Eight-year surveillance of environmental fungal contamination in hospital operating rooms and haematological units

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.

Effect of far-infrared radiation on inhibition of colonies on packaging during storage of sterilised surgical instruments

The sterilisation of surgical instruments is a major factor in infection control in the operating room (OR). All items used in the OR must be sterile for patient safety. Therefore, the present study evaluated the effect of far-infrared radiation (FIR) on the inhibition of colonies on packaging surface during the long-term storage of sterilised surgical instruments. From September 2021 to July 2022, 68.2% of 85 packages without FIR treatment showed microbial growth after incubation at 35 °C for 30 days and at room temperature for 5 days. A total of 34 bacterial species were identified, with the number of colonies increasing over time. In total, 130 colony-forming units were observed. The main microorganisms detected were Staphylococcus spp. (35%) and Bacillus spp. (21%) , Kocuria marina and Lactobacillus spp. (14%), and mould (5%). No colonies were found in 72 packages treated with FIR in the OR. Even after sterilisation, microbial growth can occur due to movement of the packages by staff, sweeping of floors, lack of high-efficiency particulate air filtration, high humidity, and inadequate hand hygiene. Thus, safe and simple far-infrared devices that allow continuous disinfection for storage spaces, as well as temperature and humidity control, help to reduce microorganisms in the OR.

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.

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.

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.

The investigation of type and concentration of bio-aerosols in the air of surgical rooms: A case study in Shariati hospital, Karaj

The presence of bio-aerosols is one of the main causes of hospital infections that can be dangerous especially for immunocompromised patients. This research aimed to determine the relationship between hospital infections and surgical incision size in addition to determining the concentration and bacterial and fungal bioaerosols found in the operating rooms. This cross-sectional descriptive-analytic study was carried out in the operating rooms of Shariati Hospital in Karaj, Iran during the years 2016 and 2017. A total of 198 bacterial samples and 198 fungal samples were collected and analyzed using a passive sampling standard method (1/1/1) for 180 days. Tryptic Soy Agar (TSA) and Sabouraud Dextrose Agar (SDA) medium were used for bacterial and fungal samples, respectively. Relevant differential tests were used to determine the genus and species of bacteria and fungi such as DNase test, Bile-esculin, motility test urease test. In general, this work presents:

•

The present evaluated the relationship between bioaerosols concentration and surgical incision size.

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The intraoperative concentration of bacterial and fungal bioaerosols in indoor air of the orthopedic, internal and cesarean operating rooms was significantly higher than their preoperative concentration (p-value<0.05).

•

Also, there was not significant difference between the bacterial and fungal concentrations in various operating rooms) p-value<0.05).

Concentration and type of bioaerosols before and after conventional disinfection and sterilization procedures inside hospital operating rooms

Operating rooms (ORs) in hospitals are sensitive wards because patients can get infections. This work aimed to characterize the type and concentration of bioaerosols in nine ORs of an educational hospital before and after sterilization and disinfection. During 2017, fungal samples were incubated at 25-28 °C for 3-7 days and bacterial samples at 37 °C for 24-48 h. The study results showed that the concentrations of fungi before cleaning procedures (for both of disinfection and sterilization) were limited from 4.83 to 18.40 CFU/m3 and after cleaning procedures ranged from 1.90 to 8.90 CFU/m3. In addition, the concentrations of bacteria before cleaning procedures were limited 14.65-167.40 CFU/m3 and after cleaning procedures ranged from 9.50 to 38.40 CFU/m3. The difference between the mean concentrations of airborne bioaerosols before and after sterilization was significantly different than the suggested value of 30 CFU/m3 (p ≤ 0.05). The bacterial concentration was higher than the recommended value (30 CFU/m3) in 41% of the ORs. The main fungal species identified in the indoor air of ORs (before vs. after sterilization) were A. fumigatus (25.6 vs. 18.3%), A. Niger (11.6 vs. 5.8%), Penicillium spp. (5.5 vs. 3.3%), Alternaria spp. (2.8 vs. 0.7%), Fusarium spp. (9.7 vs. 3.7%), Mucor spp. (15 vs. 12.7%), Cephalotrichum spp. (1.7 vs. 0.8%), A. Flavus (24.6 vs. 18.5%), Cladosporium spp. (2.6 vs. 0.8%), and Trichoderma spp. (0 vs. 0.9%). The growth of biological species even after sterilization and disinfection likely resulted from factors including poor ventilation, sweeping of OR floors, inadequate HVAC filtration, high humidity, and also lack of optimum management of infectious waste after surgery. Designing well-constructed ventilation and air-conditioning systems, replacing HEPA filters, implementing more stringent, frequent, and comprehensive disinfection procedures, and controlling temperature and humidity can help decrease bioaerosols in ORs.

