A pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, United Kingdom

Bronchoscopy-related outbreaks and pseudo-outbreaks: A systematic review

OBJECTIVE

To identify and report the pathogens and sources of contamination associated with bronchoscopy-related outbreaks and pseudo-outbreaks.

DESIGN

Systematic review.

SETTING

Inpatient and outpatient outbreaks and pseudo-outbreaks after bronchoscopy.

METHODS

PubMed/Medline databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, using the search terms "bronchoscopy," "outbreak," and "pseudo-outbreak" from inception until December 31, 2022. From eligible publications, data were extracted regarding the type of event, pathogen involved, and source of contamination. Pearson correlation was used to identify correlations between variables.

RESULTS

In total, 74 studies describing 23 outbreaks and 52 pseudo-outbreaks were included in this review. The major pathogens identified in these studies were Pseudomonas aeruginosa, Mycobacterium tuberculosis, nontuberculous mycobacteria (NTM), Klebsiella pneumoniae, Serratia marcescens, Stenotrophomonas maltophilia, Legionella pneumophila, and fungi. The primary sources of contamination were the use of contaminated water or contaminated topical anesthetics, dysfunction and contamination of bronchoscopes or automatic endoscope reprocessors, and inadequate disinfection of the bronchoscopes following procedures. Correlations were identified between primary bronchoscope defects and the identification of P. aeruginosa (r = 0.351; P = .002) and K. pneumoniae (r = 0.346; P = .002), and between the presence of a contaminated water source and NTM (r = 0.331; P = .004) or L. pneumophila (r = 0.280; P = .015).

CONCLUSIONS

Continued vigilance in bronchoscopy disinfection practices remains essential because outbreaks and pseudo-outbreaks continue to pose a significant risk to patient care, emphasizing the importance of stringent disinfection and quality control measures.

In Vitro and Ex Vivo Biofilm-Forming Ability of Rhinocladiella similis and Trichophyton rubrum Isolated from a Mixed Onychomycosis Case

Infections caused by biofilm-forming agents have important implications for world health. Mixed infections, caused by more than one etiological agent, are also an emerging problem, especially regarding the standardization of effective diagnosis and treatment methods. Cases of mixed onychomycosis (OM) have been reported; however, studies on the microbial interactions between the different fungi in biofilms formed on nails are still scarce. We describe a case of mixed OM caused by the dermatophyte Trichophyton rubrum and the black yeast-like fungus Rhinocladiella similis. Identical growths of both fungi were observed in more than 50 cultures from different nail samples. Additionally, both species were able to form organized single and mixed biofilms, reinforcing the participation of both fungi in the etiology of this OM case. R. similis seemed to grow faster during the process, suggesting that T. rubrum benefits from biofilm development when in combination. Moreover, the biofilm of the Rhinocladiella isolate exhibited exacerbated production of the extracellular matrix, which was not observed with that of a Rhinocladiella reference strain, suggesting that the isolate had natural abilities that were possibly perfected during development in the nail of the patient.

Systematic Review and Cost-Consequence Analysis of Ambu aScope 5 Broncho Compared with Reusable Flexible Bronchoscopes: Insights from Two US University Hospitals and an Academic Institution

OBJECTIVE

The aim of this study was to perform a systematic review, meta-analysis and cost-consequence analysis of the single-use bronchoscope, Ambu aScope^TM 5 Broncho, in relation to reusable flexible bronchoscopes (RFB) available within three high procedure volume university hospitals and academic institutions in the USA.

METHODS

The primary outcome was incremental cost and the secondary outcome was incremental cross-infection risk of use for both the single-use flexible bronchoscope (SUFB) and RFBs. Cost estimates included capital, repair, and reprocessing costs derived from a prospective observational micro-costing approach within three large university hospitals and academic institutions. All costs were valued in 2022 US dollars (USD). A meta-analysis based on literature covering cross-contamination and infection from 2010 to 2020 investigated cross-infection risk following bronchoscopy procedures with RFBs. Capital costs were discounted at 3% over 5-8 years. All parameters were evaluated using both univariate deterministic and probabilistic sensitivity analyses.

