Relationship between environmental fungal contamination and the incidence of invasive aspergillosis in haematology patients

Effectiveness of high efficiency particulate (HEPA) air condition combined with the antifungal prophylaxis on incidence, morbidity and mortality of invasive fungal infections in patients with acute myeloid leukemia: a retrospective single-center study

Introduction

Our monocentric and retrospective study aimed to investigate the clinical effectivity of HEPA filters in combination with the antifungal drug prophylaxis in patients with AML undergoing intensive chemotherapy and allogeneic stem cell transplantation (SCT).

Methods/Results

We included 177 patients between 2005 and 2015 representing a total of 372 in-hospital stays, 179 in the HEPA cohort (+HEPA) and 193 in the cohort without HEPA filters (-HEPA). No significant additional benefit of HEPA filtration on the risk reduction of IFI was observed. HEPA filtration did not significantly affect the risk of intensive care unit (ICU) admissions or early mortality rates. In patients who received allogeneic SCT in first complete remission with antifungal drug prophylaxis during prior induction treatment, a numerical but not significant improvement in long-term overall survival was noted in the +HEPA cohort compared to the -HEPA cohort (55% to 66%, p = 0.396). For better depicting of the clinical reality, we determined the so-called clinical suspected IFI (csIFI) -defined as cases with antifungal treatment after recommended prophylaxis without fulfilling current EORTC criteria. Especially in patients with a high risk for second IFI, significant risk reduction of csIFI and frequency of ICU admissions was observed when voriconazole was used as secondary antifungal prophylaxis. (csIFI, adjusted effect: OR 0.41, 95% CI (0.21 - 0.82), p = 0.01; csIFI, subgroup-specific effect: OR 0.35, 95% CI (0.15 - 0.78), p = 0.01; ICU, adjusted effect: OR 0.44, 95 CI (0.19 - 1.01), p = 0.05; respectively).

Discussion

In summary, the study suggests the efficacy of secondary antifungal prophylaxis in preventing IFI in AML patients undergoing intensive treatment. The addition of HEPA filtration also demonstrated additional numerous benefits in reducing the frequency of IFI-associated complications.

Risk of fungal exposure in the homes of patients with hematologic malignancies

BACKGROUND

Patients with hematological malignancies are at a high risk of developing invasive fungal infections (IFI) because they undergo several cycles of treatment leading to episodes of neutropenia. In addition, they alternate between hospital stays and periods spent at home. Thus, when an IFI is diagnosed during their hospital stays, it is highly challenging to identify the origin of the fungal contamination. The objective of this study was to analyze at home fungal exposure of 20 patients with leukemia by taking air and water samples in their living residence.

METHODS

Air was sampled in 3 rooms of each home with a portable air system impactor. Tap water was collected at 3 water distribution points of each home. For positive samples, fungi were identified by mass spectrometry or on the basis of their morphological features.

RESULTS

85 % of homes revealed the presence in air of Aspergillus spp. and those belonging to the section Fumigati presented the highest concentrations and the greatest frequency of isolation. Concerning mucorales, Rhizopus spp. and Mucor spp. were isolated in air of 20 % and 5 % of dwellings, respectively. In 4 homes, more than 70 % of the fungal species identified in air were potential opportunists; these were mainly Aspergillus spp. with concentrations greater than 20 cfu/m3. The water samples revealed the presence of Fusarium in 3 dwellings, with concentrations up to 80 cfu/L. Finally, for one patient, fungal species isolated during a period of hospitalization were phenotypically similar to those isolated in samples taken at home. For a second patient, a PCR Mucorale was positive on a sample of bronchoalveolar fluid while air samples taken at his home also revealed also the presence of mucorales.

CONCLUSION

The presence of opportunistic fungal species in the air of all the explored homes suggests the need for strengthened preventive measures in the home of immunocompromised patients. It would be interesting to compare the fungi isolated (from patients and from their environment) by genotyping studies aimed at specifying the correspondence existing between fungal species present in the patients' homes and those responsible for IFI in the same patients.

Risk Factors and Environmental Preventive Actions for Aspergillosis in Patients with Hematological Malignancies

(1) Background: Aspergillus spp. is a widely distributed filamentous fungus in the environment due to its high sporulation capacity. Currently, invasive aspergillosis (IA) is the most common invasive fungal infection in patients with hematologic malignancies, with high rates of mortality and morbidity. The multifactorial nature of the disease requires appropriate risk stratification to enable the most appropriate preventive measures to be adapted and implemented according to the characteristics of the patient. In this sense, the present research aims to identify recent risk factors and environmental control measures against invasive aspergillosis to establish preventive actions to reduce the incidence of invasive aspergillosis in hospitals. (2) Methods: We conducted a qualitative systematic review of the scientific literature on environmental risk factors and preventive measures for invasive aspergillosis in patients with hematologic malignancies. The Medline, Cochrane, and Scopus databases were consulted, following the PRISMA and STROBE guidelines. (3) Results: Adequate implementation of environmental control measures is presented as the most efficient intervention in terms of prevention to decrease the incidence of invasive aspergillosis in hospitals. Neutropenia, fungal contamination, insufficient environmental control measures in hospital and home settings, length of hospital stay, and anemia, are identified as independent risk factors. We show that HEPA, LAF, and Plasmair® systems are suitable methods to reduce the concentration of airborne fungal spores. Antifungal prophylaxis did not significantly influence IA reduction in our study. (4) Conclusions: Proper professional training and environmental control measures in hospitals are essential for the prevention of invasive aspergillosis. We should optimize risk stratification for patients with hematologic malignancies. Antifungal prophylaxis should be complementary to environmental control measures and should never be substituted for the latter. Studies should also be undertaken to evaluate the efficiency of environmental control measures against IA at patients' homes.

Assessing the impact of prophylactic anidulafungin during remission induction of acute myeloid leukemia - A propensity-score matching analysis

INTRODUCTION

Invasive fungal infection (IFI) accounts for substantial morbidity during the treatment of acute myeloid leukemia (AML) in adults. Antifungal prophylaxis (AP) is needed during intensive chemotherapy, and posaconazole is not widely available. In this study, we aimed to examine the impact of prophylactic anidulafungin during intensive AML remission induction.

METHODS

This is a retrospective cohort encompassing newly diagnosed AML adult patients. All subjects received intensive chemotherapy and were divided into three groups: patients who did not receive any AP and patients who received fluconazole (150-400 mg/day) or anidulafungin (100 mg/day).

RESULTS

During AML induction, 82 patients did not receive AP, 108 and 14 patients received anidulafungin and fluconazole, respectively. IFI incidence was 27%, classified as possible, probable, and proven in 65, 2 and 33%, respectively. Multivariable analysis showed that lower neutrophil counts are associated with IFI (OR = 2.8), whereas age, genetic classification, and lymphocyte counts were not. To examine the impact of anidulafungin in comparison with 'no AP', a propensity score matching analysis was performed. Use of anidulafungin was not related to less IFI during induction, while neutrophil counts remained significant. Patients under prophylactic anidulafungin received less amphotericin B (p < 0.001) but not voriconazole (p = 0.49).

DISCUSSION

To our knowledge, this is the first study addressing the role of anidulafungin during AML induction. Here, the incidence of mold infections did not decrease with AP, suggesting that in a setting with a high incidence of IFI, broad spectrum AP might be more suitable.