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.

Aspergillus spp. prevalence in different Portuguese occupational environments: What is the real scenario in high load settings?

The genus Aspergillus is one of the most prevalent regarding fungi in several highly contaminated occupational environments. The goal of the current study was to assess the prevalence of Aspergillus spp. in different settings, focusing on those where a higher load of fungal contamination is expected according to the European Agency for Safety and Health at Work. A specific protocol to ensure a more accurate assessment of the exposure to Aspergillus spp. is proposed aimed at allowing a detailed risk characterization and management. Two wastewater treatment plants, one wastewater elevation plant, four waste treatment plants, three cork industries, five slaughter houses, four feed industries, one poultry pavilion, and two swineries, all located in the outskirts of Lisbon, were assessed. In total, 125 air samples and 125 surface samples were collected and analysed by culture-based methods. Real-time polymerase chain reaction was performed to detect fungal presence in 100 samples, targeting the Aspergillus sections Circumdati, Flavi, and Fumigati. The highest prevalence of Aspergillus spp. was found in wastewater treatment plants (69.3%; 31.1%), waste treatment plants (34.8%; 73.6%), and poultry feed industry (6.3%; 26.1%), in air and surfaces, respectively. Aspergillus spp. was also prevalent in cork industry (0.9%; 23.4%), slaughter houses (1.6%; 17.7%), and swineries (7.4%; 9.5%), in air and surfaces, respectively. The Aspergillus sections more prevalent in the air and surfaces of all the assessed settings were the Nigri section (47.46%; 44.71%, respectively), followed by Fumigati (22.28%; 27.97%, respectively) and Flavi (10.78%; 11.45%, respectively) sections. Aspergillus section Fumigati was successfully amplified by qPCR in 18 sampling sites where the presence of this fungal species had not been identified by conventional methods. It should be highlighted that the occupational exposure burden is due not only to the Aspergillus load, but also to the toxigenic potential of this genus. Based on our results, a protocol relied in the application of conventional and molecular methods in parallel is herein suggested aimed at allowing a better risk characterization and management.

Building conditions and the risk of nosocomial infection from microbial contamination of hospital appliances in a health care facility

Nosocomial infections (NIs) remain a global health burden with higher incidence in Africa. We assessed building conditions and risk of NIs from microbial contamination of appliances and surfaces in a Specialist hospital in Southwest Nigeria. The study sampled 120 surfaces in 12 wards during normal occupational activities. Moulds on ceilings and dusty surfaces were observed in the wards. Microbial burden (1038.0 × 10⁵ cfu) peaked in the ICU but was lowest (446.9 × 10⁵ cfu) in the male ward. Bacteria counts ( × 10⁵ cfu) of 234.7, 199.7 and 67.0 were measured on ICU tap, doorknob and ECG, respectively. Theatre diatomy machine, anaesthetic machine and operating lamp had bacteria counts ( × 10⁵ cfu) of 40.0, 85.0 and 109.0, respectively. Highest total fungal count (58.2 × 10⁵ cfu) was recorded on ICU trolley handle, switch and suturing tube. Our study established surfaces as major environmental routes for NI transmission in this health care facility.

Evaluating of fungal contamination in hospital wet cooling systems in Markazi province, Central Iran

OBJECTIVE

Fungal infections are common complication among hospitalized patients especially between who is immunocompromised. Wet cooling systems in the hospital environment play a critical role as a source of these infections. The aim of this study was survey of wet cooling system of hospitals for fungal contamination in Arak city.

MATERIALS AND METHODS

This study was conducted during May to September of 2016. Sampling was done as random. Samples were obtained from water and straw of 84 wet cooling systems of four hospitals in Arak city. Samples were cultured in Sabouraud dextrose agar medium contain of chloramphenicol. Identification of fungi was performed by Slide culture method.

RESULTS

From 84 wet cooling systems, 32 (38.1%) were contaminated with fungi. The highest fungal contamination was found in wards of oncology and CCU. The most prevalent of fungi isolated in this study were Aspergillus spp. and Candida spp., respectively.

CONCLUSION

The findings of this descriptive cross-sectional study clearly indicate, in wards of the hospital that used wet cooling systems, there was considerable fungal contamination, particularly Aspergillus contamination. These results highlight a clear need for greater attention to the use of non-aqueous or closed circulation cooling systems, especially where susceptible patients receive medical care.

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.

