Geographically structured genotypes and resistance clustering in Aspergillus fumigatus

Geographically structured genotypes and resistance clustering in Aspergillus fumigatus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Geographically structured genotypes and resistance clustering in Aspergillus fumigatus Won-Bok Kim, Dukhee Nho, Sung-Yeon Cho, Dong-Gun Lee, Chulmin Park, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7547800/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Dec, 2025 Read the published version in European Journal of Clinical Microbiology & Infectious Diseases → Version 1 posted 14 You are reading this latest preprint version Abstract We analysed 498 global Aspergillus fumigatus isolates using multilocus variable-number tandem-repeat (MLVA) typing to investigate regional clustering, environmental–clinical overlap, and azole resistance patterns. The dataset, including 155 newly genotyped Korean strains, revealed extensive genotypic diversity and four distinct phylogeographic clusters. Resistance-associated mutations (TR34/TR46) were concentrated within specific clusters, particularly among European and East Asian lineages. These findings support the presence of geographically structured populations and localised emergence of resistance. This is the first global application of MLVA to A. fumigatus , underscoring its value for molecular surveillance in settings where whole-genome sequencing remains limited. Aspergillus fumigatus Molecular Epidemiology Geographic Distribution Antifungal Resistance Environmental Microbiology Figures Figure 1 Introduction Despite growing interest, key gaps persist in our understanding of A. fumigatus molecular epidemiology. Global-scale genotyping efforts are still limited, and the species’ population structure remains poorly defined across regions [ 1 ], and it is unclear whether clinical disease is primarily caused by specific virulent lineages or reflects a broad spectrum of genotypes circulating in the environment [ 2 ]. Additionally, the geographic distribution of these genotypes has not been systematically characterised, leaving unresolved whether strains are globally dispersed or exhibit regional restriction [ 3 ]. Finally, the emergence of azole-resistant isolates raises urgent questions about how local environmental selection pressures may shape the distribution of resistance-associated genotypes [ 4 ]. While whole-genome sequencing (WGS) offers the highest resolution, its global application is often constrained by resource availability and metadata limitations, particularly across environmental sources. In such contexts, multilocus variable-number tandem-repeat (MLVA) typing remains a practical and informative tool for large-scale genotypic surveillance. This study represents the first attempt to characterise the global molecular epidemiology of Aspergillus fumigatus using MLVA data, by integrating all publicly available genomes with clinical and environmental isolates from South Korea [ 5 , 6 ]. We assessed regional genotypic clustering, overlap between environmental and clinical strains, and distribution of resistance-associated mutations. These insights aimed to inform geographically tailored surveillance strategies and highlight the need for an integrated health framework that bridges clinical and environmental monitoring. Materials and Methods Data Collection and Processing Publicly available whole-genome A. fumigatus sequences in the NCBI database as of December 31, 2024, were queried using BLAST against ten MLVA loci as previously described [5]. A total of 343 genomes were identified from diverse global sources. Genomes missing ≥ 1 target locus or lacking accompanying metadata were excluded. Additionally, 155 clinical and environmental A. fumigatus isolates from South Korea were obtained from a previously published dataset, yielding 498 isolates for downstream analysis [5, 6]. Molecular Typing and Phylogenetic Analysis For each of the ten MLVA loci, alleles were defined based on sequence variation and converted into numeric codes, and sequence types (STs) were assigned by concatenating the ten-locus allele codes for each isolate. Genetic relatedness among STs was assessed using Euclidean distance and goeBURST-based algorithms. Minimal spanning trees (MSTs) were constructed using PHYLOViZ (version 2.0; Lisbon, Portugal) to visualise phylogenetic relationships. Discriminatory Power and Resistance Analysis The discriminatory capacity of MLVA typing was evaluated by calculating Simpson’s Diversity Index (SDI). Tandem-repeat (TR) mutations within target loci were also catalogued and used to generate a subset of MSTs focused on resistance-associated genotypes. Where available, resistance-associated cyp51A mutation data were mapped onto MST clusters to assess the spatial distribution of azole-resistant genotypes. Results Genotypic Diversity A total of 498 A. fumigatus isolates were analysed, comprising 343 publicly available genomes and 155 strains collected in South Korea. These isolates originated from 17 countries, with the majority originating from Germany (256, 51.4%), South Korea (155, 31.1%), and China (43, 8.6%). Additional isolates originated from France (10), the United States (7), and the United Kingdom (7). Isolates from other countries with ≤ 5 samples each were also included; detailed country-level distribution is provided in the Supplementary File and Supplementary Table S1 . MLVA typing divided the 498 isolates into 343 distinct STs, demonstrating high discriminatory capacity; 271 STs (79%) were observed only once, indicating broad genotypic diversity. ST138 comprised 26 clinical isolates collected from China in 2019, suggesting a locally dominant lineage. The SDI was 1.000, reflecting the maximal resolution ( Supplementary File ). Phylogenetic Clustering and Regional Structure MST analysis revealed four major phylogenetic clusters: Clusters 1 and 4 largely consisted of South Korean and Chinese isolates, whereas Cluster 3 was dominated by strains from Germany and other European countries. This clustering pattern highlighted the regional stratification of genotypes, suggesting local evolutionary adaptation or restricted strain flow ( Fig. 1 ). Environmental and Clinical Source Distribution Environmental and clinical isolates were broadly intermixed across all clusters without clear separation, indicating shared genotypes between environmental reservoirs and human infections ( Supplementary Fig. S1 ). Azole Resistance and Genotypic Aggregation Among the 498 isolates, 21 (4.2%) harboured cyp51A TR mutations associated with azole resistance: 15 carried TR34, and six carried TR46. These resistant strains were distributed across 18 distinct STs, indicating polyclonal emergence. TR34 mutations were identified in 12 STs (e.g., ST303, ST341, ST319), whereas TR46 mutations appeared in six (e.g., ST339, ST123). Of the 21 resistant isolates, 15 (71.4%) were recovered from Europe and six (28.6%) from East Asia. TR34 mutations were more common in European isolates (11 of 15, 73.3%), while TR46 mutations showed a more balanced distribution (4 in Europe, 2 in East Asia). In phylogenetic analysis, 13 of the 18 resistance-associated STs (72%) were localised within Cluster 3 (predominantly European), whereas the remainder—including TR46-positive ST123 and ST247—were found in Clusters 1 and 4, reflecting their prevalence in South Korea and China ( Supplementary Table S2, Supplementary Fig. S2 ). Discussion This global-scale genotypic analysis of A. fumigatus using MLVA profiling revealed distinct regional population structures. Despite the airborne nature of A. fumigatus and its presumed global dispersion, our findings showed clear phylogeographic clustering, with South Korean and Chinese isolates forming distinct lineages from the European clusters, which were dominated by strains from German and French. These results reinforce the presence of geographically enriched genotypes and suggest local clonal expansion or microevolutionary adaptation, consistent with recent pan-genomic studies indicating restricted gene flow and region-specific genomic divergence in A. fumigatus [ 7 ]. Such region-specific lineage structuring suggests local clonal expansion or niche-driven microevolution, reinforcing the need for tailored molecular surveillance for each geographic region. Genetic analysis revealed extensive intermixing of clinical and environmental isolates across all phylogenetic clusters, with no source-specific lineage segregation. The extensive overlap between environmental and clinical isolates across all phylogenetic clusters suggests shared reservoirs and the circulation of potentially pathogenic genotypes in the environment [ 5 , 8 ]. These findings reinforce the importance of environmental surveillance as part of a one-health framework that links clinical disease dynamics to environmental reservoirs. Azole resistance-associated STs were not evenly distributed but showed a regional pattern. Of the 18 STs carrying cyp51A tandem-repeat mutations (TR34 or TR46), 13 (72%) were located within Cluster 3, which was primarily composed of isolates from Germany and other European countries. This trend aligns with our quantitative analysis, showing that 73% of TR34-positive isolates originated from Europe, whereas TR46 mutations were more evenly distributed between Europe and East Asia. This regional pattern is also consistent with prior studies, which have reported TR34 mutations more frequently in European isolates [ 9 ]. The remaining five STs, including TR46-positive ST123 and ST247, were found in Clusters 1 and 4, which contained isolates from South Korea and China, respectively. Although sampling imbalances and underreporting from other regions cannot be excluded, this distribution indicates that resistance-associated genotypes are concentrated within certain geographic lineages. While the underlying drivers of this pattern remain to be confirmed, these observations support the importance of regionally focused antifungal resistance surveillance and molecular monitoring programmes [ 10 – 12 ]. This study has certain limitations. Although the dataset was geographically diverse, sampling was uneven, with an overrepresentation from Germany and South Korea potentially influencing the cluster boundaries and genotype frequencies. Additionally, only cyp51A TR mutations (TR34 and TR46) were analysed, and resistance mediated by other mutations or pathways (such as point mutations and efflux) was not assessed. While WGS provides higher resolution and broader resistance detection, it is often limited by resource constraints and incomplete metadata. MLVA, though lower in resolution, remains a feasible and informative approach for large-scale genotypic surveillance, especially in resource-limited or mixed-source datasets. Finally, the cross-sectional design did