Invasive Trichosporon Infection in Solid Organ Transplant Recipients: A Single-Center Experience in Madrid, Spain

Round 1

Reviewer 1 Report

The materials and methods section is incomplete. How was the sample selected? Which documents were reviewed: clinical records or laboratory books? How were the samples extracted? How were they stored? How were they transported? etc. Much more information needs to be included.

There is a section of definitions that explains the objective, when it should be considered which variables will be analyzed.

Why is logistic regression not used in the statistical analysis? The authors only perform a univariate analysis.

The article is interesting and provides novel information, but it should discuss certain points.

The difference between the malditof and the igs pcr should be discussed, as this point is important in demonstrating the usefulness of both techniques.

Authors should discuss the strategy for using serological and molecular markers for the diagnosis of Trichosporon spp.

Authors should discuss cases in Spain, as this is important for the epidemiology of fungal infections at the national and international levels.

The title seems to suggest that you are dealing with a systematic or narrative review. The last part should be removed and the country should be included, although it is interesting that it is a local series that is being described. 

The authors should describe how frequent the problem is in Spain. Are these the first cases described? As it stands, it seems that this is the case. It would be very interesting to demonstrate (IN NUMBERS) the impact of Trichosporon spp infections in SOT. 

Line 119 It's a discussion, it can be included in that section.

The authors show blood culture results but do not describe them in the materials and methods section.

In ICU admission, the percentage is missing.

The legend for the table should be in the materials and methods section.

It refers to the detection of CMV, but there is no description of how the technique was performed.

The description in Table 1 is very exhaustive; it should only describe the fundamentals. Table 1 provides all the details of the study.

Different isolates of fungi are used in MIC. Why is this assessment necessary?

The article is interesting and provides novel information, but it should discuss certain points.

The difference between the malditof and the igs pcr should be discussed, as this point is important in demonstrating the usefulness of both techniques.

Authors should discuss the strategy for using serological and molecular markers for the diagnosis of Trichosporon spp.

Authors should discuss cases in Spain, as this is important for the epidemiology of fungal infections at the national and international levels.

Authors must mention the hospital where the research was conducted. 

The materials and methods section is incomplete. How was the sample selected? Which documents were reviewed: clinical records or laboratory books? How were the samples extracted? How were they stored? How were they transported? etc. Much more information needs to be included.

There is a section of definitions that explains the objective, when it should be considered which variables will be analyzed.

Why is logistic regression not used in the statistical analysis? The authors only perform a univariate analysis.

Authors should briefly describe the techniques used. 

Table 2, from a concentration of 0.5 to 8, has very few values. Could these values be described in the text, since they basically correspond to only two antifungals?

 

Author Response

Manuscript ID: jof-3964032  Title: Invasive Trichosporon Infection in Solid Organ Transplant Recipients: A Life-Threatening Emerging Mycosis

 

Dear Editor

We gratefully appreciate the suggestions and recommendations of the reviewers, which will undoubtedly improve the quality of this study. Below, we attempt to respond to these recommendations by justifying the changes we have made to the manuscript.

Reviewer 1

The materials and methods section is incomplete. How was the sample selected?. Which documents were reviewed: clinical records or laboratory books? How were the samples extracted?

Cases were identified retrospectively by searching the Microbiology Laboratory database for all Trichosporon spp. isolates between January 2017 and September 2025. All positive Trichosporon cultures from each patient identified in the laboratory database were included. This information has been incorporated in Methods

How were they stored? How were they transported? etc. Much more information needs to be included.

Clinical samples (sputum, blood, tissue, etc.) were collected following standard hospital protocols. They were immediately transported to the Microbiology laboratory for processing. The samples were cultured on standard media such as Sabouraud dextrose agar and blood agar. Fungal isolates were stored at -80°C in cryovials for further analysis. This information has been added into the manuscript

There is a section of definitions that explains the objective, when it should be considered which variables will be analyzed.