Seasonal Distribution of Fungi in Soil Found in Two Hospitals in Bandar Abbas, Iran

INTRODUCTION

Fungal contamination in hospitals has been a major health concern, especially in immunosuppressed patients. Construction programs increase the risk of fungal contaminations in hospitals. This study aimed to monitor and compare fungal contamination in two hospitals in Bandar Abbas, Iran, one of which was undergoing construction. Furthermore, the study determined the seasonal variations in the prevalence of fungi identified in the two hospitals.

METHODS

This study was conducted during April-December 2014 on 146 soil samples collected from the Shahid Mohammadi Hospital that was under construction and the Shariati Hospital that was not involved in any construction program. The soil samples were collected in the morning from the dust on the ground. Statistical analysis was performed using the chi-squared test.

RESULTS

Among the fungal cultures, 83.56% were found to be positive. We identified 122 fungal isolates, representing 16 genera, 13 of the genera were isolated from Shahid Mohammadi Hospital and 14 were isolated from Shariati Hospital. Aspergillus was the dominant fungus in both hospitals. In Shariati Hospital, 100% of Aspergiluss niger were isolated in the summer. In the spring, Mocur was dominant in both hospitals, and, in the winter, Rhizopus spp. was the dominant fungus in Shahid Mohammadi Hospital (55.5%); however, this fungus was dominant in spring in Shariati Hospital (66.7%). In Shariati Hospital, Scopulariopsis, Drechslera, Penicillium spp., and Yeasts were present only in the fall, whereas yeast was the dominant fungus in summer (100%) in Shahid Mohammadi Hospital. There were not significant differences between two hospitals, with the exception of Fusarium spp., which was more frequent in Shariati Hospital, where no renovation was taking place (p = 0.008).

CONCLUSION

Our results indicated that specific ecological niches existed in the two general hospitals in Bandar Abbas. Special attention should be paid to environmental control programs. It is recommended that soil exposure be considered in patients' histories in addition to the current focus on infections related to food and water.

Spatial and temporal variations in indoor environmental conditions, human occupancy, and operational characteristics in a new hospital building

The dynamics of indoor environmental conditions, human occupancy, and operational characteristics of buildings influence human comfort and indoor environmental quality, including the survival and progression of microbial communities. A suite of continuous, long-term environmental and operational parameters were measured in ten patient rooms and two nurse stations in a new hospital building in Chicago, IL to characterize the indoor environment in which microbial samples were taken for the Hospital Microbiome Project. Measurements included environmental conditions (indoor dry-bulb temperature, relative humidity, humidity ratio, and illuminance) in the patient rooms and nurse stations; differential pressure between the patient rooms and hallways; surrogate measures for human occupancy and activity in the patient rooms using both indoor air CO₂ concentrations and infrared doorway beam-break counters; and outdoor air fractions in the heating, ventilating, and air-conditioning systems serving the sampled spaces. Measurements were made at 5-minute intervals over consecutive days for nearly one year, providing a total of ∼8×10⁶ data points. Indoor temperature, illuminance, and human occupancy/activity were all weakly correlated between rooms, while relative humidity, humidity ratio, and outdoor air fractions showed strong temporal (seasonal) patterns and strong spatial correlations between rooms. Differential pressure measurements confirmed that all patient rooms were operated at neutral pressure. The patient rooms averaged about 100 combined entrances and exits per day, which suggests they were relatively lightly occupied compared to higher traffic environments (e.g., retail buildings) and more similar to lower traffic office environments. There were also clear differences in several environmental parameters before and after the hospital was occupied with patients and staff. Characterizing and understanding factors that influence these building dynamics is vital for hospital environments, where they can impact patient health and the survival and spread of healthcare associated infections.

Fungal contamination assessment in Portuguese elderly care centers

Individuals spend 80-90% of their day indoors and elderly subjects are likely to spend even a greater amount of time indoors. Thus, indoor air pollutants such as bioaerosols may exert a significant impact on this age group. The aim of this study was to characterize fungal contamination within Portuguese elderly care centers. Fungi were measured using conventional as well as molecular methods in bedrooms, living rooms, canteens, storage areas, and outdoors. Bioaerosols were evaluated before and after the microenvironments' occupancy in order to understand the role played by occupancy in fungal contamination. Fungal load results varied from 32 colony-forming units CFU m(-3) in bedrooms to 228 CFU m(-3) in storage areas. Penicillium sp. was the most frequently isolated (38.1%), followed by Aspergillus sp. (16.3%) and Chrysonilia sp. (4.2%). With respect to Aspergillus genus, three different fungal species in indoor air were detected, with A. candidus (62.5%) the most prevalent. On surfaces, 40 different fungal species were isolated and the most frequent was Penicillium sp. (22.2%), followed by Aspergillus sp. (17.3%). Real-time polymerase chain reaction did not detect the presence of A. fumigatus complex. Species from Penicillium and Aspergillus genera were the most abundant in air and surfaces. The species A. fumigatus was present in 12.5% of all indoor microenvironments assessed. The living room was the indoor microenvironment with lowest fungal concentration and the storage area was highest.