not capture temporal trends. Longitudinal surveillance is essential for monitoring the emergence, expansion, and potential persistence of resistance-associated or regionally dominant lineages. Conclusion In conclusion, A. fumigatus demonstrates a regional population structure, environmental–clinical genetic overlap, and localised clustering of resistance-associated genotypes. These findings highlight the need for geographically informed molecular surveillance, integrated antifungal stewardship, and longitudinal epidemiological studies. Sustained genomic data sharing across clinical and environmental domains will be essential to support a health-based strategy for the early detection and containment of emerging resistance. Declarations Acknowledgments We gratefully acknowledge all the researchers who deposited A. fumigatus genome sequences in the NCBI, which were indispensable for our global comparative analyses. We thank our lab members for isolating, sequencing, and analysing the South Korean strains and for providing previously published data. Author Contributions R Lee, WB Kim, and DG Lee conceptualised the study, and R Lee, WB Kim, and C Park coordinated this study. R Lee, B. Kim, D Nho, and C Park performed the data analysis, and R Lee, WB Kim, D Nho, SY Cho, C Park, and DG Lee interpreted the data. R Lee, WB Kim, and SY Cho drafted the manuscript, and all authors have fully reviewed the manuscript. All authors agree with the content and conclusions of this manuscript. Funding This work was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2022R1I1A1A01070887) Competing Interests The authors declare no conflict of interest. Data Availability The datasets generated and analysed in this study, including the detailed MLVA profiles and resistance data, are provided in the Supplementary Files submitted for this article and are available for research use. References Kordana N, Johnson A, Quinn K, Obar Joshua J, Cramer Robert A (2025) Recent developments in Aspergillus fumigatus research: diversity, drugs, and disease. Microbiology and Molecular Biology Reviews 89 (1):e00011-00023 Simmons BC, Rhodes J, Rogers TR, Talento AF, Griffin A, Mansfield M, Sheehan D, Abdolrasouli A, Verweij PE, Bosch T, Schelenz S, Hemmings S, Fisher MC (2023) Genomic epidemiology of European Aspergillus fumigatus causing COVID-19-associated pulmonary aspergillosis in Europe. bioRxiv:2023.2007.2021.550109 Ashu EE, Hagen F, Chowdhary A, Meis JF, Xu J (2017) Global Population Genetic Analysis of Aspergillus fumigatus. mSphere 2 (1) Schoustra SE, Debets AJM, Rijs A, Zhang J, Snelders E, Leendertse PC, Melchers WJG, Rietveld AG, Zwaan BJ, Verweij PE (2019) Environmental Hotspots for Azole Resistance Selection of Aspergillus fumigatus, the Netherlands. Emerg Infect Dis 25 (7):1347-1353 Lee R, Kim WB, Cho SY, Nho D, Park C, Chun HS, Myong JP, Lee DG (2025) Genetic relationships of Aspergillus fumigatus in hospital settings during COVID-19. Microbiol Spectr 13 (5):e0190224 Lee R, Kim WB, Cho SY, Nho D, Park C, Yoo IY, Park YJ, Lee DG (2023) Clinical Implementation of β-Tubulin Gene-Based Aspergillus Polymerase Chain Reaction for Enhanced Aspergillus Diagnosis in Patients with Hematologic Diseases: A Prospective Observational Study. J Fungi (Basel) 9 (12) Lofgren LA, Ross BS, Cramer RA, Stajich JE (2022) The pan-genome of Aspergillus fumigatus provides a high-resolution view of its population structure revealing high levels of lineage-specific diversity driven by recombination. PLoS Biol 20 (11):e3001890 Loeffert ST, Melloul E, Gustin MP, Hénaff L, Guillot C, Dupont D, Wallon M, Cassier P, Dananché C, Bénet T, Botterel F, Guillot J, Vanhems P (2019) Investigation of the Relationships Between Clinical and Environmental Isolates of Aspergillus fumigatus by Multiple-locus Variable Number Tandem Repeat Analysis During Major Demolition Work in a French Hospital. Clin Infect Dis 68 (2):321-329 Escribano P, Rodríguez-Sánchez B, Díaz-García J, Martín-Gómez MT, Ibáñez-Martínez E, Rodríguez-Mayo M, Peláez T, García-Gómez de la Pedrosa E, Tejero-García R, Marimón JM, Reigadas E, Rezusta A, Labayru-Echeverría C, Pérez-Ayala A, Ayats J, Cobo F, Pazos C, López-Soria L, Alastruey-Izquierdo A, Muñoz P, Guinea J, Sánchez-Yebra W, Sánchez-Gómez J, Lozano I, Marfil E, Muñoz de la Rosa M, García RT, Cobo F, Castro C, López C, Rezusta A, Peláez T, Castelló-Abietar C, Costales I, Serra JL, Jiménez R, Echeverría CL, Pérez CL, Megías-Lobón G, Lorenzo B, Sánchez-Reus F, Ayats J, Martín MT, Vidal I, Sánchez-Hellín V, Ibáñez E, Pemán J, Fajardo M, Pazos C, Rodríguez-Mayo M, Pérez-Ayala A, Gómez E, Guinea J, Escribano P, Serrano J, Reigadas E, Rodríguez B, Zvezdanova E, Díaz-García J, Gómez-Núñez A, Leiva JG, Machado M, Muñoz P, Sánchez-Romero I, García-Rodríguez J, Luis del Pozo J, Vallejo MR, Ruiz de Alegría-Puig C, López-Soria L, Marimón JM, Vicente D, Fernández-Torres M, Hernáez-Crespo S (2021) Azole resistance survey on clinical Aspergillus fumigatus isolates in Spain. Clinical Microbiology and Infection 27 (8):1170.e1171-1170.e1177 Rivelli Zea SM, Toyotome T (2022) Azole-resistant Aspergillus fumigatus as an emerging worldwide pathogen. Microbiol Immunol 66 (3):135-144 Verweij PE, Lucas JA, Arendrup MC, Bowyer P, Brinkmann AJF, Denning DW, Dyer PS, Fisher MC, Geenen PL, Gisi U, Hermann D, Hoogendijk A, Kiers E, Lagrou K, Melchers WJG, Rhodes J, Rietveld AG, Schoustra SE, Stenzel K, Zwaan BJ, Fraaije BA (2020) The