The epidemiology of invasive pulmonary aspergillosis at a large teaching hospital

Invasive Fungal Infections after Liver Transplantation

Invasive fungal infections represent a major challenge in patients who underwent organ transplantation. Overall, the most common fungal infections in these patients are candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Several risk factors have been identified, which increase the likelihood of an invasive fungal infection developing after transplantation. Liver transplant recipients constitute a high-risk category for invasive candidiasis and aspergillosis, and therefore targeted prophylaxis is favored in this patient population. Furthermore, a timely implemented therapy is crucial for achieving optimal outcomes in transplanted patients. In this article, we describe the epidemiology, risk factors, prophylaxis, and treatment strategies of the most common fungal infections in organ transplantation, with a focus on liver transplantation.

Allergic Bronchopulmonary Mycosis due to Exposure to Eurotium herbariorum after the Great East Japan Earthquake

BACKGROUND

Indoor mold levels typically increase after natural disasters, flooding, and water damage. Eurotium herbariorum is the sexual stage of Aspergillus glaucus. Case Presentation A 66-year-old, Japanese male, ex-smoker had been diagnosed with bronchial asthma when he was five years old; he achieved remission at the age of 13 years. He was displaced from his home during the Great East Japan Earthquake on March 11, 2011 and moved to temporary housing in Miyagi Prefecture in June 2011. He experienced the first episode of chest tightness, coughing, and wheezing in February 2012, when he again was diagnosed as having bronchial asthma. Mycofloral surveillance detected high counts of Eurotium in the air of his bedroom, kitchen, and living room, with a maximal fungal count of 163,200 colony-forming units per cubic meter (CFU/m3). Although Cladosporium and Penicillium typically predominate in the indoor air of residential dwellings, only low levels of these organisms were present in the patient's home. Morphologic identification confirmed the isolates as E. herbariorum. The patient had positive reactions to E. herbariorum in skin prick testing and the presence of antigen-specific precipitating antibodies to E. herbariorum. Computed tomography of the chest in August 2013 revealed central bronchiectasis and bronchial wall thickening. The patient experienced late reactions after provocation testing with E. herbariorum.

CONCLUSION

This report presents the rare case of a patient who developed allergic bronchopulmonary mycosis (ABPM) due to exposure to E. herbariorum during temporary housing after the Great East Japan Earthquake. Oshikata C , Watanabe M , Saito A , Ishida M , Kobayashi S , Konuma R , Kamata Y , Terajima J , Cho J , Yanai M , Tsurikisawa N . Allergic bronchopulmonary mycosis due to exposure to eurotium herbariorum after the Great East Japan Earthquake. Prehosp Disaster Med. 2017;32(6):688-690.

Could Histoplasma capsulatum Be Related to Healthcare-Associated Infections?

Healthcare-associated infections (HAI) are described in diverse settings. The main etiologic agents of HAI are bacteria (85%) and fungi (13%). Some factors increase the risk for HAI, particularly the use of medical devices; patients with severe cuts, wounds, and burns; stays in the intensive care unit, surgery, and hospital reconstruction works. Several fungal HAI are caused by Candida spp., usually from an endogenous source; however, cross-transmission via the hands of healthcare workers or contaminated devices can occur. Although other medically important fungi, such as Blastomyces dermatitidis, Paracoccidioides brasiliensis, and Histoplasma capsulatum, have never been considered nosocomial pathogens, there are some factors that point out the pros and cons for this possibility. Among these fungi, H. capsulatum infection has been linked to different medical devices and surgery implants. The filamentous form of H. capsulatum may be present in hospital settings, as this fungus adapts to different types of climates and has great dispersion ability. Although conventional pathogen identification techniques have never identified H. capsulatum in the hospital environment, molecular biology procedures could be useful in this setting. More research on H. capsulatum as a HAI etiologic agent is needed, since it causes a severe and often fatal disease in immunocompromised patients.

Spatial and temporal analyses to investigate infectious disease transmission within healthcare settings

Background

Healthcare-associated infections (HCAIs) cause significant morbidity and mortality worldwide, and outbreaks are often only identified after they reach high levels. A wide range of data is collected within healthcare settings; however, the extent to which this information is used to understand HCAI dynamics has not been quantified.