A paragraph has been added to the methods section with the variables that have been collected for the study.

Why is logistic regression not used in the statistical analysis? The authors only perform a univariate analysis.

Due to the small number of cases included in the study, with only 8 cases of the event studied (mortality), we did not consider it appropriate to perform a multivariate analysis. According to standard statistical recommendations (one variable per 10 events), with only 8 deaths observed, multivariate analysis would not be statistically appropriate.

The article is interesting and provides novel information, but it should discuss certain points.

 

The difference between the malditof and the igs pcr should be discussed, as this point is important in demonstrating the usefulness of both techniques.

We have incorporated into the discussion information about the differences between the two techniques in terms of the technology on which they are based and their usefulness in this clinical context.

Authors should discuss the strategy for using serological and molecular markers for the diagnosis of Trichosporon spp.

As stated in the previous paragraph, additional information on the use of molecular markers for the diagnosis of Trichosporon spp. has been incorporated into the discussion. Furthermore, information has been added on the limited usefulness of serological methods for the diagnosis of this infection.

Authors should discuss cases in Spain, as this is important for the epidemiology of fungal infections at the national and international levels.

Information about the low frequency of this infection in transplant recipients has been added to the introduction and discussion.

Detailed comments

The title seems to suggest that you are dealing with a systematic or narrative review. The last part should be removed and the country should be included, although it is interesting that it is a local series that is being described.

The title has been modified following the reviewer's sound recommendation

The authors should describe how frequent the problem is in Spain. Are these the first cases described? As it stands, it seems that this is the case. It would be very interesting to demonstrate (IN NUMBERS) the impact of Trichosporon spp infections in SOT.

Information about the low frequency of this infection in transplant recipients has been added to the introduction and discussion.

Line 119 It's a discussion, it can be included in that section.

This information has been retained only in the discussion of the article..

The authors show blood culture results but do not describe them in the materials and methods section.

We have added in the Methods section that blood cultures were processed using the BACTEC™ automated system (Becton Dickinson New Jersey, USA)

In ICU admission, the percentage is missing.

This error has been corrected

The legend for the table should be in the materials and methods section.

We have proceeded to change the location of the legend of Table 1 as indicated by the reviewer.

It refers to the detection of CMV, but there is no description of how the technique was performed.

This information has been added in Methods

The description in Table 1 is very exhaustive; it should only describe the fundamentals. Table 1 provides all the details of the study.

Although Table 1 is extensive, and after reviewing all the rows it contains, we believe that none of them should be removed, as all the information it contains seem relevant from our point of view.

Different isolates of fungi are used in MIC. Why is this assessment necessary?

Although it is the same yeast species, MICs for antifungal agents have been somewhat different in different isolates. This has led to a description of MICs for each strain.

 

The following questions seem to be repeated and have already been answered previously.

The difference between the malditof and the igs pcr should be discussed, as this point is important in demonstrating the usefulness of both techniques.

Authors should discuss the strategy for using serological and molecular markers for the diagnosis of Trichosporon spp.

Authors should discuss cases in Spain, as this is important for the epidemiology of fungal infections at the national and international levels.

The materials and methods section is incomplete. How was the sample selected? Which documents were reviewed: clinical records or laboratory books? How were the samples extracted? How were they stored? How were they transported? etc. Much more information needs to be included

Authors must mention the hospital where the research was conducted.

We agree with the relevance of including this information, which has been added to Methods.

.

 

There is a section of definitions that explains the objective, when it should be considered which variables will be analyzed.

A paragraph has been added to the methods section with the variables that have been collected for the study.

Why is logistic regression not used in the statistical analysis? The authors only perform a univariate analysis.

Due to the small number of cases included in the study, with only 8 cases of the event studied (mortality), we did not consider it appropriate to perform a multivariate analysis. This decision could be justified by the recommendation to introduce one variable for every 10 events observed.