Environmental monitoring for filamentous fungal pathogens in hematopoietic cell transplant units

The incidence of invasive fungal disease (IFD) is on the rise due to increasing numbers of highly immunocompromized patients. Nosocomial IFD remains common despite our better understanding of its risk factors and pathophysiology. High-efficiency particulate air filtration with or without laminar air flow, frequent air exchanges, a positive pressure care environment, and environmental hygiene, amongst other measures, have been shown to reduce the mould burden in the patient environment. Environmental monitoring for moulds in areas where high-risk patients are cared for, such as hematopoietic cell transplant units, has been considered an adjunct to other routine environmental precautions. As a collaborative effort between authors affiliated to the Infection Prevention and Control Working Group and the Fungal Infection Working Group of the International Society of Antimicrobial Chemotherapy (ISAC), we reviewed the English language literature and international guidance to describe the evidence behind the need for environmental monitoring for filamentous fungi as a quality assurance approach with an emphasis on required additional precautions during periods of construction. Many different clinical sampling approaches have been described for air, water, and surface sampling with significant variation in laboratory methodologies between reports. Importantly, there are no agreed-upon thresholds that correlate with an increase in the clinical risk of mould infections. We highlight important areas for future research to assure a safe environment for highly immunocompromized patients.

Relationship Between Airborne Fungi Presence and the Position of the High Efficiency Particulate Air Filter in the Heating, Ventilation, and Air Conditioning System

AIM

Establish the influence of the terminal or nonterminal position of High Efficiency Particulate Air (HEPA) filters in the Heating, Ventilation, and Air Conditioning (HVAC) system on the presence of airborne fungi in controlled environment rooms.

BACKGROUND

Fungal infections are an important cause of morbidity and mortality in hospitalized patients.

METHODS

This study was realized from 2010 to 2017, in rooms with terminal and nonterminal HEPA filters, in eight Spanish hospitals. In rooms with terminal HEPA filters, 2,053 and 2,049 samples were recollected, and in rooms with nonterminal HEPA filters, 430 and 428 samples were recollected in the air discharge outlet (Point 1) and in the center of the room (Point 2), respectively. Temperature, relative humidity, air changes per hour, and differential pressure were recollected.

RESULTS

Multivariable analysis showed higher odds ratio (OR) of airborne fungi presence when HEPA filters were in nonterminal position (OR: 6.78; 95% CI [3.77, 12.20]) in Point 1 and (OR: 4.43; 95% CI [2.65, 7.40]) in Point 2. Other parameters influenced airborne fungi presence, such as temperature (OR: 1.23; 95% CI [1.06, 1.41]) in Point 2 differential pressure (OR: 0.86; 95% CI [0.84, 0.90]) and (OR: 0.88; 95% CI [0.86, 0.91]) in Points 1 and 2, respectively.

CONCLUSIONS

HEPA filter in terminal position of the HVAC system reduces the presence of airborne fungi. To decrease the presence of airborne fungi, adequate maintenance of the environmental and design parameters is necessary in addition to the terminal position of the HEPA filter.

Invasive aspergillosis in liver transplant recipients

BACKGROUND

Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries.

METHODS

We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions.

RESULTS

The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units.

CONCLUSION

IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.

Fungal Contamination of Building Materials and the Aerosolization of Particles and Toxins in Indoor Air and Their Associated Risks to Health: A Review

It is now well established that biological pollution is a major cause of the degradation of indoor air quality. It has been shown that microbial communities from the outdoors may significantly impact the communities detected indoors. One can reasonably assume that the fungal contamination of the surfaces of building materials and their release into indoor air may also significantly impact indoor air quality. Fungi are well known as common contaminants of the indoor environment with the ability to grow on many types of building materials and to subsequently release biological particles into the indoor air. The aerosolization of allergenic compounds or mycotoxins borne by fungal particles or vehiculated by dust may have a direct impact on the occupant’s health. However, to date, very few studies have investigated such an impact. The present paper reviewed the available data on indoor fungal contamination in different types of buildings with the aim of highlighting the direct connections between the growth on indoor building materials and the degradation of indoor air quality through the aerosolization of mycotoxins. Some studies showed that average airborne fungal spore concentrations were higher in buildings where mould was a contaminant than in normal buildings and that there was a strong association between fungal contamination and health problems for occupants. In addition, the most frequent fungal species on surfaces are also those most commonly identified in indoor air, regardless the geographical location in Europe or the USA. Some fungal species contaminating the indoors may be dangerous for human health as they produce mycotoxins. These contaminants, when aerosolized with fungal particles, can be inhaled and may endanger human health. However, it appears that more work is needed to characterize the direct impact of surface contamination on the airborne fungal particle concentration. In addition, fungal species growing in buildings and their known mycotoxins are different from those contaminating foods. This is why further in situ studies to identify fungal contaminants at the species level and to quantify their average concentration on both surfaces and in the air are needed to be better predict health risks due to mycotoxin aerosolization.

Evaluation of the Results of a Periodic Environmental Biosecurity Assessment Program on Air Quality in Controlled Environment Rooms of Hospitals

AIM

Determine the utility of the Periodic Environmental Biosecurity Assessment Program (PEBAP) in achieving clean air as measured by the number of colony-forming units (CFU) of fungi and bacteria in the air.

BACKGROUND

There is no international consensus on the sampling frequency, the recommended limits for microorganisms in the air nor on the usefulness of routine microbiological air monitoring of hospitals.

METHODS

During the PEBAP, data were recollected between 2010 and 2017 in eight hospitals in southeast Spain. Air samples were collected in very high risk rooms (VHRRs) and high risk rooms (HRRs), unoccupied, using active sampling methods. Temperature, relative humidity, air changes per hour (ACH), and differential pressure were measured. When limits of CFU of opportunistic fungi and bacteria established in the PEBAP were exceeded, corrective measures were adopted.

RESULTS

We found a reduction (p < .01) of percentage of air samples with fungi growth throughout the years of PEBAP in all rooms. Aspergillus was the most frequent opportunistic fungus. We found a high compliance of the standards of CFU of bacteria in HRR, and the percentage of compliance in VHRR was lower than in HRR in all years. Differences in environmental and design parameters were statistically significant (p < .05) between rooms, except for ACH.

CONCLUSIONS

PEBAP resulted in a useful tool to maintain and improve air quality in hospitals. The control of environmental biosecurity requires a multidisciplinary approach from preventive medicine, engineering, and cleaning services. Aspergillus is the most frequent opportunistic fungus in southeast Spain.

Microbial contamination in waste collection: Unveiling this Portuguese occupational exposure scenario

Previous studies anticipated that microorganisms and their metabolites in waste will increase as a consequence of a decreased collection frequency and due to differences in what kind of waste is bagged before collection leading to an increased exposure of workers handling the waste. This study aim was to investigate the microbial contamination present in the waste collection trucks (WCT) and in the support facilities (waste collection station - WCS). It was applied a multi-approach protocol using active (air sampling by impingement and impaction) and passive (surface swabs, electrostatic dust cloths and settled dust) sampling methods. The screening of azole-resistance, the investigation of mycotoxins and the assessment of the elicited biological responses in vitro were also carried out aiming recognizing the possible health effects of waste collection drivers. SARS-CoV-2 detection was also performed. In WCS only air samples had contamination in all the four sampling sites (canteen, operational removal core, operational removal center, and administrative service). Among all the analyzed matrices from the WCT a higher percentage of total bacterial counts and Gram-was detected in swabs (66.93%; 99.36%). In WCS the most common species were Penicillium sp. (43.98%) and Cladosporium sp. (24.68%), while on WCT Aspergillus sp. (4.18%) was also one of the most found. In the azole resistance screening Aspergillus genera was not observed in the azole-supplemented media. SARS-CoV-2 was not detected in any of the environmental samples collected, but Aspergillus section Fumigati was detected in 5 samples. Mycotoxins were not detected in EDC from WCS, while in WCT they were detected in filters (N = 1) and in settled dust samples (N = 16). In conclusion, our study reveals that a comprehensive sampling approach using active and passive sampling (e.g. settled dust sampling for a representative mycotoxin evaluation) and combined analytic methods (i.e., culture-based and molecular) is an important asset in microbial exposure assessments. Concerning the waste collection exposure scenario, the results of this study unveiled a complex exposure, particularly to fungi and their metabolites. Aspergillus section Fumigati highlight the significance of targeting this section in the waste management industry as an indicator of occupational health risk.

