Aspergillus surveillance project at a large tertiary-care hospital

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.

Characterization of 260 Isolates of Aspergillus Section Flavi Obtained from Sesame Seeds in Punjab, Pakistan

Sesame Sesamum indicum L. is a major oil-based seed crop that has been widely cultivated and consumed in Pakistan. Unfortunately, sesame is highly prone to Aspergillus fungal growth in the field, and under inappropriate storage conditions can become contaminated with aflatoxins, the most potent carcinogen found in nature. Here, we have isolated a high number of Aspergillus isolates from sesame seeds in fresh and stored conditions obtained from rainfed and irrigated zones of Punjab, Pakistan, and characterized them for aflatoxigenic potentials. Using morphological identification techniques, 260 isolates were grouped as potential Aspergillus section Flavi, with 126 and 134 originating from the rainfed and irrigated zones, respectively. Out of 260 in total, 188 isolates were confirmed to produce aflatoxins. There were no significant differences in potential aflatoxigenic isolates with respect to the rainfed and irrigated zones. However, the number of potential aflatoxigenic isolates was significantly higher (p < 0.05) in stored samples than that of those from fresh sesame seeds in the rainfed and irrigated zone. Whole genome sequencing and comparative analyses of 12 select isolates have revealed that one of the A. flavus isolates, which produced very low aflatoxins (AFP10), has an elevated missense variant rate, numerous high impact mutations, and a 600 base pair deletion in the norB gene. In summary, our study provides insights into aflatoxigenic potential and the associated genetic diversity of indigenous Aspergillus section Flavi isolates and potential management strategies for reducing aflatoxin contamination levels in a major crop consumed in Punjab, Pakistan.

A systematic review and meta-analysis of indoor bioaerosols in hospitals: The influence of heating, ventilation, and air conditioning

OBJECTIVES

To evaluate (1) the relationship between heating, ventilation, and air conditioning (HVAC) systems and bioaerosol concentrations in hospital rooms, and (2) the effectiveness of laminar air flow (LAF) and high efficiency particulate air (HEPA) according to the indoor bioaerosol concentrations.

METHODS

Databases of Embase, PubMed, Cochrane Library, MEDLINE, and Web of Science were searched from 1st January 2000 to 31st December 2020. Two reviewers independently extracted data and assessed the quality of the studies. The samples obtained from different areas of hospitals were grouped and described statistically. Furthermore, the meta-analysis of LAF and HEPA were performed using random-effects models. The methodological quality of the studies included in the meta-analysis was assessed using the checklist recommended by the Agency for Healthcare Research and Quality.

RESULTS

The mean CFU/m3 of the conventional HVAC rooms and enhanced HVAC rooms was lower than that of rooms without HVAC systems. Furthermore, the use of the HEPA filter reduced bacteria by 113.13 (95% CI: -197.89, -28.38) CFU/m3 and fungi by 6.53 (95% CI: -10.50, -2.55) CFU/m3. Meanwhile, the indoor bacterial concentration of LAF systems decreased by 40.05 (95% CI: -55.52, -24.58) CFU/m3 compared to that of conventional HVAC systems.

CONCLUSIONS

The HVAC systems in hospitals can effectively remove bioaerosols. Further, the use of HEPA filters is an effective option for areas that are under-ventilated and require additional protection. However, other components of the LAF system other than the HEPA filter are not conducive to removing airborne bacteria and fungi.

LIMITATION OF STUDY

Although our study analysed the overall trend of indoor bioaerosols, the conclusions cannot be extrapolated to rare, hard-to-culture, and highly pathogenic species, as well as species complexes. These species require specific culture conditions or different sampling requirements. Investigating the effects of HVAC systems on these species via conventional culture counting methods is challenging and further analysis that includes combining molecular identification methods is necessary.

STRENGTH OF THE STUDY

Our study was the first meta-analysis to evaluate the effect of HVAC systems on indoor bioaerosols through microbial incubation count. Our study demonstrated that HVAC systems could effectively reduce overall bioaerosol concentrations to maintain better indoor air quality. Moreover, our study provided further evidence that other components of the LAF system other than the HEPA filter are not conducive to removing airborne bacteria and fungi.

PRACTICAL IMPLICATION

Our research showed that HEPA filters are more effective at removing bioaerosols in HVAC systems than the current LAF system. Therefore, instead of opting for the more costly LAF system, a filter with a higher filtration rate would be a better choice for indoor environments that require higher air quality; this is valuable for operating room construction and maintenance budget allocation.

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.