RESULTS

In high-volume hospitals, RFBs were cost minimizing compared to SUFBs. Probabilistic sensitivity analysis showed that RFBs were cost saving in 88% of iterations. Univariate analyses illustrated sensitivity of the base-case result to the procedure volume. Data from sensitivity analyses suggest that the two interventions are cost neutral at a break-even point of 756 procedures per year or 46 procedures per bronchoscope per year.

CONCLUSION

Assuming equivalent clinical performance, single-use flexible bronchoscopes are not cost minimizing when including the costs associated with cross-infection in high-volume US university hospitals and academic institutions. Overall, the benefits of conversion from RFBs to SUFBs are dependent on the annual procedure volume of individual hospitals, expected cross-infection risk, and purchase price of the aScope 5 Broncho.

A pseudo-outbreak of Cyberlindnera fabianii funguria: Implication from whole genome sequencing assay

Background

Although the yeast Cyberlindnera fabianii (C. fabianii) has been rarely reported in human infections, nosocomial outbreaks caused by this organism have been documented. Here we report a pseudo-outbreak of C. fabianii in a urology department of a Chinese hospital over a two-week period.

Methods

Three patients were admitted to the urology department of a tertiary teaching hospital in Beijing, China, from Nov to Dec 2018, for different medical intervention demands. During the period Nov 28 to Dec 5, funguria occurred in these three patients, and two of them had positive urine cultures multiple times. Sequencing of rDNA internal transcribed spacer (ITS) region and MALDI-TOF MS were applied for strain identification. Further, sequencing of rDNA non-transcribed spacer (NTS) region and whole genome sequencing approaches were used for outbreak investigation purpose.

Results

All the cultured yeast strains were identified as C. fabianii by sequencing of ITS region, and were 100% identical to the C. fabianii type strain CBS 5640T. However, the MALDI-TOF MS system failed to correctly identify this yeast pathogen. Moreover, isolates from these three clustered cases shared 99.91%-100% identical NTS region sequences, which could not rule out the possibility of an outbreak. However, whole genome sequencing results revealed that only two of the C. fabianii cases were genetically-related with a pairwise SNP of 192 nt, whilst the third case had over 26,000 SNPs on its genome, suggesting a different origin. Furthermore, the genomes of the first three case strains were phylogenetically even more diverged when compared to a C. fabianii strain identified from another patient, who was admitted to a general surgical department of the same hospital 7 months later. One of the first three patients eventually passed away due to poor general conditions, one was asymptomatic, and other clinically improved.

Conclusion

In conclusion, nosocomial outbreaks caused by emerging and uncommon fungal species are increasingly being reported, hence awareness must be raised. Genotyping with commonly used universal gene targets may have limited discriminatory power in tracing the sources of infection for these organisms, requiring use of whole genome sequencing to confirm outbreak events.

Diversity of Filamentous Fungi Associated with Dairy Processing Environments and Spoiled Products in Brazil

Few studies have investigated the diversity of spoilage fungi from the dairy production chain in Brazil, despite their importance as spoilage microorganisms. In the present study, 109 filamentous fungi were isolated from various spoiled dairy products and dairy production environments. The isolates were identified through sequencing of the internal transcribed spacer (ITS) region. In spoiled products, Penicillium and Cladosporium were the most frequent genera of filamentous fungi and were also present in the dairy environment, indicating that they may represent a primary source of contamination. For dairy production environments, the most frequent genera were Cladosporium, Penicillium, Aspergillus, and Nigrospora. Four species (Hypoxylon griseobrunneum, Rhinocladiella similis, Coniochaeta rosae, and Paecilomyces maximus) were identified for the first time in dairy products or in dairy production environment. Phytopathogenic genera were also detected, such as Montagnula, Clonostachys, and Riopa. One species isolated from the dairy production environment is classified as the pathogenic fungi, R. similis. Regarding the phylogeny, 14 different families were observed and most of the fungi belong to the Ascomycota phylum. The understanding of fungal biodiversity in dairy products and environment can support the development of conservation strategies to control food spoilage. This includes the suitable use of preservatives in dairy products, as well as the application of specific cleaning and sanitizing protocols designed for a specific group of target microorganisms.