Fungal air quality in hospital rooms: a case study in Tehran, Iran

Fungi are usually presented in indoor environments and cause of many diseases. The aim of this descriptive study was to investigate the level of fungal contamination in hospital rooms. Sampling was conducted with an Andersen one-stage viable impactor (Quick Take-30) and counting plates containing a fungus-selective medium. A total of 120 air samples from ten hospital environments were performed. Airborne fungi concentrations were determined 72-120 hours after sampling. Total mean concentration of detected fungi in the hospital rooms was 55 ± 56 (mean ± SD) cfu/m3. The findings of the fungal concentration in the various hospital rooms revealed different levels of contamination: the lowest mean counts (37 ± 17 cfu/m3) were observed in NS 1 (Nursing Stations 1), and the highest (97 ± 217 cfu/m3) were reported in Orthopedics Operating Room (OOR). The most common fungal genus isolated were Penicillium (70%), Aspergillus (14%), Cladosporium (12%), Alternaria (2%) and others (2%). The obtained results showed that fungal concentrations in the present study were nearly high and these conditions should be considered as a risk factor for patients and other persons in the hospital.

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.

Enzymatic and toxigenic ability of opportunistic fungi contaminating intensive care units and operation rooms at Assiut University Hospitals, Egypt

Total of 110 isolates belonging to 8 fungal species collected from intensive care units (ICUs) and operation rooms (ORs) at Assiut University hospitals were examined for their ability to produce some extracellular enzymes and mycotoxins which are considered as important factors involved in for fungal pathogenicity. The results revealed that 73, 92 and 78 out of the 110 tested isolates produced protease, lipase and urease respectively; meanwhile, 77 of the tested isolates exhibited some hemolytic activities. Chromatographic analysis (TLC) of the crude extract of the fungal isolates tested revealed that 79 isolates of them had the ability to produce at least one of these mycotoxic compounds (aflatoxins B₁, B₂, G₁, gliotoxin, fumigillin, T-2, zearalenone, roridin A & E, verrucarin A & J, trichoveroids, satratoxin H & E). These results demonstrate that the opportunistic fungal species isolated from (ICUs) and (ORs) and tested exhibited some enzymatic and mycotoxic ability which are the most effective virulence factors contributing to fungal pathogenicity indicating that the management of infection control unit at Assiut University hospitals must be aware of not only bacterial but also fungal contamination.

Indoor fungal contamination: health risks and measurement methods in hospitals, homes and workplaces

Indoor fungal contamination has been associated with a wide range of adverse health effects, including infectious diseases, toxic effects and allergies. The diversity of fungi contributes to the complex role that they play in indoor environments and human diseases. Molds have a major impact on public health, and can cause different consequences in hospitals, homes and workplaces. This review presents the methods used to assess fungal contamination in these various environments, and discusses advantages and disadvantages for each method in consideration with different health risks. Air, dust and surface sampling strategies are compared, as well as the limits of various methods are used to detect and quantify fungal particles and fungal compounds. In addition to conventional microscopic and culture approaches, more recent chemical, immunoassay and polymerase chain reaction (PCR)-based methods are described. This article also identifies common needs for future multidisciplinary research and development projects in this field, with specific interests on viable fungi and fungal fragment detections. The determination of fungal load and the detection of species in environmental samples greatly depend on the strategy of sampling and analysis. Quantitative PCR was found useful to identify associations between specific fungi and common diseases. The next-generation sequencing methods may afford new perspectives in this area.

