 | 0 | 0 | 0 | - | - | - | - | - | - | - | - |
N11[37] | A. niger | 36 (21 Cln, 15 Env) | - | 19.4 (23.8 Cln, 13.3 Env) | 86.1 (81 Cln, 93 Env) | 86.1 (81 Cln, 93 Env) | 38.9 (52.4 Cln, 20 Env) | - | - | - | - | - | - |
N14[38] | A. niger | 11 | - | - | - | - | - | - | - | - | - | - | - |
N26[46] | A. niger | 21 | - | - | - | - | - | - | - | - | - | - | 4.8 |
N29[48] | A. niger | 9 | 0 | 0 | 0 | - | - | - | - | - | - | - | - |
N10[10] | A. ochraceus | 2 | 50 | 0 | 50 | 0 | 0 | - | 0 | 0 | - | - | - |
N17[40] | A. sydowii | 3 | 100 | 0 | - | - | 0 | - | - | - | - | - | - |
N02[32] | A. terreus | 3 | 0 | 0 | 0 | 0 | 100 | - | - | 0 | - | - | - |
N04[34] | A. terreus | 3 | - | - | - | 0 | - | - | - | - | - | - | - |
N05[35] | A. terreus | 1 | 0 | - | - | - | 100 | - | - | - | - | - | - |
N07[25] | A. terreus | 2 | 0 | 0 | 100 | - | - | - | - | - | - | - | - |
N09[20] | A. terreus | 103 | 0 | 1.9 | - | - | - | 0 | - | - | - | - | - |
N10[10] | A. terreus | 34 | 26.4 | 0 | 85.3 | 0 | 0 | - | 5.9 | 0 | - | - | - |
N16[39] | A. terreus | 81 | 0 | 0 | 0 | 0 | 1.20 | - | - | - | 0 | 0 | - |
N18[41] | A. terreus | 40 | - | 42.5 | 70 | 37.5 | - | - | - | - | - | - | - |
N14[38] | A. tubingensis | 32 | - | - | - | - | - | - | - | - | - | - | - |
N01[31] | Aspergillus spp. | 233 | 0 | 1.3 | 3 | 2.6 | 4.7 | - | - | 1.7 | - | 1.3 | - |
N08[36] | Aspergillus spp. | 35 | 0 | 8.3 | 0 | 0 | 0 | - | 0 | - | - | - | - |
N19[42] | Aspergillus spp. | 10 | 80 | - | - | - | - | - | - | - | - | - | - |
ITC, Itraconazole; VRC, Voriconazole; AMB, Amphotericin B; POS, Posaconazole; CFG, Caspofungin; RAV, Ravoconazole; ISA, Isavoconazole; FLC, Fluconazole; LAN, Lanoconazole; LUL, Luliconazole; CLO, Clotrimazole; KTC, Ketoconazole; ANF, Anidulafungin; n, Number of samples. |
Table 4
Results of meta-analysis on 18 species-drug pair analyzing the rate of drug resistance and generating a pooled resistance rate (RR)
Species – Antifungal | RR (%) | 95% CI | P-value | I2 (Heterogeneity) | CI to I2 | Q test | df |
A. flavus – AMB | 2.430 | 0.940–4.590 | P = 0.09 | 41.56% | 0.00–73.06 | 13.6888 | 8 |
A. flavus – CFG | 7.639 | 0.521–21.969 | P < 0.0001 | 94.45% | 91.19–96.50 | 126.0884 | 7 |
A. flavus – ITC | 3.595 | 1.153–7.317 | P < 0.0001 | 76.13% | 57.13–86.71 | 41.8924 | 10 |
A. flavus – POS | 1.480 | 0.586–2.773 | P = 0.5173 | 0.00% | 0.00–75.89 | 3.2473 | 4 |
A. flavus – VRC | 1.443 | 0.466–2.945 | P = 0.1397 | 34.78% | 0.00–69.97 | 12.2663 | 8 |
A. fumigatus – AMB | 1.388 | 0.416–2.917 | P = 0.897 | 0.00% | 0.00–24.62 | 1.6348 | 5 |
A. fumigatus – POS | 2.631 | 0.117–8.266 | P < 0.0001 | 86.67% | 73.23–93.37 | 37.5195 | 5 |
A. fumigatus – VRC | 9.165 | 4.439–15.371 | P < 0.0001 | 79.75% | 64.51–88.45 | 49.3842 | 10 |
A. fumigaus – ITC | 17.770 | 5.762–34.508 | P < 0.0001 | 95.71% | 93.96–96.95 | 256.4538 | 11 |
A. niger – AMB | 27.613 | 1.097–87.637 | P < 0.0001 | 91.92% | 82.51–96.27 | 37.1447 | 3 |
A. niger – CFG | 27.366 | 10.443–48.658 | P = 0.0268 | 67.38% | 4.93–88.81 | 9.1968 | 3 |
A. niger – ITC | 1.487 | 0.0224–6.583 | P = 0.6909 | 0.00% | 0.00–73.53 | 1.4629 | 3 |
A. niger – VRC | 15.237 | 6.798–26.278 | P = 0.3996 | 0.00% | 0.00–86.86 | 2.9484 | 3 |
A. terreus – AMB | 45.418 | 2.838–93.340 | P < 0.0001 | 97.67% | 96.29–98.53 | 171.5579 | 4 |
A. terreus – CFG | 26.023 | 2.267–63.250 | P < 0.0001 | 90.11% | 77.61–95.63 | 30.3192 | 3 |
A. terreus – ITC | 0.446 | 0.000491–1.718 | P = 0.7953 | 0.00% | 0.00–48.10 | 2.3741 | 5 |
A. terreus – POS | 6.842 | 0.0983–28.276 | P < 0.0001 | 90.82% | 81.52–95.44 | 43.5668 | 4 |
A. terreus – VRC | 6.391 | 0.864–21.467 | P < 0.0001 | 90.52% | 82.11–94.98 | 52.7332 | 5 |
RR, Resistance Rate; CI, Confidence Interval; df, Degree of Freedom; AMB, Amphotericin B; CFG, Caspofungin; ITC, Itraconazole; POS, Posaconazole; VRC, Voriconazole |