one health problem of azole resistance in Aspergillus fumigatus: current insights and future research agenda. Fungal Biology Reviews 34 (4):202-214 Lee S-O (2023) Diagnosis and Treatment of Invasive Mold Diseases. Infect Chemother 55 (1):10-21 Additional Declarations No competing interests reported. Supplementary Files SupplementaryfileGlobalstructureEJCMID.xlsx SupplementarymaterialsGlobalstructureEJCMID.pdf Cite Share Download PDF Status: Published Journal Publication published 24 Dec, 2025 Read the published version in European Journal of Clinical Microbiology & Infectious Diseases → Version 1 posted Editorial decision: Revision requested 14 Nov, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviews received at journal 15 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviews received at journal 09 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 08 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 05 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7547800","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":514658276,"identity":"a913b003-f436-443a-bebd-f2913a5185eb","order_by":0,"name":"Won-Bok Kim","email":"","orcid":"","institution":"Genes Laboratories Inc","correspondingAuthor":false,"prefix":"","firstName":"Won-Bok","middleName":"","lastName":"Kim","suffix":""},{"id":514658278,"identity":"80058e08-9727-4c9c-b99d-3f89554e8e03","order_by":1,"name":"Dukhee Nho","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Dukhee","middleName":"","lastName":"Nho","suffix":""},{"id":514658280,"identity":"9e9a2cd0-4968-453e-84b7-463bfc210612","order_by":2,"name":"Sung-Yeon Cho","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Sung-Yeon","middleName":"","lastName":"Cho","suffix":""},{"id":514658284,"identity":"0ee21128-0c30-47df-8ac4-36a1ec18e375","order_by":3,"name":"Dong-Gun Lee","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Dong-Gun","middleName":"","lastName":"Lee","suffix":""},{"id":514658285,"identity":"a55514d9-928d-4106-b6ac-2a4ec6dfaafd","order_by":4,"name":"Chulmin Park","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Chulmin","middleName":"","lastName":"Park","suffix":""},{"id":514658286,"identity":"d0223a4e-5813-4d19-9fa1-57ba4b56ac85","order_by":5,"name":"Raeseok Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIie3QPUoEMRTA8TcEMs1o2iwOewPhLYFYODexiY02M+ABtggsrM2Krd5CEKwDD8ZG8QIWpplqC7cbYQVnv7qNY2mRfxEC4cdLAhCL/cfYakEALiau2zk4ZJsD7CVC1gbAOOC9ZNfAlrgh0EOOr1Pv2ys6Q/ey+Pxq34c8ZR/QjkGd2P1EU6ZQIlUPdPM4mJlGccYxmdWgcxckXOKKuNcnyAydT1kGcGChkIGLaUobadakbJLlliTfvxLQ0nXk3pac7aawbooOk0yNLF5Wt7JWR/kFrd9CeS1VkLw9dz+2PK2mYuIX84KGQpD383ExuguQ/TmA0IxYLBaL/aUfUoJWl2S285YAAAAASUVORK5CYII=","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":true,"prefix":"","firstName":"Raeseok","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2025-09-06 02:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7547800/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7547800/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10096-025-05390-4","type":"published","date":"2025-12-24T15:57:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91423049,"identity":"41f90e13-4594-4b2c-966e-ab9a142bce29","added_by":"auto","created_at":"2025-09-16 10:38:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":10423104,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMinimum spanning tree of 498 \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAspergillus fumigatus\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e isolates based on multilocus variable-number tandem-repeat profiles\u003c/strong\u003e. Each node represents a unique sequence type (ST), with node size proportional to the number of isolates assigned to that ST. Nodes are colour-coded by country of isolation: Germany, South Korea, China, France, the United States, or other regions. Edges indicate genetic distance: solid lines denote single-locus variants, short dashed lines indicate two-locus variants, and long dashed lines correspond to three-locus variants. Four major phylogenetic clusters are shaded to highlight regional genotypic structuring.\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-7547800/v1/e29c2dd229b2ed98b4bcdecc.png"},{"id":99172249,"identity":"fd5718ff-36dd-49dc-9916-2ffb70442009","added_by":"auto","created_at":"2025-12-29 16:05:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":12798933,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7547800/v1/b5092a71-4924-4d44-9750-f6954515e6d8.pdf"},{"id":91422569,"identity":"56edc502-b69e-4ad4-9a76-e2cf44cea7e1","added_by":"auto","created_at":"2025-09-16 10:30:26","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":36660,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileGlobalstructureEJCMID.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7547800/v1/82cda01ba11b6904c0f2856c.xlsx"},{"id":91422576,"identity":"54666c66-5d3d-4089-a9d7-2662161e5660","added_by":"auto","created_at":"2025-09-16 10:30:27","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":552239,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialsGlobalstructureEJCMID.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7547800/v1/e42650258175eb6d94cd4192.