Air quality monitoring of the post-operative recovery room and locations surrounding operating theaters in a medical center in Taiwan

To prevent surgical site infection (SSI), the airborne microbial concentration in operating theaters must be reduced. The air quality in operating theaters and nearby areas is also important to healthcare workers. Therefore, this study assessed air quality in the post-operative recovery room, locations surrounding the operating theater area, and operating theaters in a medical center. Temperature, relative humidity (RH), and carbon dioxide (CO₂), suspended particulate matter (PM), and bacterial concentrations were monitored weekly over one year. Measurement results reveal clear differences in air quality in different operating theater areas. The post-operative recovery room had significantly higher CO₂ and bacterial concentrations than other locations. Bacillus spp., Micrococcus spp., and Staphylococcus spp. bacteria often existed in the operating theater area. Furthermore, Acinetobacter spp. was the main pathogen in the post-operative recovery room (18%) and traumatic surgery room (8%). The mixed effect models reveal a strong correlation between number of people in a space and high CO₂ concentration after adjusting for sampling locations. In conclusion, air quality in the post-operative recovery room and operating theaters warrants attention, and merits long-term surveillance to protect both surgical patients and healthcare workers.

A qualitative and quantitative study monitoring airborne fungal flora in the kidney transplant unit

Background

Solid organ transplantation patients are at high risk for opportunistic air-borne fungal infections due to using the potent immunosuppressive agents.

Objectives

The current study aimed to qualitatively and quantitatively evaluate the fungal flora present in the air of Kidney transplant unit of Baqiyatallah hospital.

Materials and Methods

In this prospective study, air samples from patient room, baths site, ICU and isolated room, corridor site and outside the ward were obtained by settled plate technique using plates containing Sabouraud's dextrose agar medium. In the current study, 36 agar plates containing Sabouraud dextrose agar medium were used. The plates were exposed for 20 min at height of 100-150 cm above the ground in units of hospital. Immediately after collection, samples were incubated at 27 ± 2ºC for four weeks. The slide culture method and Lacto-phenol cotton blue were used for definitive identification and staining fungal cultures, respectively.

Results

The mean of colony forming units (CFUs) on indoor and outdoor plates was 6.6 ± 1.3 and 6 ± 1.9 / plate respectively. Statistical analysis showed that the observed difference is not significant. Also, the results showed that the mean of CFUs in the air of patient's rooms (6.8 ± 1.7), halls (4.5 ± 1.7), bathrooms (6.8 ± 1.5), and ICU rooms (3.2 ± 1.8) were not significantly different. The mean of different fungal genera isolated from indoor and outdoor plates were 1.9 ± 0.2 and 4 ± 0.5 genera/plate respectively, that indicates significant difference between indoor and outdoor air quality (P < 0.001).

Conclusions

Lack of difference between quantity of outdoor and indoor air fungi indicates inefficiency of air control measures, and indoor lower genus diversity compared to outdoor air shows that there may be conditions that facilitate fungal growth in the environment of kidney transplantation unit.

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.

Microbial air monitoring in operating theatres: experience at the University Hospital of Parma

BACKGROUND

Microbial air monitoring in operating theatres has been a subject of interest and debate. No generally accepted sampling methods and threshold values are available.

AIM

To assess microbial air contamination in empty and working conventionally ventilated operating theatres over a three-year period at the University Hospital of Parma, Italy.

METHODS

Air sampling was performed in 29 operating theatres. Both active and passive sampling methods were used to assess bacterial and fungal contamination.

FINDINGS

In empty theatres, median bacterial values of 12 colony-forming units (cfu)/m(3) [interquartile range (IQR) 4-32] and 1 index of microbial air contamination (IMA) (IQR 0-3) were recorded. In working theatres, these values increased significantly (P < 0.001) to 80 cfu/m(3) (IQR 42-176) and 7 IMA (IQR 4-13). Maximum recorded values were 166 cfu/m(3) and 8 IMA for empty theatres, and 798 cfu/m(3) and 42 IMA for working theatres. Combining active and passive samplings, fungi were isolated in 39.13% of samples collected in empty theatres and 56.95% of samples collected in working theatres. Over the three-year study period, bacterial contamination decreased in both empty and working theatres, and the percentage of samples devoid of fungi increased. In working theatres, a significant correlation was found between the bacterial contamination values assessed using passive and active sampling methods (P < 0.001).

CONCLUSION

Microbiological monitoring is a useful tool for assessment of the contamination of operating theatres in order to improve air quality.

[Quantitative assessment of fungal risk in the case of construction works in healthcare establishments: Proposed indicators for the determination of the impact of management precautions on the risk of fungal infection]

Construction works in healthcare establishments produce airborne fungal spores and considerably increase the risk of exposure of immunosuppressed patients. It is necessary to reinforce protective measures, or even to implement specific precautions, during this critical phase. The aim of these precautions is to protect both those areas, which are susceptible to dust, and patients at risk of a fungal infection particularly invasive aspergillosis. When construction works are planned in healthcare establishments, the first step consists in the characterisation of the environmental fungal risk and the second one in proposing risk management methods. It is then essential to establish impact indicators in order to evaluate the risk management precautions applied. The working group promoted by the French societies of medical mycology and hospital hygiene (SFMM & SF2H) details here both environmental and epidemiological impact indicators that can be used.