CON: Serum biomarker monitoring should not replace primary antifungal chemoprophylaxis in patients with acute leukaemia receiving systemic anti-cancer therapy

Primary antifungal chemoprophylaxis (PAC) is the widespread strategy of choice for the prevention of invasive fungal disease in patients with acute leukaemia (AL). Twice-weekly monitoring of the serum biomarkers (SBM) galactomannan and 1,3-β-d-glucan has been proposed as an alternative prevention strategy to PAC for these patients. This paper outlines the arguments for why PAC should remain as the standard of care in AL, instead of switching to twice-weekly SBM. Arguments put forward in favour of PAC are the strength of evidence for its safety, cost-effectiveness and adaptability, and its adoption by multiple international guidelines as standard of care. The potential implications of PAC for drug interactions and antifungal resistance are also discussed. The drawbacks of twice-weekly SBM are appraised, including missed or delayed diagnoses, unnecessary investigations, deferral of systemic anti-cancer therapy and increased pressure on laboratory services.

Air Sampling for Fungus around Hospitalized Patients with Coronavirus Disease 2019

The risk of developing coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) depends on factors related to the host, virus, and treatment. However, many hospitals have modified their existing rooms and adjusted airflow to protect healthcare workers from aerosolization, which may increase the risk of Aspergillus exposure. This study aimed to quantitatively investigate airborne fungal levels in negative and slightly negative pressure rooms for COVID-19 patients. The air in neutral pressure rooms in ordinary wards and a liver intensive care unit with high-efficiency particulate air filter was also assessed for comparison. We found the highest airborne fungal burden in recently renovated slightly negative air pressure rooms, and a higher airborne fungal concentration in both areas used to treat COVID-19 patients. The result provided evidence of the potential environmental risk of CAPA by quantitative microbiologic air sampling, which was scarcely addressed in the literature. Enhancing environmental infection control measures to minimize exposure to fungal spores should be considered. However, the clinical implications of a periodic basis to determine indoor airborne fungal levels and further air sterilization in these areas remain to be defined.

Environmental Factors Affecting Diversity, Structure, and Temporal Variation of Airborne Fungal Communities in a Research and Teaching Building of Tianjin University, China

Airborne fungi are widely distributed in the environment and may have adverse effects on human health. A 12-month survey on the diversity and concentration of culturable airborne fungi was carried out in a research and teaching building of Tianjin University. Indoor and outdoor environments were analyzed using an HAS-100B air sampler. A total of 667 fungal strains, belonging to 160 species and 73 genera were isolated and identified based on morphological and molecular analysis. The most abundant fungal genera were Alternaria (38.57%), Cladosporium (21.49%), and Aspergillus (5.34%), while the most frequently appearing species was A. alternata (21%), followed by A. tenuissima (12.4%), and C. cladosporioides (9.3%). The concentration of fungi in different environments ranged from 0 to 150 CFU/m3 and was significantly higher outdoor than indoor. Temperature and sampling month were significant factors influencing the whole building fungal community, while relative humidity and wind speed were highly correlated with fungal composition outdoor. Variations in the relative abundance of major airborne fungal taxa at different heights above-ground could lead to different community structures at different floors. Our results may provide valuable information for air quality monitoring and microbial pollution control in university building environments.

COVID-19 Associated Pulmonary Aspergillosis (CAPA): Hospital or Home Environment as a Source of Life-Threatening Aspergillus fumigatus Infection?

Most cases of invasive aspergillosis are caused by Aspergillus fumigatus, whose conidia are ubiquitous in the environment. Additionally, in indoor environments, such as houses or hospitals, conidia are frequently detected too. Hospital-acquired aspergillosis is usually associated with airborne fungal contamination of the hospital air, especially after building construction events. A. fumigatus strain typing can fulfill many needs both in clinical settings and otherwise. The high incidence of aspergillosis in COVID patients from our hospital, made us wonder if they were hospital-acquired aspergillosis. The purpose of this study was to evaluate whether the hospital environment was the source of aspergillosis infection in CAPA patients, admitted to the Hospital Universitario Central de Asturias, during the first and second wave of the COVID-19 pandemic, or whether it was community-acquired aspergillosis before admission. During 2020, sixty-nine A. fumigatus strains were collected for this study: 59 were clinical isolates from 28 COVID-19 patients, and 10 strains were environmentally isolated from seven hospital rooms and intensive care units. A diagnosis of pulmonary aspergillosis was based on the ECCM/ISHAM criteria. Strains were genotyped by PCR amplification and sequencing of a panel of four hypervariable tandem repeats within exons of surface protein coding genes (TRESPERG). A total of seven genotypes among the 10 environmental strains and 28 genotypes among the 59 clinical strains were identified. Genotyping revealed that only one environmental A. fumigatus from UCI 5 (box 54) isolated in October (30 October 2020) and one A. fumigatus isolated from a COVID-19 patient admitted in Pneumology (Room 532-B) in November (24 November 2020) had the same genotype, but there was a significant difference in time and location. There was also no relationship in time and location between similar A. fumigatus genotypes of patients. The global A. fumigatus, environmental and clinical isolates, showed a wide diversity of genotypes. To our knowledge, this is the first study monitoring and genotyping A. fumigatus isolates obtained from hospital air and COVID-19 patients, admitted with aspergillosis, during one year. Our work shows that patients do not acquire A. fumigatus in the hospital. This proves that COVID-associated aspergillosis in our hospital is not a nosocomial infection, but supports the hypothesis of “community aspergillosis” acquisition outside the hospital, having the home environment (pandemic period at home) as the main suspected focus of infection.

Meteorological Factors Influence the Presence of Fungi in the Air; A 14-Month Surveillance Study at an Adult Cystic Fibrosis Center

Background

Cystic fibrosis is an inherited disease that predisposes to progressive lung damage. Cystic fibrosis patients are particularly prone to developing pulmonary infections. Fungal species are commonly isolated in lower airway samples from patients with cystic fibrosis. Fungal spores are prevalent in the air.

Methods

We performed environmental air sampling surveillance at the Manchester Adult Cystic Fibrosis Centre, UK (MACFC) over a 14-month period to assess fungal growth inside and outside the CF center.

Results

Airborne counts of fungal spores peaked from May to October, both in outdoor and indoor samples. Collection of meteorological data allowed us to correlate fungal presence in the air with elevated temperatures and low wind speeds. Additionally, we demonstrated patient rooms containing windows had elevated fungal counts compared to rooms not directly connected to the outdoors.

Conclusions

This study suggests that airborne Aspergillus fumigatus spores were more abundant during the summer months of the survey period, which appeared to be driven by increased temperatures and lower wind speeds. Indoor counts directly correlated to outdoor A. fumigatus levels and were elevated in patient rooms that were directly connected to the outdoor environment via an openable window designed for ventilation purposes. Further studies are required to determine the clinical implications of these findings for cystic fibrosis patients who are predisposed to Aspergillus related diseases, and in particular whether there is seasonal influence on incidence of Aspergillus related conditions and if screening for such complications such be increased during summer months and precautions intensified for those with a known history of Aspergillus related disease.