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Geographically structured genotypes and resistance clustering in Aspergillus fumigatus","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite growing interest, key gaps persist in our understanding of \u003cem\u003eA. fumigatus\u003c/em\u003e molecular epidemiology. Global-scale genotyping efforts are still limited, and the species\u0026rsquo; population structure remains poorly defined across regions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and it is unclear whether clinical disease is primarily caused by specific virulent lineages or reflects a broad spectrum of genotypes circulating in the environment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, the geographic distribution of these genotypes has not been systematically characterised, leaving unresolved whether strains are globally dispersed or exhibit regional restriction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Finally, the emergence of azole-resistant isolates raises urgent questions about how local environmental selection pressures may shape the distribution of resistance-associated genotypes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile whole-genome sequencing (WGS) offers the highest resolution, its global application is often constrained by resource availability and metadata limitations, particularly across environmental sources. In such contexts, multilocus variable-number tandem-repeat (MLVA) typing remains a practical and informative tool for large-scale genotypic surveillance.\u003c/p\u003e\u003cp\u003eThis study represents the first attempt to characterise the global molecular epidemiology of \u003cem\u003eAspergillus fumigatus\u003c/em\u003e using MLVA data, by integrating all publicly available genomes with clinical and environmental isolates from South Korea [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We assessed regional genotypic clustering, overlap between environmental and clinical strains, and distribution of resistance-associated mutations. These insights aimed to inform geographically tailored surveillance strategies and highlight the need for an integrated health framework that bridges clinical and environmental monitoring.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection and Processing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePublicly available whole-genome \u003cem\u003eA. fumigatus\u003c/em\u003e sequences in the NCBI database as of December 31, 2024, were queried using BLAST against ten MLVA loci as previously described [5]. A total of 343 genomes were identified from diverse global sources. Genomes missing \u0026ge; 1 target locus or lacking accompanying metadata were excluded. Additionally, 155 clinical and environmental \u003cem\u003eA. fumigatus\u003c/em\u003e isolates from South Korea were obtained from a previously published dataset, yielding 498 isolates for downstream analysis [5, 6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMolecular Typing and Phylogenetic Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor each of the ten MLVA loci, alleles were defined based on sequence variation and converted into numeric codes, and sequence types (STs) were assigned by concatenating the ten-locus allele codes for each isolate. Genetic relatedness among STs was assessed using Euclidean distance and goeBURST-based algorithms. Minimal spanning trees (MSTs) were constructed using PHYLOViZ (version 2.0; Lisbon, Portugal) to visualise phylogenetic relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiscriminatory Power and Resistance Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe discriminatory capacity of MLVA typing was evaluated by calculating Simpson\u0026rsquo;s Diversity Index (SDI). Tandem-repeat (TR) mutations within target loci were also catalogued and used to generate a subset of MSTs focused on resistance-associated genotypes. Where available, resistance-associated \u003cem\u003ecyp51A\u003c/em\u003e mutation data were mapped onto MST clusters to assess the spatial distribution of azole-resistant genotypes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGenotypic Diversity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 498 \u003cem\u003eA. fumigatus\u0026nbsp;\u003c/em\u003eisolates were analysed, comprising 343 publicly available genomes and 155 strains collected in South Korea. These isolates originated from 17 countries, with the majority originating from Germany (256, 51.4%), South Korea (155, 31.1%), and China (43, 8.6%). Additional isolates originated from France (10), the United States (7), and the United Kingdom (7). Isolates from other countries with \u0026le; 5 samples each were also included; detailed country-level distribution is provided in the \u003cstrong\u003eSupplementary File and Supplementary Table S1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eMLVA typing divided the 498 isolates into 343 distinct STs, demonstrating high discriminatory capacity; 271 STs (79%) were observed only once, indicating broad genotypic diversity. ST138 comprised 26 clinical isolates collected from China in 2019, suggesting a locally dominant lineage. The SDI was 1.000, reflecting the maximal resolution (\u003cstrong\u003eSupplementary File\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhylogenetic Clustering and Regional Structure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMST analysis revealed four major phylogenetic clusters: Clusters 1 and 4 largely consisted of South Korean and Chinese isolates, whereas Cluster 3 was dominated by strains from Germany and other European countries. This clustering pattern highlighted the regional stratification of genotypes, suggesting local evolutionary adaptation or restricted strain flow (\u003cstrong\u003eFig. 