Pathogenic Aspergillus species recovered from a hospital water system: a 3-year prospective study

Natural Occurrence of Fungi and Aflatoxins Associated Sugarcane Plant and Sugarcane Juice and Their Control

Sugarcane is one of the most important crops in the world. It is also considered the most popular fresh juice in Egypt. The sugar content of the sugarcane stem represents the main source of fungal growth. This study aimed to investigate the natural co-occurrence of fungi in sugarcane plants and juice, test of aflatoxins production by aflatoxigenic fungi, and improve the quality of sugarcane juice. The obtained results indicated a notable decrease in all physical parameters of the naturally infected sugarcane plants. Isolation of fungi from sugarcane plant and juice from three localities revealed that the highest mean fungal count was recorded in sugarcane rootlets (173.55 cfu/cm), followed by sugarcane stem (94.88 cfu/cm), while sugarcane juice had the least mean fungal count (24.33 cfu/mL). The frequency of the isolated fungi associated with sugarcane plant yielded 781 fungal isolates for rootlets, 427 fungal isolates for stems, and 219 fungal isolates for juice. Four isolates of Aspergillus parasiticus were aflatoxins producers. Higher aflatoxin quantity (1434.92 ng/mL) was produced by A. parasiticus (isolate No. 21) from sugarcane stem, while A. parasiticus (isolate No. 5) from sugarcane juice was less aflatoxins producer (276.95 ng/mL). On the other hand, lemon juice showed a significant reduction effect on the fungal count of peeled and non-peeled sugarcane juice. In which the highest reduction percent of the fungal count was recorded with 20% conc. of lemon on peeled sugarcane juice (36.04%).The obtained results concluded that lemon juice was found to decrease the fungal contaminants and improve the quality of sugarcane juice.

Strain heterogeneity in a non-pathogenic fungus highlights factors contributing to virulence

Fungal pathogens exhibit extensive strain heterogeneity, including variation in virulence. Whether closely related non-pathogenic species also exhibit strain heterogeneity remains unknown. Here, we comprehensively characterized the pathogenic potentials (i.e., the ability to cause morbidity and mortality) of 16 diverse strains of Aspergillus fischeri, a non-pathogenic close relative of the major pathogen Aspergillus fumigatus. In vitro immune response assays and in vivo virulence assays using a mouse model of pulmonary aspergillosis showed that A. fischeri strains varied widely in their pathogenic potential. Furthermore, pangenome analyses suggest that A. fischeri genomic and phenotypic diversity is even greater. Genomic, transcriptomic, and metabolomic profiling identified several pathways and secondary metabolites associated with variation in virulence. Notably, strain virulence was associated with the simultaneous presence of the secondary metabolites hexadehydroastechrome and gliotoxin. We submit that examining the pathogenic potentials of non-pathogenic close relatives is key for understanding the origins of fungal pathogenicity.

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.

A Multiplex PCR Melting-Curve-Analysis-Based Detection Method for the Discrimination of Five Aspergillus Species

Aspergillus mold is a ubiquitously found, airborne pathogen that can cause a variety of diseases from mild to life-threatening in severity. Limitations in diagnostic methods combined with anti-fungal resistance render Aspergillus a global emerging pathogen. In industry, Aspergilli produce toxins, such as aflatoxins, which can cause food spoilage and pose public health risk issues. Here, we report a multiplex qPCR method for the detection and identification of the five most common pathogenic Aspergillus species, Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger, Aspergillus terreus, and Aspergillus nidulans. Our approach exploits species-specific nucleotide polymorphisms within their ITS genomic regions. This novel assay combines multiplex single-color real time qPCR and melting curve analysis and provides a straight-forward, rapid, and cost-effective detection method that can identify five Aspergillus species simultaneously in a single reaction using only six unlabeled primers. Due to their unique fragment lengths, the resulting amplicons are directly linked to certain Aspergillus species like fingerprints, following either electrophoresis or melting curve analysis. Our method is characterized by high analytical sensitivity and specificity, so it may serve as a useful and inexpensive tool for Aspergillus diagnostic applications both in health care and the food industry.

Occurrence and control of fungi in water: New challenges in biological risk and safety assurance

Recently, the contamination of fungi in water has aroused widespread concern, which will pose a threat to water quality and safety, and raise diseases risk in the immunocompromised individuals. In this review, the characteristics and different physiological state of fungi in water are summarized. A comprehensive evaluation of the control efficiency and mechanism of waterborne fungi by the commonly used disinfection methods is provided as well. During the disinfection processes of chlorine, chlorine dioxide, chloramine and advanced disinfection processes (ADPs) such as O₃-based ADPs and UV-based ADPs, the fungal spores firstly lost their culturability, followed by membrane integrity, and the intracellular reactive oxygen species level increased at the same time, eventually the fungal spores were completely inactivated. The security strategies of drinking water against the contamination of fungi are also discussed in terms of water sources, water treatment plants and pipe network. Finally, future researches need to be explored are proposed: the rapid detection methods, the production laws and control of mycotoxin, and the outbreak conditions of fungi in water. Specifically, exploring efficient, safe and economical technologies, especially ADPs, is still the main direction in the disinfection of fungi in future studies. This review can offer a comprehensive understanding on the occurrence and control of fungi in water to fill the knowledge gap and provide guidance for the future research.

Occurrence of fungal spores in drinking water: A review of pathogenicity, odor, chlorine resistance and control strategies

Fungi in drinking water have been long neglected due to the lack of convenient analysis methods, widely accepted regulations and efficient control strategies. However, in the last few decades, fungi in drinking water have been widely recognized as opportunity pathogens that cause serious damage to the health of immune-compromised individuals. In drinking water treatment plants, fungal spores are more resistant to chlorine disinfection than bacteria and viruses, which can regrow in drinking water distribution systems and subsequently pose health threats to water consumers. In addition, fungi in drinking water may represent an ignored source of taste and odor (T&O). This review identified 74 genera of fungi isolated from drinking water and presented their detailed taxonomy, sources and biomass levels in drinking water systems. The typical pathways of exposure of water-borne fungi and the main effects on human health are clarified. The fungi producing T&O compounds and their products are summarized. Data on free chlorine or monochloramine inactivation of fungal spores and other pathogens are compared. At the first time, we suggested four chlorine-resistant mechanisms including aggregation to tolerate chlorine, strong cell walls, cellular responses to oxidative stress and antioxidation of melanin, which are instructive for the future fungi control attempts. Finally, the inactivation performance of fungal spores by various technologies are comprehensively analyzed. The purpose of this study is to provide an overview of fungi distribution and risks in drinking water, provide insight into the chlorine resistance mechanisms of fungal spores and propose approaches for the control of fungi in drinking water.