Antifungal susceptibility of the endophytic fungus Rhinocladiella similis (URM 7800) isolated from the Caatinga dry forest in Brazil

The present study reports a new occurrence of Rhinocladiella similis isolated as an endophytic fungus in the Caatinga dry tropical forest in Brazil and describes its antifungal susceptibility. The isolate R. similis URM 7800 was obtained from leaves of the medicinal plant Myracrodruon urundeuva. Its morphological characterization was performed on potato dextrose agar medium and molecular analysis using the ITS rDNA sequence. The antifungal susceptibility profile was defined using the Clinical and Laboratory Standards Institute (CLSI) protocol M38-A2. The colony of isolate URM 7800 showed slow growth, with an olivaceous-gray color and powdery mycelium; in microculture, it showed the typical features of R. similis. In the antifungal susceptibility test, isolate URM 7800 showed high minimal inhibitory concentration (MIC) values for amphotericin B (>16 μg/mL), voriconazole (16 μg/mL), terbinafine (>0.5 μg/mL), and caspofungin (>8 μg/mL), among other antifungal drugs. Pathogenic melanized fungi are frequently isolated in environments where humans may be exposed, and these data show that it is essential to know if these isolates possess antifungal resistance.

Hydrocarbon-Contaminated Sites: Is There Something More Than Exophiala xenobiotica? New Insights into Black Fungal Diversity Using the Long Cold Incubation Method

Human-made hydrocarbon-rich environments are important reservoirs of microorganisms with specific degrading abilities and pathogenic potential. In particular, black fungi are of great interest, but their presence in the environment is frequently underestimated because they are difficult to isolate. In the frame of a biodiversity study from fuel-contaminated sites involving 30 diesel car tanks and 112 fuel pump dispensers (52 diesel and 60 gasoline, respectively), a total of 181 black fungal strains were isolated. The long cold incubation (LCI) of water-suspended samples, followed by plating on Dichloran Rose Bengal Chloramphenicol Agar (DRBC), gave isolation yields up to six times (6.6) higher than those of direct plating on DRBC, and those of enrichment with a phenolic mix. The sequencing of ITS and LSU-rDNA confirmed the dominance of potentially pathogenic fungi from the family Herpotrichiellaceae and Exophiala xenobiotica. Moreover, other opportunistic species were found, including E. opportunistica, E. oligosperma, E. phaeomuriformis, and Rhinocladiella similis. The recurrent presence of E. crusticola, Knufia epidermidis, Aureobasidium melanogenum, Cladosporium spp., and Scolecobasidium spp. was also recorded. Interestingly, 12% of total isolates, corresponding to 50% of taxa found (16/32), represent new species. All the novel taxa in this study were isolated by LCI. These findings suggest that black fungal diversity in hydrocarbon-rich niches remains largely unexplored and that LCI can be an efficient tool for further investigations.

The Consequences of Our Changing Environment on Life Threatening and Debilitating Fungal Diseases in Humans

Human activities have significantly impacted the environment and are changing our climate in ways that will have major consequences for ourselves, and endanger animal, plant and microbial life on Earth. Rising global temperatures and pollution have been highlighted as potential drivers for increases in infectious diseases. Although infrequently highlighted, fungi are amongst the leading causes of infectious disease mortality, resulting in more than 1.5 million deaths every year. In this review we evaluate the evidence linking anthropomorphic impacts with changing epidemiology of fungal disease. We highlight how the geographic footprint of endemic mycosis has expanded, how populations susceptible to fungal infection and fungal allergy may increase and how climate change may select for pathogenic traits and indirectly contribute to the emergence of drug resistance.