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEnvironmental and Clinical Source Distribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnvironmental and clinical isolates were broadly intermixed across all clusters without clear separation, indicating shared genotypes between environmental reservoirs and human infections (\u003cstrong\u003eSupplementary Fig. S1\u003c/strong\u003e). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAzole Resistance and Genotypic Aggregation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 498 isolates, 21 (4.2%) harboured \u003cem\u003ecyp51A\u003c/em\u003e TR mutations associated with azole resistance: 15 carried TR34, and six carried TR46. These resistant strains were distributed across 18 distinct STs, indicating polyclonal emergence. TR34 mutations were identified in 12 STs (e.g., ST303, ST341, ST319), whereas TR46 mutations appeared in six (e.g., ST339, ST123). Of the 21 resistant isolates, 15 (71.4%) were recovered from Europe and six (28.6%) from East Asia. TR34 mutations were more common in European isolates (11 of 15, 73.3%), while TR46 mutations showed a more balanced distribution (4 in Europe, 2 in East Asia).\u003c/p\u003e\n\u003cp\u003eIn phylogenetic analysis, 13 of the 18 resistance-associated STs (72%) were localised within Cluster 3 (predominantly European), whereas the remainder\u0026mdash;including TR46-positive ST123 and ST247\u0026mdash;were found in Clusters 1 and 4, reflecting their prevalence in South Korea and China (\u003cstrong\u003eSupplementary Table S2, Supplementary Fig. S2\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis global-scale genotypic analysis of \u003cem\u003eA. fumigatus\u003c/em\u003e using MLVA profiling revealed distinct regional population structures. Despite the airborne nature of \u003cem\u003eA. fumigatus\u003c/em\u003e and its presumed global dispersion, our findings showed clear phylogeographic clustering, with South Korean and Chinese isolates forming distinct lineages from the European clusters, which were dominated by strains from German and French. These results reinforce the presence of geographically enriched genotypes and suggest local clonal expansion or microevolutionary adaptation, consistent with recent pan-genomic studies indicating restricted gene flow and region-specific genomic divergence in \u003cem\u003eA. fumigatus\u003c/em\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Such region-specific lineage structuring suggests local clonal expansion or niche-driven microevolution, reinforcing the need for tailored molecular surveillance for each geographic region.\u003c/p\u003e\u003cp\u003eGenetic analysis revealed extensive intermixing of clinical and environmental isolates across all phylogenetic clusters, with no source-specific lineage segregation. The extensive overlap between environmental and clinical isolates across all phylogenetic clusters suggests shared reservoirs and the circulation of potentially pathogenic genotypes in the environment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These findings reinforce the importance of environmental surveillance as part of a one-health framework that links clinical disease dynamics to environmental reservoirs.\u003c/p\u003e\u003cp\u003eAzole resistance-associated STs were not evenly distributed but showed a regional pattern. Of the 18 STs carrying cyp51A tandem-repeat mutations (TR34 or TR46), 13 (72%) were located within Cluster 3, which was primarily composed of isolates from Germany and other European countries. This trend aligns with our quantitative analysis, showing that 73% of TR34-positive isolates originated from Europe, whereas TR46 mutations were more evenly distributed between Europe and East Asia. This regional pattern is also consistent with prior studies, which have reported TR34 mutations more frequently in European isolates [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The remaining five STs, including TR46-positive ST123 and ST247, were found in Clusters 1 and 4, which contained isolates from South Korea and China, respectively. Although sampling imbalances and underreporting from other regions cannot be excluded, this distribution indicates that resistance-associated genotypes are concentrated within certain geographic lineages. While the underlying drivers of this pattern remain to be confirmed, these observations support the importance of regionally focused antifungal resistance surveillance and molecular monitoring programmes [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study has certain limitations. Although the dataset was geographically diverse, sampling was uneven, with an overrepresentation from Germany and South Korea potentially influencing the cluster boundaries and genotype frequencies. Additionally, only \u003cem\u003ecyp51A\u003c/em\u003e TR mutations (TR34 and TR46) were analysed, and resistance mediated by other mutations or pathways (such as point mutations and efflux) was not assessed. While WGS provides higher resolution and broader resistance detection, it is often limited by resource constraints and incomplete metadata. MLVA, though lower in resolution, remains a feasible and informative approach for large-scale genotypic surveillance, especially in resource-limited or mixed-source datasets. Finally, the cross-sectional design did not capture temporal trends. Longitudinal surveillance is essential for monitoring the emergence, expansion, and potential persistence of resistance-associated or regionally dominant lineages.