Airborne fungi in Universiti Sains Malaysia: knowledge, density and diversity

Airborne fungi are among common contaminants in indoor and outdoor environments, leading to poor indoor air quality (IAQ), and to some extent, implicate health risks to humans worldwide. In Malaysia, fungal contamination in institutional buildings is rarely documented although these places are frequently visited by many. This study was conducted to assess the density and diversity of airborne fungi in Universiti Sains Malaysia (USM) main campus, Penang. A total of 11 sampling sites were assessed. Fungi were collected by using Andersen Single Stage Impact Air Sampler N-6 and MEA plates. Two separate trials, namely Trial 1 and Trial 2, were conducted in 2008 and 2019, respectively. The recovered fungi were identified up to the genus level-based morphological features. A survey involving 400 respondents among USM staff and students in relation to fungal contamination in indoor air environment was also conducted to evaluate the knowledge on indoor fungi among USM community. The densities of indoor air fungi in Trial 1 were higher; ranging from 81 to 1743 CFU/m³, exceeding the recommended level set by the Malaysia Industry Code of Practice (MCPIAQ) in some sampling sites, compared to that of in Trial 2 where the densities ranged from 229 to 699 CFU/m³. A total of 154 isolates and 230 isolates of airborne fungi were recovered in Trial 1 and Trial 2, respectively. In total, 11 fungal genera were identified in both trials, and three genera were predominant: Aspergillus, Penicillium, and Cladosporium. The survey also revealed that knowledge of IAQ among staff and students was limited and that they were unaware of fungal contamination and IAQ. A continuous and wide-spread awareness should be implemented at USM main campus for safer and healthier indoor air environments, particularly university students where productivity and efficiency are of the utmost importance.

Toxicity studies of Aspergillus fumigatus administered by inhalation to B6C3F1/N mice (revised)

Aspergillus fumigatus is a thermotolerant, soil-borne fungal species that is ubiquitous in the environment. Mold was nominated to the National Toxicology Program (NTP) by a private individual due to suspected adverse health effects associated with personal exposure in indoor and occupational settings. A. fumigatus is of particular concern in the biowaste industry as the species can contaminate self-heating compost piles. Because of this potential for personal and occupational exposure and the lack of available toxicity data, toxicity studies were conducted in which male and female B6C3F1/N mice were exposed to A. fumigatus conidia (spores) two times a week for 3 months. All in-life procedures, including inhalation exposure, test article preparation, and hematology analysis, were completed by the National Institute for Occupational Safety and Health (NIOSH, Morgantown, WV). Battelle (Columbus, OH) conducted terminal necropsies, measured terminal body and organ weights, and evaluated gross lesions on-site at NIOSH. Tissue processing and histopathology were completed at Battelle. Grocott's methenamine silver (GMS) staining was performed at NIOSH. Genetic toxicology studies on mouse peripheral blood erythrocytes were conducted by Integrated Laboratory Systems, LLC (Research Triangle Park, NC). (Abstract Abridged).

Indoor Dust as a Matrix for Surveillance of COVID-19

Ongoing disease surveillance is a critical tool to mitigate viral outbreaks, especially during a pandemic. Environmental monitoring has significant promise even following widespread vaccination among high-risk populations. The goal of this work is to demonstrate molecular severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) monitoring in bulk floor dust and related samples as a proof of concept of a noninvasive environmental surveillance methodology for coronavirus disease 2019 (COVID-19) and potentially other viral diseases. Surface swab, passive sampler, and bulk floor dust samples were collected from the rooms of individuals positive for COVID-19, and SARS-CoV-2 was measured with quantitative reverse transcription-PCR (RT-qPCR) and two digital PCR (dPCR) methods. Bulk dust samples had a geometric mean concentration of 163 copies/mg of dust and ranged from nondetects to 23,049 copies/mg of dust detected using droplet digital PCR (ddPCR). An average of 89% of bulk dust samples were positive for the virus by the detection methods compared to 55% of surface swabs and fewer on the passive sampler (19% carpet, 29% polystyrene). In bulk dust, SARS-CoV-2 was detected in 76%, 93%, and 97% of samples measured by qPCR, chip-based dPCR, and droplet dPCR, respectively. Detectable viral RNA in the bulk vacuum bags did not measurably decay over 4 weeks, despite the application of a disinfectant before room cleaning. Future monitoring efforts should further evaluate RNA persistence and heterogeneity in dust. This study did not measure virus infectivity in dust or potential transmission associated with dust. Overall, this work demonstrates that bulk floor dust is a potentially useful matrix for long-term monitoring of viral disease in high-risk populations and buildings.

IMPORTANCE Environmental surveillance to assess pathogen presence within a community is proving to be a critical tool to protect public health, and it is especially relevant during the ongoing COVID-19 pandemic. Importantly, environmental surveillance tools also allow for the detection of asymptomatic disease carriers and for routine monitoring of a large number of people as has been shown for SARS-CoV-2 wastewater monitoring. However, additional monitoring techniques are needed to screen for outbreaks in high-risk settings such as congregate care facilities. Here, we demonstrate that SARS-CoV-2 can be detected in bulk floor dust collected from rooms housing infected individuals. This analysis suggests that dust may be a useful and efficient matrix for routine surveillance of viral disease.