Aim

To examine the use of spatiotemporal analyses to identify and prevent HCAI transmission in healthcare settings, and to provide recommendations for expanding the use of these techniques.

Methods

A systematic review of the literature was undertaken, focusing on spatiotemporal examination of infectious diseases in healthcare settings. Abstracts and full-text articles were reviewed independently by two authors to determine inclusion.

Findings

In total, 146 studies met the inclusion criteria. There was considerable variation in the use of data, with surprisingly few studies (N = 22) using spatiotemporal-specific analyses to extend knowledge of HCAI transmission dynamics. The remaining 124 studies were descriptive. A modest increase in the application of statistical analyses has occurred in recent years.

Conclusion

The incorporation of spatiotemporal analysis has been limited in healthcare settings, with only 15% of studies including any such analysis. Analytical studies provided greater data on transmission dynamics and effective control interventions than studies without spatiotemporal analyses. This indicates the need for greater integration of spatiotemporal techniques into HCAI investigations, as even simple analyses provide significant improvements in the understanding of prevention over simple descriptive summaries.

Invasive fungal infections in solid organ transplant recipients

Invasive fungal infections are a major problem in solid organ transplant (SOT) recipients. Overall, the most common fungal infection in SOT is candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Development of invasive disease hinges on the interplay between host factors (e.g., integrity of anatomical barriers, innate and acquired immunity) and fungal factors (e.g., exposure, virulence and resistance to prophylaxis). In this article, we describe the epidemiology and clinical features of the most common fungal infections in organ transplantation. Within this context, we review recent advances in diagnostic modalities and antifungal chemotherapy, and their impact on evolving prophylaxis and treatment paradigms.

Five-years surveillance of invasive aspergillosis in a university hospital

Background

As the most common invasive fungal infection, invasive aspergillosis (IA) remains a serious complication in immunocompromised patients, leading to increased mortality. Antifungal therapy is expensive and may result in severe adverse effects.

The aim of this study was to determine the incidence of invasive aspergillosis (IA) cases in a tertiary care university hospital using a standardized surveillance method.

Methods

All inpatients at our facility were screened for presence of the following parameters: positive microbiological culture, pathologist's diagnosis and antifungal treatment as reported by the hospital pharmacy. Patients fulfilling one or more of these indicators were further reviewed and, if appropriate, classified according to international consensus criteria (EORTC).

Results

704 patients were positive for at least one of the indicators mentioned above. Applying the EORTC criteria, 214 IA cases were detected, of which 56 were proven, 25 probable and 133 possible. 44 of the 81 (54%) proven and probable cases were considered health-care associated. 37 of the proven/probable IA cases had received solid organ transplantation, an additional 8 had undergone stem cell transplantation, and 10 patients were suffering from some type of malignancy. All the other patients in this group were also suffering from severe organic diseases, required long treatment and experienced several clinical complications. 7 of the 56 proven cases would have been missed without autopsy. After the antimycotic prophylaxis regimen was altered, we noticed a significant decrease (p = 0.0004) of IA during the investigation period (2003-2007).

Conclusion

Solid organ and stem cell transplantation remain important risk factors for IA, but several other types of immunosuppression should also be kept in mind. Clinical diagnosis of IA may be difficult (in this study 13% of all proven cases were diagnosed by autopsy only). Thus, we confirm the importance of IA surveillance in all high-risk patients.

Nosocomial fungal infections: epidemiology, infection control, and prevention

Fungal infections are an increasing cause of morbidity and mortality in hospitalized patients. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis and aspergillosis. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized.