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, \u003cem\u003eA. fumigatus\u003c/em\u003e demonstrates a regional population structure, environmental\u0026ndash;clinical genetic overlap, and localised clustering of resistance-associated genotypes. These findings highlight the need for geographically informed molecular surveillance, integrated antifungal stewardship, and longitudinal epidemiological studies. Sustained genomic data sharing across clinical and environmental domains will be essential to support a health-based strategy for the early detection and containment of emerging resistance.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge all the researchers who deposited \u003cem\u003eA. fumigatus\u003c/em\u003e genome sequences in the NCBI, which were indispensable for our global comparative analyses. We thank our lab members for isolating, sequencing, and analysing the South Korean strains and for providing previously published data. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR Lee, WB Kim, and DG Lee conceptualised the study, and R Lee, WB Kim, and C Park coordinated this study. R Lee, B. Kim, D Nho, and C Park performed the data analysis, and R Lee, WB Kim, D Nho, SY Cho, C Park, and DG Lee interpreted the data. R Lee, WB Kim, and SY Cho drafted the manuscript, and all authors have fully reviewed the manuscript. All authors agree with the content and conclusions of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2022R1I1A1A01070887)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed in this study, including the detailed MLVA profiles and resistance data, are provided in the Supplementary Files submitted for this article and are available for research use.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKordana N, Johnson A, Quinn K, Obar Joshua J, Cramer Robert A (2025) Recent developments in Aspergillus fumigatus research: diversity, drugs, and disease. Microbiology and Molecular Biology Reviews 89 (1):e00011-00023\u003c/li\u003e\n\u003cli\u003eSimmons BC, Rhodes J, Rogers TR, Talento AF, Griffin A, Mansfield M, Sheehan D, Abdolrasouli A, Verweij PE, Bosch T, Schelenz S, Hemmings S, Fisher MC (2023) Genomic epidemiology of European \u0026lt;em\u0026gt;Aspergillus fumigatus\u0026lt;/em\u0026gt; causing COVID-19-associated pulmonary aspergillosis in Europe. bioRxiv:2023.2007.2021.550109\u003c/li\u003e\n\u003cli\u003eAshu EE, Hagen F, Chowdhary A, Meis JF, Xu J (2017) Global Population Genetic Analysis of Aspergillus fumigatus. mSphere 2 (1)\u003c/li\u003e\n\u003cli\u003eSchoustra SE, Debets AJM, Rijs A, Zhang J, Snelders E, Leendertse PC, Melchers WJG, Rietveld AG, Zwaan BJ, Verweij PE (2019) Environmental Hotspots for Azole Resistance Selection of Aspergillus fumigatus, the Netherlands. Emerg Infect Dis 25 (7):1347-1353\u003c/li\u003e\n\u003cli\u003eLee R, Kim WB, Cho SY, Nho D, Park C, Chun HS, Myong JP, Lee DG (2025) Genetic relationships of Aspergillus fumigatus in hospital settings during COVID-19. Microbiol Spectr 13 (5):e0190224\u003c/li\u003e\n\u003cli\u003eLee R, Kim WB, Cho SY, Nho D, Park C, Yoo IY, Park YJ, Lee DG (2023) Clinical Implementation of \u0026beta;-Tubulin Gene-Based Aspergillus Polymerase Chain Reaction for Enhanced Aspergillus Diagnosis in Patients with Hematologic Diseases: A Prospective Observational Study. J Fungi (Basel) 9 (12)\u003c/li\u003e\n\u003cli\u003eLofgren LA, Ross BS, Cramer RA, Stajich JE (2022) The pan-genome of Aspergillus fumigatus provides a high-resolution view of its population structure revealing high levels of lineage-specific diversity driven by recombination. 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Clin Infect Dis 68 (2):321-329\u003c/li\u003e\n\u003cli\u003eEscribano P, Rodr\u0026iacute;guez-S\u0026aacute;nchez B, D\u0026iacute;az-Garc\u0026iacute;a J, Mart\u0026iacute;n-G\u0026oacute;mez MT, Ib\u0026aacute;\u0026ntilde;ez-Mart\u0026iacute;nez E, Rodr\u0026iacute;guez-Mayo M, Pel\u0026aacute;ez T, Garc\u0026iacute;a-G\u0026oacute;mez de la Pedrosa E, Tejero-Garc\u0026iacute;a R, Marim\u0026oacute;n JM, Reigadas E, Rezusta A, Labayru-Echeverr\u0026iacute;a C, P\u0026eacute;rez-Ayala A, Ayats J, Cobo F, Pazos C, L\u0026oacute;pez-Soria L, Alastruey-Izquierdo A, Mu\u0026ntilde;oz P, Guinea J, S\u0026aacute;nchez-Yebra W, S\u0026aacute;nchez-G\u0026oacute;mez J, Lozano I, Marfil E, Mu\u0026ntilde;oz de la Rosa M, Garc\u0026iacute;a RT, Cobo F, Castro C, L\u0026oacute;pez C, Rezusta A, Pel\u0026aacute;ez T, Castell\u0026oacute;-Abietar C, Costales I, Serra JL, Jim\u0026eacute;nez R, Echeverr\u0026iacute;a CL, P\u0026eacute;rez CL, Meg\u0026iacute;as-Lob\u0026oacute;n G, Lorenzo B, S\u0026aacute;nchez-Reus F, Ayats J, Mart\u0026iacute;n MT, Vidal I, S\u0026aacute;nchez-Hell\u0026iacute;n V, Ib\u0026aacute;\u0026ntilde;ez E, Pem\u0026aacute;n J, Fajardo M, Pazos C, Rodr\u0026iacute;guez-Mayo M, P\u0026eacute;rez-Ayala A, G\u0026oacute;mez E, Guinea J, Escribano P, Serrano J, Reigadas E, Rodr\u0026iacute;guez B, Zvezdanova E, D\u0026iacute;az-Garc\u0026iacute;a J, G\u0026oacute;mez-N\u0026uacute;\u0026ntilde;ez A, Leiva JG, Machado M, Mu\u0026ntilde;oz P, S\u0026aacute;nchez-Romero I, Garc\u0026iacute;a-Rodr\u0026iacute;guez J, Luis del Pozo J, Vallejo MR, Ruiz de