Water springing to life the fungal desert

Immunosuppressed patients are at increased risk of developing hospital-acquired fungal infections. The risk of fungal infection from construction is well established, but water ingress also presents a risk if it is not dealt with promptly. This article describes four such scenarios and the learning points from each. Water ingress may go under-reported and, as such, may be an underestimated source of fungal healthcare-associated infections.

Airborne Aspergillus fumigatus contamination in an intensive care unit: Detection, management and control

Intensive care unit (ICU) patients are often extremely vulnerable to suffer an infection from airborne pathogens. Therefore, an environmental outbreak of Aspergillus fumigatus in an ICU should be handled in a concise and efficient way. In this short report, we describe an outbreak of A. fumigatus in the ICU of a Belgian secondary care hospital. Following initial detection of a humidity problem and airborne A. fumigatus, the department of infection prevention took urgent measures for damage control and resolution of the problem. As such a timely resolution has been provided, with assurance of a clean and healthy environment for the critical patients.

Spatial Patterns and Impacts of Environmental and Climatic Factors on Canine Sinonasal Aspergillosis in Northern California

Sinonasal aspergillosis (SNA) causes chronic nasal discharge in dogs and has a worldwide distribution, although most reports of SNA in North America originate from the western USA. SNA is mainly caused by Aspergillus fumigatus, a ubiquitous saprophytic filamentous fungus. Infection is thought to follow inhalation of spores. SNA is a disease of the nasal cavity and/or sinuses with variable degrees of local invasion and destruction. While some host factors appear to predispose to SNA (such as belonging to a dolichocephalic breed), environmental risk factors have been scarcely studied. Because A. fumigatus is also the main cause of invasive aspergillosis in humans, unraveling the distribution and the environmental and climatic risk factors for this agent in dogs would be of great benefit for public health studies, advancing understanding of both distribution and risk factors in humans. In this study, we reviewed electronic medical records of 250 dogs diagnosed with SNA between 1990 and 2014 at the University of California Davis Veterinary Medical Teaching Hospital (VMTH). A 145-mile radius catchment area around the VMTH was selected. Data were aggregated by zip code and incorporated into a multivariate logistic regression model. The logistic regression model was compared to an autologistic regression model to evaluate the effect of spatial autocorrelation. Traffic density, active composting sites, and environmental and climatic factors related with wind and temperature were significantly associated with increase in disease occurrence in dogs. Results provide valuable information about the risk factors and spatial distribution of SNA in dogs in Northern California. Our ultimate goal is to utilize the results to investigate risk-based interventions, promote awareness, and serve as a model for further studies of aspergillosis in humans.

Genotyping bacterial and fungal pathogens using sequence variation in the gene for the CCA-adding enzyme

BACKGROUND

To allow an immediate treatment of an infection with suitable antibiotics and bactericides or fungicides, there is an urgent need for fast and precise identification of the causative human pathogens. Methods based on DNA sequence comparison like 16S rRNA analysis have become standard tools for pathogen verification. However, the distinction of closely related organisms remains a challenging task. To overcome such limitations, we identified a new genomic target sequence located in the single copy gene for tRNA nucleotidyltransferase fulfilling the requirements for a ubiquitous, yet highly specific DNA marker. In the present study, we demonstrate that this sequence marker has a higher discriminating potential than commonly used genotyping markers in pro- as well as eukaryotes, underscoring its applicability as an excellent diagnostic tool in infectology.

RESULTS

Based on phylogenetic analyses, a region within the gene for tRNA nucleotidyltransferase (CCA-adding enzyme) was identified as highly heterogeneous. As prominent examples for pro- and eukaryotic pathogens, several Vibrio and Aspergillus species were used for genotyping and identification in a multiplex PCR approach followed by gel electrophoresis and fluorescence-based product detection. Compared to rRNA analysis, the selected gene region of the tRNA nucleotidyltransferase revealed a seven to 30-fold higher distinction potential between closely related Vibrio or Aspergillus species, respectively. The obtained data exhibit a superb genome specificity in the diagnostic analysis. Even in the presence of a 1,000-fold excess of human genomic DNA, no unspecific amplicons were produced.

CONCLUSIONS

These results indicate that a relatively short segment of the coding region for tRNA nucleotidyltransferase has a higher discriminatory potential than most established diagnostic DNA markers. Besides identifying microbial pathogens in infections, further possible applications of this new marker are food hygiene controls or metagenome analyses.

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.