The protective role and mechanism of melanin for Aspergillus niger and Aspergillus flavus against chlorine-based disinfectants

Melanin is a critical component of fungal cell wall which protect fungi from adverse environmental tress. However, the role of melanin for fungi during the disinfection with chlorine-based disinfectants has not been elucidated. The results showed that the inactivation rate constants of Aspergillus niger with chlorine and chlorine dioxide decreased from 0.08 to 2.10 min^-1 to 0 after addition of 0.32 mg/L melanin. The results indicated addition of extracted fungal melanin inhibited the inactivation efficiency of chlorine and chlorine dioxide. In contrast, the k of Aspergillus niger after inactivation with monochloramine ranged from 1.50 to 1.78 min^-1 after addition of melanin which indicated effect of melanin on the inactivation efficiency of monochloramine was negligible. In addition, the extracted fungal melanin exhibited high reactivity with chlorine and chlorine dioxide but very low reactivity with monochloramine. The different inactivation mechanisms of chlorine-based disinfectants and different reactivity of melanin with chlorine-based disinfectants led to the different protective mechanism of melanin for A. niger and A. flavus spores against disinfection with chlorine-based disinfectants. The chlorine and chlorine dioxide appeared to react with functional groups of melanin in cell wall of spores, so sacrificial reactions between melanin and disinfectants decreased the available disinfectants and limited the diffusion of disinfectants to the reactive site on cell membrane, which led to the decrease of the disinfection efficiency for chlorine and chlorine dioxide. The monochloramine could penetrate into cell and damage DNA without the effect of melanin due to its strong penetration and low reactivity with melanin. Our results systematically demonstrate the protective roles of melanin on the fungal spores against chlorine-based disinfectants and the underlying mechanisms in resisting the environmental stress caused by chlorine-based disinfectants, which provides important implications for the control of fungi, especially for fungi producing melanin.

Enhanced solar inactivation of fungal spores by addition of low-dose chlorine: Efficiency and mechanism

This work demonstrated that the solar inactivation of fungal spores was enhanced by addition of low-dose chlorine. Although the effect of low-dose chlorine alone (2.0 mg/L) on culturability of fungal spores was negligible, the solar/chlorine inactivation on fungal spores performed better than solar alone inactivation, with a lower shoulder length and a higher maximum inactivation rate constant. The enhanced inactivation of Aspergillus niger can be ascribed to the membrane oxidation by chlorine, and the enhanced inactivation of Penicillium polonicum can be ascribed to the membrane oxidation by chlorine and ·OH (·OH plays a major role). The oxidization by chlorine and ·OH led to an increase in membrane permeability of fungal spores, which enhanced the solar inactivation, resulting in an increase in intracellular ROS and more serious morphological damage. Due to the presence of background substances such as dissolved organic matter and metal ions (Fe²⁺, Mn²⁺, etc.), the inactivation efficiency in real water matrices was decreased. The main disinfection by-products (DBPs) produced in the inactivation of fungal spores in chlorine alone and solar/chlorine treatments were dichloroacetic acid, trichloroacetic acid, trichloroacetone and trichloromethane. Generally, DBPs formation in solar/chlorine treatment was lower than those in chlorine alone treatment. Moreover, the regrowth potential of the two genera of fungal spores in R2A medium could be inhibited by adding low-dose chlorine.

Environmental Design Strategies to Decrease the Risk of Nosocomial Infection in Medical Buildings Using a Hybrid MCDM Model

The prevention and control of nosocomial infection (NI) are becoming increasingly difficult, and its mechanism is becoming increasingly complex. A globally aging population means that an increasing proportion of patients have a susceptible constitution, and the frequent occurrence of severe infectious diseases has also led to an increase in the cost of prevention and control of NI. Medical buildings' spatial environment design for the prevention of NI has been a hot subject of considerable research, but few previous studies have summarized the design criteria for a medical building environment to control the risk of NI. Thus, there is no suitable evaluation framework to determine whether the spatial environment of a medical building is capable of inhibiting the spread of NI. In the context of the global spread of COVID-19, it is necessary to evaluate the performance of the existing medical building environment in terms of inhibiting the spread of NI and to verify current environmental improvement strategies for the efficient and rational use of resources. This study determines the key design elements for the spatial environment of medical buildings, constructs an evaluation framework using exploratory factor analysis, verifies the complex dominant influence relationship, and prioritizes criteria in the evaluation framework using the decision-making trial and evaluation laboratory- (DEMATEL-) based analytical network process (ANP) (DANP). Using representative real cases, this study uses the technique for order preference by similarity to ideal solution (TOPSIS) to evaluate and analyze the performance with the aspiration level of reducing the NI risk. A continuous and systematic transformation design strategy for these real cases is proposed. The main contributions of this study include the following: (1) it creates a systematic framework that allows hospital decision-makers to evaluate the spatial environment of medical buildings; (2) it provides a reference for making design decisions to improve the current situation using the results of a performance evaluation; (3) it draws an influential network relation map (INRM) and the training of influence weights (IWs) for criteria. The sources of practical problems can be identified by the proposed evaluation framework, and the corresponding strategy can be proposed to avoid the waste of resources for the prevention of epidemics.