Aspergillus Section Fumigati in Firefighter Headquarters

Background: Aspergillus section Fumigati is one of the Aspergillus sections more frequently related to respiratory symptoms and by other health outcomes. This study aimed to characterize Aspergillus section Fumigati distribution in eleven firefighter headquarters (FFHs) to obtain an accurate occupational exposure assessment. Methods: A sampling approach protocol was performed using active (impaction method) and passive sampling methods (floor surfaces swabs, electrostatic dust collectors (EDCs), and settled dust). All samples were analysed by culture-based methods and passive sampling was used for molecular detection of Aspergillus section Fumigati. Results: Of all the matrices, the highest counts of Aspergillus sp. were obtained on settled dust filters (3.37% malt extract agar—MEA, 19.09% dichloran glycerol—DG18) followed by cleaning cloths (1.67% MEA; 7.07% DG18). Among the Aspergillus genus, the Fumigati section was predominant in Millipore and EDC samples in MEA (79.77% and 28.57%, respectively), and in swabs and settled dust filters in DG18 (44.76% and 30%, respectively). The Fumigati section was detected more frequently in DG18 (33.01%) compared to MEA (0.33%). The Fumigati section was observed in azole supplemented media (itraconazole and voriconazole) in several passive sampling methods employed and detected by qPCR in almost all passive samples, with EDCs being the matrix with the highest prevalence (n = 61; 67.8%). Conclusion: This study confirms that Aspergillus sp. is widespread and the Fumigati section is present in all FFHs. The presence of fungi potentially resistant to azoles in the FFHs was also observed. Further studies are needed to identify the best corrective and preventive measures to avoid this section contamination in this specific occupational environment.

Differences in clinical characteristics of invasive tracheobronchial aspergillosis according to the presence of invasive pulmonary aspergillosis

Background

The association of invasive tracheobronchial aspergillosis (ITBA) with invasive pulmonary aspergillosis (IPA) is not well established. We aimed to compare clinical characteristics between patients who exhibited ITBA with IPA and those who exhibited isolated ITBA (iITBA). Additionally, the usefulness of serum or bronchial galactomannan (GM) tests in diagnosing ITBA was evaluated.

Methods

This retrospective single-center case-control study was conducted over a period of 4 years. Fifteen patients were enrolled after confirming the presence of ITBA using bronchoscopy-guided biopsy (iITBA, 7 vs. ITBA+IPA, 8). Clinical characteristics of patients and results obtained from serum or bronchial GM tests were compared between the two groups. Mortality was assessed using data collected from a 6-month follow-up period.

Results

The ITBA+IPA group showed a higher prevalence of hematologic malignancy (75% vs. 14%, p=0.029), a greater number of patients with multiple bronchial ulcers (75% vs. 14%, p=0.029), lower platelet counts (63,000/μL vs. 229,000/μL, p<0.001), and a mortality rate which was significantly higher (63% vs. 0%, p=0.026) than the iITBA group. In the ITBA+IPA group, 57% of patients tested positive according to the serum GM assay, whereas in the iITBA group, all patients tested negative (p=0.070). The bronchial GM level was high in both groups, but there was no significant difference between them.

Conclusion

Patients with ITBA+IPA had a greater number of hematologic malignancies with lower platelet counts and a poorer prognosis than patients diagnosed with iITBA. Findings obtained from bronchoscopy and bronchial GM tests were more useful in diagnosing ITBA than the serum GM test results.

Evaluation of Nosocomial Infection Control Measures to Minimize the Risk of Aspergillus Dispersion During Major Demolition Work: A Case Study of a Japanese University Hospital

OBJECTIVES

To verify the effectiveness of our infection control measures based on the infection control risk assessment (ICRA) to minimize the risk of Aspergillus dispersion before, during, and after demolition work in a university hospital.

BACKGROUND

It is widely accepted that invasive aspergillosis is associated with construction, renovation, and demolition activities within or close to hospital sites. However, the risk is underestimated, and only limited preventive measures are taken in Japanese hospitals.

METHOD

The demolition process, carried out in July 2014, was supervised by our facility management in collaboration with the infection prevention team and followed an adapted ICRA tool. Dust containment measures were implemented to reduce the risk of airborne Aspergillus contamination. Air sampling was performed at four wards in the adjacent hospital buildings to assess the containment measures' effectiveness.

RESULTS

A high, undetermined number of colonies of bacteria and molds were detected on all outside balconies before demolition. During demolition, Aspergillus spp. was detected only in the ward closest to the demolition site. However, no case of aspergillosis was reported. The difference-in-difference analysis revealed that the interaction between the demolition activity, height of the ward, and distance of the air intake to the demolition activities resulted in a significant increase in the numbers of Aspergillus spp.

CONCLUSIONS

When large-scale demolition work occurs in hospital premises, Aspergillus spp. may increase in the ward where the vertical and horizontal distance of air intake from the demolition site is close, even though infection control measures based on the ICRA are implemented.

COVID-19 Outbreak and Hospital Air Quality: A Systematic Review of Evidence on Air Filtration and Recirculation

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

Occupational exposure to Aspergillus section Fumigati: Tackling the knowledge gap in Portugal

Aspergillus section Fumigati is one of the sections of the Aspergillus genus most often associated with respiratory symptoms. The azole-resistant clinical isolates in this section have been widely described worldwide. More recently, the environmental origin of azole resistance has been correlated with the development of fungal diseases and therapeutic failure. This paper presents a review of several studies performed in Portuguese occupational environments focusing on occupational exposure to this section and give guidance to exposure assessors and industrial hygienists to ensure an accurate exposure assessment. Future studies should tackle the limitations concerning the assessment of occupational exposure to the Fumigati section, in order to allow the implementation of adequate risk management measures. In the light of the results of previous studies, the following approach is proposed to ensure an accurate exposure assessment: a) a combination of active and passive sampling methods appropriate to each occupational environment; b) the use, in parallel, of culture-based methods and molecular tools to overcome the limitations of each method; c) evaluation of the mycobiota azole resistance profile; and d) consider the possible simultaneous presence of mycotoxins produced by this section when assessing workers occupational exposure. In sum, preventing the development of fungal strains resistant to azoles will only be achieved with a holistic approach. An adequate "One Health approach" can contribute positively to concerted actions in different sectors, by reducing the use of fungicides through the introduction of crops and agricultural practices that prevent fungal colonization, and by promoting the rational use of antifungal drugs in human and animal health.

Infectious Risk of the Hospital Environment in the Center of Morocco: A Case of Care Unit Surfaces

BACKGROUND

Equipment and hospital surfaces constitute a microbial reservoir that can contaminate hospital users and thus create an infectious risk. The aim of this work, which was carried out for the first time at a hospital in Meknes (regional hospital in the center of Morocco), is to evaluate the microbiological quality of surfaces and equipment in three potential risk areas (burn unit, operating room, and sterilization service).

METHODS

This study was carried out over a period of 4 months (February-May 2017). A total of 60 samples were taken by swabbing according to the standard (ISO/DIS 14698-1 (2004)) in an environment of dry area and equipment after biocleaning. Isolation and identification were performed according to conventional bacteriological methods and by microscopic observation for fungi.

RESULTS

The study showed that 40% of surface samples were contaminated after biocleaning. The burn unit recorded a percentage of 70% contamination (p value <0.001), 13% for the sterilization service, and 7% for the operating room. 89% of the isolates were identified as Gram-positive bacteria against 11% for fungi (p value <0.001). Bacterial identification showed coagulase-negative staphylococci (32%), Bacillus spp. (16%), Corynebacterium (8%), and oxidase-negative Gram-positive bacillus (40%) while fungal identification showed Aspergillus niger (n = 2) and Aspergillus nidulans (n = 1).

CONCLUSION

To control the infectious risk related to equipment and hospital surfaces, it would be necessary to evaluate the disinfection protocol applied in these units.

Bioburden Assessment by Passive Methods on a Clinical Pathology Service in One Central Hospital from Lisbon: What Can it Tell Us Regarding Patients and Staff Exposure?