Environmental contamination and hospital-acquired infection: factors that are easily overlooked

There is an ongoing debate about the reasons for and factors contributing to healthcare-associated infection (HAI). Different solutions have been proposed over time to control the spread of HAI, with more focus on hand hygiene than on other aspects such as preventing the aerial dissemination of bacteria. Yet, it emerges that there is a need for a more pluralistic approach to infection control; one that reflects the complexity of the systems associated with HAI and involves multidisciplinary teams including hospital doctors, infection control nurses, microbiologists, architects, and engineers with expertise in building design and facilities management. This study reviews the knowledge base on the role that environmental contamination plays in the transmission of HAI, with the aim of raising awareness regarding infection control issues that are frequently overlooked. From the discussion presented in the study, it is clear that many unknowns persist regarding aerial dissemination of bacteria, and its control via cleaning and disinfection of the clinical environment. There is a paucity of good-quality epidemiological data, making it difficult for healthcare authorities to develop evidence-based policies. Consequently, there is a strong need for carefully designed studies to determine the impact of environmental contamination on the spread of HAI.

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.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

The potential inhibitory effect of cuminum cyminum, ziziphora clinopodioides and nigella sativa essential oils on the growth of Aspergillus fumigatus and Aspergillus

The goals of this study were to evaluate the effectiveness of Cuminum cyminum, Ziziphora clinopodioides and Nigella sativa essential oils to inhibit the growth of Aspergillus fumigatus and A.flavus and to evoke ultrastructural changes. The fungi were cultured into RPMI 1640 media in the presence of oils at concentrations of 8, 6, 5, 4, 3, 2, 1.5, 1.25, 1, 0.75 and 0.5 mg/ml in broth microdilution and 2, 1.5, 1 and 0.5 mg/ml in broth macrodilution methods with shaking for 48 h at 28^oC. Conidial and mycelial samples exposed to 0.25, 0.5, 1, 1.5 and 2 mg essential oils/ml for 5 days in 2% yeast extract granulated plus 15% Saccharose media were processed for transmission electron microscopy (TEM). Based on broth dilution methods, C. cyminum and to a lesser extent Z. clinopodioides oils exhibited the strongest activity against A. fumigatus and A.flavus with MIC₉₀ ranging from 0.25 to 1.5 mg/ml, while the oil from N. sativa exhibited relatively moderate activity against two above fungi with MIC₉₀ ranging from 1.5 to 2 mg/ml. The main changes observed by TEM were in the cell wall, plasma membrane and membranous organelles; in particular, in the nuclei and mitochondria. These modifications in fungal structure were associated with the interference of the essential oils with the enzymes responsible for cell wall synthesis, which disturbed normal growth. Moreover, the essential oils caused high vacuolation of the cytoplasm, detachment of fibrillar layer of cell wall, plasma membrane disruption and disorganization of the nuclear and mitochondrial structures. Aspergillus fumigatus and A. flavus growth inhibition induced by these oils were found to be well-correlated with subsequent morphological changes of the fungi exposed to different fungistatic concentrations of the oils. Our results show the anti-Aspergillus activities of C. cyminum, Z. clinopodioides and N. sativa essential oils, which strengthens the potential use of these substances as anti-mould in the future.

Fungal pollution of indoor environments and its management

Indoor environments play important roles in human health. The health hazards posed by polluted indoor environments include allergy, infections and toxicity. Life style changes have resulted in a shift from open air environments to air tight, energy efficient, environments, in which people spend a substantial portion of their time. Most indoor air pollution comes from the hazardous non biological agents and biological agents. Fungi are ubiquitous in distribution and are a serious threat to public health in indoor environments. In this communication, we have reviewed the current status on biotic indoor air pollution, role of fungi as biological contaminants and their impact on human health.

Fungal spore concentrations in two haematopoietic stem cell transplantation (HSCT) units containing distinct air control systems

Invasive fungal diseases have emerged as important causes of morbidity and mortality in haematological patients. In this study air samples were collected in two haematopoietic stem cell transplantation (HSCT) units, in which distinct air-control systems were in place. In hospital 1 no high-efficiency particulate air (HEPA) filter was available whereas in hospital 2 HSCT rooms were equipped with HEPA filters, with positive air pressure in relation to the corridor. A total of 117 samples from rooms, toilets and corridors were obtained during December 2009 to January 2011, using a six-stage Andersen sampler. In both hospitals, the concentration of potentially pathogenic fungi in the air was reduced in patients' rooms compared to corridors (P < 0·0001). Despite the presence of a HEPA filter in hospital 2, rooms in both hospitals showed similar concentrations of potentially pathogenic fungi (P = 0·714). These findings may be explained by the implementation of additional protective measures in hospital 1, emphasizing the importance of such measures in protected environments.