Aspergillus fumigatus AcuM regulates both iron acquisition and gluconeogenesis

Relatively few transcription factors that govern the virulence of Aspergillus fumigatus are known. We constructed 11 A. fumigatus transcription factor mutants and screened them for altered virulence in Galleria mellonella larvae. We discovered that the zinc cluster transcription factor, AcuM, is essential for maximal virulence in this model, as well as in murine models of haematogenously disseminated and invasive pulmonary aspergillosis. Transcriptional profiling experiments suggested that AcuM suppresses sreA and induces hapX to stimulate expression of genes involved in both reductive iron assimilation and siderophore-mediated iron uptake. Consistent with these results, a ΔacuM mutant had reduced iron incorporation, decreased extracellular siderophore production and impaired capacity to grow under iron-limited conditions. Interestingly, an Aspergillus nidulansΔacuM mutant had normal extracellular siderophore production and growth under iron-limited conditions, indicating that AcuM does not govern iron acquisition in this organism. A. fumigatus AcuM also regulated genes involved in gluconeogenesis, and the ΔacuM mutant had impaired growth on gluconeogenic carbon sources. Deletion of sreA in the ΔacuM mutant restored iron uptake, extracellular siderophore production and virulence, but not the defect in gluconeogenesis. Thus, AcuM represses SreA and thereby induces iron acquisition, a process that is essential for the maximal virulence of A. fumigatus.

Aspergillosis: nosocomial or community-acquired?

Discrimination between nosocomial and community infections is important for investigation and prevention. Nosocomial and hospital-acquired infections require appropriate hospital control measures to avert additional cases. Nosocomial infections (NI) occur during hospitalization or are caused by microorganisms acquired during hospital stay. Such infections should not be evident when patients are admitted to the hospital. Furthermore, the definition of NI is based on epidemiological criteria, such as the time lapse between admission and onset, or microbiological criteria. This definition might be difficult to apply to invasive aspergillosis (IA) which often afflicts patients with severe immunosuppression or transplantation. Identification of the source may be difficult which could arise outside or inside the hospital. Another significant issue is the lack of valid and reproducible data on the incubation period. The incubation duration of IA is influenced by different individual or environmental determinants, including the severity of immunosuppression and air quality. The criteria of causality are also a means of discussing the contribution of hospital vs. community determinants of IA. The definition of nosocomial IA remains difficult. A better understanding of early events related to IA onset will help to prevent this disease for which the prognosis remains negative.

The Aspergillus fumigatus transcription factor Ace2 governs pigment production, conidiation and virulence

Aspergillus fumigatus causes serious and frequently fatal infections in immunocompromised patients. To investigate the regulation of virulence of this fungus, we constructed and analysed an A. fumigatus mutant that lacked the transcription factor Ace2, which influences virulence in other fungi. The Deltaace2 mutant had dysmorphic conidiophores, reduced conidia production and abnormal conidial cell wall architecture. This mutant produced an orange pigment when grown on solid media, although its conidia had normal pigmentation. Conidia of the Deltaace2 mutant were larger and had accelerated germination. The resulting germlings were resistant to hydrogen peroxide, but not other stressors. Non-neutropenic mice that were immunosuppressed with cortisone acetate and infected with the Deltaace2 mutant had accelerated mortality, greater pulmonary fungal burden, and increased pulmonary inflammatory responses compared with mice infected with the wild-type or Deltaace2::ace2-complemented strains. The Deltaace2 mutant had reduced ppoC, ecm33 and ags3 mRNA expression. It is known that A. fumigatus mutants with absent or reduced expression of these genes have increased virulence in mice, as well as other phenotypic similarities to the Deltaace2 mutant. Therefore, reduced expression of these genes likely contributes to the increased virulence of the Deltaace2 mutant.

Aspergillus flavus: an emerging non-fumigatus Aspergillus species of significance

Invasive aspergillosis is rare in immunocompetent people but contributes to significant morbidity and mortality in immunosuppressed patients. The majority (approximately 80%) of invasive Aspergillus infections is caused by Aspergillus fumigatus. The second most frequent (approximately 15-20%) pathogenic species is Aspergillus flavus and to a lesser extent, Aspergillus niger and Aspergillus terreus. Aspergillus flavus has emerged as a predominant pathogen in patients with fungal sinusitis and fungal keratitis in several institutions worldwide. To date, there has not been any publication exclusively reviewing the topic of A. flavus in the literature. This article reviews the microbiology, toxigenicity and epidemiology of A. flavus as well as describes the clinical characteristics, diagnosis and management of infections caused by this organism.