The assessment and control of microbial contamination in health care facilities is presently a mandatory and vital part of strategies to prevent and control hospital-acquired infections. This study aims to assess the bioburden with two passive sampling methods (30 ventilations grids swabs and 16 electrostatic dust collectors (EDCs)) at Clinical Pathology Services. The fungal burden was characterized through molecular tools, antifungal resistance, and the mycotoxins and cytotoxicity profile. Total bacteria presented the highest prevalence in both matrixes, whereas Gram-bacteria presented the lowest. Swabs presented a higher prevalence (27.6%) for fungal burden. Chrysonilia sitophila presented the highest prevalence in swabs, whereas for EDCs, C. sitophila and Mucor sp. were the most prevalent. Concerning Aspergillus genera on swabs, section Flavi was the one with the highest prevalence (58.02%), whereas, for EDCs, section Versicolores was the only section observed (100%). Aspergillus section Fumigati was detected in 10 swabs and 7 EDC samples and Aspergillus section Versicolores was detected in one EDC sample. Fungal growth on azole-supplemented media was observed in eight EDC samples. No mycotoxins were detected in any of the samples. A low cytotoxic effect was observed in two sites upon incubation of collected samples with A549 and SK cells and in two other sites upon incubation of collected samples with SK cells only. A medium cytotoxic effect was observed with one EDC sample upon incubation with A549 cells. This study reinforces the need of determination of the azole resistance profile for fungal species and allowed a preliminary risk characterization regarding the cytotoxicity. An intervention including the use of a ultraviolet with wavelength between 200 nm and 280 nm (UVC)—emitting device and an increased maintenance and cleaning of the central heating, ventilation, and air conditioning (HVAC) systems should be ensured to promote the reduction of microbial contamination.

Renovation in hospitals: Training construction crews to work in health care facilities

BACKGROUND

Health care facilities require frequent renovations to maintain or enhance their service, and to meet the dynamic demands of their patients. Construction activities in active health care facilities are a significant contributor to various challenges that range from infection to death. It is therefore essential to minimize the adverse impacts of construction activities on health care units as well as their adjacent sites.

METHODS

A questionnaire was developed to study current training modules to prepare construction crews to work in health care environments. The survey was disseminated among professionals of the top 15 health care contractors. A total of 129 individuals participated, and their responses were analyzed using descriptive and categorical statistics.

RESULTS

This study investigates current training practices regarding (1) the level of training, (2) the frequency of training, and (3) the impact that the sensitivity of the project has on the training. To effectively prepare construction crews, special training must be provided to them.

CONCLUSIONS

There are uncertainties about the sufficiency and impact of the existing training. Existing trainings are tailored for upper management positions, and the amount/frequency of training for construction crews are substantially low. Findings of this study contribute to characterizing the activities and conditions pertaining to training of construction crews.

The Role of Pentraxin 3 in Aspergillosis: Reality and Prospects

Pentraxin 3 (PTX3) is a soluble pattern recognition receptor (PRR), which is produced by several kinds of cells, such as neutrophils, dendritic cells, macrophages, and epithelial cells. PTX3 is known to play an important protective effect against Aspergillus. Genetic linkage in gene-targeted mice and human PTX3 plays a non-redundant role in the immune protection against specific pathogens, especially Aspergillus. Recent studies have shown that the polymorphism of PTX3 is associated with increased susceptibility to invasive aspergillosis (IA). In this review, we provide an overview of these studies that underline the potential of PTX3 in diagnosis and therapy of IA.

Exposure assessment in one central hospital: A multi-approach protocol to achieve an accurate risk characterization

The bioburden in a Hospital building originates not only from patients, visitors and staff, but is also disseminated by several indoor hospital characteristics and outdoor environmental sources. This study intends to assess the exposure to bioburden in one central Hospital with a multi-approach protocol using active and passive sampling methods. The microbial contamination was also characterized through molecular tools for toxigenic species, antifungal resistance and mycotoxins and endotoxins profile. Two cytotoxicity assays (MTT and resazurin) were conducted with two cell lines (Calu-3 and THP-1), and in vitro pro-inflammatory potential was assessed in THP-1 cell line. Out of the 15 sampling locations 33.3% did not comply with Portuguese legislation regarding bacterial contamination, whereas concerning fungal contamination 60% presented I/O > 1. Toxigenic fungal species were observed in 27% of the sampled rooms (4 out of 15) and qPCR analysis successfully amplified DNA from the Aspergillus sections Flavi and Fumigati, although mycotoxins were not detected. Growth of distinct fungal species was observed on Sabouraud dextrose agar with triazole drugs, such as Aspergillus section Versicolores on 1 mg/L VORI. The highest concentrations of endotoxins were found in settled dust samples and ranged from 5.72 to 23.0 EU.mg^-1. While a considerable cytotoxic effect (cell viability < 30%) was observed in one HVAC filter sample with Calu-3 cell line, it was not observed with THP-1 cell line. In air samples a medium cytotoxic effect (61-68% cell viability) was observed in 3 out of 15 samples. The cytokine responses produced a more potent average cell response (46.8 ± 12.3 ρg/mL IL-1β; 90.8 ± 58.5 ρg/mL TNF-α) on passive samples than air samples (25.5 ± 5.2 ρg/mL IL-1β and of 19.4 ± 5.2 ρg/mL TNF-α). A multi-approach regarding parameters to assess, sampling and analysis methods should be followed to characterize the biorburden in the Hospital indoor environment. This study supports the importance of considering exposure to complex mixtures in indoor environments.

Monitoring of Particle Environmental Pollution and Fungal Isolations During Hospital Building-Work Activities in a Hematology Ward

Building-work activities could cause dust contamination and fungal spores' dissemination. A significant relationship was found between building-work activities and the incidence of invasive aspergillosis, in profoundly immunocompromised patients. Renovation-works activities were carried out by four building sites of the hematology ward in a Teaching Hospital without the interruption of clinical activities. These sites were monitored by environmental sampling to determine the particles and fungi count. Clinical surveillance was made using galactomannan antigen test as a proxy for invasive aspergillosis diagnosis. A definitive diagnosis of IA was confirmed by clinical and radiological features. The galactomannan antigen test showed no significant difference between presence (2,75%) and absence (5,03%) of renovation work activities (p=0,522). During the renovation activities, an increment of IA cases with respect to the control period was not recorded. The particle counts showed higher values of small and big-diameter particles before the renovation works if compared to the end of the activities. It was probably due to the containment measures implemented during and immediately after the final phases of the building site. The Fungi counts showed no significant differences between the phase before and after the renovation activities. Our findings show that is possible to perform renovation work, during clinical activities, by increasing clinical and environmental surveillance.

Aspergillus spp. prevalence in Primary Health Care Centres: Assessment by a novel multi-approach sampling protocol

Exposure to Aspergillus conidia may cause adverse effects on human health; however, no specific recommendations for routine assessments of Aspergillus in the clinical environment have been suggested so far. This study intended to determine the prevalence of Aspergillus in the clinical environment, focusing on ten Primary Health Care Centres (PHCC) through a novel multi-approach sampling protocol. Air and passive sampling, culture-based methods and a probe-based real-time assay for the detection of four clinically relevant Aspergillus sections were performed. Aspergillus spp. was observed in all PHCC, with highest prevalence on floor surface swabs (n=81) (18% on MEA; 6.94% on DG18). Regarding air samples (n=81), highest Aspergillus counts were found in the waiting room (94% MEA; 18% DG18), where Nigri was the most prevalent Aspergillus section. The use of a multi-approach sampling protocol to assess Aspergillus burden in the analysed PHCC has greatly contributed to risk characterization, highlighting the need to implement corrective measures in order to avoid fungal presence in those settings.