Fungal pollution of indoor environments and its management

Indoor environments play important roles in human health. The health hazards posed by polluted indoor environments include allergy, infections and toxicity. Life style changes have resulted in a shift from open air environments to air tight, energy efficient, environments, in which people spend a substantial portion of their time. Most indoor air pollution comes from the hazardous non biological agents and biological agents. Fungi are ubiquitous in distribution and are a serious threat to public health in indoor environments. In this communication, we have reviewed the current status on biotic indoor air pollution, role of fungi as biological contaminants and their impact on human health.

Dynamics of fungal colonization in a new medical mycology laboratory

OBJECTIVE OF THE STUDY

Study of the spatio-temporal fungal colonization in a new medical mycology laboratory.

METHODS

A 17-month survey of airborne fungal contamination was conducted in a new medical mycology laboratory at a tertiary care university hospital. This survey was implemented at three different periods: before the new premises were occupied (period A), during the move into the new laboratory (period B) and after resumption of the mycological activities in these new premises (period C).

RESULTS

During period A, the airborne fungal load ranged from 2.3 to 6 cfu/m(3). The most frequently recovered airborne fungi were Penicillium spp. (75 to 100%). During period B, a dramatic increase in Penicillium chrysogenum conidia was observed in the air of the new laboratory (40 to 160 cfu/m(3)). During period C, the fungal load ranged from 4.5 to 8.4 cfu/m(3). Penicillium was the most common genus identified in rooms of the laboratory where no filamentous fungi were handled, while Aspergillus was clearly the predominant genus (78%) in the room dedicated to the culture of filamentous fungi.

CONCLUSIONS

We suggest that the specific fungal ecology in air of the room dedicated to the culture of filamentous fungi is due to the handling of a large number of medical strains of A. fumigatus.

Polyphasic taxonomy of Aspergillus section Candidi based on molecular, morphological and physiological data

Aspergillus section Candidi historically included a single white-spored species, A. candidus. Later studies clarified that other species may also belong to this section. In this study, we examined isolates of species tentatively assigned to section Candidi using a polyphasic approach. The characters examined include sequence analysis of partial beta-tubulin, calmodulin and ITS sequences of the isolates, morphological and physiological tests, and examination of the extrolite profiles. Our data indicate that the revised section Candidi includes 4 species: A. candidus, A. campestris, A. taichungensis and A. tritici. This is strongly supported by all the morphological characteristics that are characteristic of section Candidi: slow growing colonies with globose conidial heads having white to yellowish conidia, conidiophores smooth, small conidiophores common, metulae present and covering the entire vesicle, some large Aspergillus heads with large metulae, presence of diminutive heads in all species, conidia smooth or nearly so with a subglobose to ovoid shape, and the presence of sclerotia in three species (A. candidus, A. taichungensis and A. tritici). Aspergillus tritici has been suggested to be the synonym of A. candidus previously, however, sequence data indicate that this is a valid species and includes isolates came from soil, wheat grain, flour and drums from India, Ghana, Sweden, The Netherlands and Hungary, making it a relatively widespread species. All species produce terphenyllins and candidusins and three species (A. candidus, A. campestris and A. tritici) produce chlorflavonins. Xanthoascins have only been found in A. candidus. Each of the species in section Candidi produce several other species specific extrolites, and none of these have been found in any other Aspergillus species. A. candidus has often been listed as a human pathogenic species, but this is unlikely as this species cannot grow at 37 degrees C. The pathogenic species may be A. tritici or white mutants of Aspergillus flavus.

Invasive pulmonary aspergillosis due to Aspergillus terreus: value of DNA, galactomannan and (1→3)-β-d-glucan detection in serum samples as an adjunct to diagnosis

A case of invasive pulmonary aspergillosis caused by Aspergillus terreus is described. The diagnosis was based on demonstration of branched septate hyphae in a sputum specimen and isolation of the fungus in culture. The diagnosis was further supported by detection of A. terreus-specific DNA, galactomannan (GM) and (1→3)-β-d-glucan (BDG) in consecutive serum specimens. The patient was treated for about 10 weeks with voriconazole. The decreasing levels of GM and BDG in serum samples were accompanied by symptomatic and radiological improvement. The report highlights the value of surrogate markers in the diagnosis and for monitoring the course of invasive aspergillosis during therapy.

The impact of portable high-efficiency particulate air filters on the incidence of invasive aspergillosis in a large acute tertiary-care hospital

BACKGROUND

Worldwide, the frequency of invasive fungal infections has been increasing, with a corresponding increase in the numbers of high-risk patients. Exposure reduction through the use of high-efficiency particulate air (HEPA) filters has been the preferred primary preventive strategy for these high-risk patients. Although the efficiency and benefits of fixed HEPA filters is well proven, the benefits of portable HEPA filters are still inconclusive.