Alegr\u0026iacute;a-Puig C, L\u0026oacute;pez-Soria L, Marim\u0026oacute;n JM, Vicente D, Fern\u0026aacute;ndez-Torres M, Hern\u0026aacute;ez-Crespo S (2021) Azole resistance survey on clinical \u0026lt;em\u0026gt;Aspergillus fumigatus\u0026lt;/em\u0026gt; isolates in Spain. Clinical Microbiology and Infection 27 (8):1170.e1171-1170.e1177\u003c/li\u003e\n\u003cli\u003eRivelli Zea SM, Toyotome T (2022) Azole-resistant Aspergillus fumigatus as an emerging worldwide pathogen. Microbiol Immunol 66 (3):135-144\u003c/li\u003e\n\u003cli\u003eVerweij PE, Lucas JA, Arendrup MC, Bowyer P, Brinkmann AJF, Denning DW, Dyer PS, Fisher MC, Geenen PL, Gisi U, Hermann D, Hoogendijk A, Kiers E, Lagrou K, Melchers WJG, Rhodes J, Rietveld AG, Schoustra SE, Stenzel K, Zwaan BJ, Fraaije BA (2020) The one health problem of azole resistance in Aspergillus fumigatus: current insights and future research agenda. Fungal Biology Reviews 34 (4):202-214\u003c/li\u003e\n\u003cli\u003eLee S-O (2023) Diagnosis and Treatment of Invasive Mold Diseases. Infect Chemother 55 (1):10-21\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-clinical-microbiology-and-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejcm","sideBox":"Learn more about [European Journal of Clinical Microbiology \u0026 Infectious Diseases](https://www.springer.com/journal/10096)","snPcode":"10096","submissionUrl":"https://submission.nature.com/new-submission/10096/3","title":"European Journal of Clinical Microbiology \u0026 Infectious Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Aspergillus fumigatus, Molecular Epidemiology, Geographic Distribution, Antifungal Resistance, Environmental Microbiology","lastPublishedDoi":"10.21203/rs.3.rs-7547800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7547800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe analysed 498 global \u003cem\u003eAspergillus fumigatus\u003c/em\u003e isolates using multilocus variable-number tandem-repeat (MLVA) typing to investigate regional clustering, environmental\u0026ndash;clinical overlap, and azole resistance patterns. The dataset, including 155 newly genotyped Korean strains, revealed extensive genotypic diversity and four distinct phylogeographic clusters. Resistance-associated mutations (TR34/TR46) were concentrated within specific clusters, particularly among European and East Asian lineages. These findings support the presence of geographically structured populations and localised emergence of resistance. This is the first global application of MLVA to \u003cem\u003eA. fumigatus\u003c/em\u003e, underscoring its value for molecular surveillance in settings where whole-genome sequencing remains limited.\u003c/p\u003e","manuscriptTitle":"Geographically structured genotypes and resistance clustering in Aspergillus fumigatus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-16 10:30:22","doi":"10.21203/rs.3.rs-7547800/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-14T16:03:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T08:32:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115942630066209274625451397745368011273","date":"2025-10-21T12:53:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T22:06:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-15T15:28:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46719806036120381208960551319109961128","date":"2025-10-12T09:08:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45378222257563084468529506206656275050","date":"2025-10-07T13:24:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186609537993430454017749606783482410036","date":"2025-10-06T07:51:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T12:02:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146861903667011616965848061944932745808","date":"2025-09-08T16:55:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T16:50:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T08:37:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T08:34:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Clinical Microbiology \u0026 Infectious Diseases","date":"2025-09-06T02:27:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-clinical-microbiology-and-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejcm","sideBox":"Learn more about [European Journal of Clinical Microbiology \u0026 Infectious Diseases](https://www.springer.com/journal/10096)","snPcode":"10096","submissionUrl":"https://submission.nature.com/new-submission/10096/3","title":"European Journal of Clinical Microbiology \u0026 Infectious Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"755db4a7-f58a-488a-95d4-46e5a5b0a49f","owner":[],"postedDate":"September 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T15:59:45+00:00","versionOfRecord":{"articleIdentity":"rs-7547800","link":"https://doi.org/10.1007/s10096-025-05390-4","journal":{"identity":"european-journal-of-clinical-microbiology-and-infectious-diseases","isVorOnly":false,"title":"European Journal of Clinical Microbiology \u0026 Infectious Diseases"},"publishedOn":"2025-12-24 15:57:18","publishedOnDateReadable":"December 24th, 2025"},"versionCreatedAt":"2025-09-16 10:30:22","video":"","vorDoi":"10.1007/s10096-025-05390-4","vorDoiUrl":"https://doi.org/10.1007/s10096-025-05390-4","workflowStages":[]},"version":"v1","identity":"rs-7547800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7547800","identity":"rs-7547800","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}