Self-disinfecting surfaces and infection control

According to World Health Organization, every year in the European Union, 4 million patients acquire a healthcare associated infection. Even though some microorganisms represent no threat to healthy people, hospitals harbor different levels of immunocompetent individuals, namely patients receiving immunosuppressors, with previous infections, or those with extremes of age (young children and elderly), requiring the implementation of effective control measures. Public spaces have also been found an important source of infectious disease outbreaks due to poor or none infection control measures applied. In both places, surfaces play a major role on microorganisms' propagation, yet they are very often neglected, with very few guidelines about efficient cleaning measures and microbiological assessment available. To overcome surface contamination problems, new strategies are being designed to limit the microorganisms' ability to survive over surfaces and materials. Surface modification and/or functionalization to prevent contamination is a hot-topic of research and several different approaches have been developed lately. Surfaces with anti-adhesive properties, with incorporated antimicrobial substances or modified with biological active metals are some of the strategies recently proposed. This review intends to summarize the problems associated with contaminated surfaces and their importance on infection spreading, and to present some of the strategies developed to prevent this public health problem, namely some already being commercialized.

Airborne fungal spores and invasive aspergillosis in hematologic units in a tertiary hospital during construction: a prospective cohort study

Background

Invasive aspergillosis (IA) is an opportunistic fungal infection that mostly occurs in immunocompromised patients, such as those having hematologic malignancy or receiving hematopoietic stem cell transplantation. Inhalation of Aspergillus spores is the main transmission route of IA in immunocompromised patients. Construction work in hospitals is a risk factor for environmental fungal contamination. We measured airborne fungal contamination and the incidence of IA among immunocompromised patients, and evaluated their correlation with different types of construction works.

Methods

Our tertiary hospital in Seoul, Korea underwent facility construction from September 2017 to February 2018. We divided the entire construction period into period 1 (heavier works: demolition and excavation) and period 2 (lighter works: framing, interior designing, plumbing, and finishing). We conducted monthly air sampling for environmental spore surveillance in three hematologic wards. We evaluated the incidence of IA among all immunocompromised patients hospitalized in the three hematologic wards (2 adult wards and 1 pediatric ward) during this period. IA was categorized into proven, probable, and possible aspergillosis based on the revised European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria.

Results

A total of 15 patients was diagnosed with proven (1 case), probable (8 cases), or possible (6 cases) hospital-acquired IA during period 1. In period 2, 14 patients were diagnosed with either proven (1 case), probable (10 cases), or possible (3 cases) hospital-acquired IA. Total mold and Aspergillus spp. spore levels in the air tended to be higher in period 1 (p = 0.06 and 0.48, respectively). The incidence rate of all IA by the EORTC/MSG criteria was significantly higher in period 1 than in period 2 (1.891 vs. 0.930 per 1000 person-days, p = 0.05).

Conclusions

Airborne fungal spore levels tended to be higher during the period with heavier construction works involving demolition and excavation, during which the incidence of IA was significantly higher as well. We recommend monitoring airborne fungal spore levels during construction periods in hospitals with immunocompromised patients. Subsequently, the effect of airborne fungal spore level monitoring in reducing hospital-acquired IA should be evaluated.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0543-1) contains supplementary material, which is available to authorized users.

Effects of indoor environmental parameters related to building heating, ventilation, and air conditioning systems on patients' medical outcomes: A review of scientific research on hospital buildings

The indoor environment of a mechanically ventilated hospital building controls infection rates as well as influences patients' healing processes and overall medical outcomes. This review covers the scientific research that has assessed patients' medical outcomes concerning at least one indoor environmental parameter related to building heating, ventilation, and air conditioning (HVAC) systems, such as indoor air temperature, relative humidity, and indoor air ventilation parameters. Research related to the naturally ventilated hospital buildings was outside the scope of this review article. After 1998, a total of 899 papers were identified that fit the inclusion criteria of this study. Of these, 176 papers have been included in this review to understand the relationship between the health outcomes of a patient and the indoor environment of a mechanically ventilated hospital building. The purpose of this literature review was to summarize how indoor environmental parameters related to mechanical ventilation systems of a hospital building are impacting patients. This review suggests that there is a need for future interdisciplinary collaborative research to quantify the optimum range for HVAC parameters considering airborne exposures and patients' positive medical outcomes.

Development and Applications of Prognostic Risk Models in the Management of Invasive Mold Disease

Prognostic models or risk scores are frequently used to aid individualize risk assessment for diseases with multiple, complex risk factors and diagnostic challenges. However, relatively little attention has been paid to the development of risk models for invasive mold diseases encountered in patients with hematological malignancies, despite a large body of epidemiological research. Herein we review recent studies that have described the development of prognostic models for mold disease, summarize our experience with the development and clinical use of one such model (BOSCORE), and discuss the potential impact of prognostic risk scores for individualized therapy, diagnostic and antifungal stewardship, as well as clinical and epidemiological research.

UVC LED Irradiation Effectively Inactivates Aerosolized Viruses, Bacteria, and Fungi in a Chamber-Type Air Disinfection System

In this study, the possibility of inactivating viral, bacterial, and fungal aerosols in a chamber-type air disinfection system by using a UVC light-emitting-diode (LED) array was investigated and inactivation rate constants of each microorganism were calculated in fitting curves of surviving populations. UVC LED array treatment effectively inactivated viral infectivity, achieving 5-log reductions within 45 mJ/cm² for MS2, Qβ, and ϕX174 viruses. UVC LED array effectiveness in inactivating Escherichia coli O157:H7, Salmonella enterica serovar Typhimurium, Listeria monocytogenes, and Staphylococcus aureus aerosols achieved 2.5- to 4-log reductions within 1.5 to 4.6 mJ/cm² Also, 4-log reductions of Aspergillus flavus and Alternaria japonica were achieved at a dosage of 23 mJ/cm² using UVC LED array irradiation. The highest UV susceptibility, represented by the inactivation rate constant, was calculated for bacteria, followed by fungi and viruses. UVC LED, an innovative technology, can effectively inactivate microorganisms regardless of taxonomic classification and can sufficiently substitute for conventional mercury UV lamps.IMPORTANCE The United Nations Environment Programme (UNEP) convened the Minamata Convention on Mercury in 2013 to ban mercury-containing products in order to ensure human and environmental health. It will be effectuated in 2020 to discontinue use of low-pressure mercury lamps and new UV-emitting sources have to replace this conventional technology. However, the UV germicidal irradiation (UVGI) system still uses conventional UV lamps, and no research has been conducted for air disinfection using UVC LEDs. The research reported here investigated the inactivation effect of aerosolized microorganisms, including viruses, bacteria, and fungi, with an UVC LED module. The results can be utilized as a primary database to replace conventional UV lamps with UVC LEDs, a novel type of UV emitter. Implementation of UVC LED technology is truly expected to significantly reduce the extent of global mercury contamination, and this study provides important baseline data to help ensure a healthier environment and increased health for humanity.

Usefulness of Aspergillus Galactomannan Antigen Testing and the Prediction of an Outbreak during Hospital Reconstruction

Objective This study retrospectively evaluated fungal dissemination due to hospital reconstruction and explored effective methods of predicting an outbreak. Methods Patients suspected of having invasive aspergillosis were tested for Aspergillus galactomannan antigen before and after reconstruction, and the mean values of three months of testing for positive patients were determined. The characteristics of patients with aspergillosis during this period were also assessed. Results Forty-five patients were positive for Aspergillus antigen (>0.5 cut-off index) from January 2013 to December 2014. Mean Aspergillus antigen values significantly increased following reconstruction (p<0.05). Three patients developed pneumonia due to Aspergillus and were diagnosed with "probable" invasive aspergillosis according to the European Organization for Research and Treatment of Cancer and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria. We also discovered that the anteroom to contain dust was not prefabricated and a negative pressure system to remove dust was not used. After construction of the unit, no new cases of aspergillosis were diagnosed. Conclusion Many Aspergillus spores may be transiently floating during hospital reconstruction. Therefore, monthly surveillance with frequent serum galactomannan antigen testing to predict outbreaks is necessary. Surveillance of all patients in the hematology ward is especially important. Reconsideration of prophylactic antifungals may also be necessary during hospital reconstruction.