The rise in cases of mucormycosis, candidiasis and aspergillosis amidst COVID19

The Coronavirus outbreak globally has changed the medical system and also led to a shortage of medical facilities in both developing and underdeveloped countries. The COVID19 disease, being novel in nature along with high infectivity and frequent mutational rate, has been termed to be fatal across the globe. The advent of infection by SARS-CoV-2 has brought a myriad of secondary complications and comorbidities resulting in additional challenges to the health care system induced by novel therapeutic procedures. The emerging variant with respect to the Indian subcontinent and the associated genetic mutations have worsened the situation at hand. Proper clinical management along with epidemiological studies and clinical presentations in scientific studies and trials is necessary in order to combat the simultaneous waves of emerging strains. This article summarizes three of the major fungal outbreaks in India namely mucormycosis, candidiasis and aspergillosis, and elaborates their subtypes, pathogenesis, symptoms and treatment and detection techniques. A detail of future therapeutics under consideration are also elaborated along with a general hypothesis on how COVID19 is related to immunological advances leading to major widespread fungal infection in the country. The factors that contribute in promoting virus proliferation and invasive fungal infections include cell-mediated immunity, associated immunocompromised conditions and treatment protocols that slows down immune mechanisms. To better comprehend a fungal or bacterial outbreak, it is very important to conduct audits mediated through multicenter national and state research teams for recognizing patterns and studying current cases of fungal infection in both healthy and comorbid groups of COVID19 patients.

Synergistic effect of ozone and chlorine on inactivating fungal spores: Influencing factors and mechanisms

Effective control of fungal contamination in water is vital to provide healthy and safe drinking water for human beings. Although ozone was highly effective in inactivating fungi in water, it was limited by a lack of continuous disinfection ability in water supply system. In present study, the inactivation of fungal spores by combining ozone and chlorine was investigated. The synergistic effects of Aspergillus niger and Trichoderma harzianum spores reached 0.47- and 0.55-log within 10 min, respectively. The inactivation efficiency and the synergistic effect would be affected by disinfectant concentration, pH, and temperature. The combined inactivation caused more violent oxidative stimulation and more severe damage to the fungal spores than the individual inactivation based on the flow cytometry analysis and the scanning electron microscopy observation. The synergistic effect during the combined inactivation process was attributed to the generation of hydroxyl radicals by the reaction between ozone and chlorine and the promotion of chlorine penetration by the destruction of cell wall by ozone. The combined inactivation efficiency in natural water samples was reduced by 26.4-43.8% compared with that in PBS. The results of this study provided an efficient and feasible disinfection method for the control of fungi in drinking water.

Host defence peptides identified in human apolipoprotein B as promising antifungal agents

Abstract

Therapeutic options to treat invasive fungal infections are still limited. This makes the development of novel antifungal agents highly desirable. Naturally occurring antifungal peptides represent valid candidates, since they are not harmful for human cells and are endowed with a wide range of activities and their mechanism of action is different from that of conventional antifungal drugs. Here, we characterized for the first time the antifungal properties of novel peptides identified in human apolipoprotein B. ApoB-derived peptides, here named r(P)ApoB_L^Pro, r(P)ApoB_L^Ala and r(P)ApoB_S^Pro, were found to have significant fungicidal activity towards Candida albicans (C. albicans) cells. Peptides were also found to be able to slow down metabolic activity of Aspergillus niger (A. niger) spores. In addition, experiments were carried out to clarify the mechanism of fungicidal activity of ApoB-derived peptides. Peptides immediately interacted with C. albicans cell surfaces, as indicated by fluorescence live cell imaging analyses, and induced severe membrane damage, as indicated by propidium iodide uptake induced upon treatment of C. albicans cells with ApoB-derived peptides. ApoB-derived peptides were also tested on A. niger swollen spores, initial hyphae and branched mycelium. The effects of peptides were found to be more severe on swollen spores and initial hyphae compared to mycelium. Fluorescence live cell imaging analyses confirmed peptide internalization into swollen spores with a consequent accumulation into hyphae. Altogether, these findings open interesting perspectives to the application of ApoB-derived peptides as effective antifungal agents.

Key points

Human cryptides identified in ApoB are effective antifungal agents.

ApoB-derived cryptides exert fungicidal effects towards C. albicans cells.

ApoB-derived cryptides affect different stages of growth of A. niger.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00253-021-11114-3.

Occurrence of filamentous fungi in drinking water: their role on fungal-bacterial biofilm formation

Water is indispensable to life and safe and accessible supply must be available to all. The presence of microorganisms is a threat to this commitment. Biofilms are the main reservoir of microorganisms inside water distribution systems and they are extremely ecologically diverse. Filamentous fungi and bacteria can coexist inside these systems forming inter-kingdom biofilms. This review has the goal of summarizing the most relevant and recent reports on the occurrence of filamentous fungi in water distribution systems along with the current knowledge and gaps about filamentous fungal biofilm formation. Special focus is given on fungal-bacterial interactions in water biofilms.

Inactivation of fungal spores in water using ozone: Kinetics, influencing factors and mechanisms

Fungal contamination of drinking water sources is increasingly threatening the environment and human health. In this study, the inactivation of three genera of dominant fungi in drinking water sources using ozone was first reported. The inactivation of the fungal spores by ozone could be divided into two distinct stages: first a rapid reduction in survival, and then the inactivation at a slower rate. The secondary stage inactivation fitted the Chick-Watson model well, and there was no significant difference in the second-order inactivation rate constants of the three fungal spores (0.199-0.209 L mg^-1 min^-1). The inactivation rate constants of fungal spores by molecular ozone were much lower than those of viruses, which were equivalent to that of Cryptosporidium. The increase in pH and temperature showed a positive effect on the inactivation rate. Damage to cell membranes, leakage of intracellular compounds, and changes of reactive oxygen species and esterase activity in the spores were detected after inactivation. The results indicated that ozone inactivated fungal spores by firstly destroying cell walls and membranes and then causing the release of intracellular compounds. The fungicidal efficiency of ozone was superior to those of chlorine and chlorine dioxide. In addition, the inactivation efficiency of ozone on fungal spores in real water matrices was reduced to 50.7-91.2% of the efficiency in phosphate buffer. In conclusion, ozone showed high efficiency in the inactivation of fungal spores and could be used as an alternative disinfectant for fungal contamination in drinking water sources.