METHODS

This was a retrospective study to assess the impact of 48 portable HEPA filter units deployed in selected wards in Singapore General Hospital, an acute tertiary-care hospital in Singapore. Data were extracted between December 2005 and June 2008 on the diagnoses at discharge and microbiological and histological laboratory findings. All patients with possible, probable, or proven invasive aspergillosis (IA) were included.

RESULTS

In wards with portable HEPA filters, the incidence rate of IA of 34.61/100,000 patient-days in the pre-installation period was reduced to 17.51/100,000 patient-days in the post-installation period (P = .01), for an incidence rate ratio of 1.98 (95% confidence interval [CI], 1.10-2.97). In wards with no HEPA filters, there was no significant change in the incidence rate during the study period. Portable HEPA filters were associated with an adjusted odds ratio of 0.49 (95% CI, 0.28-0.85; P = .01), adjusted for diagnosis and length of hospital stay.

CONCLUSIONS

Portable HEPA filters are effective in the prevention of IA. The cost of widespread portable HEPA filtration in hospitals will be more than offset by the decreases in nosocomial infections in general and in IA in particular.

Chemical composition and antifungal activity of Hyptis Suaveolens (L.) Poit leaves essential oil against Aspergillus species

This study aimed to identify the constituents of the essential oil from Hyptis suaveolens (L.) leaves using a Gas Chromatograph - Mass Spectrometer and assess its inhibitory effect on some potentially pathogenic Aspergilli (A. flavus, A. parasiticus, A. ochraceus, A. fumigatus and A. niger). Eucaliptol (47.64 %) was the most abundant component in the oil, followed for gama-ellemene (8.15 %), beta-pynene (6.55 %), (+)-3-carene (5.16 %), trans-beta-cariophyllene (4.69 %) and germacrene (4.86 %). The essential oil revealed an interesting anti-Aspergillus property characterized by a Minimum Inhibitory Concentration and Minimum Fungicidal Concentration of 40 and 80 µL/mL, respectively. The oil at 80 and 40 µL/mL strongly inhibited the mycelial growth of A. fumigatus and A. parasiticus along 14 days. In addition, at 10 and 20 µL/mL the oil was able to cause morphological changes in A. flavus as decreased conidiation, leakage of cytoplasm, loss of pigmentation and disrupted cell structure suggesting fungal wall degeneration. These findings showed the interesting anti-Aspergillus property of H. suaveolens leaves essential oil supporting its possible rational use as alternative source of new antifungal compounds to be applied in the aspergillosis treatment.

Influence of internal and outdoor factors on filamentous fungal flora in hematology wards

BACKGROUND

Nosocomial invasive filamentous fungi infections could result from inhalation of filamentous fungi conidia present in hospital environment.

METHODS

The environmental fungal flora in 3 different hospital wards with similar air conditioning was prospectively studied during 30 months and compared to internal (presence of agranulocytosis patient, behavioral practices, activity, cleaning work) and outdoor factors (meteorologic data, outdoor fungi). The general preventive measures differed from one unit to another.

RESULTS

The hematology wards with filamentous fungi preventive measures were significantly less contaminated than a conventional ward without specific measures. Internal and outdoor factors influenced the level of fungal flora. However, the influence of internal factors was greater in the conventional ward than in hematology wards. The variation of flora in the hospital environment was seasonal, and the level of this contamination in each ward was influenced by the meteorology. However, outdoor factors more readily explain the variations of fungal load in hematology than in the conventional ward.

CONCLUSION

This study highlights that specific preventive measures participate significantly in the control of the filamentous fungal flora intensity due to internal factors but not those due to outdoor factors, stressing the importance of high-efficiency particulate air filtration in high-risk units.

Profiles and seasonal distribution of airborne fungi in indoor and outdoor environments at a French hospital

A one-year prospective survey of fungal air contamination was conducted in outdoor air and inside two haematological units of a French hospital. Air was sampled with a portable Air System Impactor. During this period of survey, the mean viable fungal load was 122.1 cfu/m(3) in outdoor air samples, and 4.1 and 3.9 cfu/m(3) in samples from adult and pediatric haematology units, respectively. In outdoor samples, Cladosporium was the dominant genus (55%) while in the clinical units, Penicillium sp. (23 to 25%), Aspergillus sp. (15 to 23%) and Bjerkandera adusta (11 to 13%) were the most frequently recovered airborne fungi. The outdoor fungal load was far higher in autumn (168 cfu/m(3)), spring (110 cfu/m(3)) and summer (138 cfu/m(3)) than in winter (49 cfu/m(3)). In indoor air, fungal concentrations were significantly lower in winter (2.7 to 3.1 cfu/m(3)) than in summer (4.2 to 5.0 cfu/m(3)) in both haematology units. In the outdoor environment, Penicillium sp. and Aspergillus sp. were more abundant in winter while the levels of Cladosporium were lowest during this season. In the haematological units, the presence of Aspergillus sp. was stable during the year (close to 20%), Bjerkandera sp. was particularly abundant in winter (close to 30%); levels of Penicillium sp. were highest in autumn while levels of Cladosporium sp. were highest in spring and summer.

