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. 2025 Jul;68(7):e70092.
doi: 10.1111/myc.70092.

ESCMID-EFISG Survey on Diagnostic and Therapeutic Capacity for Invasive Fungal Infections in Belgium, the Netherlands, and Luxembourg: A Focus on High Azole Resistance

Robina Aerts  1   2 , Lize Cuypers  3   4 , Eelco F J Meijer  5   6 , Michel Kohnen  7 , Jacques F Meis  6   8 , Oliver A Cornely  8   9   10   11   12 , Katrien Lagrou  2   13   14 , Jon Salmanton-García  8   9   10
Affiliations

ESCMID-EFISG Survey on Diagnostic and Therapeutic Capacity for Invasive Fungal Infections in Belgium, the Netherlands, and Luxembourg: A Focus on High Azole Resistance

Robina Aerts et al. Mycoses. 2025 Jul.

Abstract

Introduction: Invasive fungal infections (IFI) are a major clinical challenge, particularly in immunocompromised patients, and are associated with high morbidity and mortality. With the increasing prevalence of immunosuppressive conditions and ageing populations, the incidence of IFI is rising globally.

Objective: This survey aims to evaluate the diagnostic and therapeutic capacities for IFI in Belgium, the Netherlands, and Luxembourg (Benelux), a region of high azole-resistance among Aspergillus fumigatus isolates.

Methods: A survey evaluating the diagnostic and therapeutic capacity for IFI was conducted in the Benelux. Data were collected from specialists via an online case report form between March and September 2023. The survey addressed patient characteristics, access to microbiology labs, diagnostic methods (microscopy, culture, molecular diagnostics, etc.), IFI incidence, and the availability of antifungal drugs and therapeutic drug monitoring.

Results: In total, 32 hospitals responded to the questionnaire (12 [38%] from the Netherlands, 19 [59%] from Belgium and one [3%] from Luxembourg). Antifungal susceptibility tests were available in 29 institutions (91%), constituting 84% of the centres in Belgium and 100% for the Netherlands (p = 0.265). Aspergillus PCR testing was available in 12 centres in Belgium (63%) while in 11 centres in the Netherlands (92%, p = 0.108). Mucorales PCR testing was available in 56% of centres. Treatment with at least one amphotericin B formulation was only available in 84% of the responding centres. Therapeutic drug monitoring (TDM), although recommended, was possible for voriconazole in 26 centres (81%) while for posaconazole in 24 centres (75%). Significantly more testing (diagnostic tests and TDM) was outsourced in Belgium compared to the Netherlands (p < 0.001).

Conclusions: Antifungal susceptibility testing is widely available in Belgium and the Netherlands, but implementation in areas with high azole resistance for Aspergillus fumigatus is not yet universal, and techniques vary. Tests for coinfections, like Mucorales PCR, were only available in half of the centres. More testing is outsourced in Belgium, likely due to differences in reference centre organisation, country size, transport, and reimbursement. Delays in diagnosis can impact patient outcomes, so awareness of test availability and transport times is crucial.

Keywords: antifungal resistance; aspergillus antigen; azole‐resistance; invasive aspergillosis; invasive fungal infections; lateral flow assays; lateral flow devices; mycology.

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Conflict of interest statement

R.A. received PhD funding from the Flemish Cancer Society (Kom op Tegen Kanker) and a research grant and travel support from Pfizer and Gilead Sciences, outside of the submitted work. L.C. declares no conflicts of interest. E.F.J.M. received research grants from Mundipharma and Scynecis, is on the scientific advisory board for Pfizer and has received speaker fees from Gilead Sciences, outside of the submitted work. M.K. declares no conflicts of interest. J.F.M. declares no conflicts of interest. O.A.C. reports grants or contracts from iMi, iHi, DFG, BMBF, Cidara, DZIF, EU‐DG RTD, F2G, Gilead, MedPace, MSD, Mundipharma, Octapharma, Pfizer, Scynexis; consulting fees from Abbvie, AiCuris, Basilea, Biocon, Boston Strategic Partners, Cidara, Elion, Gilead, GSK, IQVIA, Janssen, Matinas, MedPace, Menarini, Melinta, Molecular Partners, MSG‐ERC, Mundipharma, Noxxon, Octapharma, Pardes, Partner Therapeutics, Pfizer, PSI, Scynexis, Seres, Seqirus, Shionogi, Prime Meridian Group; speaker and lecture honoraria from Abbott, Abbvie, Al‐Jazeera Pharmaceuticals/Hikma, amedes, AstraZeneca, Gilead, GSK, Grupo Biotoscana/United Medical/Knight, Ipsen Pharma, Medscape/WebMD, MedUpdate, MSD, Moderna, Mundipharma, Noscendo, Paul‐Martini‐Stiftung, Pfizer, Sandoz, Seqirus, Shionogi, streamedup!, Touch Independent, Vitis; participation on a DRC, DSMB, DMC, or Advisory Board for AstraZeneca, Cidara, IQVIA, Janssen, MedPace, Melinta, PSI, Pulmocide, Vedanta Biosciences, outside of the submitted work. K.L. received consultancy fees from Mundipharma, speaker fees from Pfizer, Gilead, Mundipharma, and FUJIFILM Wako chemicals Europe GmbH, a service fee from TECOmedical, a fee for Advisory Board participation from Pfizer, and travel support from Pfizer, Gilead, and AstraZeneca, outside of the submitted work. J.S.G. has received speaker honoraria from AstraZeneca, Gilead, Pfizer, and Menarini, and has been a member of an advisory board for Pfizer, outside of the submitted work.

Figures

FIGURE 1
FIGURE 1
Geographic distribution of the centres that have participated in the survey. Belgium (red, n = 19 centres; OLV Ziekenhuis in Aalst, AZ Rivierenland in Bornem, AZ Sint‐Jan and AZ Sint‐Lucas in Bruges, Sciensano, Brussels University Hospital, and CHU Brugmann in Brussels, Labo Nuytinck in Evergem, Ghent University Hospital and Az Jan Palfijn in Ghent, Jessa Ziekenhuis in Hasselt, Jan Yperman Hospital in Ieper, Hôpitaux IRIS SUD in Ixelles, UZ Leuven in Leuven, CHU de Liège in Liège, AZ Sint‐Maarten in Mechelen, H. Hartziekenhuis Mol in Mol, AZ Delta in Roeselare, and GZA Ziekenhuizen Antwerp in Wilrijk). Netherlands (orange, n = 12 centres; Meander Medisch Centrum in Amersfoort, AmsterdamUMC and Antoni van Leeuwenhoek in Amsterdam, University Medical Center Groningen in Groningen, Canisius‐Wilhelmina Ziekenhuis and Radboud University Medical Center in Nijmegen, ErasmusMC in Rotterdam, Jeroen Bosch Ziekenhuis in s‐Hertogenbosch, Microvida Laboratory for Medical Microbiology and Immunology across Tilburg, Breda, Roosendaal, and Terneuzen, University Medical Center Utrecht and Westerdijk Fungal Biodiversity Institute in Utrecht, and Isala Hospitals in Zwolle). Luxembourg (blue, n = 1 centre; Centre Hospitalier de Luxembourg in Luxembourg). Starts indicate European Confederation of Medical Mycology (ECMM) Excellence Centres in Leuven, Belgium and Nijmegen, Netherlands (https://www.ecmm.info/ecmm‐excellence‐centers/excellence‐centers/).
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