Occurrence of Fungi in the Potable Water of Hospitals: A Public Health Threat

Since the last decade, attention towards the occurrence of fungi in potable water has increased. Commensal and saprophytic microorganisms widely distributed in nature are also responsible for causing public health problems. Fungi can contaminate hospital environments, surviving and proliferating in moist and unsterile conditions. According to Italian regulations, the absence of fungi is not a mandatory parameter to define potable water, as a threshold value for the fungal occurrence has not been defined. This study evaluated the occurrence of fungi in potable water distribution systems in hospitals. The frequency of samples positive for the presence of fungi was 56.9%; among them, filamentous fungi and yeasts were isolated from 94.2% and 9.2% of the samples, respectively. The intensive care unit (87.1%) had the highest frequency of positive samples. Multivariable model (p < 0.0001), the variables of the period of the year (p < 0.0001) and type of department (p = 0.0002) were found to be statistically significant, suggesting a high distribution of filamentous fungi in the potable water of hospitals. Further studies are necessary to validate these results and identify the threshold values of fungi levels for different types of water used for various purposes to ensure the water is safe for consumption and protect public health.

Wide diversity of fungal species found in wellwater for human consumption: an analytical cross-sectional study

BACKGROUND

Fungi are ubiquitous in the environment. They are able to grow in water and many of them may be opportunistic pathogens.

OBJECTIVE

The aims were to identify fungi in registered wells (RWs) and nonregistered wells (NRWs) that tap into groundwater; and to correlate the results from physicochemical assays on this water (free residual chlorine and pH) with the presence of fungi.

DATA AND SETTING

Analytical cross-sectional quantitative study on groundwater wells in São José do Rio Preto, São Paulo, Brazil.

METHODS

52 samples of 500 ml of water were collected from RWs and 107 from NRWs. These were sent to a microbiology laboratory to identify any fungi that were present. In addition, free residual chlorine and pH were measured immediately after sample collection. Several statistical analysis tests were used.

RESULTS

Fungal contamination was present in 78.8% of the samples from RWs and 81.3% from NRWs. Filamentous fungi were more prevalent than yeast in both types of wells. There was no significant difference in presence of fungi according to whether chloride and pH were within recommended levels in RWs; or according to whether pH was within recommended levels in NRWs. Furthermore, there was no statistical difference in the levels of fungal contamination between RWs and NRWs.

CONCLUSION

Both RWs and NRWs are potential reservoirs for many types of fungi. Many of these may become opportunistic pathogens if they infect immunosuppressed individuals. Furthermore, this study confirms that fungi are able to grow even when chlorine and pH parameters are within the standards recommended.

Concurrent measurement of microbiome and allergens in the air of bedrooms of allergy disease patients in the Chicago area

The particulate and biological components of indoor air have a substantial impact on human health, especially immune respiratory conditions such as asthma. To better explore the relationship between allergens, the microbial community, and the indoor living environment, we sampled the bedrooms of 65 homes in the Chicago area using 23the patient-friendly Inspirotec electrokinetic air sampling device, which collects airborne particles for characterization of both allergens and microbial DNA. The sampling device captured sufficient microbial material to enable 16S rRNA amplicon sequencing data to be generated for every sample in the study. Neither the presence of HEPA filters nor the height at which the air sampling device was placed had any influence on the microbial community profile. A core microbiota of 31 OTUs was present in more than three quarters of the samples, comprising around 45% of the relative sequence counts in each bedroom. The most abundant single organisms were Staphylococcus, with other core taxa both human and outdoor-associated. Bacterial alpha diversity was significantly increased in bedrooms that reported having open windows, those with flowering plants in the vicinity, and those in homes occupied by dogs. Porphyromonas, Moraxella, Sutterella, and Clostridium, along with family Neisseraceae, were significantly enriched in homes with dogs; interestingly, cats did not show a significant impact on microbial diversity or relative abundance. While dog allergen load was significantly correlated with bacterial alpha diversity, the taxa that significantly correlated with allergen burden did not exclusively overlap with those enriched in homes with dogs. Alternaria allergen load was positively correlated with bacterial alpha diversity, while Aspergillus allergen load was negatively correlated. The Alternaria allergen load was also significantly correlated with open windows. Microbial communities were significantly differentiated between rural, suburban, and urban homes and houses that were physically closer to each other maintained significantly more similar microbiota. We have demonstrated that it is possible to determine significant associations between allergen burden and the microbiota in air from the same sample and that these associations relate to the characteristics of the home and neighborhoods.

Management of industrial high-pressure fluid injection injuries (IHPFII): the Water Jetting Association (WJA) experience with water driven injuries

Background

Industrial high-pressure fluid injection injuries (IHPFII) are largely occupational in nature, where these injuries are most often sustained by male manual workers. Such traumatic injuries are largely sustained with water, grease, paint, gasoline or paint thinner. IHPFII are extremely serious injuries with life and limb-threatening potential carrying the risk of life-long disability.

Methods

We reviewed the Water Jetting Association© adverse incident database of advisory alerts detailing cases from around the world that have been brought to the association’s attention and the English-language literature on high-pressure hydrostatic injuries from 1937 to 2018.

Results

Accidents involving high-pressure water jets in the industry are uncommon. The clinical impact in all of the cases reviewed and the effects of water jet impacts range from instant fatalities at scene to loss of limb function and amputation. The majority of observed fatalities are due to major hemorrhage (exsanguination) secondary to the direct dissection of great vessels or high-energy blunt soft tissue injury and traumatic brain injury.

Conclusions

As with any other trauma, IHPWJI commonly result in amputation or death. Nonetheless, a lack of comprehension of the potential severity of injuries and range of infective complications appears to be largely due to the apparent benignity of the initial presentation of the wound. This in turn leads to delays (both avoidable and unavoidable) in the transfer to appropriate medical facilities and definitive care. There is an identifiable need for education (including for health care providers across multiple levels), training and the availability of personal trauma kits for the timely and effective management of IHPWJI from the initial jet impact on the scene, as well as a need for an established referral system.