Long-term surveillance of air quality in medical center operating rooms

BACKGROUND

Maintenance of adequate indoor air quality (IAQ) in operating rooms (ORs) is critical to the prevention of nosocomial infection in hospitalized patients. This study evaluated the characteristics of IAQ in various ORs in a medical center.

METHODS

Air temperature, relative humidity, carbon dioxide (CO(2)), particulate matter (PM), and bacterial concentrations were monitored in the ORs, and monthly variations were noted.

RESULTS

The mean CO(2) concentrations in the ORs were lower than the suggested level (600 ppm average over 8 hours) set by Taiwan's Environmental Protection Agency. Positive relationships were found among the number of persons, temperature (Spearman's rho coefficient [r(s)] = 0.19; P < .01), and CO(2) concentration (r(s) = 0.34; P < .01) in the OR. Bacterial concentration was significantly associated with PM level when adjusted for OR category and the number of persons in the room. Gram-positive bacteria (eg, Bacillus spp, Micrococcus spp, Staphylococcus spp) were frequently found in the monitored ORs.

CONCLUSION

The IAQ in the ORs varied significantly from month to month. The number of persons in the OR affected IAQ, and a decreased PM level might indicate reduced microbial contamination in the OR.

High-throughput molecular identification of Staphylococcus spp. isolated from a clean room facility in an environmental monitoring program

BACKGROUND

The staphylococci are one of the most common environmental isolates found in clean room facility. Consequently, isolation followed by comprehensive and accurate identification is an essential step in any environmental monitoring program.

FINDINGS

We have used the API Staph identification kit (bioMérieux, France) which depends on the expression of metabolic activities and or morphological features to identify the Staphylococcus isolates. The API staphylococci showed low sensitivity in the identification of some species, so we performed molecular methods based on PCR based fingerprinting of glyceraldehyde-3-phosphate dehydrogenase encoding gene as useful taxonomic tool for examining Staphylococcus isolates.

CONCLUSIONS

Our results showed that PCR protocol used in this study which depends on genotypic features was relatively accurate, rapid, sensitive and superior in the identification of at least 7 species of Staphylococcus than API Staph which depends on phenotypic features.

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.

Mobile air-decontamination unit and filamentous fungal load in the hematology ward: how efficient at the low-activity mode?

Air treatment with a mobile Plasmair air-decontamination unit significantly reduces the fungal spore load in hematology wards. We report that this system used at a low aspiration flow does not perform total biodecontamination against filamentous fungi. Moreover, the filamentous fungus load remaining in rooms equipped with this mobile air-decontamination unit is lowest in wards in which other preventive measures against nosocomial filamentous fungal infections are implemented.

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.

A prospective survey of air and surface fungal contamination in a medical mycology laboratory at a tertiary care university hospital

BACKGROUND

Invasive filamentous fungi infections resulting from inhalation of mold conidia pose a major threat in immunocompromised patients. The diagnosis is based on direct smears, cultural symptoms, and culturing fungi. Airborne conidia present in the laboratory environment may cause contamination of cultures, resulting in false-positive diagnosis. Baseline values of fungal contamination in a clinical mycology laboratory have not been determined to date.

METHODS

A 1-year prospective survey of air and surface contamination was conducted in a clinical mycology laboratory during a period when large construction projects were being conducted in the hospital. Air was sampled with a portable air system impactor, and surfaces were sampled with contact Sabouraud agar plates. The collected data allowed the elaboration of Shewhart graphic charts.

RESULTS

Mean fungal loads ranged from 2.27 to 4.36 colony forming units (cfu)/m(3) in air and from 0.61 to 1.69 cfu/plate on surfaces.

CONCLUSIONS

Strict control procedures may limit the level of fungal contamination in a clinical mycology laboratory even in the context of large construction projects at the hospital site. Our data and the resulting Shewhart graphic charts provide baseline values to use when monitoring for inappropriate variations of the fungal contamination in a mycology laboratory as part of a quality assurance program. This is critical to the appropriate management of the fungal risk in hematology, cancer and transplantation patients.

The mold conundrum in chronic rhinosinusitis: where do we stand today?