Nosocomial fungal infections: epidemiology, diagnosis, and treatment

Invasive fungal infections are increasingly common in the nosocomial setting. Furthermore, because risk factors for these infections continue to increase in frequency, it is likely that nosocomial fungal infections will continue to increase in frequency in the coming decades. The predominant nosocomial fungal pathogens include Candida spp., Aspergillus spp., Mucorales, Fusarium spp., and other molds, including Scedosporium spp. These infections are difficult to diagnose and cause high morbidity and mortality despite antifungal therapy. Early initiation of effective antifungal therapy and reversal of underlying host defects remain the cornerstones of treatment for nosocomial fungal infections. In recent years, new antifungal agents have become available, resulting in a change in standard of care for many of these infections. Nevertheless, the mortality of nosocomial fungal infections remains high, and new therapeutic and preventative strategies are needed.

Targeted High Lung Concentrations of Itraconazole Using Nebulized Dispersions in a Murine Model

PURPOSE

The purpose of this study was to investigate the delivery of itraconazole (ITZ) particles to a murine lung model by nebulization.

METHODS

Three ITZ formulations were prepared and characterized in the dry state using contact angle, dissolution, X-ray powder diffraction, scanning electron microscopy, and Brunauer-Emmett-Teller surface area analysis. Aerodynamic particle size distributions and lung deposition studies in 14 outbred male ICR mice were performed using aqueous dispersions of all the formulations. A separate dosing uniformity study was also performed to qualify use of the chamber.

RESULTS

All formulations had an aggregated particle size of approximately 30 microm in diameter. Two formulations showed that 80% of the drug dissolved in less than 5 min. The remaining ITZ formulation had a slower dissolution and the lowest total emitted dose from the nebulizer used. High concentrations of ITZ were shown to be present in the mouse lung during the lung deposition study, up to 16.8 +/- 0.13 microg/g (+/- SE) were achieved. Concentrations of up to 0.76 +/- 0.03 microg/g (+/- SE) could be maintained from the single nebulized dose for at least 24 h.

CONCLUSION

An effective method of targeted delivery of ITZ to the deep lung is presented that may be useful for the treatment and prevention of acute fungal infections.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

Evaluation of a high-volume portable bioaerosol sampler in laboratory and field environments

This study investigated the physical and biological performances of a portable centrifugal sampler for viable bioaerosols, RCS High Flow. The performance of the test sampler in the laboratory and field environments was compared with that of a reference sampler, BioSampler. The laboratory experiments with non-biological particles of KCl, oleic acid, and polystyrene latex showed that the test sampler's collection efficiency is about 22% for 0.5-microm particles, 48% for 1.0-microm particles, and approximately 100% for particles of 2.5 microm and larger. These tests indicated that the sampler's cut-off size (d50) was 1.1 microm. The test sampler's physical performance when collecting the spores and vegetative cells of Bacillus subtilis var. niger (BG) was similar to that when collecting non-biological particles of the same size. In the laboratory tests, the RCS High Flow sampler was found to enumerate approximately 40% of BG spores and cells relative to the reference sampler, BioSampler. A similar ratio was found during testing in an indoor environment. This ratio decreased to below 10% when testing was performed in an outdoor environment. We hypothesize that the test sampler's underperformance compared with the BioSampler could be caused by the damage to sensitive microorganisms during the collection process, test sampler's sensitivity to wind direction and speed as well as break-up of particle aggregates during the impingement process in BioSampler, which resulted in more colony-forming units (CFUs) being counted by the reference sampler than by the test sampler. Overall, when the RCS High Plus is used to sample culturable airborne microorganisms, the results obtained may have to be adjusted to avoid potential underestimation of microorganism concentration in the air.