Aspergillus fumigatus resistance pattern
Six of the 29 studies included data on A. fumigatus resistance to amphotericin B, with a pooled resistance of 1.388% (95% CI: 0.416–2.917; I2 = 0%, P = 0.897). Of the 6 studies, 4 showed complete susceptibility and a resistance rate of 0%. Twelve of the 29 studies contained data on A. fumigatus resistance to itraconazole, with a pooled resistance of 17.770% (95% CI: 5.762–34.508; I2 = 95.71%, P < 0.0001). Of the 12 studies, 4 showed complete susceptibility with a resistance rate of 0%, and one demonstrated complete resistance (100%). Six of the 29 studies included data on A. fumigatus resistance to posaconazole, with a pooled resistance of 2.631% (95% CI: 0.117–8.266; I2 = 86.67%, P < 0.0001). Of the 6 studies, 4 showed complete susceptibility with a resistance rate of 0%. Eleven of the 29 studies contained data on A. fumigatus resistance to voriconazole, with a pooled resistance of 9.165% (95% CI: 4.439–15.371; I2 = 79.75%, P < 0.0001). Of the 11 studies, 4 showed complete susceptibility with a resistance rate of 0%.
Aspergillus flavus resistance pattern
Nine of the 29 studies included data on A. flavus resistance to amphotericin B, with a pooled resistance of 2.430% (95% CI: 0.940–4.590; I2 = 41.56%, P = 0.09). Of the 9 studies, 5 showed complete susceptibility with a 0% resistance rate. Eight of the 29 studies contained data on the resistance of A. flavus to caspofungin with a pooled resistance rate of 7.639% (95% CI: 0.521–21.969; I2 = 94.45%, P < 0.0001). Of the 8 studies, 5 revealed complete susceptibility with a resistance rate of 0%. Eleven of the 29 studies contained data on the resistance of A. flavus to itraconazole with a pooled resistance rate of 3.595% (95% CI: 1.153–7.317; I2 = 76.13%, P < 0.0001). Of the 11 studies, 5 showed complete susceptibility with a resistance rate of 0%. Twelve of the 29 studies included data on A. flavus resistance to posaconazole, with a pooled resistance of 1.480% (95% CI: 1.153–7.317; I2 = 76.13%, P < 0.0001). Of the 12 studies, 5 showed complete susceptibility with a resistance rate of 0%. Nine of the 29 studies included data on voriconazole resistance in A. flavus, with a pooled resistance of 1.443% (95% CI: 0.466–2.945; I2 = 34.78%, P = 0.1397). Of the 9 studies, 6 showed complete susceptibility with a resistance rate of 0%.
Aspergillus terreus resistance pattern
Five of the 29 studies included data on A. terreus resistance to amphotericin B, with a pooled resistance of 45.418% (95% CI: 2.838–93.340; I2 = 97.67%, P < 0.0001). Of the five studies, two showed complete susceptibility with a resistance rate of 0%. Four of the 29 studies contained data on A. terreus resistance to caspofungin, with a pooled resistance of 26.023%n(95% CI: 2.267–63.250; I2 = 90.11%, P < 0.0001). Among 4 studies, one revealed complete susceptibility with a resistance rate of 0%. Six of the 29 studies contained data on the resistance of A. terreus to itraconazole with a pooled resistance rate of 0.446% (95% CI: 0.000491–1.718; I2 = 0.00%, P = 0.7953). All six studies revealed complete susceptibility with a resistance rate of 0%. Five of the 29 studies contained data on resistance of A. terreus to posaconazole with a pooled resistance rate of 6.842% (95% CI: 0.0983–28.276; I2 = 90.82%, P < 0.0001). Of the five studies, four showed complete susceptibility with a resistance rate of 0%. Six of the 29 studies contained data on the resistance of A. terreus resistance to voriconazole with a pooled resistance of 6.391% (95% CI: 0.864–21.467; I2 = 90.52%, P < 0.0001). Of the 6 studies, 4 showed complete susceptibility with a resistance rate of 0%.