Primary cutaneous aspergillosis caused by Aspergillus.fumigatus in an immunocompetent patient: A case report

RATIONALE

Primary cutaneous aspergillosis in immunocompromised patients has been well described in extensive investigations. However, in immunocompetent hosts, primary cutaneous infection of aspergillus occurs rarely, and remains poorly characterized.

PATIENT CONCERNS

We present a case of primary cutaneous aspergillosis manifested by erythematous plague covered with flava eschar.

DIAGNOSES

The patient was diagnosed with primary cutaneous aspergillosis.

INTERVENTIONS

Treatments with oral itraconazole at a dose of 75 mg/d and local wound care with ciclopirox olamine ointment were administered.

OUTCOMES

After half a month, a partial resolution and a decrease in tenderness indicated gradual improvement, and a complete remission was achieved 2 months later.

LESSONS

Primary cutaneous aspergillosis could occur in immunocompetent hosts. The initial lesions may appear in different forms, including macules, papules, nodules, or plaques. Repeated biopsy of a skin lesion for both culture and histopathology is needed.

How to build an allogeneic hematopoietic cell transplant unit in 2016: Proposal for a practical framework

Allogeneic hematopoietic cell transplantation is part of the standard of care for many hematological diseases. Over the last decades, significant advances in patient and donor selection, conditioning regimens as well as supportive care of patients undergoing allogeneic hematopoietic cell transplantation leading to improved overall survival have been made. In view of many new treatment options in cellular and molecular targeted therapies, the place of allogeneic transplantation in therapy concepts must be reviewed. Most aspects of hematopoietic cell transplantation are well standardized by national guidelines or laws as well as by certification labels such as FACT-JACIE. However, the requirements for the construction and layout of a unit treating patients during the acute phase of the transplantation procedure or at readmission for different complications are not well defined. In addition, the infrastructure of such a unit may be decisive for optimized care of these fragile patients. Here we describe the process of planning a transplant unit in order to open a discussion that could lead to more precise guidelines in the field of infrastructural requirements for hospitals caring for people with severe immunosuppression.

Experimental induction of mycotic plaques in the guttural pouches of horses

Guttural pouch mycosis (GPM) is a rare but potentially life-threatening condition in horses. GPM is caused by a fungal invasion into the mucosal lining of the guttural pouches and, frequently, the associated neurovascular structures. Although several species of fungi have been associated with this disease, Aspergillus spp. appear to be the most common isolated from the guttural pouches. However, it remains unclear which are the predisposing factors leading to the development of the infection. The objectives of the present study were to experimentally reproduce an infection by Aspergillus fumigatus and to follow the natural evolution of the mycosis. Eight guttural pouches from four horses were experimentally infected by endoscopy-guided intrapouch inoculation of A. fumigatus culture. Horses were monitored for clinical signs and development of fungal plaques through endoscopic examination. Mycotic lesions were observed in all the horses and a spontaneous regression was observed within 15-28 days. No development of clinical signs was noticed. In conclusion, we were able to induce the development of mycotic lesions and to observe a natural regression of these lesions without clinical signs.

Recommendations for Risk Categorization and Prophylaxis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Expert Opinion (TEO-4)

This is the last of a series of articles on invasive fungal infections prepared by opinion leaders in Turkey. The aim of these articles is to guide clinicians in managing invasive fungal diseases in hematological malignancies and stem cell transplantation based on the available best evidence in this field. The previous articles summarized the diagnosis and treatment of invasive fungal disease and this article aims to explain the risk categorization and guide the antifungal prophylaxis in invasive fungal disease.

Could we predict airborne Aspergillus contamination during construction work?

BACKGROUND

Aspergillus fumigatus is a major opportunistic pathogen causing nosocomial infection. Hospital outbreaks of invasive aspergillosis have been associated with demolition and building construction. This study was designed to examine the impact of meteorologic factors and different periods of work on outdoor fungal airborne concentrations.

METHODS

The study was conducted at Necker Enfants Malades Hospital, a 650-bed teaching care hospital recently involved in a large construction program, including renovation, construction, and demolition. During the work phases, prospective external air samplings were performed 3 times a week, and meteorologic parameters were collected every day.

RESULTS

Two hundred and one samples were collected. Aspergillus spp were found in 80.1% of samples, with a median concentration of 16 colony forming units (CFU)/m³. A significant increase in the colony count of molds occurred after demolition. In the multivariate analysis, factors associated with overall fungi concentration were the type of work construction and temperature. Elevated Aspergillus spp concentrations (>20 CFU/m³) were associated with higher temperature.

CONCLUSIONS

Our findings underline the importance of environmental surveillance. According to our results we suggest that demolition work should be performed during the winter and fall seasons.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

The Plasmair Decontamination System Is Protective Against Invasive Aspergillosis in Neutropenic Patients

OBJECTIVE Invasive aspergillosis (IA) is a rare but severe infection caused by Aspergillus spp. that often develops in immunocompromised patients. Lethality remains high in this population. Therefore, preventive strategies are of key importance. The impact of a mobile air decontamination system (Plasmair, AirInSpace, Montigny-le-Bretonneux, France) on the incidence of IA in neutropenic patients was evaluated in this study. DESIGN Retrospective cohort study METHODS Patients with chemotherapy-induced neutropenia lasting 7 days or more were included over a 2-year period. Cases of IA were confirmed using the revised European Organization for Research and Treatment of Cancer (EORTC) criteria. We took advantage of a partial installation of Plasmair systems in the hematology intensive care unit during this period to compare patients treated in Plasmair-equipped versus non-equipped rooms. Patients were assigned to Plasmair-equipped or non-equipped rooms depending only on bed availability. Differences in IA incidence in both groups were compared using Fisher's exact test, and a multivariate analysis was performed to take into account potential confounding factors. RESULTS Data from 156 evaluable patients were available. Both groups were homogenous in terms of age, gender, hematological diagnosis, duration of neutropenia, and prophylaxis. A total of 11 cases of probable IA were diagnosed: 10 in patients in non-equipped rooms and only 1 patient in a Plasmair-equipped room. The odds of developing IA were much lower for patients hospitalized in Plasmair-equipped rooms than for patients in non-equipped rooms (P=.02; odds ratio [OR] =0.11; 95% confidence interval [CI], 0.00-0.84). CONCLUSION In this study, Plasmair demonstrated a major impact in reducing the incidence of IA in neutropenic patients with hematologic malignancies. Infect Control Hosp Epidemiol 2016;37:845-851.

Monitoring of Microscopic Filamentous Fungi in Indoor Air of Transplant Unit

AIM

The aim of the study was to control the microbial contamination of indoor air monitored monthly at the Transplant Unit of the University Hospital Olomouc from August 2010 to July 2011.

METHODS

The unit is equipped with a three-stage air filtration system with HEPA filters. The MAS-100 air sampler (Merck, GER) was used. Twenty locations were singled out for the purposes of collecting a total of 720 samplings of the indoor air. Swabs of the HVAC diffusers at the sampling locations were always carried out after the sampling of the indoor air.