Rapid detection and quantification of Aspergillus fumigatus in environmental air samples using solid-phase cytometry

Aspergillus fumigatus is an ubiquitous fungus capable of causing severe infections such as aspergilloma, allergic bronchopulmonary aspergillosis, and invasive aspergillosis, especially in immunocompromised patients. Monitoring the number of Aspergillus fumigatus spores in the air is crucial for infection control. In the present study, a novel approach for the quantification of Aspergillus fumigatus, based on solid-phase cytometry (SPC) and immunofluorescent labeling, was developed. The sensitivity and specificity of the assay were confirmed by testing pure cultures. Paecilomyces variotii and Rhizopus stolonifer were codetected but could be excluded on the basis of morphology of the microcolonies. The SPC method has considerable advantages compared to the culture-based method, including its low detection limit (4 cells/m3), its speed (results are obtained within 24 h), and the straightforward microscopic identification of Aspergillus fumigatus. Additionally, comparison of results obtained with both methods demonstrated that they are equally accurate for the quantification of Aspergillus fumigatus in environmental air samples.

A study of air microbe levels in different areas of a hospital

Airborne transmission is an important route for many microbial pathogens in outdoor and indoor environments, including hospitals. A 2-year-long survey of bioaerosol quality in operating theatres (OT), hospital rooms (HR) and maternity wards (MW) at a hospital in Murcia, Spain, was performed. Total aerobic counts (TAC) and fungal load (FL) were assessed using a microbiological air sampler (MAS-100 single-stage impactor). While fungal levels were below 1 cfu/m(3) (0-7.33 cfu/m(3)) in OT, they were higher in MW (mean, 6.9 cfu/m(3); range 0.44-44.67 cfu/m(3)) and in HR (mean, 10.6 cfu/m(3); range, 0-266 cfu/m(3)). In OT the aerobic counts were considerably higher, with a mean of 25.6 cfu/m(3) (range, 1.67-157 cfu/m(3)). MW and HR also showed higher means for total aerobic counts compared to OT. Seasonal changes were not detected in mould and bacteria levels in OT. Hospital renovation occurred during this study and OT adjacent to renovated areas were closed. A survey of TAC and FL in OT resumed when renovation was completed. We observed an outstanding increase in FL (more than 100 cfu/m(3)), particularly Aspergillus spp., during this period, but no significant changes in TAC were observed after renovation.

Effect of cinnamomum zeylanicum blume essential oil on the growth and morphogenesis of some potentially pathogenic Aspergillus species

Cinnamomum zeylanicum Blume is known for a wide range of medicinal properties. This study aimed to assess the interference of C. zeylanicum essential oil on the growth and morphogenesis of some potentially pathogenic Aspergillus species. The essential oil presented strong antifungal effect causing the growth inhibition of the assayed strains and development of large growth inhibition zones. MIC50 and MIC90 values were 40 and 80 μL/mL, respectively. 80, 40 and 20 μL/mL of the oil strongly inhibited the radial mycelial growth of A. niger, A. flavus and A. fumigatus along 14 days. 80 and 40 μL/mL of the oil caused a 100% inhibition of the fungal spore germination. Main morphological changes observed under light microscopy provided by the essential oil in the fungal strains were decreased conidiation, leakage of cytoplasm, loss of pigmentation and disrupted cell structure indicating fungal wall degeneration. It is concluded that C. zeylanicum essential oil could be known as potential antifungal compound, particularly, to protect against the growth of Aspergillus species.

Ten-year air sample analysis of Aspergillus prevalence in a university hospital

Airborne fungal samples were collected on a monthly basis for 10 years, from 1995 to 2005, at a tertiary university hospital. Paired samples were cultured at 25 and 37 degrees C. Data were interpreted according to the air filtration systems serving each location. Samples cultured at 37 degrees C from the patient care areas had a mean recovery of 18% of the mean recovery from outdoor air (22 versus 122cfu/m(3)). Recovery of Aspergillus spp. at 37 degrees C in the high-efficiency particulate air (HEPA)-filtered locations was positive for Aspergillus spp. approximately one-third of the time; the rest of the patient care areas were positive half of the time and the outdoor samples were positive 95% of the time. We found 48 sporadic bursts at 37 degrees C which produced counts >3 SD above the mean. Hospital-acquired infection was related to high recovery of Aspergillus fumigatus on at least one occasion. We have found it impossible, without implementing impractical measures, to provide an environment completely devoid of Aspergillus spp. We conclude that routine air sampling is not an effective means of predicting hospital-acquired infections. However, a transient spike, or burst, may be useful in identifying an in-house source of contamination and may be used to consider additional interventional treatments for patients at risk. Emphasis should be placed on maintaining high-efficiency filtration of the outside air and on ensuring that other environmental control methods are used to prevent dissemination of environmental opportunistic fungal spores.