Chronic rhinosinusitis (CRS) is an inflammatory disorder affecting the nose and paranasal sinuses. Although bacteria have long been implicated as pathogens in most forms of CRS, fungi may be responsible for some forms. Several recent studies demonstrated that, under optimal conditions, fungi can be identified in the nose and paranasal sinuses of nearly every individual (including all CRS patients). An aberrant immune response to these ubiquitous fungi has been suggested to explain the development of CRS in some individuals. Several mechanisms requiring additional research, including adequate controls, have been proposed and are reviewed in this article. Although preliminary trials suggested that CRS signs and symptoms improve upon treatment with topical and oral antifungal agents, several double-blind, placebo-controlled trials demonstrated the contrary. In the absence of convincing immunologic data and evidence of clinical improvement upon therapy with antifungal agents, the case against fungi remains unproven.

Quantitative and qualitative analysis of microorganisms in an assisted reproductive technology facility

OBJECTIVE

To perform a quantitative and qualitative analysis of the environmental microorganisms associated with two assisted reproductive technology (ART) laboratories.

DESIGN

Prospective descriptive study.

SETTING

Two ART laboratories at Greenville Hospital System (GHS) University Medical Center in Greenville, South Carolina.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Quantitative and qualitative analysis of colony-forming units (CFU; bacteria and fungi) and particles from an embryology clean room and an andrology laboratory.

RESULT(S)

Within these laboratories, three of the sites sampled differed significantly in the mean number of CFU per plate. These sites included external laboratory surfaces, laboratory room air, and air within cell-culture incubators. The mean number of viable CFU per cubic meter of laboratory room air differed significantly between the two laboratories. A total of 23 unique microbial species were isolated from the andrology laboratory, whereas 10 unique species were isolated from the embryology clean room.

CONCLUSION(S)

The data herein suggest that the increased positive control measures used in the embryology clean room are effective in minimizing environmental biologic contamination.

Air filtration systems and restrictive access conditions improve indoor air quality in clinical units: Penicillium as a general indicator of hospital indoor fungal levels

BACKGROUND

High-efficiency particulate air (HEPA) filters do not completely prevent nosocomial fungal infections. The first aim of this study was to evaluate the impact of different filters and access conditions upon airborne fungi in hospital facilities. Additionally, this study identified fungal indicators of indoor air concentrations.

METHODS

Eighteen rooms and wards equipped with different air filter systems, and access conditions were sampled weekly, during 16 weeks. Tap water samples were simultaneously collected.

RESULTS

The overall mean concentration of atmospheric fungi for all wards was 100 colony forming units/m(3). We found a direct proportionality between the levels of the different fungi in the studied atmospheres. Wards with HEPA filters at positive air flow yielded lower fungal levels. Also, the existence of an anteroom and the use of protective clothes were associated to the lowest fungal levels. Principal component analysis showed that penicillia afforded the best separation between wards' air fungal levels. Fungal strains were rarely recovered from tap water samples.

CONCLUSIONS

In addition to air filtration systems, some access conditions to hospital units, like presence of anteroom and use of protective clothes, may prevent high fungal air load. Penicillia can be used as a general indicator of indoor air fungal levels at Hospital S. João.

The utility of intensified environmental surveillance for pathogenic moulds in a stem cell transplantation ward during construction work to monitor the efficacy of HEPA filtration

A 12-week environmental study was performed to ensure that the patient rooms of an SCT ward with high-efficiency particulate air (HEPA) filtration remained uncontaminated by moulds during close-by construction work. The sampling included measuring the ventilation channel pressure, particle count measurements, air sampling, settled dust analysis and fungal cultures from the oral and nasal cavities of the patients. No changes in the air pressure occurred. Median particle counts in patient rooms were 63-420 particles/l. The mean particle count of the outside air was 173,659 particles/l. Patient room air samples were negative for aspergilli in 32 of 33 cases. All samples of the outside air were positive for moulds. Aspergillus fumigatus was isolated at the beginning of excavation works at the construction area and in two of 33 dust samples from patient rooms. All 70 nasal samples were negative. Of 35 mouth samples, one sample was positive for A. niger in a patient with a previously diagnosed aspergillus infection. During a median follow-up of 214 days, no invasive aspergillus infections were diagnosed in the 55 patients treated during the construction period. In conclusion, the HEPA filters seemed to have performed well in preventing an aspergillosis outbreak.

Ten-year surveillance of fungal contamination of food within a protected haematological unit

Since 1992, we have established a protocol of food management (restrictive diet, food distribution protocol and fungal surveillance) for allogeneic stem-cell transplant (SCT) recipients hospitalised in protected ward. This study analyses the results of 10-year surveillance of fungal contamination of this diet. Among the 456 types of foods tested filamentous fungi were isolated in 37 of them (8.1%). Aspergillus fumigatus was isolated in one type of food only, while the majority of the food was contaminated to a lower extent.