PRACTICAL IMPLICATIONS

The laboratory testing of the RCS High Flow bioaerosol sampler showed that the sampler collects 1 microm particles and larger with an efficiency of 50% and higher; the efficiency reaches approximately 100% for particles of 2.5 microm and larger. When considering this result, most of the airborne fungal spores would be collected with an efficiency between 50 and 100%. The field testing, however, indicated that the RCS High Flow sampler recovered from 41 to 71% of microorganisms collected relative to the reference sampler, Biosampler, and this ratio dropped to below 5% during outdoor testing. Thus, while the RCS High Flow sampler offers certain advantages over other samplers for viable bioaerosols--it is lightweight, battery operated, and collects viable microorganisms at a high flow rate directly on agar media, the results obtained may have to be adjusted to avoid potential underestimation of microorganism concentration in the air, especially if sampling is performed outdoors.

Positive-pressure isolation and the prevention of invasive aspergillosis. What is the evidence?

Positive-pressure ventilation implies a sealed room, usually with an anteroom to facilitate the donning of protective clothing, airflows of at least 12 air changes per hour and high-efficiency particulate air (HEPA) to prevent infection in susceptible patients. Laminar airflow (LAF) involves much greater air changes, expense and inconvenience to the patient due to noise and draughts. There are few, if any, truly controlled trials on the impact of positive-pressure ventilation and the prevention of invasive aspergillosis (IA); most are observational studies conducted during an outbreak or retrospective analyses of the incidence of IA over periods of time when a variety of preventative interventions were introduced. Therefore, it is often difficult to determine the specific impact of positive-pressure ventilation with HEPA in leading to a reduction in IA. During periods of hospital demolition or construction, HEPA significantly reduces the aspergillus spore counts and in many studies, the incidence of IA, but other measures such as enhanced cleaning, the sealing of windows and the use of prophylactic anti-fungal agents are also important. On balance, the additional expense and inconvenience of LAF does not appear to be justified. Where positive-pressure ventilation is installed, it is imperative that the system be monitored to ensure that the pressure differentials and air changes are appropriate. Whilst there is a role for positive-pressure ventilation in reducing the incidence of IA, we need a better definition of the importance of hospital-acquired IA compared with community-acquired infection and of the relationship between strains of Aspergillus species isolated from the environment and those strains causing infection.

Acute myelogenous leukemia complicated by acute necrotizing ulcerative gingivitis due to Aspergillus terreus

Infections caused by Aspergillus terreus are rare but have been associated with a poor outcome in immunocompromised patients due to frequent resistance to conventional antifungal therapy. This report describes a case of a woman who developed acute necrotizing ulcerative gingivitis (ANUG) due to A. terreus during induction chemotherapy for acute myelogenous leukemia. She initially failed to respond to treatment with amphotericin B but the infection resolved following the introduction of oral itraconazole. Opportunistic infections caused by A. terreus are an emerging problem and can be associated with a high mortality rate. Early microbiological diagnosis is critical since resistance to amphotericin B is likely and itraconazole appears to be an effective treatment for this infection.

Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia

Although pneumonia caused by fungi is not a common occurrence in the general population, disease in an enlarging immunocompromised population is encountered with increasing frequency. Fungal pneumonias are most frequently caused by Aspergillus spp., dimorphic fungi and Cryptococcus neoformans. Recent studies have identified risk factors of thrombocytopenia, environmental events (such as construction or renovation) and immunosuppressive drug therapies as being specific risk factors for invasive fungal disease in select patient populations. Diagnostic strategies to detect circulating antigens and polymerase chain reaction based detection systems have been explored to improve identification prior to the progressive advanced disease. Advances in prophylactic strategies include increased use of aerosolized formulations of amphotericin B, usually in conjunction with new and old systemic antifungal agents. Despite recent published guidelines for treatment of fungal pneumonia based on etiology, mortality remains high in some infections with advanced disease. Caspofungin, a new echinocandin antifungal, has recently been approved by the US Food and Drug Administration for the treatment of invasive Aspergillus infections in patients unresponsive to or unable to receive amphotericin B. A triazole antifungal, voriconazole, has shown promise in phase III clinical trials in patients with refractory fungal infections and is expected to be available in early 2002. Other echinocandin and triazole antifungals are under development in attempts to provide improved effective therapy for fungal pneumonia.