Invasive Aspergillosis in Pediatric Leukemia Patients: Prevention and Treatment

The purpose of this article is to review and update the strategies for prevention and treatment of invasive aspergillosis (IA) in pediatric patients with leukemia and in patients with hematopoietic stem cell transplantation. The major risk factors associated with IA will be described since their recognition constitutes the first step of prevention. The latter is further analyzed into chemoprophylaxis and non-pharmacologic approaches. Triazoles are the mainstay of anti-fungal prophylaxis while the other measures revolve around reducing exposure to mold spores. Three levels of treatment have been identified: (a) empiric, (b) pre-emptive, and (c) targeted treatment. Empiric is initiated in febrile neutropenic patients and uses mainly caspofungin and liposomal amphotericin B (LAMB). Pre-emptive is a diagnostic driven approach attempting to reduce unnecessary use of anti-fungals. Treatment targeted at proven or probable IA is age-dependent, with voriconazole and LAMB being the cornerstones in >2yrs and <2yrs age groups, respectively.

Enumerating Antibiotic Susceptibility Patterns of Pseudomonas aeruginosa Isolated from Different Sources in Dhaka City

Background:

Pseudomonas aeruginosa is a ubiquitous free-living bacterium and is responsible for severe nosocomial infections, life-threatening infections in immune compromised persons. The bacterium, along with its natural resistance, can acquire resistance to many antibiotics by a variety of methods.

Method:

Therefore, to compare the antibiotic sensitivity pattern of Pseudomonas aeruginosa, a total of seventeen isolates of P. aeruginosa were isolated from different sources; for example environmental sources, frozen food sources, clinical sources and medical waste materials. Isolates were confirmed to be P. aeruginosa by cultural and biochemical properties.

Result:

The isolates were tested against seventeen commercially available antibiotics to observe the antibiotic susceptibility patterns. Imipenem and meropenem were the most potent antibiotics (100% sensitivity) followed by amikacin and piperacillin with maximum sensitivity. Among others, gentamicin, ciprofloxacin, levofloxacin and aztreonam were found to be fairly active. A good number of isolates were intermediately resistant to ceftriaxone. The rates of resistance to aztreonam, cefotaxime and ceftazidime were 11.76%, 82.35% and 5.88% respectively. Complete resistance was observed against penicillin, ampicillin, cefixime and cefpodoxime.

Conclusion:

It can be concluded that the clinical isolates including isolate from medical waste, were multi-drug resistant than environmental and food isolates indicating the risk of transmission of resistance to the environmental isolates of P. aeruginosa.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Prevention of Infections in Patients with Hematological Malignancies

Infection is a major complication of patients with hematological malignancies. Prophylaxis is a key element in the management of these patients, and is composed by two main components: infection control measures and antimicrobial chemoprophylaxis. Infection control measures are safe, but not always effective. Antimicrobial prophylaxis is usually effective but may increase resistance rates, toxicity, and cost. Therefore, a careful evaluation of the actual risk for infection, the pathogens that predominate in a particular setting, and the periods at risk are important in order to define the most appropriate strategy. In this chapter we review the most important parameters to assess the risk on an individual basis, and the evidences and recommendations supporting infection control measures and antimicrobial prophylaxis against bacteria, fungi, viruses, and parasites.

Ultraviolet germicidal irradiation in tap water contaminated by Aspergillus spp

We investigated the effect of ultraviolet germicidal irradiation (UVI) from a low-pressure mercury lamp on several pathogenic Aspergillus spp. including A. flavipes, A. flavus, A. fumigatus, A. glaucus, A. nidulans, A. niger, A. terreus, A. ustus and A. versicolor suspended in tap water under laboratory-scale conditions. It was shown that within 10 s of exposure, time species such as A. glaucus, A. niudulans and A. ustus were completely inactivated, while 40 s were needed for the elimination of all the species tested. A. flavus and A. niger were found to be less susceptible than other species. Based on these results we conclude that UV disinfection could effectively inactivate Aspergillus spp. in tap water. Such disinfection could be used to reduce potential exposure of high-risk patients to fungal aerosols, particularly in hospital settings, where point-of-use (POU) UV light devices could be installed to provide safe water at a very low cost.

Free chlorine and monochloramine inactivation kinetics of Aspergillus and Penicillium in drinking water

Fungi are near-ubiquitous in potable water distribution systems, but the disinfection kinetics of commonly identified fungi are poorly studied. In the present study, laboratory scale experiments were conducted to evaluate the inactivation kinetics of Aspergillus fumigatus, Aspergillus versicolor, and Penicillium purpurogenum by free chlorine and monochloramine. The observed inactivation data were then fit to a delayed Chick-Watson model. Based on the model parameter estimation, the Ct values (integrated product of disinfectant concentration C and contact time t over defined time intervals) for 99.9% inactivation of the tested fungal strains ranged from 48.99 mg min/L to 194.7 mg min/L for free chlorine and from 90.33 mg min/L to 531.3 mg min/L for monochloramine. Fungal isolates from a drinking water system (Aspergillus versicolor and Penicillium purpurogenum) were more disinfection resistant than Aspergillus fumigatus type and clinical isolates. The required 99.9% inactivation Ct values for the tested fungal strains are higher than E. coli, a commonly monitored indicator bacteria, and within a similar range for bacteria commonly identified within water distribution systems, such as Mycobacterium spp. and Legionella spp.

Centralized Drinking Water Treatment Operations Shape Bacterial and Fungal Community Structure

Drinking water microbial communities impact opportunistic pathogen colonization and corrosion of water distribution systems, and centralized drinking water treatment represents a potential control for microbial community structure in finished drinking water. In this article, we examine bacterial and fungal abundance and diversity, as well as the microbial community taxonomic structure following each unit operation in a conventional surface water treatment plant. Treatment operations drove the microbial composition more strongly than sampling time. Both bacterial and fungal abundance and diversity decreased following sedimentation and filtration; however, only bacterial abundance and diversity was significantly impacted by free chlorine disinfection. Similarly, each treatment step was found to shift bacterial and fungal community beta-diversity, with the exception of disinfection on the fungal community structure. We observed the enrichment of bacterial and fungal taxa commonly found in drinking water distribution systems through the treatment process, for example, Sphingomonas following filtration and Leptospirillium and Penicillium following disinfection. Study results suggest that centralized drinking water treatment processes shape the final drinking water microbial community via selection of community members and that the bacterial community is primarily driven by disinfection while the eukaryotic community is primarily controlled by physical treatment processes.