Post-operative aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.

Fungal contamination in hospital environments

OBJECTIVES

To assess the degree of fungal contamination in hospital environments and to evaluate the ability of air conditioning systems to reduce such contamination.

METHODS

We monitored airborne microbial concentrations in various environments in 10 hospitals equipped with air conditioning. Sampling was performed with a portable Surface Air System impactor with replicate organism detection and counting plates containing a fungus-selective medium. The total fungal concentration was determined 72-120 hours after sampling. The genera most involved in infection were identified by macroscopic and microscopic observation.

RESULTS

The mean concentration of airborne fungi in the set of environments examined was 19 +/- 19 colony-forming units (cfu) per cubic meter. Analysis of the fungal concentration in the different types of environments revealed different levels of contamination: the lowest mean values (12 +/- 14 cfu/m(3)) were recorded in operating theaters, and the highest (45 +/- 37 cfu/m(3)) were recorded in kitchens. Analyses revealed statistically significant differences between median values for the various environments. The fungal genus most commonly encountered was Penicillium, which, in kitchens, displayed the highest mean airborne concentration (8 +/- 2.4 cfu/m(3)). The percentage (35%) of Aspergillus documented in the wards was higher than that in any of the other environments monitored.

CONCLUSIONS

The fungal concentrations recorded in the present study are comparable to those recorded in other studies conducted in hospital environments and are considerably lower than those seen in other indoor environments that are not air conditioned. These findings demonstrate the effectiveness of air-handling systems in reducing fungal contamination.

Prevention of systemic mycoses by reducing exposure to fungal pathogens in hospitalized and ambulatory neutropenic patients

PURPOSE/OBJECTIVES

To describe sources of fungal contamination that can incite invasive mycoses in hospitalized and ambulatory neutropenic patients and to discuss approaches to reduce exposure to pathogens.

DATA SOURCES

Published articles, books, and brochures.

DATA SYNTHESIS

Modifications of patient environments and lifestyles include hand hygiene for patients and healthcare workers, air filtration in hospitals, and reduction in exposure to plants, soil, standing water, and dusty environments. The effectiveness of dietary restrictions is controversial, although avoidance of pepper is recommended. These restrictions should be implemented prior to, during, and following neutropenia.

CONCLUSIONS

Mycoses can be hospital or community acquired; however, although guidelines for environmental and lifestyle modifications are well documented for the institutional setting, they are more limited for ambulatory patients.

IMPLICATIONS FOR NURSING

Nurses have a key role in the early identification of outbreaks of fungal infections, evaluation of hospital and home environments for sources of pathogens, education of patients on preventive measures, and research on neutropenic diets and improved technology to reduce exposure to fungal pathogens.

Epidemiological study of invasive pulmonary aspergillosis in a haematology unit by molecular typing of environmental and patient isolates of Aspergillus fumigatus

In order to determine the possible relationship between environmental contamination by Aspergillus fumigatus and occurrence of invasive aspergillosis, a one-year prospective study was carried out in the haematology ward of Hautepierre Hospital, Strasbourg, France. During the study period, 21 environmental isolates and 26 clinical isolates of A. fumigatus were collected. Each was genotyped using a random amplification of polymorphic DNA (RAPD) technique. Thirty-four distinct profiles were identified by RAPD analysis, indicating the great genetic diversity of A. fumigatus isolated from infected patients and from the environment. For two patients, RAPD analysis demonstrated concurrent infection by at least two different strains. In two cases, a genetic similarity was noted between isolates obtained from a patient and from the environment.

Levels of total fungus and Aspergillus on a pediatric hematopoietic stem cell transplant unit

The purpose of this descriptive study was to determine the levels of total fungus (TF) and Aspergillus in a pediatric hematopoietic stem cell transplant (HSCT) unit. One hundred twenty air samples and 120 floor samples were collected from the same locations in 10 patient rooms and bathrooms for 4 consecutive days. The count in colony-forming units of TF and Aspergillus from each of the samples was measured by the institution's mycology laboratory. Means, standard deviations, minimum values, and maximum values were determined for levels of TF and Aspergillus from different locations and on different days in the air and on the floor. Determination of a mean value of TF and Aspergillus for each room allowed for analysis of mean values of TF and Aspergillus for sample category, room side, room type, and room status. After visual examination of the mean values for the air samples collected, it was determined that the TF and Aspergillus in the air were less than the institution's acceptable air baseline standard. t tests and analysis of variance were used to verify the findings.