Authors should briefly describe the techniques used.

All microbiological techniques used in this research have been incorporated into the current version of the manuscript.

Table 2, from a concentration of 0.5 to 8, has very few values. Could these values be described in the text, since they basically correspond to only two antifungals?

Following the reviewer's recommendation, Table 2 has been removed and this information has been incorporated into the results section

 

Thanking the reviewers and editors once again for their efforts, I send you my best regards.

Andrea Gutiérrez-Villanueva

Madrid, November 17^th, 2025

Reviewer 2 Report

Single center case-series on Trichosporon spp infections among SOT from a tertiary center in Madrid Spain. Generally well-written and adds to the current scarce data on these infections among immunocompromised patients. Below find some detailed remarks 

93-94: Please state if EUCAST or CLSI adaptation was used to determine the MICs

118: there is a typo in the species 

119 : The line on the closeness with T.inkin belongs more to the discussion section 

123: incidence: this is more of a proportion or prevalence 

Also could you add more on the grouping of cases within time ? Could someone expect transmissions between patients as all were the same spp ? Or the events where chronologically and location-wise far apart ? 

Table 1: WBC, platelets and drug doses , do these refer to the time of diagnosis or surgery? please explain the time point these were taken 

Table 1: I would add 2 lines on the treatment with p-value calculation triazole vs. other treatment and voriconazole vs. other treatment between those who died and survived

Author Response

Manuscript ID: jof-3964032  Title: Invasive Trichosporon Infection in Solid Organ Transplant Recipients: A Life-Threatening Emerging Mycosis

 

Dear Editor

We gratefully appreciate the suggestions and recommendations of the reviewers, which will undoubtedly improve the quality of this study. Below, we attempt to respond to these recommendations by justifying the changes we have made to the manuscript.

 

Reviewer 2

Major comments

Single center case-series on Trichosporon spp infections among SOT from a tertiary center in Madrid Spain. Generally well-written and adds to the current scarce data on these infections among immunocompromised patients. Below find some detailed remarks

We greatly appreciate the reviewer's assessment of the contribution of this article to a better understanding of this infection.

Detailed comments

93-94: Please state if EUCAST or CLSI adaptation was used to determine the MICs

We have added in material and method that EUCAST criteria were used to interpret antifungal susceptibility.

118: there is a typo in the species

The error of typo has been corrected.

119 : The line on the closeness with T. was noinkin belongs more to the discussion section

This information has been retained only in the discussion section.

123: incidence: this is more of a proportion or prevalence

This error in the text has been corrected.

Also could you add more on the grouping of cases within time ? Could someone expect transmissions between patients as all were the same spp ? Or the events where chronologically and location-wise far apart ?

We appreciate this observation from the reviewer.  We excluded patient-to-patient transmission as cases did not overlap temporally in the same ward. Figure 1 (added to the manuscript) shows the chronological distribution of cases, demonstrating their temporal separation.  To give more information about this point, a figure showing the chronological distribution of cases has been added. In addition, we have not found a possible common source to date where the infection could have been acquired, either in the operating rooms or during the rest of the hospitalization. This information has been added to the manuscript in Results and in Discussion.

Table 1: WBC, platelets and drug doses , do these refer to the time of diagnosis or surgery? please explain the time point these were taken

As stated in the table footnote: 'The analytical results correspond to the time closest to the diagnosis of the infection.

Table 1: I would add 2 lines on the treatment with p-value calculation triazole vs. other treatment and voriconazole vs. other treatment between those who died and survived

Since all patients received some type of azole, we felt that adding this information to the table did not make much sense. However, we decided to add a row comparing voriconazole with other antifungals.

Thanking the reviewers and editors once again for their efforts, I send you my best regards.

Andrea Gutiérrez-Villanueva

Madrid, November 17^th, 2025

Round 2

Reviewer 1 Report

Accept in present form

Accept in present form