Antibodies to Molds and Satratoxin in Individuals Exposed in Water-Damaged Buildings

Immunoglobulin (Ig)A, IgM, and IgG antibodies against Penicillium notatum, Aspergillus niger, Stachybotrys chartarum, and satratoxin H were determined in the blood of 500 healthy blood donor controls, 500 random patients, and 500 patients with known exposure to molds. The patients were referred to the immunological testing laboratory for health reasons other than mold exposure, or for measurement of mold antibody levels. Levels of IgA, IgM, and IgG antibodies against molds were significantly greater in the patients (p < 0.001 for all measurements) than in the controls. However, in mold-exposed patients, levels of these antibodies against satratoxin differed significantly for IgG only (p < 0.001), but not for IgM or IgA. These differences in the levels of mold antibodies among the 3 groups were confirmed by calculation of z score and by Scheffé's significant difference tests. A general linear model was applied in the majority of cases, and 3 different subsets were formed, meaning that the healthy control groups were different from the random patients and from the mold-exposed patients. These findings indicated that mold exposure was more common in patients who were referred for immunological evaluation than it was in healthy blood donors. The detection of antibodies to molds and satratoxin H likely resulted from antigenic stimulation of the immune system and the reaction of serum with specially prepared mold antigens. These antigens, which had high protein content, were developed in this laboratory and used in the enzyme-linked immunosorbent assay (ELISA) procedure. The authors concluded that the antibodies studied are specific to mold antigens and mycotoxins, and therefore could be useful in epidemiological and other studies of humans exposed to molds and mycotoxins.

Fungal Contaminants in Drinking Water Regulation? A Tale of Ecology, Exposure, Purification and Clinical Relevance

Microbiological drinking water safety is traditionally monitored mainly by bacterial parameters that indicate faecal contamination. These parameters correlate with gastro-intestinal illness, despite the fact that viral agents, resulting from faecal contamination, are usually the cause. This leaves behind microbes that can cause illness other than gastro-intestinal and several emerging pathogens, disregarding non-endemic microbial contaminants and those with recent pathogenic activity reported. This white paper focuses on one group of contaminants known to cause allergies, opportunistic infections and intoxications: Fungi. It presents a review on their occurrence, ecology and physiology. Additionally, factors contributing to their presence in water distribution systems, as well as their effect on water quality are discussed. Presence of opportunistic and pathogenic fungi in drinking water can pose a health risk to consumers due to daily contact with water, via several exposure points, such as drinking and showering. The clinical relevance and influence on human health of the most common fungal contaminants in drinking water is discussed. Our goal with this paper is to place fungal contaminants on the roadmap of evidence based and emerging threats for drinking water quality safety regulations.

Pseudo-outbreak of Penicillium in an outpatient obstetrics and gynecology clinic

We report an unusual pseudo-outbreak of Penicillium that occurred in patients seen in an outpatient obstetrics and gynecology clinic. The pseudo-outbreak was detected in late 2012, when the microbiology department reported a series of vaginal cultures positive for Penicillium spp. Our investigation found Penicillium spp in both patient and environmental samples and was potentially associated with the practice of wetting gloves with tap water by a health care worker prior to patient examination.

Influence of surface structure and chemistry on water droplet splashing

Water droplet splashing and aerosolization play a role in human hygiene and health systems as well as in crop culturing. Prevention or reduction of splashing can prevent transmission of diseases between animals and plants and keep technical systems such as pipe or bottling systems free of contamination. This study demonstrates to what extent the surface chemistry and structures influence the water droplet splashing behaviour. Smooth surfaces and structured replicas of Calathea zebrina (Sims) Lindl. leaves were produced. Modification of their wettability was done by coating with hydrophobizing and hydrophilizing agents. Their wetting was characterized by contact angle measurement and splashing behaviour was observed with a high-speed video camera. Hydrophobic and superhydrophilic surfaces generally showed fewer tendencies to splash than hydrophobic ones. Structuring amplified the underlying behaviour of the surface chemistries, increasing hydrophobic surfaces' tendency to splash and decreasing splash on hydrophilic surfaces by quickly transporting water off the impact point by capillary forces. The non-porous surface structures found in C. zebrina could easily be applied to technical products such as plastic foils or mats and coated with hydrophilizing agents to suppress splash in areas of increased hygiene requirements or wherever pooling of liquids is not desirable.This article is part of the themed issue 'Bioinspired hierarchically structured surfaces for green science'.

Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Outbreak of Bloodstream Infection With the Mold Phialemonium Among Patients Receiving Dialysis at a Hemodialysis Unit

Background

Molds are a rare cause of disseminated infection among dialysis patients.

Objective.

We evaluated a cluster of intravascular infections with the mold Phialemonium among patients receiving hemodialysis at the same facility in order to identify possible environmental sources and prevent further infection.

Design.

Environmental assessment and case-control study.

Setting.

A hemodialysis center affiliated with a tertiary care hospital.

Methods.

We reviewed surveillance and clinical microbiology records and performed a blood culture survey for all patients. The following data for case patients were compared with those for control patients: underlying illness, dialysis characteristics, medications, and other possible exposure for 120 days prior to infection. Environmental assessment of water treatment, dialysis facilities, and heating, ventilation, and air-conditioning (HVAC) systems of the current and previous locations of the dialysis center was performed. Samples were cultured for fungus; Phialemonium isolates were confirmed by sequencing of DNA. Investigators observed dialysis access site disinfection technique.

Results.

Four patients were confirmed as case patients, defined as a patient having intravascular infection with Phialemonium species; 3 presented with fungemia, and 1 presented with an intravascular graft infection. All case patients used a fistula or graft for dialysis access, as did 12 (75%) of 16 of control patients (P = .54). Case and control patients did not differ in other dialysis characteristics, medications received, physiologic findings, or demographic factors. Phialemonium species were not recovered from samples of water or dialysis machines, but were recovered from the condensation drip pans under the blowers of the HVAC system that supplied air to the dialysis center. Observational study of 21 patients detected suboptimal contact time with antiseptic agents used to prepare dialysis access sites.

Conclusion.