Fatal brain infection caused by Aspergillus glaucus in an immunocompetent patient identified by sequencing of the ribosomal 18S–28S internal transcribed spacer

Cerebral aspergillosis has rarely been reported in immunocompetent patients. We herein describe a unique case of cerebral aspergillosis in a healthy adult that led to his death despite aggressive antifungal therapy. Sequencing of ribosomal 18S-28S internal transcribed spacer identified the organism as Eurotium herbariorum, the teleomorph of Aspergillus glaucus.

Reduced fungal contamination of the indoor environment with the Plasmair™ system (Airinspace)

Aspergillus spp. and other moulds cause life-threatening opportunistic infections in immunocompromised patients. Indoor contamination and construction work that liberate fungal spores are a major source of nosocomial aspergillosis. Dijon hospital is a tertiary care institution in northeast France undergoing construction work beside high-risk clinical units. To determine the impact of this activity, a surveillance programme was implemented one year before building work began in order to establish baseline levels of contamination. Air and surface fungal contamination in adult and paediatric haematology units were prospectively examined following use, or not, of a new air-treatment system with mobile Plasmair units (Airinspace). There were significant reductions in overall fungal contamination for the Plasmair treated rooms for air and surface samples in both clinical units. Plasmair treatment also significantly reduced A. fumigatus in the air. These data suggest that Plasmair units may provide an efficient method of reducing indoor fungal contamination in hospitals.

Filamentous fungi in a tertiary care hospital: environmental surveillance and susceptibility to antifungal drugs

OBJECTIVE

To evaluate filamentous fungi with respect to environmental load and potential drug resistance in a tertiary care teaching hospital.

DESIGN

Monthly survey in 2 buildings of the hospital during a 12-month period.

SETTING

Hippokration Hospital in Thessaloniki, Greece.

METHODS

Air, surface, and tap water sampling was performed in 4 departments with high-risk patients. As sampling sites, the solid-organ transplantation department and the hematology department (in the older building) and the pediatric oncology department and the pediatric intensive care unit (in the newer building) were selected.

RESULTS

From January to May of 2000, the fungal load in air (FLA) was low, ranging from 0 to 12 colony-forming units (cfu) per m(3) in both buildings. During the summer months, when high temperature and humidity predominate, the FLA increased to 4-56 cfu/m(3). The fungi commonly recovered from culture of air specimens were Aspergillus niger (25.9%), Aspergillus flavus (17.7%), and Aspergillus fumigatus (12.4%). Non-Aspergillus filamentous fungi, such as Zygomycetes and Dematiaceous species, were also recovered. The pediatric intensive care unit had the lowest mean FLA (7.7 cfu/m(3)), compared with the pediatric oncology department (8.7 cfu/m(3)), the solid-organ transplantation department (16.1 cfu/m(3)), and the hematology department (22.6 cfu/m(3)). Environmental surfaces were swabbed, and 62.7% of the swab samples cultured yielded filamentous fungi similar to the fungi recovered from air but with low numbers of colony-forming units. Despite vigorous sampling, culture of tap water yielded no fungi. The increase in FLA observed during the summer coincided with renovation in the building that housed the solid-organ transplantation and hematology departments. All 54 Aspergillus air isolates randomly selected exhibited relatively low minimum inhibitory or effective concentrations for amphotericin B, itraconazole, voriconazole, posaconazole, micafungin, and anidulafungin.

CONCLUSION

Air and surface fungal loads may vary in different departments of the same hospital, especially during months when the temperature and humidity are high. Environmental Aspergillus isolates are characterized by lack of resistance to clinically important antifungal agents.

Characterization of nigerlysin, hemolysin produced by Aspergillus niger, and effect on mouse neuronal cells in vitro

Aspergillus niger produced a proteinaceous hemolysin, nigerlysin when incubated on sheep's blood agar (SBA) at both 23 and 37 degrees C. Nigerlysin was purified from tryptic soy broth (TSB) culture filtrate and found to have a molecular weight of approximately 72 kDa, with an isoelectric point of 3.45. Nigerlysin is heat stable up to 65 degrees C but unstable at 75 degrees C when incubated for 10 min. Circular dichroic analysis revealed that nigerlysin has an alpha helical structure. Exposure of mouse primary cortical neuronal cells to 0.1 microg ml(-1) of nigerlysin resulted in the rapid loss of their viability, approximately 50% in 24 h. The IC50 is estimated to be 0.037 microg ml(-1), or between 0.034 and 0.041 microg ml(-1) at the 95% confidence level.