RESULTS

In total, 480 samples of the indoor air were taken for Sabouraud chloramphenicol agar. In 11 cases (2.29%) the cultivation verified the presence of microscopic filamentous fungi. Only two cases involved the sanitary facilities of a patient isolation box; the other positive findings were from the facilities. The most frequent established genus was Aspergillus spp. (4x), followed by Trichoderma spp. (2x) and Penicillium spp. (2x), Paecilomyces spp., Eurotium spp., and Chrysonilia spp. (1x each). In 2 cases the cultivation established sterile aerial mycelium, unfortunately no further identification was possible. A total of 726 swabs of HVAC diffusers were collected (2 positive-0.28%). The study results demonstrated the efficacy of the HVAC equipment.

CONCLUSIONS

With the continuing increase in the number of severely immunocompromised patients, hospitals are faced with the growing problem of invasive aspergillosis and other opportunistic infections. Preventive monitoring of microbial air contaminants is of major importance for the control of invasive aspergillosis.

A simple novel device for air sampling by electrokinetic capture

BACKGROUND

A variety of different sampling devices are currently available to acquire air samples for the study of the microbiome of the air. All have a degree of technical complexity that limits deployment. Here, we evaluate the use of a novel device, which has no technical complexity and is easily deployable.

RESULTS

An air-cleaning device powered by electrokinetic propulsion has been adapted to provide a universal method for collecting samples of the aerobiome. Plasma-induced charge in aerosol particles causes propulsion to and capture on a counter-electrode. The flow of ions creates net bulk airflow, with no moving parts. A device and electrode assembly have been re-designed from air-cleaning technology to provide an average air flow of 120 lpm. This compares favorably with current air sampling devices based on physical air pumping. Capture efficiency was determined by comparison with a 0.4 μm polycarbonate reference filter, using fluorescent latex particles in a controlled environment chamber. Performance was compared with the same reference filter method in field studies in three different environments. For 23 common fungal species by quantitative polymerase chain reaction (qPCR), there was 100 % sensitivity and apparent specificity of 87 %, with the reference filter taken as "gold standard." Further, bacterial analysis of 16S RNA by amplicon sequencing showed equivalent community structure captured by the electrokinetic device and the reference filter. Unlike other current air sampling methods, capture of particles is determined by charge and so is not controlled by particle mass. We analyzed particle sizes captured from air, without regard to specific analyte by atomic force microscopy: particles at least as low as 100 nM could be captured from ambient air.

CONCLUSIONS

This work introduces a very simple plug-and-play device that can sample air at a high-volume flow rate with no moving parts and collect particles down to the sub-micron range. The performance of the device is substantially equivalent to capture by pumping through a filter for microbiome analysis by quantitative PCR and amplicon sequencing.

Relationship between Fungal Colonisation of the Respiratory Tract in Lung Transplant Recipients and Fungal Contamination of the Hospital Environment

BACKGROUND

Aspergillus colonisation is frequently reported after lung transplantation. The question of whether aspergillus colonisation is related to the hospital environment is crucial to prevention.

METHOD

To elucidate this question, a prospective study of aspergillus colonisation after lung transplantation, along with a mycological survey of the patient environment, was performed.

RESULTS

Forty-four consecutive patients were included from the day of lung transplantation and then examined weekly for aspergillus colonisation until hospital discharge. Environmental fungal contamination of each patient was followed weekly via air and surface sampling. Twelve patients (27%) had transient aspergillus colonisation, occurring 1-13 weeks after lung transplantation, without associated manifestation of aspergillosis. Responsible Aspergillus species were A. fumigatus (6), A. niger (3), A. sydowii (1), A. calidoustus (1) and Aspergillus sp. (1). In the environment, contamination by Penicillium and Aspergillus was predominant. Multivariate analysis showed a significant association between occurrence of aspergillus colonisation and fungal contamination of the patient's room, either by Aspergillus spp. in the air or by A.fumigatus on the floor. Related clinical and environmental isolates were genotyped in 9 cases of aspergillus colonisation. For A. fumigatus (4 cases), two identical microsatellite profiles were found between clinical and environmental isolates collected on distant dates or locations. For other Aspergillus species, isolates were different in 2 cases; in 3 cases of aspergillus colonisation by A. sydowii, A. niger and A. calidoustus, similarity between clinical and environmental internal transcribed spacer and tubulin sequences was >99%.

CONCLUSION

Taken together, these results support the hypothesis of environmental risk of hospital acquisition of aspergillus colonisation in lung transplant recipients.

En-suite bathrooms in protected haematology wards: a source of filamentous fungal contamination?

BACKGROUND

In spite of 25 recently built high-risk haematology rooms with a protected environment and fitted with en-suite bathrooms in our university hospital centre in 2008, sporadic cases of hospital-acquired invasive aspergillosis remained in these wards.

AIM

This study aimed to identify unsuspected environmental sources of filamentous fungal contamination in these rooms.

METHODS

Over two months, environmental fungal flora in the air (150 samples) as well as air particle counting and physical environmental parameters (airspeed, temperature, humidity, pressure) were prospectively monitored twice on the sampling day in all 25 protected rooms and en-suite bathrooms in use, and on bathroom surfaces (150 samples).

FINDINGS

In rooms under laminar airflow, in the presence of patients during sampling sessions, fungi were isolated in two samples (4%, 2/50) with a maximum value of 2cfu/500L (none was Aspergillus sp.). However, 88% of the air samples (44/50) in the bathroom were contaminated with a median range and maximum value of 2 and 16cfu/500L. Aspergillus spp. were involved in 24% of contaminated samples (12/44) and A. fumigatus in 6% (3/44). Bathroom surfaces were contaminated by filamentous fungi in 5% of samples (8/150).

CONCLUSION

This study highlighted that en-suite bathrooms in protected wards are likely to be a source of fungi. Before considering specific treatment of air in bathrooms, technicians have first corrected the identified deficiencies: replacement of high-efficiency particulate air filters, improvement of air control automation, and restoration of initial technical specifications. Assessment of measure effectiveness is planned.

Hospital environment fungal contamination and aspergillosis risk in acute leukaemia patients in Sousse (Tunisia)

Hospital environment is considered the main source of invasive aspergillosis (IA) in leukemic patients. This study aimed to describe Aspergillus colonisation in leukemic patients and their hospital environment and to test whether Aspergillus environmental contamination was associated with IA. For a 2-year period including 14-month renovation work, 91 acute leukaemia inpatients at the hematology department of University hospital in Sousse (Tunisia) were prospectively included. The incidence of probable IA (EORTC/MSG criteria) was 9.9%. Fifty-six Aspergillus were isolated from 53 (6.5%) of 811 sputa collected from 35 (38.5%) patients. Aspergillus spp. were isolated in 59.7% of 494 air samples and in 52.8% of 1579 surface samples taken in the patients' room. Aspergillus section Nigri (72.7%) was the most frequent. Aspergillus contamination peaked in autumn and winter on surface and in summer and autumn in air samples and was higher (P = 0.03) during the renovation work period. Multivariate analysis showed that for each Aspergillus section Nigri CFU airborne contamination IA risk increased by 1.05 (P = 0.04). In Tunisia, Aspergillus section Nigri and Flavi, but not Fumigati, are chiefly involved in IA. Our findings support swift implementation of airborne fungal contamination control measures in areas where immunocompromised patient are hospitalised.

Acute graft-versus-host disease, invasive aspergillosis and Clostridium difficile colitis after peripheral blood stem cell transplantation: A complex network of causalities and a challenge for prevention

Graft-versus-host disease (GVHD) is a known risk factor for invasive aspergillosis (IA), but remains poorly studied in relation to Clostridium difficile infection (CDI). We report a case of a 58-years-old patient who developed an IA within a protected room, CDI and GVHD after allogeneic allogeneic peripheral blood stem cell transplantation (PBSCT). Factors associated with this complex condition in patients receiving allogeneic PBSCT need to be identified.