The report of this outbreak adds to previous published reports of Phialemonium infection occurring in immunocompromised patients who likely acquired infection in the healthcare setting. Recovery of this mold from blood culture should be considered indicative of infection until proven otherwise. Furthermore, an investigation into possible healthcare-related environmental reservoirs should be considered.

Fungi from a Groundwater-Fed Drinking Water Supply System in Brazil

Filamentous fungi in drinking water distribution systems are known to (a) block water pipes; (b) cause organoleptic biodeterioration; (c) act as pathogens or allergens and (d) cause mycotoxin contamination. Yeasts might also cause problems. This study describes the occurrence of several fungal species in a water distribution system supplied by groundwater in Recife—Pernambuco, Brazil. Water samples were collected from four sampling sites from which fungi were recovered by membrane filtration. The numbers in all sampling sites ranged from 5 to 207 colony forming units (CFU)/100 mL with a mean value of 53 CFU/100 mL. In total, 859 isolates were identified morphologically, with Aspergillus and Penicillium the most representative genera (37% and 25% respectively), followed by Trichoderma and Fusarium (9% each), Curvularia (5%) and finally the species Pestalotiopsis karstenii (2%). Ramichloridium and Leptodontium were isolated and are black yeasts, a group that include emergent pathogens. The drinking water system in Recife may play a role in fungal dissemination, including opportunistic pathogens.

PCR-Internal Transcribed Spacer (ITS) genes sequencing and phylogenetic analysis of clinical and environmental Aspergillus species associated with HIV-TB co infected patients in a hospital in Abeokuta, southwestern Nigeria

BACKGROUND

Aspergillosis has been identified as one of the hospital acquired infections but the contribution of water and inhouse air as possible sources of Aspergillus infection in immunocompromised individuals like HIV-TB patients have not been studied in any hospital setting in Nigeria.

OBJECTIVE

To identify and investigate genetic relationship between clinical and environmental Aspergillus sp. associated with HIV-TB co infected patients.

METHODS

DNA extraction, purification, amplification and sequencing of Internal Transcribed Spacer (ITS) genes were performed using standard protocols. Similarity search using BLAST on NCBI was used for species identification and MEGA 5.0 was used for phylogenetic analysis.

RESULTS

Analyses of sequenced ITS genes of selected fourteen (14) Aspergillus isolates identified in the GenBank database revealed Aspergillus niger (28.57%), A. tubingensis (7.14%), A. flavus (7.14%) and A. fumigatus (57.14%). Aspergillus in sputum of HIV patients were Aspergillus niger, A. fumigatus, A. tubingensis and A. flavus. Also, A. niger and A. fumigatus were identified from water and open-air. Phylogenetic analysis of sequences yielded genetic relatedness between clinical and environmental isolates.

CONCLUSION

Water and air in health care settings in Nigeria are important sources of Aspergillus sp. for HIV-TB patients.

Waterborne microorganisms and biofilms related to hospital infections: strategies for prevention and control in healthcare facilities

Water is the main stimulus for the development of microorganisms, and its flow has an important role in the spreading of contaminants. In hospitals, the water distribution system requires special attention since it can be a source of pathogens, including those in the form of biofilms often correlated with resistance of microorganisms to various treatments. In this paper, information relevant to cases of nosocomial infections involving water circuits as a source of contaminants is compiled, with emphasis on the importance of microbiological control strategies to prevent the installation, spreading and growth of microorganisms in hospitals. An overview of the worldwide situation is provided, with emphasis on Brazilian hospitals. Different approaches normally used to control the occurrence of nosocomial infections due to waterborne contaminants are analyzed, and the use of the polysaccharide chitosan for this specific application is briefly discussed.

Fungi, Water Supply and Biofilms

Even though it has been studied for many years, water-related infectious risk still exists in both care and community environments due to the possible presence of numerous microorganisms such as bacteria, fungi and protists. People can be exposed directly to these microorganisms either through aerosols and water, after ingestion, inhalation, skin contact and entry through mucosal membranes, or indirectly usually due to pre-treatment of some medical devices. Species belonging to genera such as Aspergillus, Penicillium, Pseudallesheria, Fusarium, Cuninghamella, Mucor and in some particular cases Candida have been isolated in water from health facilities and their presence is particularly related to the unavoidable formation of a polymicrobial biofilm in waterlines. Fungi isolation methods are based on water filtration combined with conventional microbiology cultures and/or molecular approaches; unfortunately, these are still poorly standardized. Moreover, due to inappropriate culture media and inadequate sampling volumes, the current standardized methods used for bacterial research are not suitable for fungal search. In order to prevent water-related fungal risk, health facilities have implemented measures such as ultraviolet radiation to treat the input network, continuous chemical treatment, chemical or thermal shock treatments, or microfiltration at points of use. This article aims to provide an overview of fungal colonization of water (especially in hospitals), involvement of biofilms that develop in waterlines and application of preventive strategies.

ISOLAMENTO E IDENTIFICAÇÃO DE FUNGOS DO GÊNERO Aspergillus spp. DE ÁGUA UTILIZADA NA REABILITAÇÃO DE PINGUINS-DEMAGALHÃES

Resumo A aspergilose caracteriza-se por ser a principal causa de mortalidade de pinguins em cativeiro. A infecção pelo gênero Aspergillus ocorre principalmente por via aérea, porém o fungo pode ter dispersão pela água. Neste sentido, este trabalho teve como objetivo avaliar a água do tanque onde os pinguins-de-Magalhães permanecem para reabilitação no Centro de Recuperação de Animais Marinhos de Rio Grande, RS, Brasil, quanto à presença de fungos filamentosos do gênero Aspergillus. As amostras de água foram coletadas semanalmente durante um período de 10 meses e processadas em um período máximo de seis horas utilizando-se a técnica da membrana filtrante, com incubação a 25 ºC e 37 ºC por até sete dias. Das 40 amostras analisadas, 32 foram positivas para o isolamento do gênero Aspergillus, sendo que dessas 60% pertenciam à espécie A. fumigatus. Algumas variáveis interferiram significativamente no isolamento do gênero Aspergillus e/ou da espécie A. fumigatus, como temperatura de incubação, sazonalidade e densidade populacional. Este trabalho demonstra que Aspergillus spp. está presente na água, podendo essa ser uma potencial fonte de infecção para os pinguins em reabilitação.

Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014

Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.

HACCP-Based Programs for Preventing Disease and Injury from Premise Plumbing: A Building Consensus

Thousands of preventable injuries and deaths are annually caused by microbial, chemical and physical hazards from building water systems. Water is processed in buildings before use; this can degrade the quality of the water. Processing steps undertaken on-site in buildings often include conditioning, filtering, storing, heating, cooling, pressure regulation and distribution through fixtures that restrict flow and temperature. Therefore, prevention of disease and injury requires process management. A process management framework for buildings is the hazard analysis and critical control point (HACCP) adaptation of failure mode effects analysis (FMEA). It has been proven effective for building water system management. Validation is proof that hazards have been controlled under operating conditions and may include many kinds of evidence including cultures of building water samples to detect and enumerate potentially pathogenic microorganisms. However, results from culture tests are often inappropriately used because the accuracy and precision are not sufficient to support specifications for control limit or action triggers. A reliable negative screen is based on genus-level Polymerase Chain Reaction (PCR) for Legionella in building water systems; however, building water samples with positive results from this test require further analysis by culture methods.

Excellent outcome of Aspergillous endophthalmitis in a case of allergic bronchopulmonary aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infections have been reported in immunocompetent individuals. The purpose is to report an eye with post-operative Aspergillus endophthalmitis, which achieved a good visual outcome following early and aggressive treatment. A young patient, known case of allergic bronchopulmonary aspergillosis presented to us with post-cataract surgery endophthalmitis. He was treated with pars plana vitrectomy and intravitreal voriconazole and systemic itraconazole. The patient regained a vision of 20/30 with follow up of 2 years.

Fungal diversity and presence of potentially pathogenic fungi in a hospital hot water system treated with on-site monochloramine

Currently, our knowledge of fungal ecology in engineered drinking water systems is limited, despite the potential for these systems to serve as a reservoir for opportunistic pathogens. In this study, hot water samples were collected both prior to and following the addition of monochloramine as an on-site disinfectant in a hospital hot water system. Fungal ecology was then analyzed by high throughput sequencing of the fungal ITS1 region. The results demonstrate that the genera Penicillium, Aspergillus, Peniophora, Cladosporium and Rhodosporidium comprised the core fungal biome of the hospital hot water system. Penicillium dominated the fungal community with an average relative abundance of 88.89% (±6.37%). ITS1 sequences of fungal genera containing potential pathogens such as Aspergillus, Candida, and Fusarium were also detected in this study. No significant change in fungal community structure was observed before and after the initiation of on-site monochloramine water treatment. This work represents the first report of the effects of on-site secondary water disinfection on fungal ecology in premise plumbing system, and demonstrates the necessity of considering opportunistic fungal pathogens during the evaluation of secondary premise plumbing disinfection systems.

How we treat invasive fungal diseases in patients with acute leukemia: the importance of an individualized approach

Invasive fungal diseases (IFDs) represent an important cause of treatment failure in adults with acute leukemia. Because of leukemia’s heterogeneity, the risk for IFDs is highly variable. We therefore apply a risk-adapted antifungal strategy with strong emphasis on pretreatment and day-15 posttreatment to allow earlier and more individualized interventions. We determine pretreatment risks for IFDs based on 4 factors: (1) host fitness for standard therapy (ie, fit, unfit, or frail); (2) leukemia resistance (high vs low probability of achieving complete remission [CR]); (3) anticipated treatment-related toxicity such as neutropenia, mucositis, and steroid-induced immunosuppression; and (4) patient exposure to opportunistic fungi. Accordingly, we stratify patients as high, intermediate, or low risk for IFDs and apply risk-adapted antifungal strategies, including primary or secondary prophylaxis and diagnostic-based preemptive or empiric therapy. Prevention of IFDs also relies on optimizing organ function, decreasing exposure to opportunistic fungi, and improving net state of immunosuppression with use of better-tolerated and investigational agents for unfit patients and those with adverse leukemia biology. Novel targeted and safe therapies that can achieve higher rates of sustained CR among patients with adverse genetics offer the best promise for reducing the burden of IFDs in these patients.

Contamination of a purified water system by Aspergillus fumigatus in a new endoscopy reprocessing unit

Use of purified water for the final rinse stage of disinfected endoscopes is an important element of quality control. We describe the detection and management of Aspergillus fumigatus contamination of a new reverse osmosis unit supplying 10 automated endoscope reprocessor basins. Prompt detection and reaction to this contaminant were possible because of the introduction of a comprehensive program for microbiological monitoring of rinse waters, which included total viable counts, endotoxin, conductivity, and Pseudomonas spp.

A comprehensive water management program for multicampus healthcare facilities

OBJECTIVE

Develop and implement an effective program for hazard analysis and control of waterborne pathogens at a multicampus hospital with clinics.

DESIGN

A longitudinal study. Several-year study including analysis of results from monitoring and tests of 26 building water systems.

SETTING

Outpatient and inpatient healthcare facilities network.

METHODS

The hazard analysis and critical control point (HACCP) process was used to develop a water management program (WMP) for the hospital campuses. The HACCP method systematically addressed 3 questions: (1) What are the potential waterborne hazards in the building water systems of these facilities? (2) How are the hazards being controlled? (3) How do we know that the hazards have been controlled? Microbiological and chemical tests of building water samples were used to validate the performance of the WMP; disease surveillance data further validated effective hazard control.

RESULTS

Hazard analysis showed that waterborne pathogens were generally in good control and that the water quality was good in all facilities. The hospital network has had several legionellosis cases that were identified as presumptive hospital acquired, but none was confirmed or substantiated by water testing in follow-up investigations. Building water system studies unrelated to these cases showed that pressure tanks and electronic automatic faucets required additional hazard control.

CONCLUSIONS

Application of the HACCP process for long-term building water systems management was practical and effective. The need for critical control point management of temperature, flow, and oxidant (chlorine) residual concentration was emphasized. The process resulted in discovery of water system components requiring additional hazard control.